SERIES REPORT 42 • MAY 2015 HAMILTON HEALTH … · MCI/MCIIT Targets ... Career Progression: ......

HAMILTON HEALTH SCIENCES, INTERNATIONALLY EDUCATED NURSE (IEN)

AND ENGLISH AS A SECOND LANGUAGE (ESL) NURSE INTEGRATION PROJECT

2012-2015 FINAL REPORT

Andrea Baumann, RN, PhD Jennifer Blythe, PhD

SERIES REPORT 42 • MAY 2015

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Hamilton Health Sciences, Internationally Educated Nurse (IEN) and English as a Second Language (ESL) Nurse Integration Project 2012-2015

Series # 42

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

This research has been generously funded by a grant from the Ministry of Citizenship, Immigration and International Trade (MCIIT). The views expressed in this report do not necessarily reflect those of the Government of Ontario.

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

A Descriptive Evaluation

Final Report 2012-2015

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

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PROJECT TEAM

Principal Investigators Dr. Ruth Lee, Project Lead, Chief of Nursing Practice, Inter-Professional Practice, Hamilton Health Sciences (HHS) 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, Inter-Professional Practice and Chief Nursing Executive, HHS Nancy Brown-Fellows, Program Manager, Mohawk College Institute for Applied Health Sciences, Bridging for Internationally Educated Nurses (BIEN) Program Jennifer Blythe, Senior Scientist, NHSRU, McMaster University Zubeida Ramji, Executive Director, CARE Centre for Internationally Educated Nurses Pat Wright, Interim Executive Director, Manager, Training & Community Engagement, Hamilton Centre for Civic Inclusion (HCCI) Project Manager Daniela Beckford, RN, HHS Administrative Support Janice Collins, HHS HHS IEN/ESL Advisory Committee Members - Standing Members for Quorum Michelle Barnard, Clinical Integrator Education & Development Clinician, HHS

Andrea Baumann (ex officio), Scientific Director, NHSRU, McMaster University

Daniela Beckford, Project Manager, IEN/ESL Integration Project, Inter-Professional Practice, HHS

Jennifer Blythe, Senior Scientist, NHSRU, McMaster University

Nancy Brown-Fellows, Manager, Mohawk College, BIEN Program

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

Abdullah Hassan, Clinical Integrator, RN, HHS

Jane Hastie, Human Rights and Diversity Specialist, HHS

Livia Jakabne, Clinical Integrator, RN, HHS

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Kirsten Krull (ex officio), Vice-President and Chief Nursing Executive, Inter-Professional Practice, HHS

Andy Le, Data and Research Assistant, HHS

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

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

Joanne Roth, Regional Manager, West, CARE Centre for Internationally Educated Nurses

Romaine Sheriff, Clinical Practice & Education, Manager, 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

John Shao, Participant, Juravinski Hospital, HHS

Maureen Williamson, Advisory and President, Ontario Nurses' Association

Pat Wright, Interim Executive Director, Manager, Training & Community Engagement, HCCI

Community Partners Mohawk College Institute for Applied Health Sciences, BIEN Program CARE Centre for Internationally Educated Nurses HCCI NHSRU, McMaster University Sponsor/Funding Agencies Ministry of Citizenship, Immigration and International Trade (MCIIT)

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ...................................................................................................... 13

Introduction ........................................................................................................................... 13

Objectives .............................................................................................................................. 13

Numeric Targets .................................................................................................................... 14

Interventions .......................................................................................................................... 14

Intervention Evaluation Results ............................................................................................ 15

Overall Results for 2012-2015 .............................................................................................. 15

INTRODUCTION .................................................................................................................... 16

Recent Developments Relevant to the Project ...................................................................... 16

PROJECT DESCRIPTION ....................................................................................................... 18

Purpose .................................................................................................................................. 18

Objectives .............................................................................................................................. 18

MCI/MCIIT Targets .............................................................................................................. 18

Design.................................................................................................................................... 18

Study Site .............................................................................................................................. 19

Project Partners ..................................................................................................................... 20

External Stakeholders ............................................................................................................ 21

Community Collaboration Employment Model (CCEM) ..................................................... 21

Project Team ......................................................................................................................... 22

METHODS ............................................................................................................................... 22

Participant Sample................................................................................................................. 22

Participant Recruitment Strategy .......................................................................................... 22

Clinical Integrator Sample .................................................................................................... 23

Clinical Integrator Recruitment Strategy .............................................................................. 23

Participants and Clinical Integrators: Description and Tracking .......................................... 23

Baseline Testing: Institutional CELBAN (I-CELBAN) ....................................................... 23

INTERVENTIONS, PROGRAMS AND RESOURCES ......................................................... 23

Mentorship Workshops ......................................................................................................... 27

NEW DEVELOPMENTS IMPLEMENTED 2014-2015 ......................................................... 27

HCCI Online Webinars ......................................................................................................... 27

Advanced Clinical Competency Assessment Tool (Critical Care Simulation)..................... 27

EVALUATION......................................................................................................................... 28

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Interventions, Programs and Resources ................................................................................ 28

Overall Project....................................................................................................................... 28

Research Ethics Board .......................................................................................................... 29

SAMPLE DESCRIPTION ........................................................................................................ 29

Participants ............................................................................................................................ 29

Clinical Integrators ................................................................................................................ 37

RESULTS ................................................................................................................................. 43

Baseline Testing: Institutional CELBAN (I-CELBAN) ....................................................... 43

CARE Centre For Internationally Educated Nurses, Language Communication for Nurses Level 3 - Advanced (LCN3).................................................................................................. 43

Participants' Self-Assessment of Nursing Communication Skills ................................ 44

Participants' Evaluation ................................................................................................. 45

Participants' Feedback ................................................................................................... 46

Instructor's Progress Report .......................................................................................... 46

BIEN Learning Resource Centre Simulation Laboratory ..................................................... 48

HCCI Cultural Awareness Training Workshop .................................................................... 48

HHS Job Coaching/Mock Interview Preparation .................................................................. 50

HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet ............................. 52

HHS SharePoint Website ...................................................................................................... 52

HHS N3 Networking Program: Nurses Nurturing Nurses .................................................... 52

HHS Professional Workplace Experience and Integration ................................................... 54

Job Shadowing .............................................................................................................. 54

Second Day of HHS General Nursing Orientation ....................................................... 54

Career Progression: Lunch and Learn Sessions ............................................................ 55

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

MCI/MCIIT Targets .............................................................................................................. 56

IEN/ESL Nurses' Hiring History ........................................................................................... 57

PARTICIPANTS' EVALUATION OF THE PROJECT: EXIT QUESTIONNAIRES 2012-2015........................................................................................................................................... 63

ASSESSMENT OF INTERVENTIONS .................................................................................. 65

Evaluation of Clinical Integrators ......................................................................................... 66

Evaluation of Project Manager .............................................................................................. 66

Use of SharePoint Website .................................................................................................... 66

Other Useful Interventions and Resources ............................................................................ 66

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Recommending the Project to Other IEN/ESL Nurses ......................................................... 66

Getting a Job.......................................................................................................................... 67

General Comments ................................................................................................................ 67

Success Stories ...................................................................................................................... 67

New Initiatives ...................................................................................................................... 67

HCCI Diversity and Inclusion Training ........................................................................ 67

Assessment Tools.......................................................................................................... 67

Project Sustainability............................................................................................................. 68

Workforce Integration Strategies .................................................................................. 68

Engaging the Community ............................................................................................. 68

Communication Among Stakeholders .......................................................................... 68

Outreach to Regional Healthcare Facilities .................................................................. 68

Career Progression ........................................................................................................ 69

Project Promotion and Dissemination .......................................................................... 69

RECOMMENDATIONS .......................................................................................................... 69

APPENDIX A. INFORMATION AND CONSENT FORMS ................................................. 70

APPENDIX B. PROJECT DISSEMINATION AND PROMOTION 2013-2014 ................... 72

APPENDIX C. EVALUATION TOOLS INDEX .................................................................... 74

APPENDIX D. PARTICIPANT EVALUATION OF THE JOB SHADOWING EXPERIENCE 2014-2015 ........................................................................................................ 76

APPENDIX E. ADVANCED STANDING ASSESSMENT TOOL DEVELOPMENT - HHS/MOHAWK COLLEGE ................................................................................................... 77

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FIGURES

Figure 1. Community Collaboration Employment Model: Bridging the Gap for IEN/ESL Nurses ...................................................................................................................................... 21

Figure 2. Project Team ............................................................................................................. 22

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TABLES

Table 1. Participant Sample Composition ............................................................................... 29

Table 2. Participant Entry to Project ........................................................................................ 29

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

Table 4. Age of Participants..................................................................................................... 30

Table 5. Gender of Participants ............................................................................................... 30

Table 6. Participants' Highest Level of Nursing Education ..................................................... 30

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 ........... 33

Table 10. Participants' Immigration Class ............................................................................... 33

Table 11. Participants' Immigration Status .............................................................................. 34

Table 12. Participants' Years of Migration .............................................................................. 34

Table 13. Participants' Years of Experience Prior to Migration .............................................. 34

Table 14. Participants' Years of Non-Nursing Practice in Canada .......................................... 35

Table 15. Participants' Length of Practice in Canada .............................................................. 35

Table 16. Participants' Employment Locations outside Canada .............................................. 35

Table 17. Participants' Examination Status at Project End ...................................................... 36

Table 18. Participants' Registration Status .............................................................................. 36

Table 19. Age of Clinical Integrators ...................................................................................... 37

Table 20. Clinical Integrator Categories .................................................................................. 37

Table 21. Clinical Integrator Project Referrals ........................................................................ 38

Table 22. Clinical Integrators' Country of Nursing Education ................................................ 38

Table 23. Clinical Integrators' Highest Level of Nursing Education ....................................... 39

Table 24. Clinical Integrators' Country of Highest Level of Non-Nursing Education ............ 39

Table 25. Clinical Integrators' Migration Status ...................................................................... 40

Table 26. Clinical Integrators' Immigration Status .................................................................. 40

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Table 27. Clinical Integrators' Year of Migration to Canada .................................................. 40

Table 28. Clinical Integrators' Nursing Experience Before Arriving in Canada ..................... 41

Table 29. Clinical Integrators' Years Not Worked as a Nurse in Canada ................................ 41

Table 30. Clinical Integrators' Time Working as a Nurse in Canada ...................................... 41

Table 31. Clinical Integrators' Place of Employment .............................................................. 42

Table 32. Clinical Integrators' Employment Status ................................................................. 42

Table 33. LCN3 Registration and Attendance ......................................................................... 43

Table 34. LCN3 Participant Status .......................................................................................... 43

Table 35. LCN3 Course Attendance ........................................................................................ 44

Table 36. Summary of Completed Assessments 2014-2015 ................................................... 44

Table 37. Course Evaluation Results ....................................................................................... 45

Table 38. Assessment of Participants' Progress ....................................................................... 46

Table 39. Learning Resource Centre Information Session Attendance ................................... 48

Table 40. Participants' Confidence Scores for Simulation Laboratory .................................... 48

Table 41. Workshop Evaluation (N=19) .................................................................................. 48

Table 42. Assessment of Information (N=19) ......................................................................... 49

Table 43. Follow-up Questionnaire (N=12) ............................................................................ 49

Table 44. Number of Interviews by Month 2014-2015 ........................................................... 50

Table 45. Participant Interviews in Canada ............................................................................. 50

Table 46. Pre- and Post-Intervention Confidence Ratings for Interviews ............................... 50

Table 47. Qualitative Assessment of Interviews...................................................................... 51

Table 48. Presentation Evaluation ........................................................................................... 51

Table 49. Interview Support Ratings ....................................................................................... 51

Table 50. Interviews and Job Offers ........................................................................................ 51

Table 51. Pre- and Post-Intervention Confidence Ratings for HHS/CNO .............................. 52

Table 52. Pre- and Post-Intervention Confidence Ratings for HHS Website .......................... 52

Table 53. Participant and Clinical Integrator Dyads 2012-2015 ............................................. 53

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Table 54. Satisfaction with Dyads 2012-2015 ......................................................................... 53

Table 55. Job Shadowing Attendance ...................................................................................... 54

Table 56. Second Day of HHS General Nursing Orientation Attendance ............................... 55

Table 57. Lunch and Learn Session Attendance 2013-2015 ................................................... 55

Table 58. Numeric Targets 2012-2015 .................................................................................... 57

Table 59. IEN/ESL Nurses' Change in Registration Status ..................................................... 58

Table 60. Nurse Employment .................................................................................................. 58

Table 61. Multiple Employment .............................................................................................. 59

Table 62. IEN/ESL Nurses' Sector of Employment ................................................................ 59

Table 63. IEN/ESL Nurses' Professional Nursing Status ........................................................ 60

Table 64. IEN/ESL Nurses' Non-Nursing Employment Status ............................................... 61

Table 65. Professional Employment Inside and Outside of HHS ............................................ 62

Table 66. Employment Status at Zero to Twelve Months ....................................................... 63

Table 67. Date of Project Exit.................................................................................................. 63

Table 68. Participants' Exit Comments .................................................................................... 64

Table 69. Number of Interventions Completed ....................................................................... 64

Table 70. Number of Participants Accessing Interventions..................................................... 64

Table 71. Intervention Ratings ................................................................................................. 65

Table 72. Intervention Recommendations ............................................................................... 65

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EXECUTIVE SUMMARY

INTRODUCTION The goal of the Internationally Educated Nurse (IEN) and English as a Second Language (ESL) Nurse Integration Project was to ensure that registered nurses (RNs) and registered practical nurses (RPNs) educated abroad or in Canada were fully integrated into the Hamilton Health Sciences (HHS) workforce. It provided IEN/ESL nurses with support from pre-hire through orientation and clinical integration. A successful three-year pilot project was implemented from April 1, 2009 to March 31, 2012. A three-year project was subsequently implemented from April 1, 2012 to March 31, 2015. Both were funded by the Ontario Ministry of Citizenship and Immigration (MCI), now the Ontario Ministry of Citizenship and Immigration International Trade (MCIIT). The third year of the project is complete. The project was informed by the Community Collaboration Employment Model (CCEM) and carried out by HHS with the support of the following 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 Bridging for Internationally Educated Nurses (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, practices equity and speaks out against discrimination. McMaster University, Nursing Health Services Research Unit (NHSRU): Conducts research on nursing human resources. Additional support was received from the following: Canadian Nurses Association: Dissemination of project model and project results. Thunder Bay Regional Health Sciences Centre: Collaboration on projects. York University: Collaboration on projects.

OBJECTIVES Below are the objectives and numeric targets for the project, as described in the contract between HHS and MCI/MCIIT: • Develop, adapt, deliver and evaluate a project to support the successful workplace

integration and retention of 120 IEN/ESL nurses into HHS and other Ontario healthcare facilities.

• Develop a suite of tools and processes for IEN/ESL nurses, particularly new hires, practicing in a hospital environment.

• Build the mentorship and coaching capacity of up to 60 frontline registered nurses (RNs/RPNs), clinical educators and clinical managers (CMs) with at least one year of nursing experience as clinical integrators (CIs) to facilitate the integration of IEN/ESL nurses.

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• Provide employment opportunities for 120 IENs and ESL nurses to obtain and retain employment in nursing at HHS and other Ontario healthcare facilities.

