HAMILTON HEALTH SCIENCES, INTERNATIONALLY EDUCATED … · Sciences (HHS) (April 1, 2015 to November 26, 2015) John Parker, Director of Inter-professional Development, Clinical Practice

HAMILTON HEALTH SCIENCES,

INTERNATIONALLY EDUCATED NURSE (IEN)

AND ENGLISH AS A SECOND LANGUAGE (ESL)

NURSE INTEGRATION PROJECT

2015-2016

SERIES REPORT #43 • MAY 2016

INTERIM REPORT

Andrea Baumann, RN, PhD

Jennifer Blythe, PhD

2

Hamilton Health Sciences, Internationally Educated Nurse (IEN) and English as a

Second Language (ESL) Nurse Integration Project

Series Report #43

Andrea Baumann, RN, PhD, Associate Vice President, Global Health, Faculty of Health Sciences and Scientific Director, Nursing Health Services Research Unit (McMaster University Site)

Jennifer Blythe, PhD, Senior Scientist, Nursing Health Services Research Unit

(McMaster University Site)

Contact Andrea Baumann Phone (905) 525-9140, ext. 22581 E-mail [email protected] Website www.nhsru.com

Funded by:

3

Community Collaboration for IEN and ESL Nurse Employment: Bridging the Gap

A Descriptive Evaluation

Interim Report 2015-2016

Report Prepared By

Dr. Andrea Baumann, Associate Vice-President, International Health, Faculty of Health

Sciences and Scientific Director, Nursing Health Services Research Unit, McMaster

University, Hamilton, Ontario

Dr. Jennifer Blythe, Senior Scientist, Nursing Health Services Research Unit, McMaster

University, Hamilton, Ontario

4

PROJECT TEAM

Principal Investigators

Dr. Ruth Lee, Chief of Nursing Practice, Inter-professional Practice, Hamilton Health

Sciences (HHS) (April 1, 2015 to November 26, 2015)

John Parker, Director of Inter-professional Development, Clinical Practice & Education and

Chief of Inter-professional Practice & Education Services, HHS (as of November 27, 2015)

Dr. Andrea Baumann, Associate Vice-President, International Health, Faculty of Health

Sciences and Scientific Director, Nursing Health Services Research Unit (NHSRU),

McMaster University

Co-Investigators

Kirsten Krull, Vice-President, Quality and Performance and Chief Nursing Executive, Inter-

professional Practice, HHS

Donna Rawlin, Associate Dean, Collaborative Nursing & Health Sciences, Mohawk College

Jennifer Blythe, Senior Researcher, NHSRU, McMaster University

Daniela Beckford, RN, Project Manager, IEN/ESL Nurse Integration Project, Inter-


Zubeida Ramji, Executive Director, CARE Centre for Internationally Educated Nurses (April

1, 2015 to August 27, 2015)

Joanne Roth, Interim Executive Director, CARE Centre for Internationally Educated Nurses

(as of August 28, 2015)

Patricia Wright, Manager Training & Community Engagement, Hamilton Centre for Civic

Inclusion (HCCI)

Michelle Barnard, Clinical Integrator, Education & Development Clinician, St. Peter's

Hospital, HHS

Livia Jakabne, Clinical Integrator, RN, St. Peter's Hospital, HHS

Project Manager

Daniela Beckford, RN, Inter-professional Practice, HHS (April 1, 2015 to August 24, 2015;

resumed position February1, 2016)

Livia Jakabne, Clinical Integrator, RN, St. Peter's Hospital, HHS (September 3, 2015 to

January 29, 2016)

Administrative Support

Janice Collins, Inter-professional Practice, HHS

5

ADVISORY COMMITTEE MEMBERS - STANDING MEMBERS FOR QUORUM

Michelle Barnard, Clinical Integrator, Education & Development Clinician, St. Peter's

Hospital, HHS

Andrea Baumann (ex officio), Associate Vice-President, International Health, Faculty of

Health Sciences and Scientific Director, NHSRU, McMaster University

Daniela Beckford, RN, Project Manager, IEN/ESL Nurse Integration Project, Inter-



Janice Collins, Administrative Assistant, Inter-professional Practice, HHS

Peter Cornakovic, Financial Controller, Decision Support Services, HHS

Ronette De Mesa, Clinical Integrator, RPN, HHS

Harwinder Grewal, Clinical Integrator, RPN, HHS

Jane Hastie, Human Rights and Diversity Specialist, HHS

Bahar Ighani, Clinical Integrator, RN, HHS

Livia Jakabne, Clinical Integrator, RN, St. Peter's Hospital, HHS

Miles Komlen, Chair of the Board, Hamilton Centre for Civic Inclusion (HCCI) and Director

of Human Rights & Equity Services, McMaster University

Kirsten Krull (ex officio), Vice-President, Quality and Performance and Chief Nursing

Executive, Inter-professional Practice, HHS

Andy Le, Clinical Integrator, RN, HHS

Ruth Lee, Project Lead and Project Evaluation Lead, Chief of Nursing Practice, Inter-

professional Practice, HHS (April 1, 2015 to November 26, 2015)

Lynzy Maskell, Human Resources & Organizational Development Consultant, Talent

Solutions, HHS

Nick Millar, Clinical Integrator, RN, Charge Nurse, Hamilton General Hospital, 5S, HHS

Jaime Morison, Human Resources Coordinator, Talent Solutions, HHS

Dave Murphy (ex officio), President, CUPE Local 7800

Dianne Norman, Clinical Practice & Education Manager, HHS

6

John Parker, Project Lead and Project Evaluation Lead, Director of Inter-professional

Development, Clinical Practice & Education and Chief of Inter-professional Practice &

Education Services, HHS (as of November 27, 2015)

Zubeida Ramji, Executive Director, CARE Centre for Internationally Educated Nurses (April

1, 2015 to August 27, 2015)

Donna Rawlin, Associate Dean, Collaborative Nursing & Health Sciences, Mohawk College

Joanne Roth, Interim Executive Director, CARE Centre for Internationally Educated Nurses

(as of August 28, 2015)

John Shao, Participant, Juravinski Hospital, E3, HHS

Cindy Smith, Clinical Integrator, RPN, Developmental Pediatrics, Rehabilitation Services,

Chedoke, HHS

Cherilyn van Berkel, Senior Advisor, Community Connection and Transitions Office, Quality

and Performance Portfolio, HHS

Nicole Wang, Clinical Integrator, RPN, HHS

Maureen Williamson, Advisory and President, Ontario Nurses' Association

Pat Wright, Liaison, HCCI

COMMUNITY PARTNERS

Mohawk College Institute for Applied Health Sciences, Bridging for Internationally Educated

Nurses (BIEN) Program

CARE Centre for Internationally Educated Nurses

HCCI

NHSRU, McMaster University

INDEPENDENT EVALUATOR


SPONSOR/FUNDING AGENCIES

Ministry of Citizenship, Immigration and International Trade (MCIIT)

7

TABLE OF CONTENTS

EXECUTIVE SUMMARY ........................................................................................................ 16

Introduction ................................................................................................................................16

Objectives ...................................................................................................................................16

MCIIT Targets for 2015-2017....................................................................................................17

Interventions ...............................................................................................................................17

Intervention Evaluation Results .................................................................................................18

Overall Results and Conclusions................................................................................................18

INTRODUCTION....................................................................................................................... 19

Background ................................................................................................................................19

Recent Developments Relevant to the Project ...........................................................................19

Changes to Language Requirements ..................................................................................19

Shortening Registration Times ..........................................................................................19

IEN Competency Assessment Program (IENCAP) ...........................................................20

PROJECT DESCRIPTION ....................................................................................................... 20

Purpose .......................................................................................................................................20

Objectives ...................................................................................................................................20

MCIIT Targets 2015-2017 .........................................................................................................21

Project Charter............................................................................................................................21

Study Site ...................................................................................................................................21

Project Partners ..........................................................................................................................22

External Stakeholders .................................................................................................................23

8

Community Collaboration Employment Model (CCEM) ..........................................................23

Project Team ..............................................................................................................................23

METHODS .................................................................................................................................. 24

Participant Sample......................................................................................................................24

Participant Recruitment Strategy ...............................................................................................24

Clinical Integrator Sample .........................................................................................................25

Clinical Integrator Recruitment Strategy ...................................................................................25

Participants and Clinical Integrators: Description and Tracking ...............................................25

Baseline Testing: Institutional CELBAN (I-CELBAN) ............................................................26

INTERVENTIONS ..................................................................................................................... 26

Mentorship Workshops ..............................................................................................................29

NEW DEVELOPMENTS IMPLEMENTED ........................................................................... 29

HCCI Online Webinars ..............................................................................................................29

EVALUATION ........................................................................................................................... 30

Interventions ...............................................................................................................................30

Overall Project............................................................................................................................30

SAMPLE DESCRIPTION ......................................................................................................... 30

Clinical Integrators .....................................................................................................................35

RESULTS .................................................................................................................................... 39

Baseline Testing: Institutional CELBAN (I-CELBAN) ............................................................39

Care Centre for Internationally Educated Nurses: Language Communication for Nurses,

Level 3 - Advanced (LCN3).......................................................................................................40

9

Participants' Self-Assessment of Nursing Communication Skills .....................................41

Course Evaluation ..............................................................................................................42

Participants' Feedback ........................................................................................................43

Instructor's Progress Report ...............................................................................................44

Instructor's Comments .......................................................................................................45

BIEN Learning Resource Centre Simulation Laboratory ..........................................................45

HCCI Cultural Awareness Training Workshop .........................................................................46

Participants' Comments ......................................................................................................48

HHS Job Coaching/Mock Interview Preparation .......................................................................48

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet ..................................49

HHS SharePoint Website ...........................................................................................................50

HHS N3 Networking Program: Nurses Nurturing Nurses .........................................................50

HHS Professional Workplace Experience/Integration ...............................................................51

Job Shadowing ...................................................................................................................51

Second Day of General Nursing Orientation .....................................................................52

Career Progression: Lunch and Learn Sessions .................................................................53

PROJECT EVALUATION: OVERALL RESULTS AND CONCLUSIONS ...................... 56

MCIIT Numeric Targets 2015-2017 ..........................................................................................57

Job Status of Participants Who Completed Four Interventions .................................................57

Job Status of All Participants .....................................................................................................57

Preparedness ...............................................................................................................................59

10

Project Exit .................................................................................................................................59

New Initiatives ...........................................................................................................................59

Success Stories ...........................................................................................................................59

Project Sustainability..................................................................................................................59

Workforce Integration Strategies .......................................................................................59

Communication Among Stakeholders ...............................................................................60

Engaging the Community ..................................................................................................60

Communicating Within the Region ...................................................................................60

Dissemination Strategies ....................................................................................................60

Membership of Relevant Committees ...............................................................................60

Future Strategies .........................................................................................................................60

RECOMMENDATIONS ............................................................................................................ 61

APPENDIX A. INFORMATION AND CONSENT FORMS ................................................. 62

APPENDIX B. EVALUATION TOOLS INDEX .................................................................... 65

APPENDIX C. PROJECT DISSEMINATION AND PROMOTION 2015-2016 ................. 67

APPENDIX D. SUCCESS STORIES ........................................................................................ 68

11

FIGURES

Figure 1. CCEM: Bridging the Gap for IENs/ESL Nurses ...................................................... 23

Figure 2. Project Team ............................................................................................................. 24

12

TABLES

Table 1. Participant Sample Composition ............................................................................... 30

Table 2. Participant Entry to Project ........................................................................................ 30

Table 3. Participant Project Referrals ...................................................................................... 30

Table 4. Gender of Participants ............................................................................................... 31

Table 5. Age of Participants..................................................................................................... 31

Table 6. Participants' Highest Level of Nursing Education ..................................................... 31

Table 7. Participants' Country of Nursing Education .............................................................. 31

Table 8. Participants' Country of Highest Level of Non-Nursing Education .......................... 32

Table 9. Participants' Highest Level of Non-Nursing Education in Country of Origin ........... 32

Table 10. Participants' Immigration Class ............................................................................... 32

Table 11. Participants' Immigration Status .............................................................................. 33

Table 12. Participants' Years of Migration .............................................................................. 33

Table 13. Participants' Years of Nursing Experience Prior to Migration ................................ 33

Table 14. Participants' Years of Non-Nursing Practice in Canada .......................................... 33

Table 15. Participants' Length of Nursing Practice in Canada ................................................ 34

Table 16. Participants' Employment Locations Outside Canada ............................................. 34

Table 17. Participants' Examination Status at Project End ...................................................... 34

Table 18. Participants' Registration Status at Project End ....................................................... 34

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Table 19. Clinical Integrator Entry to Project .......................................................................... 35

Table 20. Age of Clinical Integrators ...................................................................................... 35

Table 21. Clinical Integrator Categories .................................................................................. 36

Table 22. Clinical Integrator Project Referrals ........................................................................ 36

Table 23. Clinical Integrators' Country of Nursing Education ................................................ 36

Table 24. Clinical Integrators' Highest Level of Nursing Education ....................................... 36

Table 25. Clinical Integrators' Country of Highest Level of Non-Nursing Education ............ 36

Table 26. Clinical Integrators' Migration Status ...................................................................... 37

Table 27. Clinical Integrators' Immigration Status .................................................................. 37

Table 28. Clinical Integrators' Years of Migration .................................................................. 37

Table 29. Clinical Integrators' Years of Nursing Experience Prior to Migration .................... 37

Table 30. Clinical Integrators' Years of Non-Nursing Experience in Canada ......................... 38

Table 31. Clinical Integrators' Length of Nursing Practice in Canada .................................... 38

Table 32. Clinical Integrators' Place of Employment .............................................................. 38

Table 33. Clinical Integrators' Employment Status ................................................................. 38

Table 34. Baseline Scores ........................................................................................................ 39

Table 35. Other Language Tests .............................................................................................. 39

Table 36. I-CELBAN 2015-2016 ............................................................................................ 40

Table 37. LCN3 Registration ................................................................................................... 40

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Table 38. LCN3 Participants' Employment Status .................................................................. 40

Table 39. LCN3 Attendance and Certificates .......................................................................... 41

Table 40. LCN3 Summary of Completed Assessments........................................................... 41

Table 41. LCN3 Course Evaluation ......................................................................................... 42

Table 42. Assessment of LCN3 Participants' Progress ............................................................ 44

Table 43. BIEN Learning Resource Centre Introductory Session Attendance ........................ 45

