Towards a Pan-Canadian Bridging Program for Internationally Educated Applicants

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Towards a Pan-Canadian Bridging Program

for Internationally Educated Applicants

Final Report

Component 1 – Phase B

Received by NARTRB Council in June 2011

NATIONAL ALLIANCE OF RESPIRATORY THERAPY REGULATORY BODIES April 2011

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Introduction

The introduction of Chapter 7 of the Agreement on Internal Trade (AIT) in 2009 requires that an individual licensed in a regulated profession in a given province or territory be able to become licensed in another without any additional material requirements. This provision includes those individuals who received their formative education outside of Canada. As a result, regulators in a variety of industries are in the process of implementing common approaches to the way the qualifications of skilled immigrants are evaluated and recognized. In 2010, the National Alliance of Respiratory Therapy Regulatory Bodies (NARTRB) commissioned research proposing strategies to harmonize the assessment and admissions practices for internationally educated applicants. As part of this initiative it was

recognized that a necessary consequence of a common approach to credential evaluation is a common approach to the remediation of identified educational/competency deficiencies. As such, one of the key recommendations proffered was that NARTRB member regulators assess the feasibility, potential formats and content associated with the development of a pan-Canadian bridging program for international applicants seeking licensure as respiratory therapists in Canada1. The work compiled herein represents an initial step in meeting this objective.

This report is divided into three sections. The first describes the findings of a survey conducted with Canada’s seven respiratory therapy regulators on issues related to the potential demand and applicant pool characteristics of a new pan-Canadian bridging program. The second outlines the structure and best practices of selected bridging programs currently operating in Canada. The final section draws on the findings of the first two and proposes a bridging model suited to the specific needs of the respiratory therapy profession in Canada.

A Word on Terminology – “Bridging”

The term “bridging program” is used throughout this report and can mean different things to different people. Generally speaking, it refers to a set of centralized resources made available to applicants either in a regulated or non-regulated profession who are seeking to address certain educational and/or practice deficiencies relative to their profession’s entry-to-practice standards. In most cases these programs are offered through educational institutions (i.e. colleges and universities). At present, the form, content and delivery system of this resource as it pertains to the respiratory therapy professions is as of yet undetermined and is the focus of this phase of research. Ultimately, the final product may consist of a variety of components and modules, potentially including: course work, language training, online resources, clinical placements and mentorship programs. Through the investigation and analysis of best practices, this work aims to set out potential models which meet the educational needs of international applicants seeking licensure as respiratory therapists in Canada.

1

Keith Johnson, “Towards a Pan-Canadian Framework for the Assessment of Internationally Educated Respiratory Therapists” (National Alliance of Respiratory Therapy Regulatory Bodies, November, 2010), Pg. 29.

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Regulator Survey Methodology

A survey concerning the development of a pan-Canadian bridging program for international applicants was conducted with respiratory therapy regulators in Canada (see Appendix 1). Data was collected via a series of telephone interviews with key informants during November and December, 2010. The majority of questions were qualitative in nature. Numeric estimates related to the composition of the

international applicant pool were also requested. A total of seven organizations participated including: the College and Association of Respiratory Therapists of Alberta (CARTA), the College of Respiratory Therapists of Ontario (CRTO), the Manitoba Association of Registered Respiratory Therapists (MARRT), the Nova Scotia College of Respiratory Therapists (NSCRT), the New Brunswick Association of

Respiratory Therapists (NBART), the Saskatchewan College of Respiratory Therapists (SCRT) and l'Ordre professionnel des inhalothérapeutes du Québec (OPIQ).

Questionnaire Themes and Findings

Questions set out in the regulator survey aimed at revealing the issues and characteristics which are relevant to the design of a pan-Canadian bridging program. Specifically, the information collected sought to inform three distinct streams of inquiry:

1. Content and Scope: What is the expected professional/educational background of a typical bridging candidate and what is the nature and extent of the gaps they will be seeking to remediate?