• Measure participant and employer satisfaction and evaluate program components, including interventions and stakeholder satisfaction.

NUMERIC TARGETS To assist with the integration of IEN/ESL nurses into HHS and other Ontario healthcare facilities, a cohort of experienced nurses was recruited to act as CIs. The numeric targets for IEN/ESL nurses participating in the project were as follows: • Nurses assessed for eligibility: 180 • Participants accessing the program (a minimum of two interventions): 145 • Participants completing a significant component of the project (a minimum of four

interventions): 120 • Participants who become/remain employed as nurses: 120 • CIs completing training: 60

INTERVENTIONS The interventions listed below were implemented during the 2012-2015 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 IEN/ESL nurses. BIEN Learning Resource Centre Simulation Laboratory: Participants have the opportunity to practice two nursing skills identified during their self-assessment learning plan. HHS Job Coaching/Mock Interview Preparation: Sessions conducted by the PM helped prepare participants for job interviews. HCCI Cultural Competency Awareness Workshop: This three-hour workshop for IEN/ESL nurses, CIs and CMs or their delegates was created with input from HSS. An online version of the HCCI Diversity and Inclusion Module has been completed. 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 IEN/ESL nurses, CIs, CMs and external partners. The site posts relevant forms and provides updates on the project, including interventions, evaluation and activities (e.g., the N3 program) as well as available resources for IEN/ESL nurses. 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. HHS Professional Workplace Experience/Integration: This intervention focuses on job shadowing, nursing orientation and career progression.

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INTERVENTION EVALUATION RESULTS CARE Centre for Internationally Educated Nurses, Language Communication for Nurses Level 3 - Advanced (LCN3): Thirty-five participants registered for the April 3 to July 17, 2014 course, 35 registered for the August 7 to November 20, 2014 course and 29 registered for the August 8 to November 21, 2014 course. Participants reported a high level of satisfaction with the course and the instructor reported significant participant improvement.

BIEN Learning Resource Centre Simulation Laboratory: Thirty-three participants attended the lab sessions offered in 2014-2015. Pre-intervention questionnaires showed a relatively high level of confidence. Post-intervention questionnaires showed a moderate increase in confidence. All participants were eligible to attend the simulation laboratory and introductory sessions were provided.

HHS Job Coaching/Mock Interview Preparation: During the three years of the project, 186 participants have taken part in a mock interview: 75 in 2012-2013, 51 in 2013-2014 and 60 in 2014-2015. One participant from 2014-2015 attended a second session Attendees gave it high ratings and reported that their knowledge about the interview process had increased and their self-confidence had improved. HCCI Cultural Competency Awareness Workshop: Nineteen IENs and one CM/delegate attended a three-hour workshop on February 20, 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. HHS SharePoint Website: Participants reported 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: Thirty-five partnerships were established over the three years of the project, with 29 CIs working with 35 participants. Participants and CIs were very satisfied with the partnerships. HHS Professional Workplace Experience/Integration: Some of the activities offered in 2012-2013 were retained and new activities were introduced. Participants rated the activities highly and noted their confidence and knowledge had increased.

OVERALL RESULTS FOR 2012-2015 As indicated below, all numeric targets were on track or were exceeded: • Nurses assessed for eligibility: 689 • Participants accessing the program (a minimum of two interventions): 416 • Participants completing a significant component of the project (a minimum of four

interventions): 317 • Participants who become/remain employed as nurses: 189 • CIs completing training: 73 All interventions were successfully implemented. The CCEM continued to be successful. The model benefited the IEN/ESL nurses, increased the partners' awareness of their diverse roles and provided opportunities for collaboration.

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INTRODUCTION The Internationally Educated Nurse (IEN) and English as a Second Language (ESL) Nurse Integration Project was implemented April 1, 2012 to March 31, 2015 and funded by the Ontario Ministry of Citizenship and Immigration (MCI), now the Ontario Ministry of Citizenship and Immigration International Trade (MCIIT). The aim of the project was to ensure registered nurses (RNs) and registered practical nurses (RPNs) educated abroad and ESL nurses educated in Canada are fully integrated into the Hamilton Health Sciences (HHS) workforce. The project focused on language and clinical skills and provided cultural competency training for nurses, clinical managers (CMs) and clinical integrators (CIs). The project supported IEN/ESL nurses from pre-hire through orientation and during integration. It helped IEN/ESL nurses perform competently within their scope of practice, communicate effectively and function optimally as part of an interdisciplinary healthcare team. It also assisted managers in facilitating the integration process. In this report, the third year of the project (2014-2015) is described and all three years are summarized.

RECENT DEVELOPMENTS RELEVANT TO THE PROJECT In recent years, there have been several developments relevant to the global movement of nurses. Foremost, international collaboration to create standardized practices has increased. For example, regulatory bodies and nurse regulators in Australia, British Columbia, Canada New Zealand, Singapore, the United Kingdom and the United States renewed their commitment to ongoing collaboration, which began in 2011 with the International Nurse Regulator Collaborative (INRC).1 The intent is to share information, identify common principles and work on cross-jurisdictional mechanisms to promote public safety. Below are the current priorities of the INRC: • Exploring the implications of telepractice • Identifying common principles related to the appropriate use of social media by nurses • Planning an international nurse regulator symposium in October 2014 • Researching recidivism among nurses who have been disciplined Within Canada, an important initiative was the creation of the National Nursing Assessment Service (NNAS).2 The purpose is to provide increased access for IENs based on multiple delivery channels, enhanced online capabilities and faster turnaround time for basic processes. The NNAS, which is comprised of member nurse regulatory bodies, has developed a harmonized approach to the initial assessment of IENs. This approach should better serve the public by ensuring greater transparency, timeliness and predictability across Canadian jurisdictions and increasing the standards for qualification assessment. Key funding for Phase 1 and Phase 2 of the NNAS project was provided by the Government of Canada's Foreign Credential Recognition Program. Regulatory bodies and some provincial governments also supported the preliminary stages. The NNAS will provide the following: • A single national web portal

1 http://www.cno.org/Global/1-WhatIsCNO/annualreport/2013/collaboration.html 2 http://www.nnas.ca/about-us/

http://www.cno.org/Global/1-WhatIsCNO/annualreport/2013/collaboration.html

http://www.nnas.ca/about-us/

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• A common approach to initial document collections, authentication, validation and fraud screening

• A consistent competency-based assessment of the IEN application file • A consistent format for advisory reports to regulatory bodies to inform eligibility

assessments • A bilingual customer care centre for IEN applicants • A national IEN database providing enhanced reporting and analysis capabilities On January 1, 2015, the National Council Licensure Examination (NCLEX-RN exam), developed by the National Council of State Boards of Nursing (NCSBN), became the entry-to-practice examination for RNs in 10 Canadian jurisdictions, including Ontario. The College of Nurses of Ontario (CNO) began collaborating with other Canadian nurse regulators and the NCSBN in 2013 to prepare for this change. In October 2013, approximately 50 educators from Ontario nursing programs attended a workshop hosted by the CNO to learn about the exam and how to help students prepare for it. Since 2013, more than 100 Ontario nurses have volunteered to contribute to NCLEX-RN exam development activities, including item writing and review panels. In 2013, the CNO initiated other changes affecting IENs. For example, all applicants must pass a jurisprudence examination. Internationally educated nurses must provide evidence of practice within the last three years and achieve the required benchmark scores in the following approved English or French language proficiency tests: • Canadian English Language Benchmarks Assessment for Nurses (CELBAN) • International English Language Testing System (IELTS) • Test d' Évaluation de Français (TEF) There is now a two-year limit for meeting registration requirements after applications are accepted. Additionally, IENs applying for RN status may be asked to demonstrate nursing competence. The CNO assesses each IEN application to determine if the applicant's education background meets program requirements. If it does not, the CNO instructs the applicant to undergo an Objective Structured Clinical Examination (OSCE) evaluation to be completed over a four-hour period at the Centre for the Evaluation of Health Professionals Educated Abroad in Toronto. The results determine whether the applicant has the necessary entry-to-practice competencies. Additional research is being conducted on the OSCE. There are concerns about accessibility, fairness, clarity of information, reporting of results and further education to address competency gaps. Regulators have also attempted to streamline their application processes. Beginning in 2013, they have endeavoured to reduce the application backlog. The CNO has started to lay the groundwork for moving the application process online.3

It is vital to ensure that IENs entering the workforce are competent. However, meeting the requirements of practice presents immigrant nurses with challenges and increases their need for support. To help IENs transition to full-time practice in Ontario, the Ministry of Health and Long-Term Care has expanded the Nursing Graduate Guarantee (NGG) to include the Nursing Career OrIENtation Initiative (NCO). The NGG and the NCO will provide nursing graduates educated outside Ontario with the opportunity to gain employment and work with experienced nurses to enhance their knowledge and skills. 3 http://www.cno.org/Global/1-WhatIsCNO/annualreport/2013/entry-to-practice.html

http://www.cno.org/en/become-a-nurse/new-applicants1/accepted-language-proficiency-tests/

http://www.cno.org/Global/1-WhatIsCNO/annualreport/2013/entry-to-practice.html

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PROJECT DESCRIPTION

PURPOSE The aim of the project was to ensure RNs and RPNs who have been 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 provided IEN/ESL nurses with various clinical and communication skills and focused on clinical assessment, problem solving, team relationships, professionalism, workplace experience and managing conflict in a hospital setting. The objectives and numeric targets for the project, as described in the contract between HHS and MCI/MCIIT, are provided below.

OBJECTIVES

• Between April 1, 2012 and March 31, 2015, develop, adapt, deliver and evaluate a project to support the successful workplace integration and retention of IEN/ESL nurses into HHS and other Ontario healthcare facilities.

• Develop a suite of tools and processes for IEN/ESL nurses, particularly new hires, practicing in a hospital environment.

• Meet the numeric targets established by the MCI/MCIIT. • Build the mentorship and coaching capacity of up to 60 frontline RNs, CIs and CMs with

at least one year of nursing experience as CIs to facilitate the integration of IEN/ESL nurses.

• Develop and implement a strategy (i.e., a sustainability plan) to ensure that project delivery will continue beyond the end of funding.

• Evaluate project components, including interventions and stakeholder satisfaction. A pre- and post-evaluation of project interventions will measure participant confidence, communication and preparation for integration into the healthcare workforce.

MCI/MCIIT TARGETS

• Nurses assessed for eligibility: 180 • Participants accessing the project (a minimum of two interventions): 145 • Participants completing a significant component of the project (a minimum of four

interventions): 120 • Participants who become/remain employed as nurses: 120 • CIs completing training: 60

DESIGN A project charter was developed, approved by the IEN/ESL Project Advisory Committee and submitted to the MCI. 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 Bridging for

Internationally Educated Nurses (BIEN) Program to be a project partner. 3. Identification of community organizations: Partners provided organization-specific

expertise to meet project goals. HHS invited the CARE Centre for Internationally Educated Nurses 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.

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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: The 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 of the committee was to provide strategic direction and leadership to champion the development, adaptation, delivery and evaluation of the project and facilitate integration of IEN/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: Employers and project partners identified the evaluation tools to be used and an independent evaluator led 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 course 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 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 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.

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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 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: 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, practices 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.

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EXTERNAL STAKEHOLDERS Additional support was received from the following:

Canadian Nurses Association: Responsible for dissemination of project model and project results. Thunder Bay Regional Health Sciences Centre: Responsible for collaboration on projects. York University: Responsible for project collaboration and results. Thunder Bay Multicultural Association: Facilitated dissemination of project model at job fairs in Thunder Bay area. Confederation College: Facilitated dissemination of project model at a virtual job fair in the Thunder Bay area.

COMMUNITY COLLABORATION EMPLOYMENT MODEL (CCEM) The research team developed the CCEM (see Figure 1) to engage stakeholders and guide the project.

Figure 1. Community Collaboration Employment Model: Bridging the Gap for IEN/ESL Nurses

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PROJECT TEAM As shown in Figure 2, HHS worked with community organizations and educational institutions to implement the model. The principal investigators were the Chief of Nursing Practice, HHS, and the Scientific Director, NHSRU, McMaster University. Co-investigators included the Vice-President, Professional Affairs and Chief Nursing Executive, HHS. Co-investigators were also from the Mohawk College Institute for Applied Health, the CARE Centre for Internationally Educated Nurses and the NHSRU, McMaster University.

Figure 2. Project Team

METHODS

PARTICIPANT SAMPLE The project was approved by the Research Ethics Board at McMaster University. To be eligible, participants had to be IENs with English as a second language, IENs with English as a first language or ESL nurses graduating from a Canadian nursing program.

PARTICIPANT RECRUITMENT STRATEGY Marketing and promotion of the project was carried out externally and internally at HHS. On the second day of general nursing orientation, the project manager (PM) provided an outline of the project together with a hard copy description and contact information. IEN/ESL nurses were encouraged to enrol in the project to receive increased support throughout the employment integration process. The information and consent forms are provided in Appendix A. The PM and Human Resources at HHS collaborated to recruit IEN/ESL nurses who were not employed at HHS. Current and anticipated vacancies were identified by Human Resources, 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 in the project. The PM provided an

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overview of the project to BIEN and CARE students and graduates and contacted CMs and education clinicians at HHS, BIEN and CARE to assist with recruitment. CMs also approached the PM for support of their IEN/ESL employees.

CLINICAL INTEGRATOR SAMPLE To be eligible, clinical integrators (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 IEN/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 60 by the MCI/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, in the documents section of 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 (e.g., the McMaster University/Mohawk College/HHS/Long-Term Care Joint Executive Committee).

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. Participants were tracked on a number of variables, including those collected for MCI/MCIIT monthly numeric performance indicator reports.

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."4 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."5

INTERVENTIONS, PROGRAMS AND RESOURCES All interventions initiated in the pilot project (2009-2012) were retained, as was access to various opportunities and resources. In addition, new interventions and resources were developed. CARE Centre for Internationally Educated Nurses, Language Communication for Nurses Level 3 - Advanced (LCN3): Course provides advanced communication strategies for working and work-ready IEN/ESL nurses. Topics include introducing, managing and ending a nurse-client interview; intercultural communication; documentation and reporting; communicating assertively with clients and colleagues; lay vs. technical vocabulary; telephone communication; therapeutic communication; and health teaching. 4 http://www.celbancentre.ca/ 5 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

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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 were supported in various ways such as 1:1 student-faculty relationships and peer tutoring. In addition, RN technologists helped participants develop their clinical skills. All participants self-evaluated their level of confidence for medical/surgical and physical assessment nursing skills. They were required to complete a pre-intervention self-assessment checklist for both medical/surgical and physical assessment skills at the time of enrolment in the project. In 2012, the pre- and post-physical assessment checklist was revised to better capture the participants' experiences. The gastrointestinal and gyne-urinary assessment skills checkpoints were removed and a comment section was added. All data were collected by the project team and forwarded to the NHSRU. Participants had the opportunity to practice two selected nursing skills identified during 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 IEN/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 IEN/ESL nurses, CIs and CMs or their delegates was created with input from HSS. It focuses on the exploration of communication methods, including verbal and non-verbal, and facilitates understanding of how culture can help avoid misunderstandings and improve intercultural communication. The workshop included case scenarios based on cultural diversity awareness that were drawn from the participants' experiences and was evaluated upon completion. The purpose of the workshop was to enable attendees to do the following: • Deepen their understanding of diversity and inclusion • Develop a framework for an inclusive approach to nursing, patient care and counselling • Reflect on their style of communication and the effect their use of language might have

on communication • Review their personal frames of reference, biases and ladders of inference • Understand culture and strategies for cross-cultural communication and conflict

resolution HHS Job Coaching/Mock Interview Preparation: These sessions were conducted by the PM and are intended to prepare participants for job interviews. Before the interview, the IEN/ESL nurses' résumés, cover letters and three references were reviewed. The 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 sessions took one to two hours. The interviewees practiced 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.