Table 44. BIEN Simulation Laboratory Sessions: Participants' Confidence Scores ............... 46

Table 45. HCCI Workshop Evaluation .................................................................................... 46

Table 46. HCCI Post-Workshop Questionnaire....................................................................... 47

Table 47. HCCI Post-Workshop Questionnaire: Three Months .............................................. 47

Table 48. Number of HHS Interviews by Month .................................................................... 48

Table 49. Pre- and Post-Intervention Confidence Ratings for HHS Interviews ...................... 48

Table 50. Qualitative Assessment of HHS Interviews............................................................. 49

Table 51. Evaluation of HHS Interviews ................................................................................. 49

Table 52. HHS Post-Interview Survey: Support and Job Offers ............................................. 49

Table 53. Pre- and Post-Intervention Confidence Ratings for HHS/CNO .............................. 50

Table 54. N3 Participant and Clinical Integrator Dyads .......................................................... 50

Table 55. Satisfaction with Dyads ........................................................................................... 50

Table 56. Job Shadowing Attendance ...................................................................................... 51

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Table 57. Job Shadowing Evaluation....................................................................................... 52

Table 58. Second Day of General Nursing Orientation ........................................................... 52

Table 59. Second Day of General Nursing Orientation Evaluation ......................................... 53

Table 60. Evaluated Lunch and Learn Sessions ...................................................................... 54

Table 61. Non-Evaluated Lunch and Learn Sessions .............................................................. 56

Table 62. Participants' Employment Positions ........................................................................ 57

Table 63. Participants' Employment Status ............................................................................. 57

Table 64. Participants' Commensurate Employment at Zero to Twelve Months .................... 58

Table 65. Participants' Location of Employment at Zero to Twelve Months .......................... 58

Table 66. Participants' Employment Status at HHS at Zero to Twelve Months ...................... 58

Table 67. Participants' Employment Status at Non-HHS Organizations ................................. 58

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EXECUTIVE SUMMARY

INTRODUCTION

The Internationally Educated Nurse (IEN) and English as a Second Language (ESL) Nurse

Integration Project helps registered nurses (RNs) and registered practical nurses (RPNs)

educated abroad or in Canada become fully integrated into Hamilton Health Sciences (HHS)

and other healthcare organizations. It supports IENs/ESL nurses from pre-hire through

orientation and clinical integration and includes clinical assessment, problem solving, clinical

skills development, team relationships, professionalism and managing conflict in a hospital

setting.

It builds on an IEN demonstration project funded by the Ministry of Health and Long-Term

Care (MOHLTC) that informed clinical managers (CMs) responsible for hiring about

resources available to IENs and how to access them. The project period is from April 1, 2015

to August 31, 2017. This report focuses on the first year of the project. Participants include

nurses from the Mohawk College Bridging for Internationally Educated Nurses (BIEN)

program and ESL nurses from mainstream nursing programs who are currently employed at

HHS. The project uses a Community Collaboration Employment Model (CCEM) and

involves various partners:

CARE Centre for Internationally Educated Nurses: A non-profit agency providing services to

IENs in Ontario.

Mohawk College Institute for Applied Health Sciences: Offers the BIEN program to help

IENs meet the criteria of the College of Nurses of Ontario (CNO) for registration as an RN or

RPN.

Hamilton Centre for Civic Inclusion (HCCI): A community-based organization committed to

creating a united community that respects diversity, practises equity and speaks out against

discrimination.

McMaster University, Nursing Health Services Research Unit (NHSRU): Conducts research

on nursing human resources.

It also receives support from the following:

Professions North, Laurentian University, Sudbury, ON

Partnering with Employers: Increasing IEN Employment in Healthcare Organizations

Project Advisory Committee, NHSRU

IEN stakeholder network

OBJECTIVES

The project objectives as described in the Ministry of Citizenship and Immigration (MCIIT)

contract with HHS are as follows:

Revise/adapt, deliver and evaluate between April 1st 2015 and August 17th 2017 a project

to support the successful workplace integration and retention of 60 IEN and ESL nurses

inside and outside of Hamilton Health Sciences (HHS).

Review/revise/adapt a continuum of workplace integration tools and processes for IEN

and ESL nurses, particularly new hires working in a hospital setting.

17

Continue to build the informal mentorship and coaching capacity of up to 30 more

frontline registered nurses, registered practical nurses, clinical educators, clinical

managers and inter-professional practice health care professionals as clinical integrators

to provide informal mentorship and coaching for IEN and ESL nurses.

Provide employment opportunities for up to 60 IEN and ESL nurses inside and outside of

HHS.

Evaluate program components to include workplace culture and communication

workshops and modified BIEN tools for workplace integration.

MCIIT TARGETS FOR 2015-2017

Nurses assessed for eligibility: 90

Participants accessing the program (minimum of two interventions): 70

Participants completing a significant component of the project (minimum of four

interventions): 60

Participants who become/remain employed as nurses: 60

Clinical integrators (CIs) completing training: 30

INTERVENTIONS

The interventions1 listed below are being implemented during the 2015-2017 funding period:

CARE Centre for Internationally Educated Nurses Language Communication for Nurses,

Level 3 - Advanced (LCN3): Course provides advanced communication strategies for

working/workplace-ready IENs/ESL nurses.

BIEN Learning Resource Centre Simulation Laboratory: Participants have the opportunity to

practise two nursing skills identified during their self-assessment learning plan.

HHS Job Coaching/Mock Interview Preparation: Sessions conducted by the project manager

(PM) help prepare participants for job interviews.

HCCI Cultural Competency Awareness Workshop: This three-hour workshop for IENs/ESL

nurses, CIs and CMs or their delegates was created with input from HHS. An online version

has been developed.

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet: Participants are

asked to review all materials incorporated in the learning plan within a year of project

enrolment.

HHS SharePoint Website: This is a resource hub for IENs/ESL nurses, CIs, CMs and other

internal stakeholders. The site provides updates on interventions, activities and resources for

IENs/ESL nurses. LinkedIn is used as a network for external partners.

HHS N3 Networking Program: The Nurses Nurturing Nurses program, written by the

Academy of Medical-Surgical Nurses in the United States, is a loosely structured supportive

arrangement for sharing between two nurse colleagues: a CI and an IEN/ESL nurse. It is

based on the principles of adult learning and focuses on the needs of the individual being

nurtured.

1 For additional information on the interventions, see http://www.hamiltonhealthsciences.ca/body.cfm?id=3203.

http://www.hamiltonhealthsciences.ca/body.cfm?id=3203

18

HHS Professional Workplace Experience/Integration: Focuses on job shadowing, nursing

orientation and career progression.

INTERVENTION EVALUATION RESULTS

CARE Centre for Internationally Educated Nurses LCN3 Course:

21 participants registered for the January 15, 2015 to May 8, 2015 course

14 participants registered for the April 30, 2015 to August 20, 2015 course

16 participants registered for August 15, 2015 to November 27, 2015 course

Participants reported a high level of satisfaction and the instructor reported significant

participant improvement.

BIEN Learning Resource Centre Simulation Laboratory: Twenty-two participants attended

the lab sessions offered throughout 2015-2016. Pre-intervention questionnaires revealed a

relatively high level of confidence. A moderate increase in confidence was shown in the post-

intervention questionnaires. All participants were eligible to attend the simulation laboratory

and introductory sessions were provided.

HHS Job Coaching/Mock Interview Preparation: Sixty participants took part in this

intervention. They rated it highly and reported that their knowledge about the interview

process had increased and their self-confidence had improved.

HCCI Cultural Competency Awareness Workshop: Thirteen IENs and one CM/delegate

attended a three-hour workshop June 25, 2015. Participants' evaluations were favourable.

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet: Pre- and post-

intervention surveys indicated that confidence in locating policies and procedures on the

intranet increased significantly. Participants claimed a much higher level of confidence in the

post-questionnaire than in the pre-questionnaire. Most described themselves as very

confident.

HHS N3 Networking Program: Eleven partnerships were set up with nine CIs working with

11 participants. Participants and CIs were very satisfied with the partnerships.

HHS Professional Workplace Experience/Integration: Participants rated the activities highly

and noted their confidence and knowledge had increased.

OVERALL RESULTS AND CONCLUSIONS

As indicated below, all numeric targets were on track or were exceeded:



Participants accessing the program (minimum of four interventions): 87


CIs completing training: 19

All interventions were implemented and the CCEM continued to be successful. The model

benefited the IENs/ESL nurses, increased the partners' awareness of their diverse roles and

provided opportunities for collaboration.

19

INTRODUCTION

BACKGROUND

The Internationally Educated Nurse (IEN) and English as a Second Language (ESL) Nurse

Integration Project helps registered nurses (RNs) and registered practical nurses (RPNs)

educated abroad or in Canada become fully integrated into Hamilton Health Sciences (HHS)

and other healthcare organizations. It supports IENs/ESL nurses from pre-hire through

orientation and clinical integration and includes clinical assessment, problem solving, clinical

skills development, team relationships, professionalism and managing conflict in a hospital

setting.

It uses a Community Collaboration Employment Model (CCEM) and builds on an IEN

demonstration project funded by the Ministry of Health and Long-Term Care (MOHLTC),

which informed clinical managers (CMs) responsible for hiring about resources available to

IENs and how to access them. The project period is from April 1, 2015 to August 31, 2017.

Participants include nurses from the Mohawk College Bridging for Internationally Educated

(BIEN) program and ESL nurses from mainstream nursing programs who are currently

employed at HHS. This report focuses on the first year of the project.

RECENT DEVELOPMENTS RELEVANT TO THE PROJECT

Changes to Language Requirements

The College of Nurses of Ontario (CNO) Annual Report 2014 noted that significant changes

have been made to the language requirements for IENs. Prior to 2014, applicants could

demonstrate proficiency in English or French via the following:

Completing an accepted language test such as the Canadian English Language

Benchmarks Assessment for Nurses (CELBAN), the International English Language

Testing System (IELTS) or Test d' Évaluation de Français (TEF)

Graduating from a nursing program taught in English or French

Practising in a predominantly English or French workplace

In 2014, several new requirements were introduced:

Completion of additional nursing or non-nursing courses (e.g., a degree in social work)

taught in English or French

Experience teaching nursing or other health profession courses in English or French at the

college or university level

Other work or volunteer experience that provides evidence of language proficiency

Shortening Registration Times

The CNO Annual Report 2014 acknowledged that the application process took longer for

some applicants, e.g., when additional information was required from schools, employers or

overseas nursing regulators. The College shortened "the time to review the required

documents and qualifications between receiving an application and notifying an applicant of

eligibility to take the national exam from 115 days (in 2008) to 74 days (in 2014)."2 The

2 CNO Annual Report 2014, p. 7 (http://www.cno.org/globalassets/1-whatiscno/annualreport/2014/pdf/cno-

2014-annual-report-print-english.pdf)

http://www.cno.org/globalassets/1-whatiscno/annualreport/2014/pdf/cno-2014-annual-report-print-english.pdf

http://www.cno.org/globalassets/1-whatiscno/annualreport/2014/pdf/cno-2014-annual-report-print-english.pdf

20

CNO also revised its information for international applicants to increase understanding and

relevance.3

IEN Competency Assessment Program (IENCAP)

Candidates with diverse overseas qualifications need to be screened for eligibility to write the

National Council Licensure Examination for Registered Nurses (NCLEX-RN). Previously

applicants wrote the Canadian Registered Nursing Examination (CRNE). Launched in 2013,

IENCAP helps assess the equivalency of international qualifications to Canadian nursing

programs. The Touchstone Institute collaborated with the CNO to develop IENCAP.

In 2014-2015, 1002 RN candidates took the test.4 Candidates may attempt the test only once,

so it is important to ensure readiness. In addition to nursing skills, IENCAP assesses client

interactions, ethics, professionalism, language proficiency and comprehension. Preparation

courses for the IENCAP are available through HealthForceOntario. A communication skills

workshop is offered by the CARE Centre for Internationally Educated Nurses. Only

candidates who have been referred by the CNO may register for the exam. The fee for the

IENCAP is CAD 400.5

PROJECT DESCRIPTION

PURPOSE

The aim of the project is to ensure that RNs and RPNs educated in Canada or abroad are fully

integrated into the workforce of HHS and other healthcare facilities in Ontario. The project

targeted IENs with English as a second language, IENs with English as a first language and

ESL nurses who graduated from Canadian universities and colleges. It was designed to

remove workplace barriers to entry and create greater employment equity. The project

provides IENs/ESL nurses with various clinical and communication skills and focuses on

clinical assessment, problem solving, team relationships, professionalism, workplace

experience and managing conflict in a hospital setting.

OBJECTIVES

The project objectives as described in the Ministry of Citizenship and Immigration (MCIIT)

contract with HHS are as follows:

Revise/adapt, deliver and evaluate between April 1st 2015 and August 17th 2017 a project

to support the successful workplace integration and retention of 60 IEN and ESL nurses

inside and outside of Hamilton Health Sciences (HHS).

Review/revise/adapt a continuum of workplace integration tools and processes for IEN

and ESL nurses, particularly new hires working in a hospital setting.

Continue to build the informal mentorship and coaching capacity of up to 30 more

frontline registered nurses, registered practical nurses, clinical educators, clinical

managers and inter-professional practice health care professionals as clinical integrators

to provide informal mentorship and coaching for IEN and ESL nurses.

Provide employment opportunities for up to 60 IEN and ESL nurses inside and outside of

HHS.

3 http://www.cno.org/en/learn-about-standards-guidelines/magazines-newsletters/the-standard/the-standard-

june-2015 4 http://www.touchstoneinstitute.ca/Touchstone/media/Annual-Reports/AnnualReport_2014-15.pdf 5 http://www.touchstoneinstitute.ca/competency-assessment/iencap.aspx

http://www.healthforceontario.ca/en/M4/Internationally_Educated_Health_Professionals/Sessions/Nurses_IENCAP

http://www.healthforceontario.ca/en/M4/Internationally_Educated_Health_Professionals/Sessions/Nurses_IENCAP

http://www.cno.org/en/learn-about-standards-guidelines/magazines-newsletters/the-standard/the-standard-june-2015

http://www.cno.org/en/learn-about-standards-guidelines/magazines-newsletters/the-standard/the-standard-june-2015

http://www.touchstoneinstitute.ca/Touchstone/media/Annual-Reports/AnnualReport_2014-15.pdf

http://www.touchstoneinstitute.ca/competency-assessment/iencap.aspx

21

Evaluate program components to include workplace culture and communication

workshops and modified BIEN tools for workplace integration.