2. Overall Demand: How many individuals would be expected to benefit from a bridging program on an annual basis?

3. Rationale: What are the potential benefits (for both the regulator and the internationally educated applicant) of implementing a pan-Canadian bridging program?

Selected survey questions have been organized per the research objectives described above; a discussion of themes and findings for each follows below. This data, combined with the best practice information collected on other bridging programs, will help inform the development of a system suited to the specific needs of the respiratory therapy profession.

Content and Scope

What is the professional/educational background of your applicant pool?

One of the most salient issues and challenges related to the work described herein is the fact that in many countries outside of North America, the practice of respiratory therapy either does not exist or is not a regulated profession. As a result, Canadian regulators report a great degree of variability in the qualifications of those who apply for licensure. There are a few schools in operation abroad that offer respiratory therapy programs with comparable content to those in Canada. Graduates from these schools who apply to Canadian jurisdictions have relatively minor gaps to remediate before meeting entry-to-practice requirements. In contrast, regulators report a large cohort of applicants whose professional/educational background is considerably different than set out in the Canadian National

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4 Competency profile2. These individuals have significant educational and practice deficiencies which must be addressed before being allowed to practice.

Based on the collective estimates provided by regulators, approximately half of all international applicants seeking licensure were professional “respiratory therapists” before immigrating to Canada and the other half were educated in “something else”. This second category consists of physicians from a number of practice areas (anaesthesia, pneumology, obstetrics and internal medicine), anaesthesia technicians and general medical technicians. The characteristics of this applicant pool echoes recent work conducted by the College of Respiratory Therapists of Ontario (CRTO) in which 53% of all

international applications received by the College between 1999 and 2008 had education in respiratory therapy and the remaining 47% in a non-respiratory therapy program3.

It is also essential to note that applicants in the first group (i.e. those educated as “respiratory

therapists”) are not all created equal from an entry-to-practice perspective. Survey results suggest that there are considerable differences in the scope and content offered by respiratory therapy programs abroad. Specifically, regulators have indicated that there are some schools in the Philippines and the United States that have curriculum comparable to that offered in Canada, however this generalization is by no means universal. Within the United States specifically, there are also considerable differences in the quality of education offered among accredited programs. At present, programs in respiratory therapy are offered at the “associate” degree level as well as via an “advanced care” program. Canadian regulators report that applicants from the former category are much further from meeting entry-to-practice standards than those with an advanced care degree.

What source countries to do you typically receive applicants from?

Regulators were asked to consider the main source countries from which they have received

international applications over the past five years (see table below). With the exception of Quebec, the majority are received from practitioners educated in the Philippines, United States, China and India. Individuals from these countries are expected to constitute the primary demand for a pan-Canadian bridging program.

Alberta Manitoba Nova Scotia Ontario Quebec

United States United States Philippines Philippines Morocco

Philippines Philippines China India Haiti

Iran India United States China Columbia

Columbia Bangladesh Algeria

Syria Columbia Ukraine

Egypt United States Russia

2

See: http://www.nartrb.ca/eng/documents/2011NCPfinal.pdf

3

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What deficiencies are typically identified in the credential assessment of international

applicants?

As expected, the educational/practice gaps identified in the credential assessment process are as varied as the applicant pool described above. According to survey responses, typical gaps among the

internationally educated cohort include: pharmacology, mechanical ventilation, pulmonary function, anaesthesia, and orientation to the health care system. Deficiencies in broncodialitis, physiology, anatomy, chemistry, basic cardiac life support and respiratory care were less frequently reported by regulators. While a number of these gaps can be remediated through course work (in class or online), many can only be addressed in a clinical setting. The practice of respiratory therapy in Canada involves significant use of specialized technology and equipment, some of which may be unknown to

international applicants. Hence, an appropriate and successful pan-Canadian approach to bridging international respiratory applicants will need to incorporate a clinical placement component to account for this learning need.