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HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet: Each participant follows a customized learning plan that includes both clinical and communication skills development. The plans were created in collaboration with the BIEN program. After recruitment, participants met with the PM and discussed the learning plan to be followed for the duration of the course. The plan was intended to help participants understand and become familiar with the CNO Quality Assurance (QA) program and included the CNO Learning Plan. 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 participate in all interventions) • 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 SharePoint Website: This website was adapted from a site that targeted CMs. It was modified to serve as a resource hub for IEN/ESL nurses, CIs, CMs and external partners. The site provided relevant forms, resources for IEN/ESL nurses and updates on the project, including interventions, evaluation and activities. Participants were informed about the site by the PM and received passwords and access instructions. In 2012, the site was updated with a general user name and password. A short survey was conducted to evaluate the users' satisfaction. A blog and a discussion board for the IEN/ESL network were also created. The website is still evolving to become more interactive. A review of the content to allow for external access is underway.

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HHS N3 Networking Program: The Nurses Nurturing Nurses 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 or 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 now offered online.

CIs received information pertinent to helping IEN/ESL nurses develop their careers. The program provides participants with an opportunity to review their careers and learn strategies to facilitate future career decisions. The participants' career plans might include finding a mentor or a mentee to help them achieve their goals. CIs and participants completed an N3 program form to identify their areas of interest. Based on four to five topics, the PM matched the participant with a CI to form a dyad. CIs were invited to attend a Lunch and Learn session to review the project goals, the N3 program and the participants' learning plans. 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 acted as the coordinator of the program and oversaw the completion of the evaluation forms. The HHS/CNO Learning Plan was used as a basis for the discussions. The CI and the participant determined the objectives for each meeting. The objectives reflected the needs, concerns and issues identified by the participant. 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: As outlined below, 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 in which CIs were working (e.g., medical/surgical, rehabilitation, child and youth and mental health) 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 the following: • 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-Doc (MEDITECH clinical documentation) • Job applications

b. Academic writing and documentation

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c. Charge nurse role education program d. Career development/mentorship workshops (i.e., CPR, ACLS Perioperative, HELP,

E-learning) e. Nursing rounds (Lunch and Learn sessions and IEN/ESL network)

MENTORSHIP WORKSHOPS All CIs were encouraged to complete mentorship workshops offered in-person or online by the Oncology Nursing e-Mentorship Program, McMaster University, Juravinski Cancer Centre. The workshops helped prepare CIs to 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 The marketing strategy developed in 2009-2012 to raise awareness of the project and encourage recruitment remained in place. Results of the project were disseminated through various media such as posters and presentations (see Appendix B).

NEW DEVELOPMENTS IMPLEMENTED 2014-2015

HCCI ONLINE WEBINARS The HCCI worked with the project coordinator to develop content and instructional material for a series of webinars for IENs/ESL nurses, staff, supervisors, managers and healthcare personnel at HHS. Three webinars have been planned and two have been completed. PowerPoint presentations were presented to the Project Advisory Committee for comment and feedback. They were also presented at workshops for HHS staff. Following feedback, the presentations were edited and converted into video webinars. Webinar 1. Understanding Diversity in Healthcare • Deepen understanding of diversity, equity and inclusion • Review personal frames of reference, biases and ladders of inference • Develop a framework for an inclusive approach to nursing, patient care and counselling Webinar 2. Exploring Context and Communication • Explore how "context" impacts intercultural communication • Reflect upon communication style and how use of language may affect communications • Develop a framework for an inclusive approach to nursing, patient care and counselling Webinar 3. Conflict Resolution • Develop an understanding of different cultures and cultural practices • Understand culture and strategies for cross-cultural communication and conflict

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

ADVANCED CLINICAL COMPETENCY ASSESSMENT TOOL (CRITICAL CARE SIMULATION) An Objective Structured Clinical Examination (OSCE) using high and low fidelity simulation has been created for IENs who have critical care experience and are seeking employment in this area. A development team was established and literature and standards from the Canadian Association of Critical Care Nurses and the Critical Care Secretariat were

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summarized. A needs assessment was conducted using focus groups with IENs who have worked in critical care at HHS (N=8) and elsewhere (N=9). Survey questions were developed and a questionnaire administered to 30 critical care managers and educators. Twenty-two questionnaires were returned. The consensus was that language, communication and mentorship were essential for the success of IENs working in critical care. A pre-OSCE guide was provided for review online. It included two OSCEs (10 to 12 minutes in length): 1. A high fidelity case study - Focused on patients whose conditions had begun to

deteriorate. The intended learning outcome was the use of critical thinking to assess and develop a nursing diagnosis and care plans; anticipate next steps and establish priorities; provide care during simulation; and verbalize next steps.

2. A low fidelity OSCE based on OSCE 1 - Involved standardized actors (e.g., doctors, peers and family members). The intended learning outcome was the use of assertive, professional communication during interactions, including the transfer of accountability; asking for help; and interprofessional relations.

The IENs participating in the intervention were required to have completed the following: • BIEN Learning Resource Centre Simulation Laboratory • CARE Centre for Internationally Educated Nurses, Language Communication for Nurses

Level 3 - Advanced (LCN3) • CNO Standards of Practice review • HCCI Cultural Competency Awareness Workshop A pilot involving two participants with overseas critical care experience was conducted April 24, 2014. Revisions were completed by August 1, 2014.

EVALUATION

INTERVENTIONS, PROGRAMS AND RESOURCES The partners evaluated the individual interventions for which they were responsible. A mechanism was developed and implemented to track the participants engaged in interventions and their employment status at 3, 6 and 12 months after completing the interventions.

OVERALL PROJECT Project evaluation, approved by the MCI/MCIIT, was delivered by the NHSRU, McMaster University. 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 analyse additional data to assess the partners' satisfaction with the project. The project design was experiential rather than experimental. As limited research has been conducted on the workplace integration of IEN/ESL nurses, the intention was to allow for modification based on experience. Ongoing evaluation of the project led to changes resulting in increased efficacy. Interventions introduced in the early stages of the project were refined and strengthened and new activities were introduced to enhance workplace exposure for participants. Some evaluation tools used in the pilot study were modified and new tools created. An index of evaluation tools for all interventions is presented in Appendix C.

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RESEARCH ETHICS BOARD The project was approved by the Hamilton Integrated Research Ethics Board (HIREB), a jointly constituted board of St. Joseph's Healthcare Hamilton, HHS and the Faculty of Health Sciences at McMaster University.

SAMPLE DESCRIPTION

PARTICIPANTS During year 6, 161 nurses enrolled, surpassing the targeted sample of 60 for that year. At the end of the year, 231 remained in the project. One nurse from year six exited in 2014-2015 before project completion (see Table 1). As shown in Table 2, participants entered the project throughout the year. Table 1. Participant Sample Composition

Time IEN & ESL

IEN & EFL*

ESL Total Exits Before Project

Completion

Total Exits

Totals at Year

End Year One to Year Three

32 0 3 35 N/A 140 0

Year Four

147 15 2 166 2 166 0

Year Five

83 0 6 89 0 18 71

Year Six

152 6 3 161 1 1 160

Total 413 21 14 445 3 325 231 * EFL = English as a foreign language. Table 2. Participant Entry to Project

Year Four Number of Participants

Year Five Number of Participants

Year Six Number of Participants

April 2012 18 April 2013 20 April 2014 52 May 2012 19 May 2013 5 May2014 7 June 2012 16 June 2013 9 June 2014 12 July 2012 10 July 2013 6 July 2014 32 August 2012 12 August 2013 9 August 2014 5 September 2012 17 September 2013 8 September 2014 7 October 2012 14 October 2013 16 October 2014 8 November 2012 5 November 2013 12 November 2014 8 December 2012 17 December 2013 4 December 2014 10 January 2013 18 January 2014 0 January 2015 8 February 2013 6 February 2014 0 February 2015 4 March 2013 14 March 2014 0 March 2015 0 Total 166 89 161

The majority of participants were referred to the project from the community or referred by staff from HHS (see Table 3). Most were women between 25 and 44 years of age (see Table 4).

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Table 3. Participant Project Referrals

Reference Year One to Year Three

Year Four

Year Five Year Six

Totals

Academic 2 6 1 5 14 Community 6 38 15 32 91 HHS staff 13 23 17 22 75 Self-referral 2 21 20 55 98 Other 12 9 0 0 21 Colleague 0 3 0 0 3 Friend/Relative 0 24 14 0 36 Participant 0 28 18 46 92 St. Elizabeth Health Care

0 11 0 0 11

HHS website 0 3 1 0 4 CARE Centre 0 0 3 1 4 Total 35 166 89 161 451

Table 4. Age of Participants

Age Range Year One to Year Three

Year Four Year Five Year Six Totals

18-24 3 11 9 5 28 25-29 5 40 18 47 90 30-34 5 29 23 42 99 35-39 11 33 17 36 97 40-44 7 37 15 23 82 45-49 4 11 5 7 27 50-54 0 5 2 1 9 Total 35 166 89 161 451

Of the 166 nurses who entered the project in year four, 23 were male (see Table 5). Of the 89 nurses who entered the project in year five, 13 were male. Of the 161 nurses who entered the project in year six, 27 were male. Table 5. Gender of Participants

Gender Year One to Year Three


Male 5 23 13 27 68 Female 30 143 76 134 383 Total 35 166 89 161 451

As shown in Table 6, Table 7 and Table 8, the participants' level of nursing education and country of nursing and non-nursing education varied widely. Table 6. Participants' Highest Level of Nursing Education

Education Year One to Year Three


BScN 5 years 0 2 0 0 2 BScN 4 years 0 85 54 76 215 BScN 3 years 16 5 4 6 31 BScN 2 years 2 6 2 5 15

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BScN - not specified

0 1 0 1 2

RN diploma 3 years

1 5 1 0 7

RN diploma - not specified

9 41 20 40 110

Post graduate 2 6 3 9 20 RPN diploma 5 15 4 14 38 Other BSC physiotherapy

0 0 1 0 1

Total 35 166 89 161 451 Table 7. Participants' Country of Nursing Education

Country Year One to Year Three

Year Four Year Five Year six Totals

Bulgaria 0 0 1 1 2 Cameroon 0 1 0 0 1 Columbia 0 1 1 1 3 Canada 6 14 3 6 29 China 2 7 4 1 14 Singapore 0 1 0 0 1 Croatia 1 0 0 0 1 England 0 0 0 1 1 Ethiopia 1 0 0 0 1 Germany 0 0 0 1 1 Greece 0 0 0 1 1 Haiti 0 2 0 0 2 Hong Kong 0 0 0 1 1 Iran 0 7 1 3

(1 via Netherlands)

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Iraq 0 0 1 0 1 India I7 42 20 79 158 Ireland 0 1 0 0 1 Israel 0 2 1 0 3 Jamaica 0 1 0 0 1 Japan 0 1 0 0 1 Jordan 2 3 4 3 12 Kenya 0 1 0 2 3 Lebanon 0 1 0 1 2 Lithuania 1 0 0 0 1 Malaysia 0 0 0 1 1 Nepal 0 1 0 1 2 Nigeria 0 2 0 2

(1 via United Kingdom)

4

Pakistan 1 1 1 0 3 Philippines 6 63 46 43 158 Philippines and Canada

0 0 0 1 1

Poland 1 0 0 0 1 Portugal 0 1 0 0 1 Romania 4 4 1 1 10 Serbia 0 1 1 0 2 Slovakia and Canada

0 0 1 0 1

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Taiwan 1 0 0 0 1 Thailand 0 0 2 2 4 South Korea 1 3 0 2 5 Sweden 0 0 0 1 1 Uganda 0 0 0 1 1 Ukraine 0 0 1 1 2 United States 0 2 0 4 6 Zimbabwe 0 2 0 0 2 Total 35 166 89 161 451

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



N/A 20 0 0 0 20 Argentina 1 0 0 0 1 Bulgaria 0 0 1 1 2 Cameroon 0 1 0 1 2 Canada 0 2 0 2 4 China 2 10 4 2 18 Columbia 0 1 1 1 3 Croatia 1 0 0 1 2 Ethiopia 1 0 0 1 2 Haiti 0 2 0 0 2 India 2 42 21 79 120 Iran 0 6 1 3 10 Iraq 0 0 1 0 1 Ireland 0 0 1 0 1 Israel 0 2 0 0 2 Ivory Coast 0 0 0 2 2 Jamaica 0 1 0 0 1 Japan 0 1 0 0 1 Jordan 0 3 3 3 9 Kenya 0 2 0 2 4 Lebanon 0 1 0 1 2 Mexico 0 1 0 0 1 Nepal 0 1 0 1 2 Nigeria 0 3 0 3 6 Pakistan 0 1 1 0 2 Philippines 3 63 45 43 154 Portugal 0 1 0 0 1 Qatar 0 1 0 0 1 Romania 3 5 2 2 12 Russia 1 0 0 0 1 Serbia 0 1 1 0 2 Slovakia 0 0 1 0 1 South Korea 1 3 1 2 7 Sri Lanka 0 1 0 0 1 Sweden 0 0 0 1 1 Thailand 0 0 2 2 4 Uganda 0 0 0 1 1 Ukraine 0 0 3 1 4 United Kingdom

0 0 0 5 5

United States 0 0 0 1 1 Zimbabwe 0 3 0 0 3 Total 35 166 89 161 451

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The majority of participants reported high school as their highest level of non-nursing education, although some had degrees or diplomas (see Table 9). Table 9. Participants' Highest Level of Non-Nursing Education in Country of Origin

Level of Education Year One to Year Three

Year Four Year Five Year Six

Totals

High school 0 120 70 131 316 College/diploma 2 6 2 2 12 University – BA/BSc 11 22 10 17 60 University - MA, MBA, post graduate

1 4 3 1 9

Medical doctor/dentist 0 3 1 3 7 Dentistry - unspecified 0 0 2 0 2 Pre-degree 0 8 1 1 10 Other - certificate/ diploma

0 2 0 6 8

Not clearly specified 0 1 0 0 1 N/A 21 0 0 0 21 Total 35 166 89 161 451

As shown in Table 10, most participants reported their immigration class as independent professional or family sponsored. The majority of participants were permanent residents or Canadian citizens (see Table 11). Table 10. Participants' Immigration Class

Immigration Class

Year One to Year Three

Year Four Year Five Year 6 Totals

Independent - professions/ Skilled trades

16 96 51 116 279

Family sponsored

15 34 25 33 107

Convention refugee

1 7 1 1 10

*Work permit 1 9 3 1 14 Live-in caregiver

1 19 9 7 36

Born in Canada

1 1 0 1 3

Student visa 0 0 0 2 2 Total 35 166 89 161 451

*In process of obtaining permanent resident status.