MCIIT TARGETS 2015-2017



Participants completing a significant component of the project (minimum of four

interventions): 60


Clinical integrators (CIs) completing training: 30

PROJECT CHARTER

A project charter was developed and approved by the IEN/ESL Project Advisory Committee

(PAC). Implementation involved an eight-step process:

1. Project initiation: HHS defined the project goal, scope, parameters and infrastructure

needed for appropriate funding.

2. Identification of educational institution: HHS invited the Mohawk College BIEN program

to be a project partner.

3. Identification of community organizations: Partners provided organization-specific

expertise to meet project goals. HHS invited CARE and the Hamilton Centre for Civic

Inclusion (HCCI) to be community partners. CARE has expertise in preparing IENs for

registration and entry to the Canadian workplace, while HCCI has expertise in cultural

competence and equity.

4. Identification of evaluator: HHS invited the Nursing Health Services Research Unit

(NHSRU) at McMaster University to be an evaluator and assess the effectiveness of each

intervention and the overall project.

5. Formation of an interagency Advisory Committee: Consisted of up to 14 members

(excluding ex officio members) representing the broad multicultural and diverse nature of

HHS and the community. Meetings were held semi-annually. The purpose was to provide

strategic direction and leadership to champion the development, adaptation, delivery and

evaluation of the project and facilitate integration of IENs/ESL nurses into HHS and the

community.

6. Refinement of project interventions: The team confirmed intake criteria and each partner's

role in the project.

7. Development of an evaluation plan: Employer and project partners identified the

evaluation tools to be used. The independent evaluator and the team collaborated in the

development of the research plan.

8. Implementation of the project: To meet the participants' needs, the team collaborated with

partners and HHS stakeholders to make corrections and modify the interventions.

STUDY SITE

The project was implemented at HHS, which offers a range of acute and specialized services

to meet healthcare needs from preconception through to aging adults. The internationally

renowned hospitals and cancer centre within the HHS network advance excellence in

healthcare through research and education.

Hamilton General Hospital

This regional cardiac centre specializes in cardiac and vascular surgery and is home to the

22

state-of-the-art Heart Investigation Unit. With rooftop heliports, Hamilton General is the

regional centre for trauma, burns, neurosurgery and stroke care. The Regional Rehabilitation

Centre and the David Braley Cardiac, Vascular and Stroke Research Institute are located on

campus.

Chedoke Hospital

This non-acute care site hosts specialty outpatient programs and services, including autism,

developmental pediatrics and rehabilitation and mental health. Many of the pediatric-related

services are offered through McMaster Children's Hospital.

Juravinski Hospital

This full service organization is an established leader in cancer care and orthopedics,

specifically joint replacement. It also provides inpatient acute and palliative care and

diagnostic laboratory and imaging services to support the needs of cancer patients throughout

the region.

Juravinski Cancer Centre

The Juravinski Cancer Centre works with hospitals and community partners to provide timely

access to expert care and treatment for cancer patients living in Hamilton, Niagara,

Haldimand and Brant. It provides chemotherapy and radiation treatment and various other

services such as genetic and psychological counselling, nutrition, education and supportive

care. Through its affiliation with McMaster University, the centre is involved in laboratory

research and clinical trials to discover and apply better treatments for cancer.

McMaster Children's Hospital

One of Canada's leading pediatric healthcare facilities and the regional referral centre for

children who are seriously ill, injured or require specialized services in south central Ontario.

Specialized services include 40 pediatric clinics, the province's largest neonatal intensive care

unit and the only pediatric trauma centre in the region.

McMaster University Medical Centre

This centre for adult services, including women's reproductive health, is also the regional

centre for high-risk obstetrics and provides ambulatory clinics and same-day surgery. The

centre has an innovative digestive diseases program, which works in partnership with

McMaster University and conducts more research than any other program in Canada. The

centre is undergoing redevelopment to enhance and support the range of specialized services

it offers.

St. Peter's Hospital

This complex care hospital provides inpatient, outpatient and community-based programs and

services focusing on dementia, aging, palliative care and rehabilitation.

West Lincoln Memorial Hospital

This large community hospital serves the towns of Grimsby, Lincoln and West Lincoln. It

offers various healthcare services, including surgical/medical, obstetrics, complex continuing

care, intensive care and emergency services.

PROJECT PARTNERS

The integration of IEN/ESL nurses into the workplace depends on various stakeholders,

including employers, educational institutions and community organizations. Below is a list of

project partners:

23

CARE Centre for Internationally Educated Nurses: This non-profit agency provides services

to IENs in Ontario and is responsible for sector-specific nurse training in workplace

communication for IENs.

Mohawk College Institute for Applied Health Sciences: Offers the BIEN program to help

IENs meet the CNO registration criteria for RNs and RPNs. Responsibilities include the

assessment and preparation of IENs for employment through the Institutional CELBAN (I-

CELBAN) nursing language assessment tool, skills labs and development of clinical

assessment tools with HHS.

HCCI: This community-based organization is committed to creating a united community that

respects diversity, practises equity and speaks out against discrimination. The centre is

responsible for cultural inclusion and diversity training for project participants and HHS staff.

NHSRU, McMaster University: Conducts research on nursing human resources. As co-chair

of the Project Research Committee, the NHSRU was responsible for overall project

evaluation.

EXTERNAL STAKEHOLDERS

Professions North, Laurentian University, Sudbury, ON


PAC, NHSRU

IEN stakeholder network

COMMUNITY COLLABORATION EMPLOYMENT MODEL (CCEM)

The research team developed the model to engage stakeholders and guide the project (see

Figure 1).

Figure 1. CCEM: Bridging the Gap for IENs/ESL Nurses

PROJECT TEAM

As shown in Figure 2, HHS worked with community organizations and educational

institutions to implement the model.

24

Figure 2. Project Team

METHODS

Participants and CIs were recruited from April 1, 2015 to December 31, 2016. The project

was approved by the Hamilton Integrated Research Ethics Board (HiREB), a jointly

constituted board of St. Joseph's Healthcare Hamilton, HHS and McMaster University's

Faculty of Health Sciences. Marketing and promotion were carried out externally and

internally at HHS. The marketing strategy developed in 2009-2012 to raise awareness of the

project and encourage recruitment remained in place.

PARTICIPANT SAMPLE

To be eligible, participants had to meet the following criteria:

IEN/ESL nurse registered with the CNO

Qualified to write the Canadian RN or RPN entrance exam

Recent immigrant living in Ontario

Have English as a second language

Canadian Language Benchmarks6 of 7

IEN/ESL nursing students in clinical placements

ESL students with student visa hired by HHS as new grads

IENs/ESL nurses hired by HHS on temporary work permits

PARTICIPANT RECRUITMENT STRATEGY

Potential participants were selected from phone inquiries and referrals by CMs, CIs and ECs

at HHS, BIEN, CARE, HealthForceOntario website, SharePoint website and non-HHS

6 This "standard is a descriptive scale of language ability in English as a Second Language (ESL) written as 12

benchmarks or reference points along a continuum from basic to advanced"

(http://www.language.ca/index.cfm?Voir=sections&Id=17355&M=4038&Repertoire_No=2137991327).

http://www.language.ca/index.cfm?Voir=sections&Id=17355&M=4038&Repertoire_No=2137991327

25

healthcare employers. Referrals were also made by project participants, Collège Boréal and

Ontario Works.

The PM and Human Resources (HR) collaborated to recruit IENs/ESL nurses who were not

employed at HHS. Inclusion criteria included ESL students with student visa hired by HHS

as new graduates and IENs/ESL nurses hired by HHS on temporary work permits. Current

and anticipated vacancies were identified by HR, while the PM monitored the Careers at

HHS website for new job postings, advised on their suitability and helped participants create

an applicant profile. The PM invited BIEN students assigned to clinical placements at HHS to

participate. The PM gave an overview of the project to BIEN and CARE students and

graduates and contacted BIEN, CARE and CMs and ECs at HHS to assist with recruitment.

CMs also approached the PM for support of their IEN/ESL employees.

On the second day of general nursing orientation, the PM provided an outline and printed

description of the project along with contact information. IENs/ESL nurses were encouraged

to enrol in the project to receive increased support throughout the employment integration

process. The information and consent forms are included in Appendix A.

CLINICAL INTEGRATOR SAMPLE

To be eligible, CIs had to be HHS RNs or RPNs working inside or outside HHS with at least

one year of nursing experience and an interest in supporting IENs/ESL nurses. The role of the

CIs included supporting and giving informal advice to a paired participant. The numeric

target for CIs completing training was set at 30 by the MCIIT.

CLINICAL INTEGRATOR RECRUITMENT STRATEGY

The PM contacted CIs and provided an overview of the project. A project charter and booklet

were developed and made available along with other information on the SharePoint website.

The PM gave a presentation about the project on the second day of general nursing

orientation. The project lead and PM also promoted the project in committees in which they

were members:


PAC

BIEN program PAC

HHS Nursing Advisory Council and Nursing Stewardship Committee

IEN/ESL PAC

PARTICIPANTS AND CLINICAL INTEGRATORS: DESCRIPTION AND TRACKING

Participants and CIs worked with the PM to complete personal profiles that included

demographic information and professional experience. Intake questionnaires were used to

create a participant profile. Participants were tracked on a number of variables, including

those collected for the MCIIT monthly numeric performance indicator reports and

employment status at enrolment and 3 months and 12 months post-enrolment. Other

evaluation data included information about participation in interventions and project

activities. An index of evaluation tools for all interventions is provided in Appendix B.

26

BASELINE TESTING: INSTITUTIONAL CELBAN (I-CELBAN)

CELBAN was designed to assess the English language proficiency of IENs applying for

registration. It "evaluates proficiency in listening, writing, reading and speaking and is

recognized as proof of language proficiency by all Canadian nursing regulators."7

I-CELBAN, which is based on CELBAN, helps educational institutions in Canada "assess the

English language proficiency of internationally-educated nurses who are applying for

licensure in the nursing profession in Canada."8 Participants are encouraged to take I-

CELBAN.

INTERVENTIONS

CARE Centre for Internationally Educated Nurses: Language Communication for Nurses,

Level 3 - Advanced (LCN3): Course provides advanced communication strategies for working

and work-ready IENs/ESL nurses. Topics include introducing, managing and ending a nurse-

client interview; intercultural communication skills; documentation and reporting;

communicating assertively with clients and colleagues; lay vs. technical vocabulary;

telephone communication skills; therapeutic communication skills; and health teaching.

BIEN Learning Resource Centre Simulation Laboratory: The centre houses a high-fidelity

simulation laboratory, clinical practice laboratory, activities of daily living apartment and a

nursing station. It also offers a wide selection of models, audiovisual resources and clinical

skills equipment for use by nursing students and faculty. Participants are supported in various

ways such as 1:1 student-faculty relationships and peer tutoring. In addition, RN

technologists help participants develop their clinical skills.

All participants were required to evaluate their level of confidence. They completed a pre-

intervention self-assessment checklist for medical/surgical and physical assessment skills at

the time of enrolment. All data were collected by the project team and forwarded to the

NHSRU.

Participants had the opportunity to practise two selected nursing skills identified in their self-

assessment learning plan. A pamphlet provided information for orientation and use of the

simulation lab. It was expected that within one year of participating in the project, the

IENs/ESL nurses would have improved confidence and increased ability in clinical skills

such as recording vital signs and the administration, measurement and recording of client

intake and output.

HCCI Cultural Competency Awareness Workshop: This three-hour workshop for IENs/ESL

nurses, CIs and CMs or their delegates was created with input from HHS. A cultural training

session was held June 25, 2015 at HHS. It focused on the exploration of communication

methods, including verbal and non-verbal, and facilitated understanding of how to avoid

cultural misunderstandings and improve intercultural communication. The workshop

included case scenarios based on cultural diversity awareness, which were drawn from the

participants' experiences, and it was evaluated afterwards.

The purpose of the workshop was to enable attendees to do the following:

Deepen their understanding of diversity and inclusion

7 http://www.celbancentre.ca/ 8 http://www.mohawkcollege.ca/studentservices/assessments/I-CELBAN_Testing_at_Mohawk_College.html

http://www.celbancentre.ca/

http://www.mohawkcollege.ca/studentservices/assessments/I-CELBAN_Testing_at_Mohawk_College.html

27

Review their personal frames of reference, biases and ladders of inference

Reflect on their style of communication and the effect their use of language might have

on communication

Understand culture and strategies for cross-cultural communication and conflict

resolution

Develop a framework for an inclusive approach to nursing, patient care and counselling

HHS Job Coaching/Mock Interview Preparation: The sessions conducted by the PM were

intended to prepare participants for job interviews. Before the interviews, participants'

résumés, cover letters and three references were reviewed. Participants received a pre-

interview preparation kit, which included a description of the interview structure. A pre-

intervention survey was used to assess the participants' level of confidence and their

interview skills. Job coaching/mock interview sessions took three to four hours. Participants

practised establishing rapport with the interviewer and responding to general and specific

nursing-related questions based on the RPN and RN medical/surgical job description

provided by HHS.

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet: Each participant

followed a customized learning plan that included the development of clinical and

communication skills. The plan was based on the CNO standards and guidelines. It was

intended to help participants understand and become familiar with the CNO Quality

Assurance (QA) program, healthcare legislation and organization of the healthcare system in

Canada. After recruitment, participants met with the PM and discussed the learning plan to be

followed.

The QA program is based on the principle that lifelong learning is essential to continuing

competence. It is mandatory for every nurse registered in the general, transitional and

extended classes in Ontario to participate in the program, which includes self-assessment

practice reflection, developing and maintaining a learning plan, practice assessment and peer

assessment. The customized learning plan used in the project included a review of the

following:

5 South Nursing Standards for Patient Safety During Transfer of Accountability

CNO Professional Nursing Standards and Guidelines and the learning modules from the

CNO website

Documentation - Transcription Process for Kardex

ED - Emergency Department Patient Safety and Restraints Policy

ENG - Lockout/Tagout Procedure

Entry to practice competencies for RNs and RPNs in Ontario from CNO website

HHS policies and procedures

HR - Confidentiality

HSW - Guidelines for Pregnant HHS Employees Working Directly or Indirectly with In-

Patients with Communicable Diseases

Infection Control - Clostridium Difficile Protocol

Infection Control - Management of Proven or Suspected Diseases - Guidelines

MAC - Consent, Withdrawal or Refusal of Consent for Treatment Policy

NUR - RPN Scope of Practice F5 Medicine Policy

PRI - Disclosure of Personal Health Information of Current In-Patients to Friends and

Family Guideline

Project interventions (participants were encouraged to take part in all seven interventions)

28

Transcription Process for Orders

Participants were asked to review all materials incorporated in the learning plan within a

year. There are spaces in the document to record the participants' scores for the CNO learning

modules quizzes. Participants were allowed a year to complete the quizzes.