In short, the interviews with respiratory therapy regulators reveal a shared (i.e. multijurisdictional) trend regarding the educational/professional background of international applicants. Three discrete streams of applicants are evident4. The first group is comprised of those individuals whose qualifications are profoundly different than entry-to-practice standards; gaps identified are so significant that these individuals are told by many regulators that they need to complete an entire full-time Canadian respiratory therapy program in order to practice. The second group (often physicians and anaesthesia technicians) typically have less significant gaps, but are still missing some fundamental areas of practice knowledge. The final group consists of graduates from certain schools in the Philippines and the United States whose educational and practice background are fairly comparable to Canadian standards; only a few gaps need to be remediated before their qualifications are deemed substantially equivalent and they can become licensed to practice.

Do applicants need to prove official language proficiency to meet entry-to-practice

requirements?

According to survey results, all jurisdictions with the exception of Manitoba require applicants to provide proof of official language proficiency. In Ontario and Nova Scotia a number of widely accessible tests are accepted each with respective minimum scores (TOEFL, MELA, MELAB, IELTS and CanTest). CARTA accepts one test, CCLB 9, which is offered at two locations in Alberta. In Quebec, applicants that need to prove language proficiency are given a one year temporary licence to fulfill the requirements administered by L’Office de la Langue Française. Regulators in New Brunswick and Saskatchewan which have been in existence for less than two years are currently in the process of developing assessment mechanisms for their international applicants, including language proficiency requirements.

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6 Alberta Manitoba Nova Scotia Ontario Quebec Proof of official

language proficiency required?

Y No policy Y Y Y

Accepted tests CCLB 9 N/A TOEFL, MELA, MELAB, IELTS, CanTest TOEFL, MELA, MELAB, IELTS, CanTest L'office de la langue Française

It is likely that a newly developed pan-Canadian bridging initiative would also require individuals to demonstrate a minimum level of language proficiency as a condition of admission. As such, program designers will need to establish a single set of accepted tests and scores. Additional research will be required to determine what levels are appropriate given the target cohort.

Overall Demand

How many applications do you receive annually from internationally educated practitioners?

Regulators were asked to estimate the number of applications for licensure they have received from internationally educated applicants. It is this group that would form the core demand for a pan-Canadian bridging program.

Based on an annualized average taken over the past five years (2006-2010),

Canadian jurisdictions received approximately 59 such

applications each year. This figure is approximately 10% higher than a similar survey conducted in 2008, when it reported that Canadian regulators assessed a total of 50-56 international applicants annually5. In fact, a number of

5

Paulette Blais, “Access Issues Regarding Internationally Educated Health Professionals and the Respiratory Profession in Canada” (National Alliance of Respiratory Therapy Regulators, February, 2008).

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7 regulators report a significant increase during the most recent year (2010). On average, OPIQ receives approximately 30 such applications annually; in 2010 that figure increased to 48. Similarly, CARTA which typically processes 6 international applicants annually received 8 in the past year. MAART also reported a slight increase in this regard as well. While it is too soon to determine whether this increase is part of larger trend, the potential for significant increased demand for bridging programs exists relative to historic levels.

NBART, SCRT and CSRT are currently unable to assess and process applications from internationally educated health practitioners; typically these cases are referred to another Canadian jurisdiction for consideration. With that said, these organizations were asked how many applications they would expect to receive on a annual basis once a comprehensive system of credential assessment and remediation is in place. Based on survey responses, these three groups would collectively expect to receive an estimated 35 applications per year; another potential source of demand for a pan-Canadian bridging program.

How many registration/licensing inquiries do you receive annually from internationally

educated health practitioners in addition to “official” applications?