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Table 11. Participants' Immigration Status

*In process of obtaining permanent resident status. Most of the participants had migrated after 2000, the majority between 2006 and 2010 (see Table 12). Table 12. Participants' Years of Migration

Year Year One to Year Three


1990-1995 2 2 0 0 4 1996-2000 3 1 4 4 11 2001-2005 6 16 7 11 40 2006-2010 18 84 35 32 169 2011 6 40 17 17 80 2012 0 22 21 48 71 2013 0 0 5 39 44 2014 0 0 0 10 10 In process 0 1 0 0 1 Total 35 166 89 161 451

The majority of participants who had practiced prior to migration had between one and five years of experience (see Table 13). However, since coming to Canada, most had not practiced for one to five years (see Table 14). Table 13. Participants' Years of Experience Prior to Migration

Years Year One to Year Three


>1 4 13 2 6 25 1-5 6 47 33 60 146 6-10 10 41 23 48 122 11-15 7 24 8 27 66 16-20 2 16 7 9 34 20+ 0 7 1 3 11 N/A 7 18 15 8 48 Total 35 166 89 161 451

Status Year One to Year Three


Canadian citizen

10 29 14 15 68

Permanent resident

24 108 68 142 342

*Work permit 1 25 7 4 37 Convention refugee

0 4 0 0 4

Total 35 166 89 161 451

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



>1 5 21 15 11 52 1-5 6 108 59 129 302 6-10 2 7 6 13 28 10+ 1 1 4 2 8 N/A 21 29 5 6 61 Total 35 166 89 161 451

As shown in Table 15, most participants had not worked as nurses in Canada. Of those who had, the majority had worked for less than six years. A number of nurses had worked outside their own country and Canada (see Table 16). Table 15. Participants' Length of Practice in Canada



>1 5 21 10 9 45 1-5 6 15 3 7 31 5+ 3 0 1 1 5 N/A or 0 21 130 76 144 370 Total 35 166 89 161 451

Table 16. Participants' Employment Locations outside Canada

Location Year Four Year Five Year Six Abu Dhabi 0 0 2 Bahrain 1 0 0 Bermuda 1 0 0 China & Singapore 1 0 0 Dubai 0 3 0 Dubai & United Arab Emirates 2 1 0 Hungary 1 0 0 Ireland 1 0 1 Israel 0 1 0 Jordan 0 1 0 Kuwait 4 0 5 Malaysia 0 0 2 Malaysia & Uganda 0 0 1 Maldives 1 0 0 Netherlands & England 0 0 1 Oman 1 0 2 Qatar 1 0 0 Qatar, California, England 1 0 0 Saudi Arabia 24 12 12 Saudi Arabia & United Arab Emirates 1 0 1 Singapore 1 2 2 Spain 0 1 0 Swaziland 1 0 0 United Arab Emirates 0 2 5 United Arab Emirates & Dubai 0 0 0

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United Arab Emirates & United States 0 1 0 United Kingdom 0 0 1 United States 3 0 5 Viet Nam, Sri Lanka, South Africa, Ethiopia & Sudan 1 0 0 Yemen &Saudi Arabia 1 0 0 Total 48 24 40

All participants had CNO safe practice. By the end of the 2014-2015 year, the majority had passed their registration examinations (see Table 17).

Table 17. Participants' Examination Status at Project End

Status Year One to Year Three


Passed CRNE 12 40 10 17 79 Passed CPNRE 14 78 54 112 258 Passed CRNE and CPNRE

0 7 3 4 14

Not yet passed 9 41 22 28 100 Total 35 166 89 161 451

Note. CRNE=Canadian Registered Nurse Examination; CPNRE=Canadian Practical Nurse Registration Examination. The majority of participants had completed registration (see Table 18). In year four, 85 had permanent registration, 2 had temporary registration, 4 were pending and the remainder had not yet registered. In year five, 42 had permanent registration and 2 were pending. The remainder had not yet registered. In year six, 57 had permanent registration, 1 had temporary registration and 103 had not registered. Table 18. Participants' Registration Status

Status Year One to Year Three/At End of

Year

Year Four Year Five Year Six

Registered as RN 10 38 7 5 Registered as RPN 17 53 32 44 Registered as RN and RPN

0 3 1 2

Eligible to register as RN

2 10 6 14

Eligible to register as RPN

5 45 38 74

Eligible to Register as RN and RPN

1 15 5 22

Not eligible to register

0 2 0 0

Total 35 166 89 161

Many participants were members of the BIEN program. Some had joined CARE and some were engaged in both programs. In 2012-2013, 4 participants were in the BIEN program and 11 had joined CARE. Fifteen were members of both BIEN and CARE. Thirty-nine were in BIEN, CARE or both but did not specify. In 2013-2014, 15 participants were in the BIEN program and 56 had joined CARE. Twenty-two were members of both BIEN and CARE. Of

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these, one was in the George Brown College bridging program. In 2014-2015, 22 participants were members of BIEN, 26 had joined CARE and 24 were in BIEN and CARE. Since the beginning of the project, 38 participants have obtained placements at HHS. Twelve participants who joined the project in 2014-2015 completed placements in the current year or in previous years at the following sites: • HGH, neurosurgery • HGH and Bayshore Home Health • HGH, Stroke Unit and St. Peter's Hospital, Palliative Care Unit • Juravinski (2) • Juravinski and St. Peter's Hospital (2) • Juravinski and HGH • McMaster University Medical Centre • Oakville Hospital, surgical • St. Joseph's Hospital • St. Peter's Hospital

CLINICAL INTEGRATORS Forty-two CIs were recruited in years one to three. Four exited, leaving 38. An additional 26 joined the project in year four. Twenty-one joined in year five and 26 joined in year six. At the end of year six, 109 of 113 CIs remained in the project. Eleven of the CIs were men, including four who joined in year six. The CIs ranged from less than 24 to over 55 years of age (see Table 19) and fell into one of four categories (see Table 20). The CIs were referred to the project by various sources (see Table 21). Table 19. Age of Clinical Integrators

Age Range Year One to Year Three*


18-24 2 0 0 1 3 25-44 19 20 18 20 77 45-54 13 6 2 5 26 55+ 8 0 1 0 9 Total 42 26 21 26 115

Table 20. Clinical Integrator Categories

Time IEN & ESL IEN & EFL EFL ESL Educated in

Canada

Total


20 2 9 11 42

Year Four 15 2 8 1 26 Year Five 12 1 5 3 21 Year six 20 0 5 1 26 Total 67 5 27 15 115

38

Table 21. Clinical Integrator Project Referrals

Reference Year One to Year Three


Hospital staff 37 20 16 25 97 Academic advisor

1 1 0 0 2

Community 1 2 4 0 7 Others 2 1 0 0 3 Self-referred 1 2 1 1 6 Total 42 26 21 26 115

Similar to the project participants, the CIs received their nursing education in various countries (see Table 22). The majority had completed a four-year BScN (see Table 23) and almost all had completed their non-nursing education in their countries of origin (see Table 24). Table 22. Clinical Integrators' Country of Nursing Education



Australia 1 0 0 0 1 Bosnia-Herzegovina 2 0 0 0 2 Canada 23 9 7 5 44 Canada/China 0 0 1 0 1 Canada/United States 1 0 1 0 2 China 0 2 1 3 6 Croatia 2 0 0 0 2 El Salvador 1 0 0 0 1 England 0 1 0 0 1 Ethiopia 0 0 0 1 1 Haiti 0 0 0 1 1 Hungary 1 0 0 0 1 India 3 4 2 4 13 Iran 1 1 0 1 3 Ireland 0 1 0 0 1 Jamaica 0 0 1 0 1 Nepal 0 0 1 0 1 Philippines 3 3 5 4 15 Philippines/Canada 1 0 0 0 1 Poland 2 2 0 0 4 Republic of Moldova 0 1 0 0 1 Romania 1 1 2 3 7 Serbia 0 1 0 0 1 Slovakia 0 0 0 1 1 South Korea 0 0 0 2 2 Ukraine 0 0 0 1 1 United States 1 0 0 0 1 Yugoslavia 2 0 0 0 2 Total 42 26 21 24 115

39

Table 23. Clinical Integrators' Highest Level of Nursing Education

Education Year One to Year Three


BScN 1 year 1 0 0 0 1 BScN 2 years 1 2 1 0 4 BScN 3 years 1 1 0 4 6 BScN 4 years 11 16 11 8 46 BScN 5 years 0 0 1 0 1 BScN - not specified

0 0 0 0 0

RN diploma 2 years 6 5 0 0 11 RN diploma 3 years 7 0 0 0 7 RN diploma 4 years 6 1 4 0 11 RN diploma - not specified

3 0 0 7 10

RN not specified 0 0 0 1 1 Post graduate 5 0 2 2 8 RPN diploma 2 years

1 0 0 0 1

RPN diploma - not specified

0 1 2 4 7

Total 42 26 21 26 115 Table 24. Clinical Integrators' Country of Highest Level of Non-Nursing Education



Afghanistan 0 0 0 1 1 Canada 1 1 6 1 9 China 0 3 2 4 9 England 0 1 0 0 1 Ethiopia 0 1 0 1 2 Haiti 0 0 0 1 1 Ghana 0 1 0 0 1 India 1 4 1 5 111 Iran 0 2 0 1 3 Nepal 0 0 1 0 1 Kenya 0 1 0 0 1 Netherlands 0 1 0 0 1 Philippines 1 3 6 4 14 Poland 1 2 0 0 3 Republic of Moldova

0 1 0 0 1

Romania 1 1 3 3 8 Serbia 0 1 0 0 1 Slovakia 0 0 0 1 1 South Korea 0 1 0 2 3 Togo 0 1 0 0 1 Nepal 0 0 0 0 0 Zimbabwe o 1 0 0 1 Jamaica 0 0 1 0 1 Ukraine 0 0 0 1 1 N/A 37 0 0 0 37 Total 42 26 21 26 115

40

Fourteen CIs reported tertiary education other than nursing: 5 in year one to year three, 5 in year four, 4 in year five and 7 in year six. Education included an MA in leadership, an MA in psychology, medical degrees (4), a BA in economics (2), a BA in commerce, a BSc in agribusiness, a Bachelor of Education and unspecified university degrees (2). Others CIs had two years of teachers college, a BSc in chemistry and physics, a degree in English and French, a diploma in plastics engineering, a diploma in accounting and experience as a lab technician Most CIs entered Canada as family sponsored or independent professionals (see Table 25). Sixty-five CIs were Canadian citizens, 24 were permanent residents and 1 was in the process of becoming a permanent resident (see Table 26). Two-thirds of the CIs entered Canada before 2006 (see Table 27). Table 25. Clinical Integrators' Migration Status

Category Year One to Year Three


Convention refugee 2 2 0 2 6 Family sponsored 21 10 5 8 44 Independent professional

7 11 12 13 43

Landed immigrant 1 0 0 0 1 Student visa 0 1 0 1 1 Work permit 0 1 0 1 (skilled

worker) 2

Permanent resident status in process

0 0 1 0 1

N/A 11 1 3 1 16 Total 42 26 21 26 115

Table 26. Clinical Integrators' Immigration Status

Category Year One to Year Three

Year Four

Year Five Year Six Totals

Canadian citizen 39 14 11 9 73 Permanent resident 2 12 8 17 39 Permanent resident status in process

0 0 1 0 1

N/A 1 0 1 0 2 Total 42 26 21 26 115

Table 27. Clinical Integrators' Year of Migration to Canada

Year Year One to Year Three


Before 1991 11 1 1 0 13 1991-1995 4 1 1 1 7 1996-2000 9 0 3 2 14 2001-2005 4 14 3 6 27 2006-2010 2 9 8 11 30 2011-2014 0 0 2 5 7 NA 12 1 3 1 17 Total 42 26 21 26 115

41

One CI from the year one to year three group had worked in the United Arab Emirates. Another from the same group had worked abroad but did not specify the country of employment. One CI from year five had worked in the United States. One CI from year six had previously worked in Dubai, 1 had worked in the United States and 1 had worked in New Brunswick. Forty-seven CIs had no nursing experience before arriving in Canada, while 21 had more than 10 years of experience (see Table 28). Table 28. Clinical Integrators' Nursing Experience Before Arriving in Canada



<1 0 2 1 3 6 1-5 7 6 3 6 22 6-10 5 4 5 4 18 10+ 8 5 3 6 22 N/A 22 9 9 7 47 Total 42 26 21 26 115

Forty-four CIs found the question about the number of years they had not worked as a nurse in Canada after migration as not applicable. Of the remainder, 4 had not worked as a nurse for one year or less and 3 had not worked as a nurse for 10 years or more (see Table 29). Table 29. Clinical Integrators' Years Not Worked as a Nurse in Canada



<1 year 2 1 1 0 4 1-5 13 10 11 17 51 6-10 4 6 2 3 15 10+ 2 1 0 0 3 N/A 21 8 7 6 44 Total 42 26 21 26 115

Eighteen CIs found the question about how long they had worked in Canada since migration as not applicable. Of the remainder, 54 had worked as a nurse in Canada for five years or less and 10 had worked as a nurse for more than 20 years (see Table 30). Table 30. Clinical Integrators' Time Working as a Nurse in Canada



1-5 8 18 11 19 56 6-10 12 4 2 4 22 11-15 2 1 1 2 6 20 2 0 1 0 3 20+ 6 2 2 0 10 N/A 12 1 4 1 18 Total 42 26 21 26 115

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Most of the CIs worked at HHS, the majority at either Hamilton General Hospital or the Juravinski Hospital. Seventeen did not work for HHS (see Table 31). Table 31. Clinical Integrators' Place of Employment

Site Year One to Year Three


Juravinski Hospital

13 12 5 4 34

Juravinski Cancer Centre

0 1 0 1 2

Hamilton General Hospital

21 10 4 6 41

McMaster Children's Hospital

4 1 3 0 8

St Peter's Hospital

1 2 1 4 8

Chedoke Hospital

2 0 0 1 3

All sites 1 0 1 0 2 Other HHS 1 0 0 0 1 Non-HHS 0 0 7 10 17 Total 42 26 21 26 115

Note. Only the first of multiple jobs is included. In terms of employment status, 77 CIs had permanent full-time, 6 had temporary full-time, 14 had permanent or regular part-time, 3 had occasional part-time and 4 had casual part-time (see Table 32). Four CIs left employment at HHS during the project: 1 from the year one to year three group, 1 from the year four group, 1 from the year five group and 1 from year six group. Table 32. Clinical Integrators' Employment Status

Employment Status



CPT 0 2 2 0 4

OPT 1 0 1 1 3

PFT 40 18 10 9 77

PPT 0 0 3 9 12

RPT 0 1 1 0 2

TFT 1 4 0 1 6

TPT 0 0 1 0 1

Missing 0 1 0 0 1

N/A 0 0 3 6 9

Total 42 26 21 26 115

Note. CPT=casual part-time; OPT=occasional part-time; PFT=permanent full-time; PPT=permanent part-time; RPT=regular part-time; TFT=temporary full-time; TPT=temporary part-time.