HHS N3 Networking Program: The Nurses Nurturing Nurses (N3) program was written by

the Academy of Medical-Surgical Nurses in the United States. It is a loosely structured

supportive arrangement for sharing between two nurse colleagues: an experienced CI and an

IEN/ESL nurse. It is based on the principles of adult learning and focuses on the needs of the

individual being nurtured. To prepare for their role, CIs were invited to attend a Career

Development Day offered by the Oncology Nursing e-Mentorship Program at the Juravinski

Cancer Centre. This program is also offered online through the de Souza Institute.9

CIs received information pertinent to helping IENs/ESL nurses develop their careers. The

program provides participants with an opportunity to review their careers to date and learn

strategies to facilitate future career decisions. The participants' career plans might include

finding a mentor to help them achieve their goals. The PM used Lunch and Learns to

introduce the N3 program, project goals and the participants' learning plans and areas of

interest. Based on their needs, the PM matched participants with CIs to form a dyad. If a CI

and a matched participant were unable to attend the Lunch and Learn session, a separate

meeting was arranged with the PM. The PM coordinated the N3 program and oversaw

completion of the evaluation forms.

The HHS/CNO learning plan was the basis for the discussions between CIs and participants.

The objectives for each meeting reflected needs, concerns and issues identified by

participants. CIs and participants arranged to meet on a regular basis (preferably every two

weeks). It was envisaged that meetings might become less frequent after three months

provided both parties agreed, but monthly meetings were the requirement.

HHS Professional Workplace Experience/Integration: This intervention involved three

components:

1. Job shadowing - The PM met with the Manager of Clinical Practice and Education to

organize this process. It was decided to streamline participants waiting for placements

into specific areas (medical/surgical, rehab, child and youth and mental health) in which

CIs were working and involve them in this process. Participants summarized their job

shadowing experience in a one-page narrative.

2. Nursing orientation: Second day of general nursing orientation - This was held on the

third week of each month. Topics included vascular access therapy, senior friendly care,

Alaris® pumps, glucose meter and chest drainage.

3. Career progression resources included the following:

a. E-learning lab - Two computers are available to provide participants with access to

50 online learning courses, including infection control and reviews for fire,

WHMIS and emergency codes

CNO Learning Modules

computer keyboarding practice

clinical skills DVDs

E-documentation (MEDITECH clinical documentation)

9 www.desouzainstitute.com

../www.desouzainstitute.com

29

job applications

b. Academic writing and documentation

c. Charge nurse role education program

d. Career development/mentorship workshops (i.e., CPR, ACLS Perioperative, HELP,

E-learning

e. Nursing rounds (Lunch and Learns and IEN/ESL network)

MENTORSHIP WORKSHOPS

All CIs were encouraged to complete the workshops in-person at the Oncology Nursing e-

Mentorship Program or online through the de Souza Institute. The workshops helped prepare

CIs assist participants in the N3 program. The following were included:

The five phase mentoring relationship

Networking opportunities with nurses in different specialities across the country

Electronic resources to support mentorship

NEW DEVELOPMENTS IMPLEMENTED

HCCI ONLINE WEBINARS

Three cultural training webinars have been added to SharePoint website. The HCCI worked

with the project coordinator to develop the content and instructional material for IENs/ESL

nurses, staff, supervisors, managers and healthcare personnel at HSS. The webinars can be

accessed through the project homepage10 and include the following:

Webinar 1. Understanding Diversity in Healthcare

Objectives

Deepen understanding of diversity, equity and inclusion

Review personal frames of reference, biases and ladders of inference


Webinar 2. Exploring Context and Communication

Objectives

Explore how "context" impacts intercultural communication

Reflect upon communication style and how use of language may affect communications


Webinar 3. Conflict Resolution

Objectives

Develop an understanding of different cultures and cultural practices

Understand culture and strategies for cross-cultural communication and conflict

resolution


10 http://www.hamiltonhealthsciences.ca/body.cfm?id=3203

http://www.hamiltonhealthsciences.ca/body.cfm?id=3203

30

EVALUATION

INTERVENTIONS

The partners evaluated the interventions for which they were responsible. A mechanism was

developed and implemented to track participants engaged in the interventions and their

employment status at 3 and 12 months after completion.

OVERALL PROJECT

Project evaluation, approved by the MCIIT, was conducted by the NHSRU. The role of the

NHSRU was to integrate and discuss the implications of all evaluative data collected by the

partners and the research team and to collect and analyze additional data to assess the

partners' satisfaction with the project. The project design is experiential rather than

experimental. Ongoing evaluation leads to increased efficacy. In addition to this report,

results have been disseminated through various media (see Appendix C).

SAMPLE DESCRIPTION

During 2015-2016, 113 nurses were enrolled in the project, surpassing the target of 60. There

were no exits during the year (see Table 1). As shown in Table 2, participants entered the

project throughout the year.

Table 1. Participant Sample Composition

IEN &

ESL

IEN &

EFL*

ESL Total Exits Before

Project

Completion

Total Exits Totals at

Year End

102 6 5 113 0 0 113

* EFL = English as a foreign language.

Table 2. Participant Entry to Project

Month Number

April 35

May 3

June 0

July 29

August 20

September 11

October 7

November 7

December 1

Total 113

The majority of participants were referred to the project from the community or by HHS staff

(see Table 3). Most were women between 25 and 44 years of age (see Table 4 and Table 5).

Table 3. Participant Project Referrals

Reference Number

Academic 5

Community 24

HHS staff 14

Self-referral 23

31

Other 1

Colleague 0

Friend 5

Participant 39

HHS website 1

CARE Centre 1

Total 113

Table 4. Gender of Participants

Gender Number

Male 15

Female 98

Total 113

Table 5. Age of Participants

Age Range Number Age Range Number

18-24 3 45-49 7

25-29 38 50-54 4

30-34 20 55-59 2

35-39 22 Total 113

40-44 17

As shown in Table 6, Table 7 and Table 8, there were variances in the participants' level of

nursing education and country of nursing and non-nursing education. The majority reported

high school as their highest level of non-nursing education, although some had degrees or

diplomas (see Table 9).

Table 6. Participants' Highest Level of Nursing Education

Education Number

BScN 4 years 64

BScN 3 years 5

BScN 2 years 4

RN diploma 23

Post graduate 8

RPN diploma 8

Certificate of Nursing Leadership & Management 1

Total 113

Table 7. Participants' Country of Nursing Education

Country Number Country Number

Columbia 1 Kenya 1

Canada 5 Korea 1

China 3 Nigeria 4

Eritrea 1 Philippines 40

Germany 1 Mauritius 1

Ghana 1 South Africa 1

Iran 1 South Korea 1

Ivory Coast 1 Thailand 1

India 38 Uganda 1

Israel 1 Ukraine 1

32

Jamaica 1 United States 1

Jamaica and Canada 1 Zimbabwe 1

Jordan 4 Total 113

Table 8. Participants' Country of Highest Level of Non-Nursing Education

Country Number Country Number

Canada 1 Mauritius 1

China 3 Nigeria 5

Columbia 2 Poland 1

Eritrea 1 Philippines 40

Ethiopia 1 South Africa 1

Germany 1 South Korea 2

Ghana 1 Thailand 1

India 38 Uganda 1

Iran 1 Ukraine 2

Ivory Coast United States 2

Jamaica 2 Zimbabwe 1

Jordan 4 Total 113

Kenya 1

Table 9. Participants' Highest Level of Non-Nursing Education in Country of Origin

Level of Education Number

High school 90

University - Bachelors 7

University - MA, MBA, post

graduate

1

Medical doctor 3

Pre-degree 1

Pre-degree 1

Other - certificate/diploma 10

Total 113

The majority of participants reported their immigration class as independent professional or

family sponsored (see Table 10). Most were permanent residents or Canadian citizens who

had migrated after 2000 (see Table 11 and Table 12).

Table 10. Participants' Immigration Class

Immigration Class Number

Independent - professions/

Skilled trades

63

Family sponsored 32

Convention refugee 3

*Work permit 2

Live-in caregiver 6

Skilled worker program 1

Student visa 6

Total 113 *In process of obtaining permanent resident status.

33

Table 11. Participants' Immigration Status

*In process of obtaining permanent resident status.

Table 12. Participants' Years of Migration

Year Number

1980-1995 2

1996-2000 0

2001-2005 8

2006-2010 28

2011 16

2012 24

2013 23

2014 12

Total 113

The majority of participants who had practised prior to migration had between one and five

years of experience (see Table 13). However, since coming to Canada, most had not practised

for one to five years (see Table 14).

Table 13. Participants' Years of Nursing Experience Prior to Migration

Years Number

>1 5

1-5 45

6-10 30

11-15 8

16-20 6

20+ 6

N/A 13

Total 113

Table 14. Participants' Years of Non-Nursing Practice in Canada

Years Number

>1 7

1-5 87

6-10 7

10+ 2

N/A 10

Total 113

The majority of participants had not worked as nurses in Canada (see Table 15). Of those that

had, most had worked for less than six years. Twenty-five nurses had worked outside their

own country and Canada (see Table 16).

Status Number

Canadian citizen 16

Permanent resident 91

*Work permit 5

Student visa 1

Total 113

34

Table 15. Participants' Length of Nursing Practice in Canada

Years Number

>1 9

1-5 9

5+ 1

N/A or 0 94

Total 113

Table 16. Participants' Employment Locations Outside Canada

Location Number

Abu Dhabi &United Arab

Emirates

1

Bahrain 2

Ireland 1

Israel 1

Kuwait 1

Malaysia 1

Malaysia & Uganda 1

Netherlands 1

Oman, Dubai & United

Kingdom

1

Saudi Arabia 10

Sudan 1

United Arab Emirates 2

United States 1

Other 1

Total 25

Two participants had worked in a province outside Ontario (i.e., Nova Scotia and Quebec).

All had CNO safe practice. By the end of the project year, the majority had passed their

registration examinations and about half had completed registration (see Table 17 and Table

18).

Table 17. Participants' Examination Status at Project End

Status Number

Passed CRNE 23

Passed CPNRE 69

Passed CRNE and CPNRE 6

Not yet passed 15

Total 113 Note. CRNE = Canadian Registered Nurse Examination; CPNRE = Canadian Practical Nurse Registration

Table 18. Participants' Registration Status at Project End

Status Number

Registered as RN 14

Registered as RPN 29

Registered as RN and RPN 3

Eligible to register as RN 9

Eligible to register as RPN 45

Eligible to register as RN

and RPN

12

35

Not eligible to register 1

Total 113

Note. RN = registered nurse; RPN = registered practical nurse.

Twenty-five participants were members of BIEN, 16 had joined CARE and 30 were in BIEN

and CARE. Twenty participants completed placements at the following sites during present

or previous funding periods:

Credit Valley Hospital

HGH & Juravinski Hospital

HGH & St. Peter's (2)

HGH, Rehabilitation

HGH, Rehabilitation, Spinal cord, Amputee

HGH Neurosurgery

HGH, Stroke Unit (2)

HGH, Stroke Unit & St. Peter's Hospital, Palliative Care Unit

Juravinski

Juravinski, Surgical

Juravinski, Acute Medicine

Juravinski, E2 (Ortho) (2)

MUMC 3B/3C

Oakville Trafalgar Hospital(2)

St. Peter's, HGH, Juravinski

St. Peter's Hospital, Juravinski, Complex Care, Medical Unit

Trillium Hospital

CLINICAL INTEGRATORS

During 2015-2016, 19 CIs were enrolled in the project. As shown in Table 19, they entered

the project throughout the year. Four were men. The CIs ranged from under 24 to over 55

years of age (see Table 20) and fell into one of four categories (see Table 21). They were

referred to the project by various sources (see Table 22).

Table 19. Clinical Integrator Entry to Project

Month Number

April 4

May 2

July 2

August 1

September 3

October 6

November 1

Total 19

Table 20. Age of Clinical Integrators

Age Range Number

18-24 1

25-44 13

45-54 5

55+ 0

Total 19

36

Table 21. Clinical Integrator Categories

IEN &

ESL

IEN &

EFL*

ESL ESL

Educated

in

Canada

Total Exits Before

Project

Completion

Total Exits Totals at

Year End

9 0 2 8 19 0 0 19

* EFL = English as a foreign language.

Table 22. Clinical Integrator Project Referrals

Reference Number

Hospital staff 19

Academic 0

Community 0

Others 0

Self-referred 0

Total 19

The CIs received their nursing education in a variety of countries (see Table 23). The

majority had completed a four-year BScN (see Table 24) and almost all had completed their

non-nursing education in their countries of origin (see Table 25). Three reported tertiary

education other than nursing.

Table 23. Clinical Integrators' Country of Nursing Education

Country Number

Canada 10

China 1

India 2

Philippines 4

Serbia 1

Thailand 1

Total 19

Table 24. Clinical Integrators' Highest Level of Nursing Education

Education Number

BScN 2 years 1

BScN 3 years 1

BScN 4 years 9

RN diploma - not

specified

5

RPN diploma - not

specified

3

Total 19

Table 25. Clinical Integrators' Country of Highest Level of Non-Nursing Education

Country Number

Canada 9

China 1

India 3

Philippines 4

37

Serbia 1

Thailand 1

Total 19

Most of the 11 CIs not born in Canada had entered as family sponsored or independent

professionals (see Table 26). Twelve CIs were currently Canadian citizens and seven were

permanent residents (see Table 27). Most new CIs who had immigrated to Canada had

entered after 2000 (see Table 28).