At present, regulators receive a number of inquires each year from internationally educated individuals concerning the process of becoming licensed which do not evolve into official applications. While there is no specific data to explain this discrepancy, potential reasons might include: i) in two jurisdictions (NBART, SCART) as well as the CSRT, comprehensive mechanisms for screening the qualifications of international practitioners have not yet been established; in these cases individuals are often referred to another Canadian regulator; ii) some applicants may find the current system too difficult and confusing to navigate and therefore choose not to pursue registration/licensing; iii) applicants may be “jurisdiction shopping” in an effort to find the most expedited route for becoming licensed to practice.

It is likely that once a clearly articulated, pan-Canadian system of assessment and remediation is in place, a portion of these

preliminary inquires will manifest themselves as official applications.

According to the survey results, regulators across Canada receive approximately 28 such inquiries per week. When scoping aggregate need for a new bridging program it is important to account for this latent demand which may be realized if a new system is implemented.

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What existing mentorship placement programs/resources are available to internationally

educated health professionals seeking licensure in Canada?

At present there are only three such programs in Canada. Two of these operate in the province of Alberta. One at the North Alberta Institute of Technology (NAIT) in Edmonton and one at the South Alberta Institute of Technology (SAIT) in Calgary. The College Rosemont in Montreal is currently piloting a bridging program for internationally educated individuals looking to become licensed respiratory therapists in Québec. This program, which just opened its doors in 2010, offers a total of 13 spaces; the first cohort is expected to graduate in May, 2011.

What existing mentorship placement programs/resources are available to

Canadian-educated respiratory therapists who wish to re-enter professional practice after a break?

In estimating the total potential demand for a pan-Canadian bridging program, it is also instructive to consider those individuals who were once licensed in Canada, have left the profession for a number of years and need to make up practice hours or certain courses before they can become licensed again. While often Canadian educated, these practitioners could also benefit from the coursework, mentorship opportunities and clinical placements offered through a new bridging program. As such, regulators were asked to comment on the existence of refresher courses in their jurisdiction and the number of individuals annually who re-enter the profession after a hiatus. Presently, there are very few resources available for these people. Only one program was identified (NAIT) via the survey that is specific to this purpose. In total, regulators estimate demand for those seeking to re-enter the profession at

approximately 15 annually. While not a large figure, it may be worth considering a modular approach which also meets the needs of this cohort thus improving overall economies of scale.

Rationale

What do you see as the potential benefits of a bridging/mentorship program?

Responses to this question fall into two broad categories of benefits: those for the regulatory colleges and those for the internationally educated applicants. A summary of the salient feedback for each category follows below.

Regulator Benefits:

 A one-stop-shop for international applicants to meet typical entry-to-practice gaps.

 A pan-Canadian approach to bridging will make the best use of resources via improved economies-of-scale.

 A common inter-jurisdictional approach allows for sharing of ideas, best practices and talent.

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 Internationally educated practitioners are likely to be more acculturated to the Canadian system before entering the workforce.

 A modular/flexible bridging system can be customized to the specific needs of individual applicants.

 Will likely help decrease incidences of “jurisdiction shopping”.

Applicant Benefits:

 A clearly articulated and transparent pathway for addressing gaps identified in the credential assessment process.

 May serve to expedite the credential assessment and remediation process resulting in becoming licensed to practice in a timelier manner.

 Potentially improved and systematized access to clinical placements.

 Greater exposure to “Canadian” language, culture and soft skills.

 Can help orient international applicants to the intricacies of the Canadian health care system and provide them with educational and social supports.

Summary of Regulator Survey Findings

The findings associated with the regulator survey set out above, should be considered when assessing the feasibility of potential formats for a pan-Canadian bridging program. There are certain

characteristics specific to the respiratory therapy community which must be accounted for such a program to be applicable and successful. Firstly, there is significant variation in the

readiness-to-practice of the applicant pool. As the readiness-to-practice of respiratory therapy does not exist in many jurisdictions outside of North America, a significant proportion of international applicants have significant

academic/practice deficiencies relative the Canadian standard. Due to the extent of these gaps, these individuals are not ideal candidates for a bridging program and instead should be integrated into a full-time Canadian respiratory therapy program. According to regulators, a relatively small subset of the international applicant pool has limited gaps that need to be addressed before meeting entry-to-practice requirements. These individuals typically graduate from certain schools in the United States and the Philippines with curriculum comparable to that offered domestically. It is these individuals who require just a few courses and some clinical exposure before being able to practice in Canada that form the target group for a pan-Canadian bridging program.