43

RESULTS

BASELINE TESTING: INSTITUTIONAL CELBAN (I-CELBAN) The CNO only accepts scores from CELBAN tests that have been administered at a recognized CELBAN site. It does not accept scores from CELBAN tests that have been administered by academic institutions for educational purposes. Twenty-eight participants took I-CELBAN tests during 2014-2015 to gauge their level of proficiency before taking the CELBAN test at a CELBAN site. One took the test twice. The CNO requires a score of 7 for writing, 8 for speaking and reading and 10 for listening. Seven tests met or surpassed these scores. Another 11 tests included one or more scores one grade lower than CNO requirements. Eleven tests showed one or more scores with two or more grades lower than CNO requirements. These results suggest that many participants require assistance to achieve the required standards.

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. Instruction focuses on introducing, managing and ending a nurse-client interview; intercultural communication; documentation and reporting; communicating assertively with clients and colleagues; lay vs. technical vocabulary; telephone communication; therapeutic communication; and health teaching. 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. The format of the course has changed from year one to year six (i.e., over the course of the three-year pilot project and the three-year project). To accommodate as many participants as possible, class schedules are negotiated at the beginning of each session. The best scheduling option for the most recent cohort was six one-hour classes given once a week for 16 weeks. Classes ran from 9:30 AM to 3:30 PM to assist students using public transit. Table 33 shows registration and attendance for the three sessions taught in 2014.

Table 33. LCN3 Registration and Attendance

Participant Status April 3 to July 17, 2014

August 7 to November 20, 2014

August 8 to November 21, 2014

Registered 35 34 29 No shows 2 2 1 Attendance 33 32 28

The majority of attendees were unemployed or employed outside nursing (see Table 34). Table 34. LCN3 Participant Status

Participants and Employment Status

April 3 to July 17, 2014

August 7 to November 20,

2014

August 8 to November 21,

2014 IENs

Employed at HHS 0 1 0 Employed outside HHS 2 0 0 Employed in non-nursing outside HHSC

11 9 10

Not employed 18 19 17

44

ESLs Employed at HHS 0 1 0 Employed outside HHS 0 0 1 Not employed 2 1 0 Total 33 32 28

Note. HHS=Hamilton Health Sciences; HHSC=Hamilton Health Sciences Corporation. Approximately one-half to two-thirds of registrants received a Certificate of Completion (see Table 35). Reasons provided for low attendance or withdrawal from the course included work schedule conflicts, distance from the site, preparation for the national exam, family illness/bereavement and personal illness.

Table 35. LCN3 Course Attendance

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 the nine tasks listed in Table 36. The assessment results were tabulated, averaged and summarized. The respondents reported considerable improvement overall. Table 36. Summary of Completed Assessments 2014-2015

Communication Tasks Course One Pre

Average N=20

Course One Post

Average N=20

Course Two (1)

Pre Average N=2424

Course Two (1)

Post Average

N=24

Course Two (2)

Pre Average

N=20

Course Two (2)

Post Average

N=20 Nurse-Client Interview 3.1 4.6 3.2 4.5 3.1 4.5 Document Progress Notes 2.9 4.3 2.9 4.3 3.2 4.6 Give Verbal Reports 2.9 4.6 3.1 4.5 3.5 4.6 Receive Verbal Reports 2.7 4.6 3.5 4.4 3.5 4.6 Make and Receive Telephone Calls

2.7 4.2 2.7 4.3 3.5 4.6

Receive Doctors' Orders 2.8 4.4 2.6 4.2 3.3 4.0 Health Teaching 3.1 4.5 3.0 4.4 3.2 4.4 Therapeutic Listening and Responding

3.3 4.5 3.3 4.4 3.1 4.5

Communicate Assertively with Colleagues and Clients

2.8 4.4 2.9 4.7 3.3 4.5

Average 2.9 4.6 3.0 4.4 3.3 4.4

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

Attendance April to July 2014 Session

April to October 2014 Session 1

April to October 2014 Session 2

Number of registrants 35 34 29 > 50% attendance (withdrawal) 6 (18%) 4(12%) 5(18%) 50-69% attendance Certificate of Participation

6(18%) 1(3%) 1(3%)

Certificate of Attendance 70-84% attendance

4(12%) 5(16%) 5(18%)

Certificate of Completion 85%+ attendance

17 (52%) 22(69%) 17(61%)

Total 33 32 28

45

Participants' Evaluation Participants completed a course evaluation questionnaire (see Table 37). The majority indicated the course was excellent. Table 37. Course Evaluation Results

Course One (N=21)

Course Element 1 2 3 4 5 Course content 0 0 1 7 13 Audio and video materials 0 1 3 9 8 E-learning lab materials 0 2 3 7 9 Your learning experience in this class 0 0 3 5 13 Opportunity for participation and discussion 0 0 2 5 14 Class schedule 0 1 2 7 11 Length of breaks (30 minutes) 0 0 0 7 14 Fairness of evaluation methods 0 0 2 4 15 Instructor's knowledge of communication skills 0 0 2 3 16 Instructor's presentation of the material 0 0 3 3 15 Helpfulness of instructor 0 0 3 2 16

Course Two (1) (N=28)

Skill Area 1 2 3 4 5 Course content 0 0 0 10

(36%) 18

(64%) Audio and video materials 0 1

(4%) 4

(14%) 18

(34%) 5

(18%) E-learning lab materials 0 0 3

(11%) 9

(32) 16

(57%) Your learning experience in this class 0 0 0 5

(19%) 23

(92%) Opportunity for participation and discussion 0 0 0 2

(7%) 26

(93%) Class schedule 0 0 0 7

(25%) 21

(75%) Length of breaks (30 minutes) 0 1

(4%) 0 5

(18%) 22

(78%) Fairness of evaluation methods 0 0 0 5

(18%) 23

(82%) Instructor's knowledge of communication skills 0 0 0 2

(7%) 26

(93%) Instructor's presentation of the material 0 0 0 2

(7%) 26

(93%) Helpfulness of instructor 0 0 0 2

(7%) 26

(93%) Course Two (2)

(N=20) Course content 0 0 0 4

(20%) 16

(80%) Audio and video materials 0 0 3

(15%) 12

(60%) 4

(20%) E-learning lab materials 0 0 0 8

(40%) 12

(60%) Your learning experience in this class 0 0 0 6

(30%) 14

(70%) Opportunity for participation and discussion 0 0 1

(5%) 5

(25%) 14

(70%)

46

Class schedule 0 0 0 7 (35%)

13 (65%)

Length of breaks (30 minutes) 0 0 0 7 (35%)

12 (60%)

Fairness of evaluation methods 0 0 0 2 (10%)

18 (90%)

Instructor's knowledge of communication skills 0 0 1 1 (5%)

19 (95%)

Instructor's presentation of the material 0 0 1 (5%)

2 (10%)

17 (85%)

Helpfulness of instructor 0 0 0 6 (30%)

14 (70%)

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: • Being pushed beyond their comfort zone • Interacting with other IENs • The learning experience - documentation; communication, including interacting with

clients, colleagues and others; being assertive; health teaching; medical terminology; the Canadian healthcare system

• The quality of teaching/resources - motivation of instructor, use of realistic scenarios, E-learning lab, handouts

They made the following recommendations for change: • Better audio and visual equipment • Better management of E-learning lab (e.g., improved tech support) • Longer course or adjusted timetable • More comfortable chairs and tables • More E-learning lab and video materials • More handouts

Instructor's Progress Report The instructor reported on the participants' progress in key skill areas (see Table 38) and evaluated their overall progress in both courses. Table 38. Assessment of Participants' Progress

Course One (N=22)

Skill Area Level 2 Level 3 Level 4 Level 5 Speaking accuracy: Ability to use correct grammar and word choice

2 (9%) 15 (68%) 5 (23%) 0 (0%)

Speaking fluency: Ability to get your meaning across while maintaining a fluid and coherent flow of conversation

0 (0%)

7 (32%) 14 (64%) 1 (4%)

Pronunciation: Ability to speak clearly and comprehensibly to others

3 (14%)

6 (27%) 11 (50%) 2 (9%)

Listening comprehension: Ability to understand main ideas and relevant details in conversation

1 (4.5%) 5 (23%) 15 (68%) 1 (4.5%)

Writing proficiency: Ability to write logical, coherent and grammatically accurate text when documenting

1 (4.5%) 10 (45.5%) 11 (50%) 0 (0%)

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Socio-cultural proficiency: Ability to interact according to commonly accepted cultural norms and expectations

0 (0%) 8 (36%) 12 (55%) 2 (9%)



0 (0%) 14 (50%) 13 (46%) 1 (4%)


0 (0%) 3 (11%) 22 (78%) 3 (11%)


0 (0%) 5 (18%) 20 (71%) 3 (11%)


0 (0%) 1 (4%) 24 (85%) 3 (11%)


0 (0%) 21 (75%) 7 (25%) 0 (0%)


0 (0%) 4 (14%) 19 (68%) 5 (18%)



0 (0%) 7 (32%) 15 (68%) 0 (0%)


0 (0%) 2 (9.0%) 20 (91%) 0 (0%)


0 (0%) 5 (23%) 16 (73%) 1 (4%)


0 (0%) 1 (4%) 19 (87%) 2 (9%)


0 (0%) 15 (68%) 7 (32%) 0 (0%)


0 (0%) 4 (18%) 14 (94%) 4 (18%)

Note. 1=not consistent, 2=fairly consistent, 3=somewhat consistent, 4=consistent, 5=very consistent. The instructor commented that the withdrawal rate decreased and the number of participants who attended 85% or more of the classes increased. She suggested that to allow participants to fully engage in classroom activities and achieve optimum benefit, future registration for each class should not exceed 20, with 16-18 participants being the ideal number. Alternatively, a larger classroom would be needed to accommodate participants.

Overall, the instructor felt the courses had been successful in helping participants acquire communication skills to facilitate their integration into the healthcare system in Ontario. She noted that the students had reported greater self-confidence and had made substantial progress in conducting effective assessment interviews, using listening techniques and asking appropriate questions. They had 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.

48

BIEN LEARNING RESOURCE CENTRE SIMULATION LABORATORY Six information sessions were provided in 2014-2015 and were open to all participants (see Table 39). Anyone needing further practice was able to access the lab more than once. Table 40 shows an average of the participants' pre- and post-confidence scores: 1=not confident, 2=not very confident, 3=somewhat confident, 4=confident and 5=very confident. Participants across the three years of the study were confident before the sessions. Consequently, the post-confidence scores were only slightly higher than the pre-confidence scores. Table 39. Learning Resource Centre Information Session Attendance

Session Date Number of Sessions Number of Attendees June 26, 2014 1 4 (Group 1) July 17, 2014 1 6 (Group 1) Sept 23, 2014 1 5 (Group 1) November 18, 2014 2 Session 1: 4 (Group 1=3, Group 2=1)

Session 2: 4 (Group 1) February 6, 2015 2 Session 1: 5 (Group 1)

Session 2: 3 (Group 1) Total 7 31

Table 40. Participants' Confidence Scores for Simulation Laboratory

Session Pre 2012-2013 N-87

Post 2012-2013 N=45

Pre 2013-2014 N=89

Post 2013-2014 N=24

Pre 2014-2015

N=147

Post 2014-2015 N=34

A. Cardiovascular C2 (7 subcategories) N=87/

4.41 4.58 4.2 4.63 4.22 4.54

B. Respiratory C1 (8 subcategories)

4.31 4.45 3.96 4.68 4.22 4.43

C. Central Nervous System (i) Glasgow Coma Scale

3.69 4.27 3.65 4.36 3.89 4.53

HCCI CULTURAL AWARENESS TRAINING WORKSHOP The workshop was facilitated by the manager of HCCI and a CARE language instructor. It was held on February 20, 2015 at Chedoke Hospital and attended by 19 participants and 1 CM/delegate. Based on the participants' evaluations, the workshop was well received and highly rated (see Table 41). Table 41. Workshop Evaluation (N=19)

Did the course Not at all Somewhat Mostly Completely Missing Data

Deepen your understanding of diversity and inclusion

0 1 7 11 0

Cause you to review your personal frames of reference, biases and ladders of inference

0 1 4 14 0

Cause you to reflect upon your communication style

0 2 4 13 0

Provide strategies for cross cultural communication and conflict resolution

0 1 6 11 1

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

0 2 4 12 1

Do you agree Not at all Somewhat Mostly Completely Missing Data

The material presented was relevant to your needs

0 1 2 16 0

You will be able to apply the strategies recommended to your practice

0 1 5 13 0

How do you rate Poor Adequate Good Excellent Missing Data

The course overall 0 0 1 18 0 The presenter 0 0 1 18 0 The group exercises 0 2 4 13 0 The usefulness of the case study 0 1 4 14 0 The handouts 0 1 4 12 2

Participants indicated the workshop provided information about diversity, Canadian culture, overcoming barriers, caring for clients in ethnically diverse contexts and reflecting on biases and preconceptions (see Table 42). They also made positive comments about the instructor's teaching style and knowledge. Suggested improvements included a longer session, greater student involvement though sharing experiences and more visual aids (e.g., video scenarios). Table 42. Assessment of Information (N=19)

Did the workshop provide you with Yes Somewhat Missing Data

An understanding of equity and inclusion concepts? 18 1 0 An understanding of the social and cultural pressures that impact on IEN or ESL nurses new to healthcare system?

17 2 0

A useful equity lens that can be used in assessing workplace environments? 16 2 1 Insights on how to help staff overcome barriers to inclusion? 18 1 0 Strategies to engage staff in creating positive and welcoming workplace environments?

17 2 0

An understanding of how to develop and use a culturally proficient approach in working with nurses from different backgrounds and training?

17 1 1

A second questionnaire was distributed three months after the workshop. Most of the respondents reported that what they had learned was applicable to their work environments (see Table 43). Table 43. Follow-up Questionnaire (N=12)

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 3 9

Improve your ability to communicate cross cultural situations

0 0 3 9

Avoid or deal with conflict in cross-cultural situations 0 0 2 10 Adopt an inclusive approach to nursing, patient care and counselling

0 0 3 9

50

HHS JOB COACHING/MOCK INTERVIEW PREPARATION From 2012 to 2015, 186 participants took part in mock interviews. There were 75 participants in 2012-2013, 51 in 2013-2014 and 60 in 2014-2015. One participant attended two sessions in 2014-2015 (see Table 44). During the three years of the project, 73 participants had a previous interview in Canada (see Table 45). Table 44. Number of Interviews by Month 2014-2015

Month Number of Interviews

Month Number of Interviews

April 2014 11 October 2014 6 May 2014 6 November 2014 3 June 2014 6 December 2015 3 July 2014 4 January 2015 5 August 2014 0 February 2015 5 September 2014 5 March 2015 7 Total 32 Total 29

Table 45. Participant Interviews in Canada

Year One Two Three Yes 39 23 11 No 48 17 29 Total 88 40 25

When asked what they would like to gain from the mock interview, participants cited the following: • Being prepared • Discovering Employer expectations • Familiarity with likely questions and relevant answers • Gaining skills in answering questions • Increased confidence • Knowing what to expect • Learning interview procedures • Professional presentation of self Prior to the intervention, participants had relatively little confidence that they would be successful in an interview. Following the intervention, most participants were either confident or very confident (see Table 46). Table 46. Pre- and Post-Intervention Confidence Ratings for Interviews

Year Not Confident

Not Very Confident

Somewhat Confident

Confident Very Confident

2012-2013 Pre-confidence (N=87) 5 26 34 17 4 2012-2013 Post-confidence (N=25) 0 0 0 16 9 2013-2014 Pre-confidence (N=38) 2 10 16 10 0 2013-2014 Post-confidence (N=35) 0 0 2 23 10 2014-2015 Pre-confidence (N=23) 2 5 12 4 0 2014-2015 Post-confidence (N=28) 1 0 3 14 10

Participants were asked what they liked about the interview, what they did not like and what could be improved. Their responses are provided in Table 47.