Table 26. Clinical Integrators' Migration Status

Category Number

Family sponsored 3

Independent professional 4

Work permit 1

Live-in caregiver 2

Canadian citizen 9

Total 19

Table 27. Clinical Integrators' Immigration Status

Category Number

Canadian citizen 12

Permanent resident 7

Permanent resident status

in process

0

Total 19

Table 28. Clinical Integrators' Years of Migration

Year Number

Before 1991 1

1991-1995 0

1996-2000 0

2001-2005 3

2006-2010 4

2011-2014 3

NA 8

Total 19

Many CIs reported no nursing experience prior to arriving in Canada (see Table 29). Eight

found the question regarding the number of years they had not worked as a nurse in Canada

after migration as not applicable. Of the remainder, most had one to five years of experience

(see Table 30).

Table 29. Clinical Integrators' Years of Nursing Experience Prior to Migration

Years Number

<1 0

1-5 2

6-10 1

10+ 4

N/A 12

Total 19

38

Table 30. Clinical Integrators' Years of Non-Nursing Experience in Canada

Years Number

<1 year 0

1-5 8

6-10 1

10+ 0

N/A 10

Total 19

Nine CIs found the question regarding how long they had worked in Canada since migration

as not applicable. Of the remainder, 10 had worked as a nurse in Canada for five years or less

(see Table 31). None had worked in a province other than Ontario.

Table 31. Clinical Integrators' Length of Nursing Practice in Canada

Years Number

1-5 10

6-10 0

11-15 0

20 0

20+ 0

N/A 9

Total 19

Most of the CIs worked at HHS (see Table 32). Nine CIs had permanent full-time status, five

had permanent part-time status and one had temporary part-time status (see Table 33). No CIs

left HHS during the project year.

Table 32. Clinical Integrators' Place of Employment

Site Number

Juravinski Hospital 1

Juravinski Cancer

Centre

1

Hamilton General

Hospital

6

McMaster Children's

Hospital

0

St Peter's Hospital 7

Chedoke Hospital 0

All sites 0

Non-HHS 4

Total 19 Note. Only the first of multiple jobs is included.

Table 33. Clinical Integrators' Employment Status

Employment Status Number

PFT 9

PPT 5

TPT 1

N/A 4

Total 19 Note. PFT=permanent full-time; PPT=permanent part-time; TPT=temporary part-time.

39

RESULTS

BASELINE TESTING: INSTITUTIONAL CELBAN (I-CELBAN)

The CNO accepts scores only from CELBAN tests that have been administered at a

recognized CELBAN site. It does not accept scores from CELBAN tests administered by

academic institutions for educational purposes. In the project year, 21 participants had

CELBAN scores at baseline and 18 reported their scores (see Table 34). Ninety-two

participants had taken language tests other than or in addition to CELBAN (see Table 35).

Thirteen participants took an I-CELBAN test organized by the project (see Table 36). Of

these, one had an I-CELBAN score at project entry and 12 had taken at least one other

language test. Eleven had taken CLB (Canadian Language Benchmarks), three had taken

IELTS (International English Language Testing System) and one had taken OSSLT (Ontario

Secondary School Literary Test).

Table 34. Baseline Scores

Table 35. Other Language Tests

Test Number

MELAB 8

TOEFL 1

IELTS 29

TOEIC & MELAB 1

CLB 39

ELTPA 1

CLB & IELTS 7

Unspecified 2

CLB & CLBAN 1

CLB, CELBAN & IELTS 2

IELTS, CLB, I-CELBAN &

CELBAN

1

Total 92 Note. MELAB=Michigan English Language Assessment Battery; TOEFL=Test of English as a Foreign

Language; IELTS=International English Language Testing System; TOEIC=Test of English for International

Communication; CLB=Canadian Language Benchmarks; ELTPA=Enhanced Language Training Placement

Assessment; CELBAN=Canadian English Language Benchmark Assessment for Nurses; I-

CELBAN=Institutional Canadian Language Benchmark Assessment for Nurses.

Score Score

10-10-7-8 8-8-8-8

10-10-7-9- 8-9-6-8

10-9-7-8- 8-9-7-8

10-9-7-8- 9-5-6-7

10-9-8-7 9-7-7-7

10-9-8-9 9-7-8-8

6-7-7-8 9-8-7-8

7-9-9-7 9-8-8-7

8-7-7-8 8-7-6-7

40

Table 36. I-CELBAN 2015-2016

Test Date Participant I-CELBAN Baseline Scores

March 2015 1 10-9-7-8

April 2015 2 10-9-7-8

May 2015 3 8-7-7-8

4 8-8-7-8

June 2015 5 9-9-8-8-

6 8-6-6-7

7 10-8-7-8-

October 2015 8 9-9-7-8

9 10-7-7-8

10 8-7-7-7

11 9-8-7-7

12 10-9-8-8

March 2016 13 Pending

CARE CENTRE FOR INTERNATIONALLY EDUCATED NURSES: LANGUAGE COMMUNICATION

FOR NURSES, LEVEL 3 - ADVANCED (LCN3)

This course provides advanced communication strategies for working and workplace-ready

IENs. Tools used to evaluate the efficacy of the course included a participant pre- and post-

course self-assessment of nursing communication skills, an instructor progress report and a

participant final course evaluation.

Changes have been made to the format over six years (i.e., during a three-year pilot project

and the study underway). To accommodate as many participants as possible, class schedules

are negotiated at the beginning of each new session. Six one-hour classes offered once a week

for 16 weeks were considered the best scheduling option. Classes ran from 9:30 a.m. to 3:30

p.m. to assist participants using public transit to travel long distances.

The course was offered three times in the project year (see Table 37). The majority of

participants were either unemployed or employed outside nursing (see Table 38). Forty

participants received certificates of attendance, participation or completion (see Table 39).

Conflict with work schedules and educational pursuits were the reasons cited by those who

withdrew from the course (i.e., attended less than 50% of classes).

Table 37. LCN3 Registration

Participant Status January 16 to

May 8, 2015

April 30 to

August 20, 2015

August 15 to

November 27, 2015

Registered 21 14 16

Attended 21 14

(2 attended only first

session)

16

(3 attended only one

session)

Table 38. LCN3 Participants' Employment Status

Status January 16 to

May 8, 2015

April 30 to

August 20, 2015

August 15 to

November 27, 2015

Employed at HHS 0 0 0

Employed outside HHS 2 1 2

Employed in non-nursing

outside HHSC*

10 6 4

41

Not employed 9 7 7

Missing data 0 0 3

Total 21 14 16 Note. Non-nursing jobs included personal support worker, healthcare aid, live-in caregiver, food services, retail,

sales representative. HHS=Hamilton Health Sciences; HHSC=Hamilton Health Sciences Corporation.

Table 39. LCN3 Attendance and Certificates

Participants' Self-Assessment of Nursing Communication Skills

Participants were required to complete a self-assessment survey in class at the beginning and

end of the course. Participants were required to rate themselves from 1 to 5 in each of nine

tasks. The assessment results were tabulated, averaged and summarized. Table 40 shows the

pre- and post-averages for each course. One participant from course 1, seven from course 2

and seven from course 3 completed both the pre- and post-assessment questionnaire.

Participants reported considerable improvement overall.

Table 40. LCN3 Summary of Completed Assessments

Communication

Tasks

Course 1

Pre-

Average

Course 1

Post-

Average

Course 2

Pre-

Average*

Course 2

Post-

Average

Course 3

Pre-

Average

Course3

Post-

Average

Nurse-client interview 3.2 6 3.4 4 3.3 3.7

Document progress

notes

3.2 1 2.7 4 3.4 4.7

Give verbal reports 2.8 4 3.1 4.1 3.4 4.7

Receive verbal reports 2.9 3 3.9 3.6 3.9

Make and receive

telephone calls

2.9 4.5 3.3 3.7 3.6 3.9

Receive doctors'

orders

3.8 4.5 2.4 3.7 3.6 4.6

Health teaching 3.4 4.8 2.6 4.1 3.6 4.9

Therapeutic listening

and responding

3.2 4.5 3.4 4.1 3.6 5.0

Communicate

assertively with

colleagues and clients

3.8 4.6 3.0 4.1 3.0 4.9

Average 3.2 4.8 3.0 4.0 3.5 4.8

Note. 1=not confident, 2=slightly confident, 3=somewhat confident, 4=fairly confident, 5=very confident.

*In course 2, low scores for one individual depressed the average

Attendance January 16 to

May 8, 2015

April 30 to

August 20, 2015

August 15 to

November 27,

2015

> 50% attendance (withdrawal)

No certificate

4(19%) 2(14.3%) 5 (31%)

50%-69% attendance

Certificate of Participation

5(25%) 3(21.4%) 0(0%)

70%-84% attendance

Certificate of Attendance

3(15%) 3(21.4%) 4(25%)

85%+

Certificate of Completion

9(43%) 6(42.8%) 7 (44 %)

Total 21 14 16

42

Course Evaluation

Participants completed a course evaluation questionnaire (see Table 41). The majority

indicated the course was excellent.

Table 41. LCN3 Course Evaluation

Course 1 (N=15)

Course Element 1 2 3 4 5

Course content 0 0 0 1

(7%)

14

(93%)

Audio and video materials 0 0 0 7

(47%)

8

(53%)

E-learning lab materials 0 0 0 8

(53%)

7

(47%)

Your learning experience in

this class

0 0 0 2

(13%)

14

(93%)

Opportunity for participation

and discussion

0 0 0 0

(0%)

15

(100%)

Class schedule 0 0 0 1

(7%)

14

(93%)

Length of breaks (30 minutes) 0 0 0 1

(7 %)

14

(93%)

Fairness of evaluation

methods

0 0 0 1

(7%)

14

(93%)

Instructor's knowledge of

communication skills

0 0 0 0

(0%)

15

(100%)

Instructor's presentation of the

material

0 0 0 1

(7%)

14

(93%)

Helpfulness of instructor 0 0 0 1

(7%)

14

(93%)

Course 2 (N=11)

Skill Area 1 2 3 4 5

Course content 0 0 0 2

(18%)

9

(82%)


(55%)

5

(45%)

E-learning lab materials 0 0 0 6

(55%)

5

(45%)


this class

0 0 0 2

(18%)

9

(82%)


and discussion

0 0 0 2

(18%)

9

(82%)

Class schedule 0 0 1

(9%)

4

(36%)

6

(55%)

Length of breaks (30 minutes) 0 0 0 9

(82%)

7

(63%)


methods

0 0 0 9

(82%)

7

(54%)



0 0 0 0 11

(100%)


material

0 0 0 1(9%) 10

(91%)

43

Helpfulness of instructor 0 0 0 0 11

(100%)

Course 3 (N=11)

Skill Area 1 2 3 4 5

Course content 0 0 0 0 11

(100%)


(18%)

9

(82%)

E-learning lab materials 0 0 1

(9%)

7

(64%)

3

(27%)


this class

0 0 0 1

(9%)

10

(91%)


and discussion

0 0 0 1

(9%)

10

(91%)

Class schedule 0 0 0 2

(18%)

9

(82%)

Length of breaks (30 minutes) 0 0 0 0 11

(100%)


methods

0 0 0 2

(18%)

9

(82%)



0 0 0 0 11

(100%)


material

0 0 0 0 11

(100%)

Helpfulness of instructor 0 0 0 0 11

(100%) Note. 5=excellent, 4=great, 3=good, 2=fair, 1=poor.

Participants' Feedback

Participants rated the following aspects of the course as the most valuable:

Study material and course content

Learning therapeutic interviewing techniques, communication and assertiveness

Increased confidence in communicating with colleagues and clients

Class interaction

Gained new friends

Increased knowledge of appropriate expressions for use in healthcare

Opportunities to practise

Cultural sensitivity tips

The instructor fostered an environment conducive to learning

Audiotapes helped improve listening skills

They also made several recommendations for change:

Increase workshop time

More audio and video clips

More scenarios and listening practices

Increase the length of instruction each day to reduce the overall number of days

More practice materials and videos on the E-learning lab

More time and practise on telephone skills

More individual and group work

44

Instructor's Progress Report

The instructor reported on the participants' progress in key skill areas (see Table 42) and

evaluated their overall progress. One participant in course 3 did not complete the pre- and

post-assessment questionnaire. Consequently, this individual's progress was not tracked.

However, the participant did attend enough classes to earn a certificate and was included in

the total participant number for the course.

Table 42. Assessment of LCN3 Participants' Progress

Course 1 (N=15)

Skill Area Level 2 Level 3 Level 4 Level 5

Speaking accuracy: Ability to use

correct grammar and word choice

0 4

(27%)

10

(67%)

1

(6%)

Speaking fluency: Ability to get

your meaning across while

maintaining a fluid and coherent

flow of conversation

0 1

(6%)

9

(60%)

5

(34%)

Pronunciation: Ability to speak

clearly and comprehensibly to others

0 1

(6%)

10

(67%)

4

(27%)

Listening comprehension: Ability to

understand main ideas and relevant

details in conversation

0 2

(13%)

10

(67%)

3

(20%)

Writing proficiency: Ability to write

logical, coherent and grammatically

accurate text when documenting

0 0 15

(100%)

0

Socio-cultural proficiency: Ability to

interact according to commonly

accepted cultural norms and

expectations

0 1

(6%)

8

(54%)

6

(40%)

Course 2 (N=11)




1

(9%)

3

(27%)

7

(64%)

0





0 2

(18%)

7

(64%)

2

(18%)



1

(9%)

2

(18%)

4

(36.5)

4

(36.5)




1

(9%)

1

(9%)

7

(64%)

2

(18%)




0 0 1

(9%)

10

(91%)




expectations

0 1

(9%)

9

(82%)

1

(9%)

45

Course 3 (N=11)




0 4

(36%)

6

(65%)

1

(9%)





0 1

(9%)

8

(73%)

2

(18%)



0 1

(9%)

8

(73%)

2

(18%)




0 3

(27%)

2

(18%)

6

(66%)




0 3

(27%)

8

(73%)

0




expectations

0 1

(9%)

4

(36%)

6

(55%)

Note. 1=not consistent, 2=fairly consistent, 3=somewhat consistent, 4=consistent, 5=very consistent.

Instructor's Comments

The instructor reported that participants enjoyed the course because it provided them with the

skills and training they need to succeed in the workplace. The students' greater self-

confidence enabled their progress in conducting effective assessment interviews, using

listening techniques and asking appropriate questions. They learned to write and speak

concisely and prioritize information. The course was effective in eliminating fears related to

answering the telephone and helped participants interact assertively with physicians and

managers. Advocating for themselves and their clients is not easy for IENs/ESL nurses who

are used to working in a physician dominated practice environment. Overall, the course

facilitated the participants' integration into the Canadian healthcare system.