Survey information is also of value in scoping the demand for a newly developed pan-Canadian bridging program. Potential demand can be estimated via a number of different metrics including: total number of applications, informal inquires, anticipated volume from jurisdictions not currently processing international applications and practitioners needing refresher courses to renter the profession. It is

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10 important to note however, that as described above, only a portion of those in each of these categories (i.e. those with relatively small deficiencies that need to be remediated) are likely to be suitable

candidates for a bridging program. As such these figures represent the potential, maximum demand; the actual realized demand for a pan-Canadian bridging program is likely to be far less. A summary of these associated demand characteristics is provided in the table below.

Demand Type/ Source Totals

Average number of applications, per year, from internationally educated practitioners – 2006-2010 (AB, MB, NS, ON, QC)

59

Number of applications from internationally educated practitioners – 2010 (AB, MB, NS, ON, QC)

80

Anticipated number of applications, per year, from internationally educated practitioners (CSRT, NB, SK)

35

Number of informal inquiries per week (not including official applications) from internationally educated practitioners (ALL)

28

Number of Canadian-educated individuals, per year, who would benefit from “refresher courses” for re-entry-to-practice purposes

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Best Practices of Selected Bridging Programs Currently Operating in

Canada

Survey of bridging programs

A survey was conducted of bridging programs offered in Canada (see Appendix 2) to determine methodologies for and insights on bridging programs for international applicants of various regulated professions. Data was collected via a series of telephone interviews with key informants (e.g., program manager/director, program coordinator) between November 2010 and March 2011. The majority of questions were qualitative in nature. Most of the programs selected for the survey serve a health care profession regulated in multiple jurisdictions in Canada with one exception (Accounting) which was chosen to illustrate an alternative model of bridging. Three major program categories were surveyed:

 Category I: Programs for large healthcare professions that bridge hundreds of internationally educated professionals (IEPs) annually. In this category the following two programs were surveyed:

o Bridge to Canadian Nursing (BCN), offered through Mount Royal University in Alberta o International Pharmacy Graduate (IPG) Program, offered through University of Toronto,

Ontario.

 Category II: Programs for smaller healthcare professions (potentially comparable to respiratory therapy) that bridge 20-30 IEPs annually. In this category the following four programs were surveyed:

o Internationally Educated Dieticians Pre-registration Program (IDPP), offered through Ryerson University, Toronto, Ontario.

o Internationally Educated Physiotherapists Bridging (IEPB) Pre-registration Program, offered through Ryerson University, Toronto, Ontario.

o International Midwifery Pre-registration Program (IMPP), offered through Ryerson University, Toronto, Ontario.

o The Bridging Program for Medical Laboratory Technology offered through Mohawk College, Hamilton, Ontario. This program serves a medium sized healthcare profession.

 Category III: Alternative bridging strategies to the Category I and Category II programs surveyed in this report. The following two programs were surveyed:

o International Accounting and Finance Professionals (IAFP) Program, offered through Ryerson University, Toronto, Ontario.

o The Overseas Nursing Programme, offered in the UK. This program was described for structure and flow; no personal survey was conducted with program leaders.

A summary and flow chart outlining the structure and content of each of these programs are set out below. Collective themes gleaned from this environmental scan are discussed and analyzed in the subsequent section.

