Navigating the Complexities: Challenges Faced by Internationally Educated Nurses

Internationally Educated Nurses (IENs) play a vital role in addressing global healthcare shortages. However, their journey to practice in countries like the United States and Canada is often fraught with challenges. From lengthy credentialing processes to cultural adaptation and financial hurdles, IENs face a unique set of obstacles. This article delves into these challenges and offers insights to help aspiring IENs navigate their path successfully.

Credentialing Delays: Examples and Scenarios

Credentialing delays are one of the most significant hurdles for internationally trained nurses (ITNs) trying to enter the workforce in the U.S. and Canada. These delays can result from a variety of systemic inefficiencies, stringent requirements, and resource constraints. Here are detailed examples and scenarios highlighting how these delays impact ITNs:

Scenario 1: Lengthy Verification Process (Canada)

The NNAS Evaluation Bottleneck

In Canada, ITNs must first have their credentials evaluated by the National Nursing Assessment Service (NNAS). This involves reviewing their educational background, nursing licenses, and professional work history. However, the NNAS evaluation can take six months to over a year due to:

• Volume of Applications: A surge in ITN applications has overwhelmed the system, particularly in high-demand regions like Ontario and British Columbia.

  
  

• Document Validation Challenges: Many ITNs face delays in obtaining official transcripts or verification from their home countries. For instance:

  
  

  • Nurses from countries experiencing political unrest (e.g., Ukraine or Sudan) may struggle to get documents validated promptly.

    
    

  • Language translation errors or inconsistencies can lead to further delays.

Impact:

• A nurse awaiting evaluation cannot apply for provincial licensure or begin working, leading to financial strain and prolonged unemployment.

  
  

• Employers facing critical shortages are left with unfilled positions, affecting patient care delivery.

  
  

Scenario 2: Multi-Step Licensing Processes (U.S.)

State-Specific Requirements

In the U.S., ITNs often experience delays due to variations in state licensure requirements. For example:

• Some states, like California, require additional documentation and background checks that other states do not.

  
  

• States like New York may require completion of CGFNS certification even if the nurse has already passed the NCLEX-RN.

  
  

Example:

An ITN who passes the NCLEX-RN and obtains licensure in one state (e.g., Texas) may face significant hurdles when trying to transfer to another state due to differing requirements. This is particularly problematic for nurses in the U.S. under temporary work visas who may need to relocate frequently based on employer demand.

Impact:

• Delays in obtaining state licensure mean that ITNs might lose job opportunities or incur additional costs for reapplying and fulfilling specific state requirements.

  
  

• Employers may turn to less qualified candidates to fill urgent roles.

  
  

Scenario 3: Credentialing During a Global Pandemic

COVID-19 and Remote Processing

The COVID-19 pandemic exacerbated credentialing delays for ITNs:

• In-person document submission and licensing exams were halted in many countries, creating a backlog that persists even in 2024.

  
  

• Example: Nurses from the Philippines, a major source of ITNs for both the U.S. and Canada, reported significant delays in obtaining VisaScreen® certification and NCLEX-RN testing due to limited availability of testing centers during the pandemic.

  
  

Impact:

• The backlog forced thousands of ITNs to remain in their home countries, delaying their entry into the workforce.

  
  

• Hospitals and healthcare systems in North America struggled to fill critical nursing positions, leading to burnout among existing staff.

  
  

Scenario 4: Regulatory Complexity

Changing Standards

Regulatory bodies in both countries frequently update their requirements, leaving ITNs unprepared or misinformed. For example:

• In 2024, some provinces in Canada introduced jurisdiction-specific nursing jurisprudence exams, which added an extra layer of testing for nurses who were already mid-process.

  
  

• U.S. nursing boards occasionally adjust NCLEX testing standards or eligibility criteria, requiring ITNs to redo steps they previously completed.

  
  

Impact:

• ITNs often need to retake exams, submit additional documentation, or repeat parts of the process, prolonging their wait time and incurring additional costs.

  
  

• Frustration with unclear or changing rules leads some ITNs to abandon their applications altogether.

Financial Barriers: Costs for Exams, Licensing, and Immigration Processes Can Be High

Internationally trained nurses (ITNs) face significant financial hurdles in their journey to practice in the United States and Canada. The costs associated with exams, credential evaluations, licensing, and immigration can amount to thousands of dollars, creating barriers for nurses, particularly those from low- or middle-income countries. These financial challenges often delay or deter qualified professionals from completing the process.

Scenario 1: Exam Fees and Preparation Costs

U.S. Licensing Requirements

• The NCLEX-RN, the primary licensing exam for registered nurses in the U.S., costs approximately $200 for registration.

  
  

• If taken internationally, additional fees (up to $150) apply for testing at overseas centers.

  
  

• Many ITNs spend $500–$1,000 on preparatory courses and materials, as passing the NCLEX on the first attempt is critical to advancing their career prospects.

  
  

Example: A nurse from the Philippines may take the NCLEX at a test center in Singapore due to the lack of local availability, adding travel, accommodation, and meal expenses to the overall cost.

Canada’s Credentialing Pathway

• In Canada, the National Nursing Assessment Service (NNAS) charges $650 CAD for the initial credential assessment.

  
  

• The NCLEX-RN costs $360 CAD, while additional provincial jurisprudence exams can add $100–$200 per attempt.