BIEN LEARNING RESOURCE CENTRE SIMULATION LABORATORY

All participants were eligible to attend the simulation laboratory and introductory sessions

were provided (see Table 43). Participants needing further practise were able to access the lab

more than once. Confidence was measured using a five-point Likert scale: 1=not confident,

2=not very confident, 3=somewhat confident, 4=confident and 5=very confident. Participants

were confident before the sessions. Consequently, the post-confidence scores were only a

little higher than the pre-confidence scores (see Table 44).

Table 43. BIEN Learning Resource Centre Introductory Session Attendance

Date Number of Sessions Number of Attendees

July 31, 2015 1 5

August 14, 2015 1 3

October 23, 2015 1 3

February 19, 2016 1 4

March 3, 2016 1 7

Total 5 22

46

Table 44. BIEN Simulation Laboratory Sessions: Participants' Confidence Scores

Session Pre-confidence Scores

(N=110)

Post-confidence Scores

(N=22)

A. Cardiovascular C2

(7 Subcategories)

4.22 4.78

B. Respiratory C1

(8 Subcategories)

4.28 4.78

C. Central Nervous System

(i) Glasgow Coma Scale

4.01 4.68

HCCI CULTURAL AWARENESS TRAINING WORKSHOP

The workshop was facilitated by Pat Wright from HCCI and presented by Angi Gyongyver, a

language instructor from CARE. It was held June 25, 2015 at Chedoke Hospital and attended

by 13 participants and 1 CM/delegate. Participants were asked to evaluate the effectiveness

and relevance of the workshop (see Table 45). The majority found the material germane to

their needs. However, not all were confident they could apply it to their practice.

Table 45. HCCI Workshop Evaluation

Question Not at all Somewhat Mostly Completely Average

Did the course

Deepen your understanding of

diversity and inclusion

- - 6 7 3.54

Cause you to review your personal

frames of reference, biases and

ladders of inference

- 1 5 7 3.46

Cause you to reflect upon your

communication style

- - 6 7 3.54

Provide strategies for cross-cultural

communication and conflict

resolution

- 1 5 7 3.46

Offer a framework for an inclusive

approach to nursing, patient care and

counselling

- - 5 8 3.62

Do you agree

The material presented was relevant

to your needs

- - 4 9 3.69

You will be able to apply the

strategies recommended to your

practice

- 1 6 6 3.38

How do you rate

The course overall - - - 13 4.00

The presenter - - - 13 4.00

The group exercises - - 4 9 3.69

The usefulness of the case study - - 5 8 3.62

The handouts - - 6 7 3.54

Thirteen participants also completed a post-workshop questionnaire (see Table 46). A third

questionnaire was distributed three months after the workshop and completed by five

participants (see Table 47). The majority reported that they were able to use what they had

learned in the workshop.

47

Table 46. HCCI Post-Workshop Questionnaire

Question Rating

1 2 3 4 5

1 Do you recognize and challenge the perceptions, assumptions and biases

that affect your thinking?

5 2 4 1 1

2 Do you think about the impact of what you say or how you act before you

speak or act?

4 6 3 0 0

3 Do you do everything that you can to prevent the reinforcement of

prejudices, including the avoidance of negative stereotypes when you

speak?

4 6 2 1 0

4 Do you demonstrate a respect for people from diverse or ethnic

communities by doing things that show them that you believe them to be as

competent as others, including giving them responsibility, as often as you

do those who are not from diverse or ethnic communities?

4 7 1 1 0

5 Do you encourage people who are from diverse or ethnic communities to

voice their concerns by actively listening to them?

4 7 2 0 0

6 Do you make recommendations about performance to IENs/ESL nurses in

an appropriate and respectful manner

7 2 4 0 0

7 Do you speak up when someone is making racial, sexual or other remarks,

or is humiliating another person?

1 8 4 0 0

8 Do you apologize when you realize that you might have offended someone

due to inappropriate behaviour or comments?

6 6 1 0 0

9 Do you try to know people as individuals and not as representatives or

groups and try to include different types of people in your work groups?

2 8 3 0 0

10 Do you try to create or support the creation of an environment in which

IENs/ESL nurses feel accepted, included and safe in expressing a view or

opinion?

4 8 1 0 0

11 Do you consider and respect alternative ways to integrate IENs/ESL nurses

into your team or work unit? (1 missing datum)

7 4 1 0 0

12 Do you go out of your way to try to make a newcomer from a diverse group

feel welcome and included in your circle? (1 missing datum)

4 5 3 0 0

13 Do you look for similarities between yourself and IENs/ESL nurses? 4 8 1 0 0

14 Do you feel comfortable when speaking to people with foreign accents? 1 3 8 1 0

15 Do you recognize that there are many ways that an individual may

experience discrimination?

6 5 2 0 0

Note. 1=almost always, 2=frequently, 3=sometimes, 4=seldom, 5=almost never.

Table 47. HCCI Post-Workshop Questionnaire: Three Months

Were you able to use what you

learned in the course to

No A Little Yes A Great Deal

Deepen your understanding of

diversity and inclusion

0 0 1 4

Improve your ability to communicate

cross cultural situations

0 0 3 2

Avoid or deal with conflict in cross-

cultural situations (1 missing datum)

0 0 3 1

Adopt an inclusive approach to

nursing, patient care and counselling

1 0 2 2

48

Participants' Comments

Overall, the workshop was well received and highly rated. It raised the participants'

awareness of the importance of cultural sensitivity in the healthcare setting. There was

recognition that values, beliefs and concerns should be considered to provide optimal care.

The session guided participants and showed them how to deal with conflicts related to

cultural diversity. The use of examples from workplace scenarios increased understanding of

intercultural healthcare environments.

HHS JOB COACHING/MOCK INTERVIEW PREPARATION

All participants received job coaching by the PM. Sixty participants took part in this

intervention from April 1, 2015 to March 31, 2016 (see Table 48).

Table 48. Number of HHS Interviews by Month

Month Number Month Number

April 2015 6 October 2015 3

May 2015 3 November 2015 1

June 2015 1 December 2015 1

July 2015 12 January 2015 0

August 2015 22 February 2015 1

September 2015 6 March 2015 4

Total 50 Total 10

Only eleven participants had previous interviews in Canada. When asked what they would

like to gain from the intervention, participants cited the following:

Overview of interview process

How to sell myself and my skills to get the job

Best interview strategies

Familiarity with likely questions and relevant answers

Knowing what to expect

Gaining skills in answering questions (e.g., what to say and what to avoid)

Discovering employer expectations and selection criteria

Learning interview procedures

All participants who answered the post-interview questionnaire indicated the intervention had

increased their confidence (see Table 49). They were asked what they liked, what they did

not like and what could be improved (see Table 50). Overall, participants rated the interview

highly (see Table 51).

Table 49. Pre- and Post-Intervention Confidence Ratings for HHS Interviews

Level of Confidence Pre-Interview (N=38) Post-Interview (N=36)

Not confident 2 0

Not very confident 12 1

Somewhat confident 18 2

Confident 6 23

Very confident 0 10

Total 38 36

49

Table 50. Qualitative Assessment of HHS Interviews

Liked Not Liked Could Be Improved

Knowledgeable and

friendly instructor

Relevant information and

materials

Good presentation

Interactive setting

Small group teaching

Questions and sample

scenarios

Common interview

questions and strategies

Review of health

assessment, safety

Language and terms

A lot of information in a

short period of time

Would like actual interview

practise

Too short to practise much

Too long

No visuals

One-to-one mock interview

More opportunities to

practise

Role playing with feedback

Divide the session into

information and practice

components

Include videos about

nursing interviews

More time or more days for

training

Table 51. Evaluation of HHS Interviews

Question Response

How do you rate the instructor's presentation? (Difficult=1 >

Easy to Understand=5)

1 0

2 0

3 0

4 0

5 36

Total 36

How do you rate the topics of presentation? (Not Informative=1

> Very Informative=5)

1 0

2 0

3 0

4 1

5 35

Total 36

Should this presentation remain in the training modules? Yes 36

No 0

Total 36

Forty-one participants completed a further post-interview survey. All indicated they had

received support from the team during the intervention. However, none had been offered jobs

at HHS at the time of survey (see Table 52).

Table 52. HHS Post-Interview Survey: Support and Job Offers

Support From

Team

Interview at

HHS

Other Job Interview Job Offer at HHS Job Offer

Outside HHS

Yes 41 Yes 1 Yes 10 Pending 1 Yes 6

Pending 1

HHS/CNO LEARNING PLAN/HHS POLICIES AND PROCEDURES ON THE INTRANET

All participants took part in this intervention. The learning plan included the CNO Entry to

Practice National Competencies for RNs and RPNs, professional nursing standards, quality

assurance and the use of updated learning modules as outlined on the CNO website. The

50

learning plan integrates HHS policies and procedures. As noted in their post-intervention

responses, most participants were very confident in their use of the policies and procedures

(see Table 53).

Table 53. Pre- and Post-Intervention Confidence Ratings for HHS/CNO

Rating Pre-Intervention Post-Intervention

Very Confident 67 98

Confident 20 14

Somewhat confident 9 0

Not very confident 8 0

Not confident 9 0

Missing 0 1

Total 113 113

HHS SHAREPOINT WEBSITE

The website is available only to participants and CIs working at HHS. The HCCI Cultural

Awareness Training Workshop has been added to the website.

HHS N3 NETWORKING PROGRAM: NURSES NURTURING NURSES

The project continues to build on the existing N3 program to create an HHS network for

IENs/ESL nurses that allows them to support for one another and communicate about

professional practice issues, integration, inclusion and cultural diversity. Eleven partnerships

were established (see Table 54). One CI was partnered with three participants. Nine CIs

established partnerships with one participant. When asked to rate their satisfaction with the

dyads from 1 (very much) to 5 (not at all), participants and CIs reported a high level of

satisfaction (see Table 55).

Table 54. N3 Participant and Clinical Integrator Dyads

Month Number of

Partnerships

Month Number of

Partnerships

April 3 October 1

May 1 November 1

June 0 January 1

July 0 February 3

September 1 March 0

Total 5 Total 6

Table 55. Satisfaction with Dyads

Question Three Months

(N=6)

Six Months

(N=5)

Twelve Months

(N=3)

P CI P CI P CI

How satisfied are you with

communication with your

CI/participant?

1=6 1=6 1=5 1=5 1=3 1=3

How satisfied are you with the

discussions at your meetings with

your CI/participant?

1=6 1=6 1=5 1=5 1=3 1=3

How satisfied are you with your

contact with your PM?

1=6 1=6 1=5 1=5 1=3 1=3

51

To what degree does the N3

program assist you in developing

supportive relationships?

1=6 1=6 1=5 1=5 1=3 1=3


program contribute to your

professional growth?

1=6 1=6 1=5 1=5 1=3 1=3


program contribute to your personal

growth?

1=6 1=6 1=5 1=5 1=3 1=3

What degree does the N3 program

enhance your ability to problem-

solve work-related issues?

1=6 1=6 1=5 1=5 1=3 1=3


program enhance your ability to

communicate with your nurse

colleagues?

1=6 N/A 1=5 N/A 1=3 N/A



communicate with patients

1=6 N/A 1=5 N/A 1=3 N/A



communicate with physicians?

1=6 N/A 1=5 N/A 1=3 N/A



communicate with other healthcare

providers?

1=6 N/A 1=5 N/A 1=3 N/A

HHS PROFESSIONAL WORKPLACE EXPERIENCE/INTEGRATION

Activities included job shadowing, nursing orientation and career progression.

Job Shadowing

Six participants completed job-shadowing assignments (see Table 56). Five participants

provided assessments of their experience (see Table 57). The intervention was rated highly.

However, participants indicated it could be improved by adding more hours, which would

allow them to experience a full shift of RN activities and provide greater understanding the

RN role.

Table 56. Job Shadowing Attendance

Date Number of

Participants

Location

November 19, 2015 1 Juravinski, Surgical

March 29, 2016 1 Juravinski, Medicine

February 9, 2016 1 Hamilton General Hospital, Heart Investigation Unit, CI

February 19, 2016 1 Hamilton General Hospital, 7 West, Clinical Neurosciences

February 17, 2016 1 Hamilton General Hospital, 8 South, Medical

March 13, 2016 1 Hamilton General Hospital, 7 South

52

Table 57. Job Shadowing Evaluation

Question Response

To what extent did the activity meet your learning needs? Completely 3

Considerably 1

Somewhat 1

Not at all 0

Total 5

How confident are you that you can apply what you have

learned to your practice?

Completely 4

Considerably 1

Somewhat 0

Not at all 0

Total 5

Did this experience identify gaps in your knowledge or

understanding the RN/RPN role in a Canadian healthcare

setting?

Yes 5

No 0

Total 5

Second Day of General Nursing Orientation

This event is held on the third week of each month and is available to five participants when

spaces permit (see Table 58). It is not available during summer months because all places are

taken by New Graduate Guarantee hires. Topics include vascular access therapy, senior

friendly care, Alaris® pumps, glucose meter and chest drainage. Sixteen participants provided

assessments of their experiences (see Table 59).

Table 58. Second Day of General Nursing Orientation

Date Number Group 1 Group 2 Group 3

April 2015 1 1 0 0

May 2015 5 5 0 0

June 2015 6 6 0 0

July 2015 3 3 0 0

August 2015 5 5 0 0

September 2015 2 2 0 0

October 2015 2 1 0 1

November 2015 3 3 0 0

December 2015 4 3 1 0

January 2016 2 2 0 0

February 2016 1 1 0 0

March 2016 cancelled 0 0 0 0

Total 34 32 1 1

53

Table 59. Second Day of General Nursing Orientation Evaluation

Question Response


Considerably 6

Somewhat 0

Not at all 1

Total 16



Completely 10

Considerably 4

Somewhat 1

Not at all 1

Total 16



setting?

Yes 16

No 0

Total 16

This activity was evaluated highly. However, participants recommended the following:

Greater specificity regarding certain policies and procedures

More hands-on activities

Increased practise time

Additional days of orientation

Career Progression: Lunch and Learn Sessions

Various topics were presented. Some sessions were evaluated, but others were not (see Table

60 and Table 61).