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Bridging Program Survey Outcomes

Program Descriptions

Bridge to Canadian Nursing (BCN), Alberta6_{- The BCN program is currently offered through Mount}

Royal University at two sites in Alberta (Calgary and Edmonton) and is funded by the government of Alberta. This program serves approximately 300 internationally educated nurses (IENs) annually. The BCN Program provides components that aim to enhance professional communication, build knowledge and practice skills, strengthen clinical and ethical reasoning and bridge to licensed, Canadian nursing practice.

Nursing is regulated in all 10 provinces. Approximately 300-400 internationally educated nurses (IENs) are served annually in Alberta. Each province manages a separate system of credential assessment.

Prior to admission to the bridging program, applicants are required to be assessed by The College and Association of Registered Nurses of Alberta (CARNA). Through this process, gaps are identified and specific courses are assigned to applicants to remediate those gaps. This process includes a credential-based and a demonstration-credential-based component, using the College’s “Substantially Equivalent

Competency” (SEC) assessment. The SEC assessment is designed to evaluate an applicant’s professional knowledge, skills and abilities. Based on the outcomes of the CARNA credentialing process, an applicant may be asked to have an assessment in any (or all) of the professional areas. The SEC uses the following four strategies to evaluate the competencies of those seeking to become registered nurses:

 Written Diagnostic Exam: includes both multiple choice and short answer questions that aim to test the general nursing knowledge required of professional nurses in Alberta. The medical surgical exam is six hours long; each focused diagnostic exam is three hours long.

 “Triple Jump” Assessment: problem solving and critical thinking skills are tested using an assessment interview called the “Triple Jump”. In an interview setting, candidates are presented with a brief client situation and are asked to generate hypotheses about client and nursing issues and concerns; identify relevant data; develop a management plan; and, self-evaluate. The triple jump process is designed to assess knowledge, problem-solving, critical thinking, organizational, client assessment and self-evaluation skills, as well as self-directed learning abilities.

6

Adapted from the BCN website; retrieved on Jan 10, 2011 from

http://www.mtroyal.ca/ProgramsCourses/FacultiesSchoolsCentres/HealthCommunityStudies/Programs/BridgetoC anadianNursing/

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 Clinical Judgment Assessment: evaluates the ability to make sound clinical judgments in situations that are complex and have no "simple" answers. These clinical judgment situations assess an applicant’s ability to think deliberately and critically through a nursing situation, apply essential and relevant knowledge, consider possibilities and options and make reasoned, reflective and insightful decisions.

 Objective Structured Clinical Examination (OSCE): used to assess professional knowledge and skills including nurse-client relationships; critical thinking and clinical judgment skills; health assessment and nursing skills; ethical decision making skills; pharmacology and pathophysiology; and, rapidly changing patient situations. This assessment is conducted in a lab setting, where participants role-play as the nurse and demonstrate their ability to care for a patient.

 Self evaluation: participants have the opportunity to provide a self-assessment of their ability to meet professional standards based on their nursing experience in their country of origin using the Self Assessment of CRNBC’s Nursing Professional Standards.

Upon completion of the SEC assessment process, CARNA notifies the applicant whether or not they have met initial entry-to-practice requirements for registration as a registered nurse in Alberta. The possible assessment decisions are as follows:

1. The applicant is eligible to write the Canadian Registered Nurse Exam (CRNE) and granted temporary registration allowing them to work as a graduate nurse while completing the remaining requirements for registration.

2. Eligibility for registration is deferred. The applicant must successfully complete additional nursing education to address identified competency gaps. At this point the applicant is referred to The Bridge to Canadian Nursing (BCN) program.

3. The application is refused and the applicant is not eligible for registration. This decision is made when extensive competency gaps are identified during the review of application documentation or as established through the results of a SEC assessment.