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Table 47. Qualitative Assessment of Interviews

Liked Not Liked Could be Improved

• Informative • Easy to understand • Good explanations with

examples/scenarios • Systematic approach • Enhanced confidence

No negative comments • More time and sessions • Less distracting environment • Use of simulations and

videotaping

Overall, participants rated the presentations highly (see Table 48). Table 48. Presentation Evaluation

Question 2012-2013 (N=79)

2013-2014 (N=37)

2014-2015 (N=31)

How do you rate the instructor’s presentation? (Difficult=1 > Easy to Understand=5)

3=1 3=0 3=0 4=4 4=2 4=2

5=74 5=33 5=27 Missing data=0 Missing data=2 Missing data=2

How do you rate the topics of presentation? (Not Informative=1 > Very Informative=5)

4=3 4=5 4=1

5=76 5=32 5=29 Missing data=0 Missing data=0 Missing data=1

Overall, how would you rate the presentation? (Poor=1 > Excellent=5)

4=3 4=6 4=1 5=76 5=31 5=29

Missing data=0 Missing data=0 Missing data=1 Should this presentation remain in the training modules?

Yes=77 Yes=37 Yes=31 No=2 No=0 No=0

Missing data=0 Missing data=0 Missing data=0 The majority of participants indicated they received support during their mock interviews (see Table 49). Table 49. Interview Support Ratings

Year Support Received Yes No

One 81 0 Two 39 1 Three 34 0 Total 154 1

Twenty-nine participants were offered jobs at HHS and 64 were offered jobs at other institutions (see Table 50). Table 50. Interviews and Job Offers

Year Interview at HHS

Other Job Interview

Job Offer at HHS

Job Offer Outside HHS

One 19 47 25 39 Two 5 23 3 15 Three 3 18 1 10 Total 27 88 29 64

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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 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 51). Table 51. Pre- and Post-Intervention Confidence Ratings for HHS/CNO

Year Not Confident

Not Very Confident

Somewhat Confident


2012-2013 Pre-confidence (N=166)

15 16 26 65 44

2012-2013 Post-confidence (N=166)

0 0 0 19 116


5 6 21 35 22


0 0 0 5 84


6 8 33 78 36


0 0 0 6 155

HHS SHAREPOINT WEBSITE The website is used by participants, CIs, CMs and the public. A blog for the IEN/ESL network has been created and a discussion board is available. The website has been updated with a general user name and password. In 2014-2015, as in previous years, the participants indicated a much higher level of confidence in the post-questionnaire. Almost all described themselves as very confident after being shown how to use the website (see Table 52). Table 52. Pre- and Post-Intervention Confidence Ratings for HHS Website

Year Not Confident

Not Very Confident

SomewhatConfident


2012-2013 Pre (N=165) 21 17 31 57 39 2012-2013 Post (N=165) 0 0 0 31 134 2013-2014 (N=89) 8 16 26 27 22 2013-2014 (N=89) 0 0 0 10 75 2014-2015 Pre(N=161) 8 9 36 69 38 2014-2015 Post (N=161) 0 0 0 14 147

HHS N3 NETWORKING PROGRAM: NURSES NURTURING NURSES The project expanded the existing N3 program to create an HHS network for IEN/ESL nurses that allowed them to provide support for one another and communicate about professional practice issues, integration, inclusion and cultural diversity. Thirty-five partnerships were established over the three years of the project, with 29 CIs working with 35 participants (see Table 53).

53

Table 53. Participant and Clinical Integrator Dyads 2012-2015

Month Partnerships Established 2012-2013

Partnerships Established 2013-2014

Partnerships Established 2014-2015

April 4 0 0 May 1 0 0 June 1 0 4 July 4 3 1 September 1 0 2 October 2 0 0 November 3 2 1 January 1 1 0 February 0 2 0 March 0 0 2 Total 17 8 10

When asked to rate their satisfaction with the dyads from 1 (very much) to 5 (not at all), participants and CIs indicated they were extremely satisfied (see Table 54). However, because fewer pairs completed questionnaires at 6 and 12 months than at 3 months, it was not possible to estimate the persistence of the partnerships over time. Table 54. Satisfaction with Dyads 2012-2015

Question Three Months P: N=34* CI N=33

Six Months P: N=34 CI: N=33*

Twelve Months P: N=25 CI: N=24*

To what degree does the N3 program assist you in developing supportive relationships?

1=32 2=1

1=31 2=2

1=33 1=34 1=30 1=29

To what degree does the N3 program contribute to your professional growth?

1=32 2=1

1=31 2=1 4=1

1=33 1=33 1=30 1=29

To what degree does the N3 program contribute to your personal growth?

1=32 2=1

1=31 3=1 2=1

1=33 1=33 1=30 1=29

To what degree does the N3 program enhance your ability to communicate with your nurse colleagues?

1=32 2=1

1=30 2=3

1=32 2=1

1=30 2=2 3=1

1=30 1=29

To what degree does the N3 program enhance your ability to communicate with patients?

1=32 3=1

1=30 2=2 3=1

1=32 3=1

1=32 3=1

1=30 1=29

To what degree does the N3 program enhance your ability to communicate with physicians?

1=31 2=2

1=29 2=2 3=1 5=1

1=32 2=1

1=32 2=1

1=30 1=29

To what degree does the N3 program enhance your ability to communicate with other healthcare providers?

1=32 3=1

1=31 2=1 5=1

1=32 2=1

1=32 3=1

1=30 1=28 2=1

To what degree does the N3 program enhance your ability to problem-solve work-related issues?

1=32 2=2

1=32 2=1 3=1

1=31 2=2

1=30 2=2 3=1

1=24 2=1

1=23 2=2

54

How satisfied are you with communication with your clinical integrator/ participant?

1=32 2=1

1=32 2=1

1=33 1=33 1=25 1=25

How satisfied are you with the discussions at your meetings with your clinical integrator/participant?

1=33 1=33 1=32 2=1

1=32 2=1

1=25 1=25

Note. P=Participants; CI=Clinical Integrators. * One CI had a partnership with two participants.

HHS PROFESSIONAL WORKPLACE EXPERIENCE AND INTEGRATION This intervention involved job shadowing, nursing orientation and career progression.

Job Shadowing Between 2011 and 2015, 20 participants were scheduled for job shadowing and 18 took part (see Table 55). Table 55. Job Shadowing Attendance*

Years Numbers Location 2011-2012 3 Juravinski, Medical Surgical=1

E3, Medical Surgical, Juravinski=1 C4, Oncology, Juravinski=1

2012-2013 5 Hamilton General Hospital, 6S, Trauma Surgery=1 E3, Medical Surgical, Juravinski=1 Hamilton General Hospital, Rehabilitation, B2 North=2 Juravinski, ICU and CICU=1

2013-2014 5 Juravinski, E3=3 Juravinski, F3=2

2014-2015 5 Juravinski, E3=2 Juravinski, F3=2 Juravinski, E3 and F3=1

Participants wrote a one-page summary of their experiences. Appendix D provides representative accounts from the 2014-2015 participants. The comments were overwhelmingly positive and were related to the following: • Friendly reception • Good unit orientation • Helpful and knowledgeable preceptors • Introduction to workplace practice and team relations • Opportunity to become familiar with Canadian medical terminology

Second Day of HHS General Nursing Orientation This event is held on the third week of each month and is available to 5 participants. Fifty-eight participants have attended since the beginning of the project (see Table 56). The intervention is not available during the summer because all available places are taken by NGG hires. Topics include vascular access therapy, senior friendly care, Alaris® pumps, glucose meter and chest drainage.

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Table 56. Second Day of HHS General Nursing Orientation Attendance

Date Number of Attendees

Group 1 Group 2 Group 3

May 2012 5 4 0 1 September 2012 5 5 0 October 2012 5 3 1 1 November 2012 3 3 0 0 December 2012 5 4 0 1 February 2013 1 0 1 March 2013 4 4 0 0 April 2013 4 4 0 0 May 2013 5 4 0 1 September 2013 5 3 0 2 November 2013 2 2 0 0 December 2013 2 2 0 0 January 2014 2 1 0 1 February 2014 2 2 0 0 November 2014 3 3 0 0 December 2014 2 2 0 0 March 2015 3 2 1 0 Total 58 48 2 8

Career Progression: Lunch and Learn Sessions Various topics were presented during the project, but they were not formally evaluated (see Table 57). Table 57. Lunch and Learn Session Attendance 2013-2015

Title Date and Location Presenter Number of Participants

Clinical Skills Wound Care Assessment & Management

June 25, 2014 HHS, Chedoke Site

Fariba Shahin, CI and HHS RN

Group 1=15

Quality Assurance Information Sessions for Nurses

October3, 2014 HHS, Chedoke Site

CNO Outreach Group 1=14 Group 3=1

Getting a Job Virtual Job Fair - HHS and Confederation College, Thunder Bay, ON

May 30, 2014 HHS, Chedoke Site

Group 1=6

Grand Canyon University - Academic Pathway to Further IEN/ESL Nursing Education

June 12, 2014 HHS, Chedoke Site

Yinka Ogundare, University Development Manager, International Division, Grand Canyon University, Arizona, USA

Group 1=36 Group 2=1 Group 3=1

CIs=3 Potential participants=3

OSCE Information Session

July 16, 2014 HHS, Chedoke Site

2 CIs and 1 PM Group 1=6 Group 2=2

OSCE Information Session I


2 CIs and 1 PM Group 1=3 Group 2=1

HHS and Confederation College Focus Group


Tim Kerbashian, Director of Planning and Development, Confederation College

Group 1=4

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Resume Review and Applying for Jobs

February 18, 2015 HHS, Chedoke Site

Daniela Beckford, PM Group 1=9 Group 2=1

Gaining Confidence Academic writing: How to write a scholastic paper

April 22, 2014 HHS, Chedoke Site

Gerry Benson, Faculty, McMaster University and HHS Clinical Instructor for BScN/CI

Group 1=6 Group 3=2

CIs=4

CARE Telephone Tactics Workshop

August 12, 2014 and August 19, 2014 CARE Centre for Internationally Educated Nurses, Hamilton, ON

Angi Gyongyver, CARE Language Instructor

Group 1=6

Academic Writing Skills, APA Format Workshop

HHS, Chedoke Site Andy Le, Research Assistant

Group 1=2


September 2, 2014 and September 9, 2014 CARE Centre for Internationally Educated Nurses


Group 1=12

Nursing Career OrIENtation Information Session

HHS, Chedoke Site Daniela Beckford, PM Group 1=14 Group 3=15


October 7, 2014 and October 28, 2014, CARE Centre for Internationally Educated Nurses


Group 1=6

Nursing Career OrIENtation Online Webinar

November 20, 2014 CARE and the Ministry of Health and Long-Term Care

Group 1=5 CIs=1

Best Care Agency Ltd., Job Interviews

November 5, 2014 HHS, Chedoke Site

Best Care Agency Ltd. Group 1=4

Listening to Others IEN/ESL Network - Christmas Celebration

December 19, 2014 HHS, Chedoke Site

IEN/ESL Network Group 1=11 Group 3=1

PROJECT EVALUATION: OVERALL RESULTS AND CONCLUSIONS This section focuses on the success of the project in meeting the numeric targets set by MCI/MCIIT. The participants' evaluations of the interventions 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.

MCI/MCIIT TARGETS

• Nurses assessed for eligibility: 180 • Participants accessing the project (a minimum of two interventions): 145 • Participants completing a significant component of the project (a minimum of four

interventions): 120 • Participants who become/remain employed as nurses: 120 • CIs completing training: 60 As shown in Table 58, all targets were exceeded. In 2014-2015, 89 participants remained in the project from the 2012-2013 intake and 73 remained from the 2013-2014 intake. An additional 161 participants joined the project, increasing the number of participants to 323.

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Table 58. Numeric Targets 2012-2015 Numeric Targets Targets Set Results Achieved

Nurses Assessed or Eligibility 2012-2013 60 228 2013-2014 60 248 2014-2015 60 213 Total 180 689

Participants Accessing the Project (a minimum of two interventions) 2012-2013 49 166 2013-2014 48 89 2014-2015 48 161 Total 145 416

Participants Completing a Significant Component of the Project (a minimum of four interventions)

2012-2013 40 109 2013-2014 40 76 2014-2015 40 132 Total 120 317

Participants who Become/Remained Employed as Nurses 2012-2013 40 73 2013-2014 40 68 2014-2015 40 58 Total 120 199

Participants Who Become/Remained Employed as Nurses by Employment Location 2012-2013 Inside HHS 24

Outside HHS 49 2013-2014 Inside HHS 10

Outside HHS 58 2014-2015 Inside HHS 9

Outside HHS 49 Total Inside HHS 43

Outside HHS 156 Clinical Integrators Completing Training

2012-2013 20 26 2013-2014 20 21 2014-2015 20 26 Total 60 73

IEN/ESL NURSES' HIRING HISTORY Participants were surveyed about their registration and employment status at 0, 3, 6, 9 and 12 months and at project exit. To determine overall progress, it was necessary to wait until a sufficiently large sample of participants had completed a full year of the project. By the end of year three (2014-2015), all year one (2012-2013) and year two (2013-2014) participants had done so. The survey results are provided in Table 59. At project exit, one additional participant from 2013-2014 was RPN and RN eligible and another was RPN eligible.