54

Table 60. Evaluated Lunch and Learn Sessions

Performing a Head to Toe Assessment

May 25, 2015 – Nick Millar

N=13 (Group 1=12, Group 3=1)

Question Response


Considerably 2

Somewhat 0

Not at all 0

Total 13



Completely 6

Considerably 6

Somewhat 0

Not at all 0

Missing 1

Total 13



setting?

Yes 13

No 0

Total 13

CARE Telephone Tactics: Session 1

July 15, 2015. Angi Gyongyver

N=7 (Group 1=7)

Question Response


Considerably 2

Somewhat 0

Not at all 0

Total 7

55



Completely 6

Considerably 0

Somewhat 0

Not at all 0

Missing 1

Total 7



setting?

Yes 7

No 0

Total 7

CARE Telephone Tactics: Session 2

July 29, 2015 – Angi Gyongyver

N=7 (Group 1=6, Group 2=1)


Considerably 0

Somewhat 0

Not at all 0

Missing 1

Total 7



Completely 5

Considerably 1

Somewhat 0

Not at all 0

Missing 1

Total 7



setting?

Yes 6

No 0

Missing 1

Total 7

56

Table 61. Non-Evaluated Lunch and Learn Sessions

Accent Reduction

April 17, 2015 – Kate Buchan

(N=11)

Participants Number

Group 1 11

Total 11

IEN/ESL Network

August 13, 2015

(N=12)

Group 1 9

Clinical Integrator(s) 1

Project Manager 1

Project Lead 1

Total 12

N3 Clinical Integrators Meeting

October 22, 2015 – Livia Jakabne

(N=6)

Clinical Integrator(s) 6

Total 6

IEN/ESL Network

November 20, 2015

(N=7)

Group 1 7

Project Manager 1

Project Lead 1

Total 9

Transitioning from RN to RPN

November 25, 2015

(N=46)

Group 1 44

Group 3 2

Total 46

Additional career progression activities included connecting with CIs employed outside of

HHS, job fairs (e.g., Bayshore Healthcare Agency) and the Registered Nurses' Association of

Ontario Nursing Career and Professional Development Showcase. Suggestions for

improvement to the evaluated sessions included the following:

Add more visuals and video

More time for lecture and practise

Include MCQ as part of OSCE preparation

More phone lines and units available for practising

Include worse case telephone scenarios and unexpected phone calls from people other

than hospital staff or doctors

PROJECT EVALUATION: OVERALL RESULTS AND CONCLUSIONS

This section focuses on the success of the project in meeting the numeric targets set by

MCIIT. The participants' evaluations of the project and their experiences finding professional

employment are presented. The success of the CCEM and the sustainability of the project are

considered and recommendations are made.

57

MCIIT NUMERIC TARGETS 2015-2017

The MCIIT set the following numeric targets:


Participants accessing the project (a minimum of two interventions): 70

Participants completing a significant component of the project (at least four

interventions): 60



As indicated below, all numeric targets were on track or were exceeded:



Participants accessing the program (minimum of four interventions): 87



JOB STATUS OF PARTICIPANTS WHO COMPLETED FOUR INTERVENTIONS

Forty-nine participants who had completed four interventions were hired into nursing

positions at HHS or other healthcare organizations (see Table 62). More obtained full-time

employment status at HHS than at non-HHS organizations (see Table 63).

Four participants were hired as healthcare aids or personal support workers by non-HHS

organizations. Thirteen participants were employed through the Nursing Career OrIENtation

Initiative and one was employed through the Nursing Graduate Guarantee after three months

in the program.11,12

Table 62. Participants' Employment Positions

Location RN RPN Number

HHS 11 8 21

Non-HHS 6 13 28

Total 17 21 49

Table 63. Participants' Employment Status

Location Part-Time Full-Time Number

HHS 10 12 22

Non-HHS 23 4 27

Total 33 16 49

JOB STATUS OF ALL PARTICIPANTS

The 113 participants who registered in 2015-2016 enrolled in the project at different times.

Thirty-five participants have been in the project for a year. Sixty-two were employed when

they joined. Eighty-two were employed three months after enrolment and 34 were employed

12 months after enrolment. These figures indicate that participant employment increases over

11 The Nursing Career OrIENtation Initiative is intended to facilitate full-time job opportunities and transition to

practice for newly registered IENs in Ontario. 12 The Nursing Graduate Guarantee is intended to provide Canadian newly graduated RNs and RPNs with full-

time job opportunities in Ontario.

58

time. When all participants have been in the project for a year, it will be possible to track

their progress in obtaining permanent full-time employment more accurately.

Participants were asked if they were employed in a job commensurate with their skills and

education and where they were employed at 0, 3 and 12 months (see Table 64 and Table 65).

They were also asked about employment status at HHS and non-HHS organizations (see

Table 66 and Table 67).

Table 64. Participants' Commensurate Employment at Zero to Twelve Months

Status Zero Months Three Months Twelve Months

Commensurate 28 56 31

Non-commensurate 36 28 3

Unemployed 48 27 1

Missing 1 0 0

Total 113 111 35

Table 65. Participants' Location of Employment at Zero to Twelve Months

Location Zero Months Three Months Twelve Months

HHS 4 13 10

Non-HHS 57 65 21

Neither 47 26 1

Both 4 7 3

Missing 1 0 0

Total 113 111 35

Table 66. Participants' Employment Status at HHS at Zero to Twelve Months

Status Zero Months Three Months Twelve Months

PFT 1 1 2

PPT 0 4 1

TFT 1 8 1

TPT 0 0 0

RPT 1 1 3

OPT 4 5 3

Total 7 19 10 Note. OPT=occasional part-time; PFT=permanent full-time; PPT=permanent part-time; RPT=regular part-time;

TFT=temporary full-time; TPT=temporary part-time.

Table 67. Participants' Employment Status at Non-HHS Organizations

Status Participants

PFT 13

PPT 20

TFT 8

TPT 3

RPT 4

OPT 31

RPT & PFT 1

Total 80 Note. OPT=occasional part-time; PFT=permanent full-time; PPT=permanent part-time; RPT=regular part-time;

TFT=temporary full-time; TPT=temporary part-time.

59

PREPAREDNESS

At 3 and 12 months after project enrolment, participants were asked the following questions:

1. Do you think the intervention helped prepare you for future employment as a nurse?

2. Do you think the intervention helped you understand the Canadian work environment?

At 3 months, 112 (99%) participants provided affirmative responses to both questions. Data

for one participant was missing. At 12 months, 35 (100%) of participants provided

affirmative responses to both questions.

PROJECT EXIT

No participants exited the project in 2015-2016. Consequently, there are no participant

evaluations of the project and its components.

NEW INITIATIVES

As time conflicts and transportation challenges sometimes prevented participants from

accessing interventions, the project team is developing various online resources and

assessment tools.

SUCCESS STORIES

The MCIIT provided participants and CIs with templates to document personal experiences

and stories. Eleven stories were submitted. The stories reflect the participants' increased

confidence. All participants who completed the template supported the continuation of the

project (see Appendix D).

PROJECT SUSTAINABILITY

Workforce Integration Strategies

The PAC is comprised of CIs, participants and members from community organizations,

educational institutions and HHS. The latter includes the Office of Human Rights and

Diversity, which develops policies and procedures for cultural inclusivity and provides advice

and support. The PAC suggested several strategies to enhance the project:

1. Develop a long-term strategy in collaboration with the PAC to ensure project

sustainability.

2. Build on the CCEM through commitment by all organizational levels at HHS and existing

and future partners.

3. Ensure interventions created by project staff are embedded at HHS.

4. Maintain support from the IEN/ESL network, CIs and clinical, academic and community

stakeholders.

5. Apply to the MCIIT for renewal of funding for 2017 onward.

Obtaining funding to support a project team to implement and disseminate the CCEM was

also discussed. The possibility of attaching a service fee to the interventions delivered by the

partner institutions was acknowledged. However, it was recognized that doing so might be a

barrier to employment of IENs/ESL nurses

60

Communication Among Stakeholders

Communication among stakeholders continues to be a priority. Partners are represented on

the PAC. Meetings are held semi-annually. The PAC provides advice regarding project

promotion and sustainability. The PM is a member of the Hamilton-Wentworth Long Term

Care Joint Executive Committee and the HHS Nursing Graduate Guarantee Advisory

Committee. Several CIs are also members of the Nursing Advisory Council and the Nursing

Stewardship Committee.

Engaging the Community

In-line with the CCEM, the project encourages the participation of other healthcare

organizations. HHS routinely collaborates with its community partners through formal

meetings and informal communication. Partners are responsible for executing and evaluating

project interventions. The PM connects with community agencies and healthcare

organizations, including retirement homes, long-term care facilities and hospitals in

Hamilton-Wentworth, the Greater Toronto Area and central and northwestern Ontario.

Communicating Within the Region

Opportunities for IEN employment were enhanced by the following:

Employment collaboration with Professions North, Laurentian University, Sudbury

Monthly employment opportunities in northern Ontario for RNs, RPNs and nurse

practitioners

Employment collaboration with Sioux Lookout Meno Ya Win Health Centre, Sioux

Lookout

Employment collaboration with North West Training and Adjustment Board, Dryden

Employment collaboration with Trillium Health Partners, Mississauga Hospital,

Mississauga

Dissemination Strategies

Displaying panels to promote the project to employees and visitors at all HHS sites.

Using the template provided by MCIIT to record the stories of successful participants.

Making formal and informal presentations and holding events and conferences inside and

outside HHS.

Distributing a resource folder at stakeholder meetings that includes a project information

booklet and contact information for the PM.

Giving project pins to participants, CIs, supporters and partners inside and outside HHS.

Inviting participants and CIs to attend Nursing Week activities.

Ongoing updating of the SharePoint website and exploring opportunities to use social

media to create a more user-friendly environment.

Membership of Relevant Committees

The PM is a member of the Hamilton-Wentworth Long Term Care Joint Executive

Committee and the HHS Nursing Graduate Guarantee Advisory Committee. Several CIs are

also members of the Nursing Advisory Council and the Nursing Stewardship Committee.

FUTURE STRATEGIES

The project team will focus on the following:

61

Matching project participants with current and anticipated job vacancies at HHS, in

Hamilton and the surrounding area.

Working closely with HR at HHS to anticipate future job vacancies and trends in health

human resources planning.

Promoting enhanced career path and hiring opportunities outside of HHS through

ongoing collaborating with project stakeholders, bridging programs, community colleges,

multicultural associations and the Nursing Career OrIENtation Initiative.

Enhancing professional and workplace experience/integration opportunities for

participants (e.g., job shadowing, nursing orientation and career progression).

Enabling participants to remain in the project in order to complete the CNO registration

process.

RECOMMENDATIONS

Refer IENs/ESL nurses to the project at an early stage to facilitate registration.

Mitigate the challenges participants face in accessing project interventions due to work

schedules, personal responsibilities, travel and distance.

Encourage stakeholders inside and outside of HHS to participate in the Nursing Career

OrIENtation Initiative to help newly registered IENs/ESL nurses transition to practice and

obtain full-time employment.

Provide guidance and networking opportunities for participants seeking employment

outside HHS and Hamilton-Wentworth.

Encourage participants to accept available healthcare-related positions to establish

themselves as internal candidates for other job opportunities.

Build inclusive workplaces through cultural awareness training.

Explore opportunities for sharing and replication of the CCEM with other healthcare

organizations in Ontario.

62

APPENDIX A. INFORMATION AND CONSENT FORMS

Internationally Educated Nurse (IEN) and English as a Second Language (ESL)

Nurse Integration Project

2015-2017

Information & Consent Form

________________________________________________________________

Co-Principal Investigators:

(1) Dr. Ruth Lee, Chief of Nursing Practice, Hamilton Health Sciences, McMaster Site, 1200

Main Street West, Hamilton, ON L8N 3Z5

(905) 521-2100 x 73828

(2) Dr. Andrea Baumann, Associate Vice President, Global Health, Faculty of Health

Sciences, Scientific Director, Nursing Health Services Research Unit (NHSRU), McMaster

Site,

1280 Main St. West MDCL 3500, Hamilton, ON L8S 4K1

(905) 525-9140 x 22581

Community Partners:

Centre for Internationally Educated Nurses (CARE)

Hamilton's Centre for Civic Inclusion (HCCI)

McMaster University, Nursing Health Services Research Unit (NHSRU)

Mohawk College, Bridging for Internationally Educated Nurses (BIEN)

Sponsor/Funding Agency:

Government of Ontario, Ministry of Citizenship, Immigration and International Trade

(MCIIT)

The Project

You are being invited to take part in a project to improve the integration of internationally

educated nurses and English as a second language nurses into the workforce at Hamilton

Health Sciences and community. The project will provide you with assistance in improving

your clinical, cultural, communication skills and competencies. Recruitment, hiring and

retention of internationally educated nurses will be improved as a result of this project.

Clinical managers/educators and clinical integrators will also be involved.

63

What will be expected of you as a participant? You will meet with the clinical

managers/educators/clinical integrators to assess your needs and to incorporate these into an

individualized learning plan based on the National Entry to Practice Competences for nurses.

You will participate in communication and cultural workshops, school to career transition

curriculum, a language screening tool assessment and focus groups. Following completion of

your involvement with the project, you will be able to join the IEN/ESL network and the

project team will continue to support you.

How will you benefit from participating in the project? Taking part in the study is by

choice. You are free to decide whether you will participate. There are no known risks to

participation. An individualized learning plan is developed with you. You will have free

access to communication, clinical and cultural competency resources and tools to help you to

better integrate into your clinical unit. Your involvement will assist in the further

development of tools and resources to improve and support the integration of internationally

educated nurses into the workforce.

Who can participate? Participants will be recruited from Mohawk College's Bridging for

Internationally Educated Nurses program, as well as English as a second language nurses

who have graduated from Canadian nursing institutions. Another recruitment source is the

community.

Confidentiality Any personal information collected during this project will be kept

confidential. It may appear in reports or publications with your permission. Your name will

not be identified in transcripts of interviews or focus groups. Only members of the research

team will have access to the information you provide us. Audiotapes and digital audio files

will be stored in locked filing cabinets until the end of the project, at which time they will be

destroyed. Transcripts from the focus group sessions and face-to-face interviews will be

entered into the INVIVO software package for analysis. All electronic files will be password

protected and will not be transmitted over the Internet. Only members of the investigation

team will have access to this stored information. You have the right to listen to any tapes

made during interviews. When the project is completed, study database files, including

NVivo files, will be burned to CD/memory disc and removed from all study computers.