  
  

Example: A nurse from India applying for licensure in Ontario incurs costs not only for the NNAS assessment and NCLEX-RN but also for the College of Nurses of Ontario (CNO) application fee, which is $300 CAD, plus any applicable renewal fees.

Scenario 2: Visa and Immigration Costs

U.S. Immigration

• Obtaining a VisaScreen® certificate, mandatory for ITNs immigrating to the U.S., costs about $540, excluding fees for English proficiency tests (IELTS or TOEFL), which range between $200–$300.

  
  

• Employers often sponsor the green card application under the EB-3 visa category, but nurses are responsible for associated costs, including:

  
  

  • Medical exams ($200–$500).

    
    

  • Document notarization and translations ($50–$200 per document).

    
    

Example: A nurse from Nigeria spends over $1,000 on documentation, medical exams, and VisaScreen requirements before even applying for an EB-3 visa.

Canada’s Express Entry and PNP Costs

• Application fees under Canada’s Express Entry system total $1,365 CAD per applicant. Additional fees apply for dependents, biometrics ($85 CAD), and language testing (IELTS: $300 CAD).

  
  

• Provincial Nominee Programs (PNPs) often have separate fees, such as $1,500 CAD in Ontario.

  
  

Example: A nurse moving to British Columbia through the PNP pathway spends over $4,000 CAD, including provincial fees, language tests, and federal processing charges.

Scenario 3: Hidden Costs of Credentialing

Delayed Workforce Entry

• Nurses often incur opportunity costs due to the time required for credentialing and immigration. A delay of six months to a year translates to lost income opportunities in their destination country.

  
  

Example: An ITN who could earn $75,000 annually as a starting salary in the U.S. or Canada loses nearly $37,500 in wages due to credentialing delays.

Bridging Programs

• Many provinces in Canada and some states in the U.S. require bridging programs to fill gaps in education. These programs can cost $10,000–$20,000, which is often unaffordable for ITNs without financial aid or employer sponsorship.

  
  

Cultural Adaptation: Adjusting to New Healthcare Systems and Professional Environments Requires Support

Cultural adaptation poses another significant challenge for ITNs. Beyond technical and procedural differences, adjusting to cultural norms, communication styles, and workplace dynamics in a new healthcare system can be overwhelming.

Scenario 1: Communication Challenges in Patient Care

Language Barriers

• Despite passing English proficiency tests, ITNs may struggle with colloquial phrases, regional accents, or medical jargon.

  
  

• In Canada, particularly in Quebec and other bilingual regions, nurses may need to provide care in French and English, which can be daunting for non-native speakers.

  
  

Example: A nurse from Vietnam working in a rural Canadian hospital misinterprets a patient’s description of symptoms due to unfamiliarity with local slang, leading to communication gaps and increased stress.

Nonverbal Communication

• Cultural differences in nonverbal communication, such as eye contact or gestures, can lead to misunderstandings between ITNs and patients or colleagues.

  
  

Example: A nurse from India avoids direct eye contact with senior doctors as a sign of respect, which is misinterpreted as disengagement in a U.S. hospital.

Scenario 2: Adapting to New Professional Norms

Hierarchical Differences

• Many ITNs come from healthcare systems with strict hierarchies. Transitioning to more collaborative or egalitarian systems, like those in North America, can be challenging.

  
  

Example: A nurse from the Philippines may hesitate to question a physician’s orders due to ingrained norms, even when encouraged to do so.

Patient-Centered Care

• Western healthcare emphasizes patient autonomy, requiring nurses to involve patients in decision-making. This may differ from more directive approaches common in other countries.

  
  

Example: A nurse from China initially struggles to shift from a paternalistic approach to encouraging patients to make their own informed choices about treatment.

Scenario 3: Emotional and Psychological Stress

Isolation

• ITNs often work far from their families and familiar support networks. Feelings of loneliness and cultural isolation can impact their mental health and job performance.

  
  

Example: A nurse from Kenya working in a remote U.S. town experiences cultural shock and homesickness, exacerbated by the lack of a local African community.

Discrimination and Bias

• ITNs may encounter bias or microaggressions, such as skepticism about their training or negative stereotypes about their countries of origin.

  
  

Example: A nurse from Pakistan faces subtle comments from patients questioning her qualifications, leading to frustration and reduced confidence.

Scenario 4: Ethical Dilemmas

Conflicts with Cultural or Religious Beliefs

• ITNs may face ethical dilemmas when cultural or religious values conflict with local practices or laws. For example:

  
  

  • Administering end-of-life care or engaging in procedures that their home country prohibits.

    
    

Example: A nurse from a conservative background is assigned to assist in an abortion procedure, conflicting with her personal beliefs.

Cultural adaptation is an ongoing process for ITNs, involving a combination of learning, unlearning, and emotional resilience. Without adequate support, these challenges can lead to burnout, high turnover rates, or difficulty in fully integrating into their new roles.

While the path for IENs to practice in the US and Canada can be challenging, it is well wroth it for most who decide to pursue it.

By understanding the specific requirements, seeking guidance, and building strong professional networks, IENs can successfully navigate the process and contribute to the global healthcare workforce. As healthcare systems continue to evolve, it is crucial to recognize the valuable contributions of IENs and work towards creating a more supportive and inclusive environment for these skilled professionals.

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