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Table 59. IEN/ESL Nurses' Change in Registration Status

Employment Status Project Year

Project Entry

Three Months

Six Months

Nine Months

Twelve Months

RN 2012-2013 37 37 38 40 41

2013-2014 7 7 7 8 10

RPN 2012-2013 52 53 54 65 69

2013-2014 31 36 38 40 44

RN and RPN 2012-2013 3 4 5 6 6

2013-2014 1 2 4 4 4

RN eligible 2012-2013 15 16 13 10 8

2013-2014 7 6 5 3 2

RPN eligible 2012-2013 49 47 46 41 40

2013-2014 44 44 43 36 33

RN eligible and RPN eligible

2012-2013 11 11 12 9 0

2013-2014 4 3 3 3 2

RPN and RN eligible 2012-2013 5 4 3 2 2

2013-2014 2 2 1 1 1

Missing data 2012-2013 0 0 1 1 1

2013-2014 0 0 7 9 9

Total 2012-2013 89 89 89 89 89

2013-2014 166 166 166 166 166 There has been an overall decrease in the number of participants in non-nursing jobs as IENs have moved into non-professional and then professional healthcare roles (see Table 61). The number of participants working as professional nurses and unregulated care providers increased during the course of the project. At the end of 2012-2013, 58 nurses (out of 205) were unemployed. At the end of 2013-2014, 16 nurses (out of 89) were unemployed. Table 60. Nurse Employment

Employment Project Entry

Three Months

Six Months

Nine Months

Twelve Months

RN 2012-2013 20 40 45 48 49 2013-2014 2 8 8 9 10

RPN 2012-2013 28 42 52 60 61 2013-2014 4 23 24 22 26

RN and RPN 2012-2013 0 0 0 0 0 2013-2014 0 1 1 1 1

UCP 2012-2013 20 21 26 23 22 2013-2014 20 17 20 19 17

RPN and UCP 2012-2013 0 0 0 0 2 2013-2014 1 1 1 3 4

RPN and non-nursing 2012-2013 0 0 0 0 0 2013-2014 1 1 1 1 1

Non-nursing 2012-2013 33 27 25 24 25 2013-2014 12 9 9 9 5

Unemployed 2012-2013 80 56 40 34 29 2013-2014 49 25 18 16 16

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Missing data 2012-2013 0 0 1 1 1 2013-2014 0 4 7 9 9

Total 2012-2013 166 166 166 166 166 2013-2014 89 89 89 89 89

Note. RN=registered nurse; RPN=registered practical nurse; UCP=unregulated care provider. A significant proportion had multiple jobs, which reflects the current nursing labour market (see Table 61). The number of professional nurses with single and multiple employers rose throughout 2012-2013 and 2013-2014. At project exit, one additional participant from 2013-2014 had two employers and another had more than two employers. Table 61. Multiple Employment

Employment Status Project Entry

Three Months

Six Months

Nine Months

Twelve Months

Nursing -1employer 2012-2013 31 50 61 68 72

2013-2014 6 24 22 21 26

Nursing - 2 employers 2012-2013 1 9 8 12 13

2013-2014 0 7 8 8 7

Nursing - more than 2 employers

2012-2013 1 3 3 2 1

2013-2014 0 1 3 3 4

Employed in nursing and non-nursing

2012-2013 0 0 0 0 0

2013-2014 2 2 2 4 4

Total 2012-2013 33/166 62/166 72/166 82/166 86/166

2013-2014 8/89 34/89 35/89 36/89 41/89

In 2012-2013 and 2013-2014, there was an increase in overall employment in healthcare as participants obtained professional qualification. Numbers rose in all sectors, but the proportion of participants working in long-term care and the community rose significantly. Of particular note was the five-fold increase in the number of nurses employed in hospitals in 2012-2013. In contrast, few participants accepted jobs in hospitals in 2013-2014. However, relatively more IENs found jobs in the community (see Table 62). At project exit, one additional participant from 2013-2014 was employed in hospital and long-term care and another was employed in long-term care and the community. Table 62. IEN/ESL Nurses' Sector of Employment

Sector of Employment

Year Project Entry

Three Months

Six Months

Nine Months

Twelve Months

Hospital 2012-2013 4 19 26 28 30

2013-2014 2 4 4 4 6

Long-Term Care

2012-2013 18 25 26 21 30

2013-2014 6 17 16 15 17

Community 2012-2013 12 14 16 21 22

2013-2014 4 14 13 14 16

60

Other healthcare

2012-2013 0 0 1 1 1

2013-2014 0 0 0 0 0

N/A 2012-2013 131 102 90 78 71

2013-2014 77 46 42 39 35

Hospital and Long-Term Care

2012-2013 1 1 1 1 1

2013-2014 0 0 1 3 3

Hospital and Community

2012-2013 0 4 3 3 2

2013-2014 0 2 3 2 0

Hospital and other healthcare

2012-2013 0 0 0 1 1

2013-2014 0 0 0 0 0

Long-Term Care and Community

2012-2013 0 1 2 2 2

2013-2014 0 2 3 3 3

Missing data 2012-2013 0 0 1 1 1

2013-2014 0 4 7 9 9

Total 2012-2013 166 166 166 166 166

2013-2014 89 89 89 89 89

The number of participants with professional nursing status who were in permanent full-time or part-time work increased each year (see Table 63). At project exit, one additional participant from 2013-2014 was employed OPT and OPT. In comparison, there was little change in the participants' status in non-nursing employment (see Table 64). At project exit, one additional participant from 2013-2014 was employed OPT and another was designated N/A. Table 63. IEN/ESL Nurses' Professional Nursing Status

Employment Status

Project Year

Project Entry

Three Months

Six Months

Nine Months

Twelve Months

PFT 2012-2013 5 13 18 21 26

2013-2014 2 4 5 7 8

PPT 2012-2013 9 17 21 25 23

2013-2014 1 7 7 5 9

TFT 2012-2013 3 6 6 5 5

2013-2014 0 1 2 2 1

TPT 2012-2013 3 1 1 1 1

2013-2014 3 3 3 2 2

OPT 2012-2013 10 12 14 17 20

2013-2014 2 11 7 8 9

N/A 2012-2013 133 104 94 83 76

2013-2014 81 51 47 46 41

PFT and OPT 2012-2013 0 0 1 2 2

2013-2014 0 0 1 2 2

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PPT and TPT 2012-2013 0 0 0 0 0

2013-2014 0 0 0 1 2

PPT and OPT 2012-2013 0 5 4 5 5

2013-2014 0 3 3 3 2

PPT, OPT and OPT

2012-2013 1 1 1 1 1

2013-2014 0 1 2 2 2

TPT and OPT 2012-2013 1 1 1 0 0

2013-2014 0 1 1 0 0

OPT and OPT 2012-2013 0 2 2 2 2

2013-2014 0 3 3 2 1

OPT, OPT and OPT

2012-2013 0 1 1 1 1

2013-2014 0 0 1 0 1

OPT, OPT, OPT and OPT

2012-2013 0 0 0 0 0

2013-2014 0 0 0 1 1

PPT and PPT 2012-2013 0 1 0 3 4

2013-2014 0 0 0 0 0

PFT, PFT and PFT

2012-2013 0 0 1 0 0

2013-2014 0 0 0 0 0

PFT, PPT, OPT, OPT and OPT

2012-2013 0 1 0 0 0

2013-2014 0 0 0 0 0

PFT and PPT 2012-2013 1 1 1 0 0

2013-2014 0 0 0 0 0

TFT and OPT 2012-2013 1 1 1 0 0

2013-2014 0 0 0 0 0

Missing data 2012-2013 0 0 0 0 0

2013-2014 0 4 7 8 8

Total 2012-2013 166 166 166 166 166

2013-2014 89 89 89 89 89

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 64. IEN/ESL Nurses' Non-Nursing Employment Status

Employment Status

Project Year

Project Entry

Three Months

Six Months

Nine Months

Twelve Months

PFT 2012-2013 15 13 12 11 11

2013-2014 13 9 11 8 7

PPT 2012-2013 15 16 17 17 17

2013-2014 10 10 11 12 9

TFT 2012-2013 2 2 2 2 1

2013-2014 1 0 0 0 1

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TPT 2012-2013 7 6 7 3 2

2013-2014 5 4 3 3 1

OPT(casual) 2012-2013 11 10 14 12 13

2013-2014 3 5 6 6 7

N/A 2012-2013 113 118 113 113 113

2013-2014 55 56 50 49 53

PFT and OPT 2012-2013 1 1 1 1 1

2013-2014 0 0 0 1 1

PPT and PPT 2012-2013 0 0 0 1 1

2013-2014 0 0 0 0 0

PPT and OPT 2012-2013 1 1 1 1 1

2013-2014 0 0 0 0 0

OPT and OPT 2012-2013 0 0 0 1 1

2013-2014 2 1 1 2 2

OPT, OPT and OPT

2012-2013 0 0 0 0 1

2013-2014 0 0 0 0 1

Missing data 2012-2013 0 0 0 0 0

2013-2014 0 4 7 8 8

Total 2012-2013 166 166 166 166 166

2013-2014 89 89 89 89 89

Note. OPT=occasional part-time; PFT=permanent full-time; PPT=permanent part-time; TFT=temporary full-time, TPT=temporary part-time. In 2012-2013, the number of IENs employed at HHS and at HHS and another employer increased. In 2013-2014, numbers employed at HHS did not increase and only two participants became employed in jobs inside HHS and with a second employer. In both 2012-2013 and 2013-2014, a significant number of participants became employed outside HHS (see Table 65). Table 65. Professional Employment Inside and Outside of HHS

Employment Status

Year Project Entry

Three Months

Six Months

Nine Months

Twelve Months

HHS 2012-2013 3 9 15 16 16

2013-2014 2 2 2 2 2 Outside HSS 2012-2013 82 97 108 111 117

2013-2014 38 57 60 60 60 Inside and outside of HSS

2012-2013 1 4 2 4 4 2013-2014 0 1 2 2 2

Total 2012-2013 86/166 110/166 125/166 131/166 137/166 2013-2014 40/89 60/89 64/89 64/89 65/89

In 2012-2013 and 2013-2014, the number of participants employed in jobs commensurate with their skills and education increased (see Table 66).

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Table 66. Employment Status at Zero to Twelve Months

Employment Status Year Zero Months

Three Months

Twelve Months

Employed: Job commensurate with skills and education

2012-2013 36 58 87

2013-2014 8 33 42

Employed: Job not commensurate with skills and education

2012-2013 49 50 46

2013-2014 32 26 22

Not employed 2012-2013 81 58 33

2013-2014 49 26 16

Missing data 2012-2013 0 0 0

2013-2014 0 4 9

Total 2012-2013 166 166 166 2013-2014 89 89 89

At 3 and 12 months after project recruitment, 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, all 166 recruits for 2012-2013 and all 89 recruits for 2013-2014 provided affirmative responses to both questions. At 12 months, 166 recruits for 2012-2013 and 80 recruits for 2013-2014 provided affirmative responses to both questions. Data for the remaining nine recruits for 2013-2014 were missing. There was some indication that employers were using the NGG and NCO to integrate IENs. In 2012-2013, one participant had an NCO placement. In 2013-2014, three participants had NGG placements and five had NCO placements.

PARTICIPANTS' EVALUATION OF THE PROJECT: EXIT QUESTIONNAIRES 2012-2015

Seventy-eight participants exited the project (see Table 67). Seventy-one left because they had completed the project, 6 left for other reasons and one did not provide a reason.

Table 67. Date of Project Exit

Date of Exit Number February 2013 35 May 2013 11 November 2013 1 January 2014 2 March 2014 1 May 2014 16 October 2014 1 January 2015 5 March 2015 6 Total 78

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Participants who completed the project were sent exit questionnaires. Fifty-seven questionnaires were returned. Fifty-five participants indicated the project had completely met their needs. The remaining two indicated it had somewhat met their needs. Table 68 provides examples of the participants' comments. Table 68. Participants' Exit Comments

The program is informative and offers many helpful resource and workshops. . . . I also recommended this program to my fellow classmate/friend who also found this program very helpful. Hopefully, this program would continue to help more IEN/ESL nurses. The program immensely met my needs. Courses, materials and advisors for integration in the nursing system were offered for free and in a friendly, impeccable manner. I think this program is really helpful to the IEN who has not had any experiences in Canada. The IEN project has had helped me a lot in building my career and life in Canada. . . . Currently, I am working as a Relief Care Specialist, which falls under the healthcare-related and community support worker category. This project assisted me in obtaining my RPN registration and my first full-time job as an RPN. Through taking part in the activities and attending classes, workshop, etc., [it] helped me meet my goal and expectations. It is a great project, very helpful. I sat for my RN exams and passed. [It] also gave me all the confidence I need to move on in nursing. The program is always available to guide me, e.g., mock interview, résumé, I- CELBAN, etc. The program showed me how to regain my confidence and not to give up. [It] also provided me the way to start my license process and taught me in developing my résumé and interview skills.

The majority of participants completed 5 to 9 interventions (see Table 69). However, the number of participants who accessed the interventions varied considerably (see Table 70). Table 69. Number of Interventions Completed

Interventions Completed

1 2 3 4 5 6 7 8 9 Missing Data

Number of participants

0 1 1 7 13 14 4 6 10 2

Table 70. Number of Participants Accessing Interventions

Intervention Number of Participants

I-CELBAN 24 CARE Centre for Internationally Educated Nurses Language Communication for Nurses, Level 3 - Advanced (LCN3)

30

BIEN Learning Resource Centre Simulation Laboratory 46 HHS Job Coaching/Mock Interview Preparation 45 HCCI Cultural Competency Awareness Workshop 18 HHS/CNO Learning Plan/HHS Policies and Procedures on the Intranet 48 HHS SharePoint Website 51 HHS N3 Networking Program 25 HHS Professional Workplace Experience/Integration 47

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ASSESSMENT OF INTERVENTIONS Participants' ratings of and recommendations for each intervention are summarized in Table 71 and Table 72, respectively. Table 71. Intervention Ratings

Intervention Relevancy Ratings 1=very

relevant 2=relevant 3=somewhat

relevant 4=not

relevant N/A

I-CELBAN 16 4 2 2 4 CARE Centre for Internationally Educated Nurses Language Communication for Nurses, Level 3 - Advanced (LCN3)

33 2 0 0 2

BIEN Learning Resource Centre Simulation Laboratory

43 2 1 0 1

HHS Job Coaching/Mock Interview Preparation

43 2 0 0 2

HCCI Cultural Competency Awareness Workshop

12 4 2 0 1

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

39 5 3 0 1

HHS SharePoint Website 40 9 1 1 2 HHS Networking Program 22 2 1 0 1 HHS Professional Workplace Experience/Integration

46 0 1 0 2

Note. Numbers do not add up to 57 because participants did not complete all interventions. Table 72. Intervention Recommendations

Intervention Recommendation Ratings 1=retain 2=minor

changes 3=major changes

4=remove N/A

I-CELBAN 22 2 0 0 3 CARE Centre for Internationally Educated Nurses Language Communication for Nurses, Level 3 - Advanced (LCN3)

32 4 0 0 1

BIEN Learning Resource Centre Simulation Laboratory

39 3 0 0 1

HHS Job Coaching/Mock Interview Preparation

36 1 0 1 2

HCCI Cultural Competency Awareness Workshop

19 4 0 0 1

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

44 5 0 0 0

HHS SharePoint Website 42 4 2 0 0 HHS Networking Program 24 2 1 0 0 HHS Professional Workplace Experience/Integration

42 3 0 0 1

Note. Numbers do not add up to 57 because participants did not complete all interventions. Positive comments were made about the usefulness of the mock interview, the N3 program and the BIEN Learning Resource Centre Simulation Laboratory. Twenty participants were interested in participating in interventions in which they had not taken part. Three participants were interested in becoming CIs and one expressed a willingness to help other IENs.

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EVALUATION OF CLINICAL INTEGRATORS When asked if their assigned CI provided helpful guidance, 27 participants responded affirmatively, one said somewhat and 30 found the question not applicable. The participants' comments indicated that the CIs had provided advice, emotional support and answers to their questions.

EVALUATION OF PROJECT MANAGER The PM received very positive evaluations. All 57 respondents agreed that she had explained project activities clearly, facilitated their participation and answered their questions. Comments emphasized that the PM had performed her duties well and the team had been supportive.

USE OF SHAREPOINT WEBSITE Thirty-nine participants used the SharePoint website and 18 did not. Of those who did not use it, eight cited "no time" and two cited "no need for information" as the reason. Six had other reasons. Four participants had used the website once, 21 had used it 2-5 times, six had used it 6-10 times and six had used it more than 19 times. Thirty-one participants said the website was easy to use, four said it was somewhat easy to use and two said it was not easy to use. Thirty-two said it gave them useful information, two said it sometimes gave them useful information and three said it did not give them useful information.