These files will be retained on CD/memory disc only, for 10 years in secure storage as per

Research Ethics Board policy.

Initials

Person obtaining consent_____

Participant_____

64

Internationally Educated Nurse (IEN) and English as a Second Language (ESL)

Nurse Integration Project

2012-2015

Consent Form

________________________________________________________________

Consent to participate

I understand the information given to me about this study. My questions about the study have

been answered clearly. I am willing to participate in the project using an individualized

learning plan developed for me, in addition to culture and communication workshops, school

to career transition curriculum, language screening tool and focus groups. I understand that

all information collected for this study will be confidential and that I will not be identified in

reports or publications without my permission. I know that I can leave the study at any time

and that this will not affect my job as a nurse. I understand that I will receive a signed copy of

this form.

I agree to participate in this study explained to me by

________________________________________________________________

Person obtaining consent Signature Date

________________________________________________________________

Participant Signature Date

For questions about this project, please contact:

Dr. Ruth Lee, Co-Principal Investigator, HHS, IEN/ESL Nurse Integration Project

[email protected]

(905) 521-2100 x 73828

Daniela Beckford, Project Manager, HHS IEN/ESL Nurse Integration Project

[email protected]

(905) 521-2100 x 77512

If you have any questions regarding your rights as a research participant, you may contact the

Office of the Chair of Hamilton Integrated Research Ethics Board (HIREB) at (905) 521-

2100 x 42013

mailto:[email protected]

mailto:[email protected]

65

APPENDIX B. EVALUATION TOOLS INDEX

CARE Centre for Internationally Educated Nurses Workplace Communication Course

Participant self-assessment of nursing communication skills (pre- and post-course)

Instructor's progress report on the participants' overall level of proficiency in their

communication

Participant final course evaluation

BIEN Mohawk College Learning Resource Centre Simulation Laboratory

Nursing skills assessment - pre

Physical skills assessment- pre

Nursing skills assessment - post

Physical skills assessment - post

HHS Job Coaching/Mock Interviews

Pre-interview prep kit

Pre-confidence survey

Post-confidence survey

Effectiveness survey

Presentation evaluation sheet

Post-interview questionnaire

APS - Procedure for the assessment of pain in adult, paediatric and neonatal patients as

per HHS policy

HHS: NUR - Nursing unit-to-unit transfer of accountability (TOA)

HHS: Braden Scale for predicting pressure sore risk

HHS: Critical care nursing: Hints and kinks for nurses PQRST method of pain assessment

HHS: MAC - Unapproved abbreviations, symbols and dose designations on HHS

medication orders, medication documentation and pharmacy labels

College of Nurses of Ontario (CNO): Dispensing medications, new controlled act for RNs

and RPNs (began using this tool February 2014) Canadian Triage and Acuity Scale

(CTAS) National Guidelines

Interview questions based on real patient case scenarios

HCCI Cultural Competency Awareness Workshop

HCCI pre- and post-diversity questionnaire

HCCI workshop evaluation - Exploring successful practices IEN/ESL Nurse Integration

Project

HCCI post-session cultural competency survey for IENs/ESL nurses (three months post)

NHSRU post-session cultural competency for IENs/ESL nurses course assessment

NHSRU post-session cultural competency survey for IENs/ESL nurses (three months

post)

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet

HHS policies and procedures pre-confidence survey

HHS policies and procedures post-confidence survey

MAC Consent, Withdrawal or Refusal of Consent for Treatment Policy

Documentation - Transcription Process for Kardex

ENG - Lockout/Tagout Procedure

66

Infection Control - Clostridium Difficile Protocol

NUR - RPN Scope of Practice F5 Medicine Policy

5 South Nursing Standards for Patient Safety During Transfer of Accountability

HR - Confidentiality

PRI - Disclosure of Personal Health Information of Current In-Patients to Friends and

Family Guideline

ED - Emergency Department Patient Safety and Restraints Policy

HSW - Guidelines for Pregnant HHS Employees Working Directly or Indirectly with In-

Patients with Communicable Diseases

Infection Control - Management of Proven or Suspected Diseases - Guidelines

Transcription Process for Orders

HHS N3 Networking Program

Participants' N3 program satisfaction survey

HHS Professional Workplace Experience/Integration

HHS Professional Workplace Experience/Integration post-survey

Program Exit

Exit survey

Follow-up survey

67

APPENDIX C. PROJECT DISSEMINATION AND PROMOTION 2015-2016

INTERNAL PRESENTATIONS

Beckford, D. (2015, April 22). The Path to Integration: A Workshop for Employers of

IENs/ESL Nurses – Innovative Practices: Recruiting and Integration. Diversity Grand

Rounds McMaster University Medical Centre, Hamilton, ON.

Jakabne, L. (2015, November 10). Project Presentation & Dissemination of CCEM. HHS

Clinical Managers/Education Clinicians Meeting, Hamilton, ON.

CONFERENCES/PRESENTATION INFORMATION

Beckford, D. (2015, April 20).The Path to Integration: A Workshop for Employers of

IEN/ESL Nurses – Innovative Practices: Recruiting and Integration. Brantford General

Hospital, Brantford, ON.

Lee, R., Beckford, D., & Brown-Fellows, N. (2015, April 30 & May 1). Empowering

Experienced Critical Care Nurses Educated Overseas Using a Community Collaboration

Employment Model. 9th Partners in Education and Integration of Internationally Educated

Nurses. Delta Regina Hotel, Regina, SK.

Beckford, D. (2015, August 11). The Path to Integration: A Workshop for Employers of

IENs/ESL Nurses – Innovative Practices: Recruiting and Integration. Sioux Lookout Meno

Ya Win Health Centre, Sioux Lookout, ON.

Lee, R., Jakabne, L (2015, October 23). Project Presentation & Dissemination of CCEM.

Knowledge Translation Workshop. The National New Graduate Nurse Colloquium, London,

ON.

Woods, P (2015, October 29). The Path to Integration: A Workshop for Employers of

IENs/ESL Nurses – Innovative Practices: Recruiting and Integration. International Langara

College School of Nursing, Vancouver, BC.

Jakabne, L. (2015, November 17). Integrating Diverse Staff. Health Care Employment

Summit, Quality Workforce for Quality Care. OHA Education Centre, Toronto, ON.

Lee, R. (2015, November 17). Panel Discussion: Integrating Diverse Staff, Project

Presentation & Dissemination of CCEM. OHA Education Centre, Toronto, ON.

Jakabne, L. (2016, February 18). Panel Presentation: Project Promotion & Dissemination of

CCEM. McMaster University Medical Centre, Hamilton, ON; Juravinski Hospital, Hamilton,

ON: Hamilton General Hospital, Hamilton, ON; St. Peter's Hospital, Hamilton, ON: West

Lincoln Memorial Hospital, Grimsby, ON.

68

APPENDIX D. SUCCESS STORIES

Eleven success stories were submitted. Table 1 shows the participants' responses to standard

questions. Table 2 provides their individual narratives.

Table 1.

Questions Responses

Position held prior to arrival in Canada Nurse (self-employed)=1

RN=5

Volunteer school nurse=1

Nursing services manager=1

RN/nursing educator=2

RN/Surgical assistant=1

Barriers to licensure/employment Did not recognize nursing credentials

Recognition of previous experience

Had communication problems and lacked

references

Assessment by CNO took a long time, safe practice

expired, difficult to get jobs without Canadian

experience

Employers prefer Canadian education and

experience

Language barriers, lack of experience, lack of jobs

Lack of experience

Language, cultural awareness, interview skills,

need to build résumé, Canadian nursing system

Upgrading required

Problems with credentials

Language, culture shock

Employment/licensure goals on arrival in

Canada Obtain RN licensure and practice profession

Become RN in operating room

Work as nurse, preferably surgical assistant

Become licensed (took CARE courses, etc.)

Have licence and job (RN or RPN) by the end of

2016

Have full-time job and be licensed as RN

Have full-time job and be licensed as RN

Have job and be licensed as RN or RPN

Job and be licensed as RN

Job and licence

Job and licence

Last position in Canada prior to bridge

training RPN=1

Unemployed=4 (one became a PSW after joining

the project)

Live-in caregiver=1

PSW=3

BIEN student=1

Housekeeper=1

How learned about project Mohawk College=1

Friend=3

Spouse (also in project)=1

69

BIEN student=1

CARE=1

Faculty Mohawk College=1

Online searching=2

Fellow students=1

Currently licensed to practice Yes=10

No=1

Year became licensed 2016=2

2015=1

2014=4

Not yet licensed=1

2013=3

Position currently held RN=4

RPN=6

Live-in caregiver=1

Evaluation of program (1=unsatisfactory

to 10=excellent)

8=1

10=10

70

Table 2.

1 The project has been very supportive in my endeavours to become a registered nurse in Canada.

It has provided me guidance when I went back to school, resources and opportunities to enhance

my clinical knowledge and skills. Daniela and Janice, the project manager and administrative

assistant, respectively, are genuine and passionate in helping IENs have a smooth transition in

achieving their educational and career goals.

2 This program helped me understand what is nursing in Ontario, Canada. The project leader,

Daniela Beckford, helped me with my career goals by outlining what needed to be done. They

first helped me to achieve my licensure. They guided me on what needed to be submitted and

what I could do to further improve my credentials for me employment goals. I was a participant

in various trainings they had such as the English course, telephone workshop for nurses, building

my résumé, mock interview, physical examination training and other hands-on experience that

prepared me for my current job. I gained confidence and determination from the support and

encouragement that they constantly gave me. In fact, I would not have had the opportunity to be

given an interview from my current manager if I hadn't had their support.

3 This program helped me in visioning and aligning my goals to get licensed on time. [It] gave me

lots of information with regard to the processes [of Canadian healthcare]. The program helped

me become more confident. It included language courses, training workshops, etc. The best part

was the personal counselling, which really helped a lot.

4 The project enabled me to develop my nursing communication skills. Through networking, I

learned about the operating room course at Mohawk College. I also received financial assistance

from the project, which really helped me to complete the course, and I got employment at HHS.

All the staff in the project helped me gain knowledge and confidence for my success.

5 I gained a lot from the communication class. [It] improved my documentation, client assessment

and how to handle culturally sensitive aspects in any setting. Also, the group support from

members during exam preparation added more weight to my passing. This was followed by a

mock interview preparation by my supervisor, watching videos for nursing skills and job

shadowing at the General hospital was a great help to obtain licensure and employment.

6 The bridge training program enhanced my knowledge about the standards of nursing in the

Canadian healthcare system. It also improved my knowledge and skills, most especially my

communication and interpersonal skills in the nursing field. The workplace communication

course had helped me pass the CELBAN to gain my language proficiency requirement in the

College of Nursing of Ontario. The teacher was very supportive and inspiring. The project

manager, Daniela Beckford, and her staff are very committed and optimistic in helping me reach

my nursing goals. They really motivated me to succeed.

7 The manager of the bridging program is someone who went through the same difficulties to

become adapted in Canada. She understands us. That is the reason why the bridging program

focuses on helping all internationally trained nurses to achieve their goal in Canada. I got useful

tips from the bridging program such as communication language for healthcare. I have learned

how to approach patients in a Canadian way. [It] provided different short courses for free . . .

[and] helped me with my résumé, guided me through my registration as an PRPN with the CNO

[and] helped me prepare for the national RPN exam. Good networking to help me find a job. . . .

I was the first one who went through this program.

71

8 The very first day I walked in to this integration program, I knew I was in the right place. I

started by writing my CELBAN, attended the English class and prepared for the CNO exams. I

borrowed pre-exam question books, watched videos on procedures [and] attended several

meetings and workshops sponsored by the project. Most importantly, the project coordinator and

staff were very warm, receptive and ever ready to give information and guidance on the right

way to go. When I passed my CNO exams, I was also assisted in securing this very job at

Hamilton General Hospital as an NCO. I also attended an interview workshop. I, therefore, rate

my satisfaction level with this program as excellent (10) and strongly recommend that it continue

to help other internationally trained nurses find their feet.

9 This program helped me to learn more about Canadian nursing strategies. The program also

refreshed both my nursing clinical skills and knowledge and helped me familiarize myself with

the Canadian culture and clinical and legal practices and concerns. Other than nursing, the

program helped me build my résumé in a Canadian style that sounded attractive and

distinguished to employers.

10 The most important thing is the project manager provided me job opportunities and assisted me

to register in the NCO program. The second thing is that the project manager is the greatest

resource person. . . . [She] recommended me to the hospital where I am not employed. I would

like to say that HHS IEN integration project helped me achieve my goals and let my dreams

come true in Canada.

11 I arrived in Canada with my family in 2012 in BC. From the first day, I started to search and

gather information regarding the registration process for becoming an RN in Canada. I found out

that each province has its own way of registration. When I called the College of Nursing in

Vancouver and explained my situation, they said it might take seven years before I can get my

licence. I tried to find a job as a health care aide (HCA). There was no chance for me due to

competition and not having a good network. . . . However, I was positive. Through searching, I

got connected with Skills Connect, funded by the government. Their goal was to help immigrants

with skills to go back to their field. Three months later, I find I cannot reach my goal through

them All that Skills Connect does is find you a job and close your file. Very soon I realized I

can't get enough support in BC to reach my goal . . . I came to the conclusion that there was and

is more support in Ontario and job opportunities. I came to Mississauga somewhere in April

2013. I did four weeks of training for a security guard role. My plan was to get a job as a security

guard to support my family. I also tried to find a job as HCA or support worker. But I could not

reach success because there were asking for a certificate as support worker. I decided to call the

bridging program manager for internationally trained nurses and made an appointment. With

their help and advice I was able to apply for a job as an HCA in Hamilton Health Sciences Very

soon, I got an interview for a HCA position at the Juravinski Hospital in Hamilton. The bridging

program prepared me for the interview and I got the job. I started as an HCA in August 2013. In

June 2014, I passed my RPN exam and was licensed as an RPN in Ontario. In November 2014, I

started as the NGG for RPN at the place that I started with HCA. After my six months NGG, I

received a regular part-time position at the same place in the short-term. I also had a regular part-

time job as RPN at St Joseph's Hospital in Hamilton. I am working in the day surgery

department.

Documents

HAMILTON HEALTH SCIENCES, INTERNATIONALLY EDUCATED … · Sciences (HHS) (April 1, 2015 to November 26, 2015) John Parker, Director of Inter-professional Development, Clinical Practice