OTHER USEFUL INTERVENTIONS AND RESOURCES Participants suggested the following would be helpful to IENs attempting to integrate into the Canadian workforce. • Certification in basic cardiac life support (BCLS) and cardiopulmonary resuscitation

(CPR) • Courses for skill enhancement (e.g., wound care) • Dedicated IEN/ESL website • Development and expansion of job shadowing • Exam preparation • Further language and job interview support • Mask fittings and other basic requirements needed in the workplace • Practical skills programs • Referral to websites for the CNO, Registered Practical Nurses Association of Ontario and

Registered Nurses' Association of Ontario • Seminar on OSCE • Working with their CI in the workplace

RECOMMENDING THE PROJECT TO OTHER IEN/ESL NURSES The majority of participants found the project very useful to IEN/ESL nurses. However, a few thought it was less suited to those who spoke English as a first language and nurses who were educated in Canada. Participants' recommendations were as follows: • Recommend to EFL nurses educated abroad: Yes=43, No=9 • Recommend to ESL nurses educated abroad: Yes=57 • Recommend to ESL nurses educated in Canada: Yes=40, No=4,

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GETTING A JOB Forty-six of the participants who exited the project said that they had applied for a job at HHS and 33 had subsequently attended an interview. Thirty of these applicants were offered jobs at HHS. One participant did not accept the job offer because it was not in her specialty area. Forty-three respondents had jobs outside HHS. This number includes 16 participants who had jobs at both HHS and elsewhere. Fifty respondents said the project had helped them secure employment. Two said that it had possibly helped them. One did not comment. Four indicated that it had not helped them. However, two of these participants did not take part in any interventions.

GENERAL COMMENTS Participants' general comments referred to the following: • Helpfulness and support of the PM and administrative assistant • Importance of the project in getting nurses back to work • Importance of the project in offering encouragement, emotional support and building

confidence • Learning from other participants and those involved with the project • Usefulness and relevance of the interventions • Usefulness of the project in providing information about the Canadian healthcare system

SUCCESS STORIES The MCI/MCIIT provided participants and CIs with templates to document personal experiences and stories. Over 20 stories were submitted and they reflect the participants' increased confidence. All participants who completed the template supported continuation of the project.

NEW INITIATIVES Time conflicts and transportation challenges sometimes prevented participants from taking part in interventions. Consequently, the project team is developing various online resources and assessment tools, which are outlined below.

HCCI Diversity and Inclusion Training To enhance the training it already provides to IEN/ESL nurses, HCCI now makes course materials available on the SharePoint website in addition to the registration forms for the cultural competency awareness workshop at HHS. Three webinars were posted on the SharePoint website in April 2015.

Assessment Tools The Mohawk College BIEN program and HHS collaborated in the development of an advanced standing tool for use by HHS and other employers to test clinical and communication competencies for IENs with previous critical care experience (see Appendix E). The tool is intended for internationally educated RNs who are employment ready, have completed all relevant project interventions and language specifications and have 3 to 5 years of practice within last the 10 years in ICU/CCU/Emergency/OR. The intervention will include high fidelity simulation exposure to a critical care situation and enable participants to build a professional portfolio and learning plan to reflect the standards of critical care nursing practice in Ontario. The tool was piloted with 10 IENs.

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PROJECT SUSTAINABILITY

Workforce Integration Strategies The Project Advisory Committee 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. The committee suggested the following strategies to ensure project sustainability: 1. Continued support for the project from HHS and the partnership. 2. Embed some of the CCEM interventions (e.g., offering the online Cultural Competency

Awareness Workshop on the SharePoint website). 3. Link the SharePoint website to the HHS website and intranet as a resource for IEN/ESL

nurses and stakeholders. 4. Urge employers in Ontario to implement the NCO to facilitate hiring and integration of

IENs into the healthcare system. This initiative provides six months of learning and working opportunities to IENs and can help ease the chronic nursing shortage in critical care areas such as the ICU, OR and Step-Down Units.

5. Use HHS interventions such as the HHS/CNO Learning Plan, the N3 program and the professional workplace experience for employed and employment-ready IEN/ESL nurses.

Engaging the Community The project has had a very successful third year despite the current labour market. The project team is committed to working with other organizations in implementing the CCEM to ensure sustainability and capitalize on the project's work-ready human resource pool. Collaboration among HHS and its community partners is ongoing and supported by partner-led interventions, formal meetings and informal communication.

Communication Among Stakeholders Communication among stakeholders continues to be a priority. Partners are represented on the Project Advisory Committee. The PM is a member of the Hamilton-Wentworth Long Term Care Joint Executive Committee and the HHS Nursing Graduate Guarantee Advisory Committee. One of the PIs is Chair of the HHS Nursing Advisory Council and she and the PM are Co-Chairs of the HHS Nursing Stewardship Committee. Several CIs are members of the Nursing Advisory Council and the Nursing Stewardship Committee.

Outreach to Regional Healthcare Facilities Between April 1, 2014 and March 31, 2015, collaboration with long-term care facilities and community agencies led to the hiring of 16 RPNs and 1 RN. The PM maintains communication with the following organizations: • Acclaim Health, Hamilton • Bayshore Healthcare Agency, Hamilton/Kitchener/Waterloo/Halton • Best Care Agency Ltd., Hamilton (owner is a former project participant and currently a

CI) • Brampton Civic Hospital • Directors of Care, Hamilton-Wentworth • Lakeridge Health, Oshawa • London Health Science, London • Mount Sinai Hospital, Toronto • Niagara Healthcare System (six sites) • Nurses Education Inc., Toronto

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• Royal Victoria Hospital, Barrie • St. Elizabeth Healthcare Agency, Hamilton-Wentworth • St. Joseph's Hospital, Hamilton • St. Mary's Hospital, Guelph The PM worked with the Directors of Care at Villa Italia on the implementation of a transitional care pilot program. Three RPN participants were hired because of this program. In collaboration with the Thunder Bay Multicultural Association, the IEN/ESL nurse project participated in the Immigration Forum and Job Fair in Thunder Bay in October 2014. As a result, one RN was hired in a leadership role and another was hired in an acute care hospital.

Career Progression Related activities for participants included an IEN/ESL network and contact with CIs employed outside of HHS.

Project Promotion and Dissemination Promotion and dissemination of the project and the CCEM was achieved through formal and informal presentations within and outside of HHS.

RECOMMENDATIONS

• Build a network of support for IEN/ESL nurses that includes emotional, clinical, academic and community support; professional and workplace experience; and CIs

• Continue to share strategies, challenges and lessons learned with other community and healthcare organizations

• Encourage organizational commitment at all levels • Listen to and engage all stakeholders • Promote coaching for employment and career path navigation • Replicate and embed the CCEM in other healthcare organizations • Test the CCEM by working collaboratively with community and academic partners • Provide workplace exposure to enable IENs to gain Canadian healthcare experience

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APPENDIX A. INFORMATION AND CONSENT FORMS

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APPENDIX B. PROJECT DISSEMINATION AND PROMOTION 2013-2014

Presentations and Publications

Wright, P., Beckford, D., Lee, R., Baumann, A., & Blythe, J. (2013, August). The path to a healthy work environment. Poster presented at the 2013 Healthy Work Environment Institute, Niagara Falls, ON.

Lee, R., Baumann, A., Blythe, J., Beckford, D., Krull, K., & Le, A. (2013, October). Building

a vibrant workforce by capitalizing on the strength of internationally educated nurses and English as a second language nurses. Poster presented at the 2013 Canadian Association of Pediatric Health Centres (CAPHC) Annual Conference, Toronto, ON.

Krull, K., Lee, R., & Beckford, D. (2013, November). The path to integration: A workshop

for employees of IEN/ESL nurses - Innovative practices: Recruiting and integration. Presented at Confederation College, Thunder Bay, ON.

Beckford, D. (2013, December). Alternative careers in health care. Presented at Consortium

of Agencies Serving Internationally-Trained Persons (CASIP) and Citizenship and Immigration Canada (CIC), Toronto, ON.

Lee, R., Baumann, A., Blythe, J., Beckford, D., Krull, K., & Le, A., (2014, March). Building

a vibrant workforce by capitalizing on the strength of internationally educated nurses and English as a second language nurses. Poster presented at the Nursing Leadership Network of Ontario, Toronto, ON.

Lee, R., Baumann, A., Blythe, J., Beckford, D., Krull, K., & Le, A. (2014, May). Building a

vibrant workforce by capitalizing on the strength of internationally educated nurses and English as a second language nurses. Poster presented at the Partners in Education and Integration of Internationally Educated Nurses 8th National Conference, Toronto, ON.

Wright, P., Lee, R., Beckford, D., Baumann, A., Blythe, J. (2014, May). The path to a healthy

work environment. Poster presented at the Partners in Education and Integration of Internationally Educated Nurses 8th National Conference, Toronto, ON.

Ramji, Z., Lee, R., & Beckford, D. (2014, May). Language and communication supports for

work-ready nurses - A successful employer - Bridging program collaboration. Oral presentation at the Language Matters - Exploring Communication Challenges in Bridging Education for Immigrant Professionals Conference, York University, Toronto, ON.

Lee, R., & Beckford, D. (2014, July). Bridging the gap for IEN/ESL Nurses - Innovative

practices: Recruiting/integration/retention - An employment model. Presented at Conestoga College, Kitchener, ON.

Lee, R., & Beckford, D. (2014, October). The path to integration: A workshop for employers

of IEN/ESL nurses and innovative practices. Presented at the Recruiting and Integration Immigration Forum and Employment Fair, Thunder Bay Multicultural Association, Thunder Bay, ON.

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Brown-Fellows, N., Lee, R., & Beckford, D. (2014, November). Internationally educated nurses: Enhancing Canadian healthcare. Presented at the CARE First Annual Conference for IENs, Toronto, ON.

Lee, R., & Beckford, D. (2015, March). Bridging the gap for internationally educated nurses:

International critical care experience to Canadian practice. Poster presented at the Nursing Leadership Network of Ontario, Toronto, ON.

Additional Activities

• Participants, CIs, supporters and partners inside and outside HHS receive project pins • Project materials are available on the SharePoint website inside and outside of HHS • The PM distributes a resource folder at internal and external stakeholder meetings that

includes information about the project • The Project Charter has been regularly updated

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APPENDIX C. 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) and Canadian Triage and Acuity Scale (CTAS) National Guidelines

• Interview questions based on real patient 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 IEN/ESL nurses (three months post) • NHSRU post-session cultural competency for IEN/ESL nurses course assessment

NHSRU post-session cultural competency survey for IEN/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

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• 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 SharePoint • SharePoint website pre-confidence survey • SharePoint website post-confidence survey 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

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APPENDIX D. PARTICIPANT EVALUATION OF THE JOB SHADOWING EXPERIENCE 2014-2015

Job Shadowing Summaries

1. I got a job shadowing experience on Ward F3 at the Juravinski Hospital with Mary Ann. It was a great experience. I got the opportunity to watch an IV reinsertion and blood work. I saw the E-Doc program for documentation. I got familiar with some BS, BP, G-feed and IV machines. I visited the supplies room and I saw how they are stocked.

2. I want to thank you for giving me the opportunity for job shadowing at Juravinski Hospital. It was a wonderful experience and made me even more confident in my nursing career. The advice and experience has been tremendously helpful throughout the hours. Because you gave me the opportunity to visit the unit, I had the chance to observe numerous aspects of patient care. You and your staff . . . were extremely welcoming and helpful and offered me career advice. In addition to my qualification and experience, it helped me to develop excellent work habits and judgement for this position. Thank you once again for your time and the sharing of experiences that you gave me through this job shadowing.

3. With a lot of thanks, [the project team] gave me an opportunity to do the job shadowing in the Juravinski Hospital under the supervision of . . . [an RPN]. I had a great time there and I learned lot of things from her. . . . For example, how to give the medication, taking orders from the doctor, doing the rounds, meeting the clients with their needs, communicating with them, asking about complaints or illnesses and informing the doctor, up-to-date recording, collecting samples for test and how to send to the lab, how to transport clients to other department for further investigation and personal care. Secondly, I got the opportunity to communicate with the health team members and with the client. I thank all of them . . . [for] teaching me how to work in a hospital without any fear.

4. Job shadowing helped me to get an exposure to the health system directly. Though the duration is short, staff helped to cover everything in the given time. This exposure helped me to increase my self-confidence. If more hours are given at different departments, [it] will help us to learn more about the technology used in the health system and will be helpful in all aspects. 5. Having no Canadian hospital experience or exposure, the job shadowing experience I had at HHS F3, Medicine Unit was very informative and educational. I was shadowing a staff [member] who was working for the unit for 5+ years. She was very thorough with the job responsibilities and routines as an RPN. She toured me around the unit, informally introduced me to other members of the interdisciplinary team from MDs, fellow nurses, OT, PT, SW as well as to her patients. I appreciate how proactive the nurses are, being an advocate for the patient/family. It was a total opposite to where I practiced my nursing outside of Canada. Different kinds of diagnostic tools and equipment were also shown to me. Overall, the shadowing experience is very helpful for those who are aiming to be working in Canada's healthcare system. Having that idea and picture of how things work will definitely boost one's confidence once working in the healthcare industry. I highly recommend this opportunity to everyone who is aspiring to be in healthcare.

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APPENDIX E. ADVANCED STANDING ASSESSMENT TOOL DEVELOPMENT - HHS/MOHAWK COLLEGE

Goal: Develop an OSCE experience using high and low fidelity simulation for IENs with critical care experience seeking employment in this specialized area. Experience will be built upon gap analysis from an online survey with clinical managers, educators and focus groups with IENs currently employed in critical care at HHS and IENs with critical care experience but not registered to practice. Learning outcome: Provide an opportunity for IENs with critical care experience who are not practicing in Canada to participate in high and low fidelity simulation to develop a learning plan using reflective practice. Requirements for IENs: 1. Must have completed HHS integration projects interventions including the following: • Assessment simulation • Communication course • Cultural course • Review of CNO Standards of Practice Framework 2. Pre-OSCE materials (adapted from existing materials/broad overview) for review online

(approx. 4 hours) including the following: • Critical thinking case studies • Inter-professional practice • Overview of critical care equipment • Overview of critical care procedures • Terminology in critical care • Therapeutic communication/transfer of accountability 3. Two OSCEs (timed 10 to 12 minutes) • A high fidelity case study - Focuses on patients whose conditions have begun to

deteriorate. The intended learning outcome is the use of critical thinking to assess and develop a nursing diagnosis and care plans; anticipate next steps and establish priorities; provide care during simulation; and verbalize next steps.

• A low fidelity OSCE based on OSCE 1 - Involves standardized actors (e.g., doctors, peers and family members). The intended learning outcome is the use of assertive, professional communication during interactions, including the transfer of accountability; asking for help; and inter-professional relations.

4. Reflective Practice • Debrief with large group (5 to 6 members) on two simulations • Provide individual feedback sheets for each • Reflective practice tool for self-development of learning plan Based on feedback from the participants and the implementation team, changes have been made to the pilot materials and simulation. The following areas need to be strengthened: • Application of knowledge

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• Assertive communication • Cardio-electric system • Fluid resuscitation in critical care patients • Hemodynamic/meds • Invasive ventilation • Knowledge of CNO competencies • Nursing standards • Patient safety issue • Physical assessment • Principles of shock • Privacy and confidentiality • Self-regulation • Specialized body of knowledge • Standards of critical care nursing • Therapeutic communication • Use of critical thinking

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