The application process requires applicants to provide a letter from CARNA indicating their eligibility for registration/licensure in Alberta and identifying their specific required coursework. Applicants must also demonstrate sufficient language proficiency as follows:

 Minimum score of 6 on the CLB 12 point scale for entry into BCN Level I

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14 The BCN is an individualized program of study which spans one full-time academic semester. The

program provides applicants with three major core courses and other courses from the full-time nursing program as per CARNA requirements. Level I courses are designed for self-referred applicants whose level of language is insufficient for the bridging courses (CLB 6). This level includes four basic, profession-specific courses designed to improve language. Level II includes the core bridging courses and level III includes clinical, specialty-specific courses. The last course of the BCN program (Professional Clinical Practice) includes a supervised, 193 hour clinical practicum for those required by CARNA to have nursing practice experience in a Canadian healthcare setting. The program’s structure and flow are illustrated in Chart 1; bridging components are greyed.

Chart 1: Flow and Structure of Bridge to Canadian Nursing (BCN) Program

Sufficient language proficiency (CLB 8) Common gaps Specialty based gaps as per need

Specialty-based as per need Language gaps identified (CLB 6) Significant gaps identified No gaps identified Some gaps identified

Application for Registration with CARNA

CRNE Exam

Substantially Equivalent Competency (SEC) assessment including:

 Written Diagnostic Exams

 Clinical Judgment Assessment

 Triple Jump Assessment

 OSCE

 IEN Candidate Self-Assessment

Courses: BCN Level I

No gaps identified

Courses: BCN Level II + practical placement

Courses: BCN Level III (optional) Degree studies Self-referral based on insufficient language proficiency

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15 International Pharmacy Graduate (IPG) Program, Ontario7 – The IPG program is offered through the Leslie Dan Faculty of Pharmacy, University of Toronto with initial program development funded by the Government of Ontario. The IPG is a bridging program designed to assist pharmacists trained in countries outside Canada to meet Canadian entry-to practice standards. This is a university-based program that provides access to university-level curriculum delivered by experienced faculty members. The program includes a mentorship network that provides opportunities for students to connect with practicing pharmacists.

The practice of pharmacy is regulated in all provinces. Each province manages a separate system of credential assessment (based on standards common to all provinces and territories apart from Quebec), but all provinces use a centralized Pharmacy Examining Board of Canada (PEBC) Evaluating exam. Admission to the IPG program requires applicants to submit a letter of successful completion of the PEBC Evaluating exam and valid English fluency test scores that meet the minimum requirement (see Appendix B for a table of accepted language test scores).

Approximately 100-120 internationally educated pharmacists (IEPs) are served annually by the bridging program in Ontario. Program course content is adapted from courses offered in the Faculty of Pharmacy undergraduate program and is comprised of Canadian Pharmacy Skills (CPS) I and CPS II course modules and the Canadian Practical Experience (CPE) mentoring program.

The courses provide enculturation to Canadian pharmacy practice and training for entry-level competence. CPS I and CPS II courses are offered twice a year. These include Therapeutics, Patient Counselling Skills, Law, Drug Distribution, Practice Management, Pharmaceutical Care, Communication Skills, Drug Information, The Canadian Health Care System, and Workplace Success Skills.

The academic modules are very intensive and consist of a combination of didactic, problem-based, practical and simulated course work. All courses in Canadian Pharmacy Skills I (CPS I) must be

successfully completed and a minimum average of 60% must be achieved prior to beginning the CPS II module.

An examination period follows each module. Results are made available to participants following review and approval by the IPG Examinations Committee. The Canadian Practical Experience (CPE) Program is designed to provide an opportunity for the IPG student to understand and develop Canadian pharmacy practice skills and is an optional component of CPS I and II.

During the CPE program the participant observes practical aspects and concepts of pharmacy practice. The participant is assigned to a community practice site and a Pharmacist Mentor (PM) by the IPG program staff. The participant is encouraged to work closely with the PM and pharmacy team members

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16 to optimize the CPE opportunity. The volunteer time of the PM and pharmacy team is recognized and instrumental to the success of this component of the program.

The objectives and activities of CPE are to be completed within the suggested timeframe (CPE 1 should be completed prior to the beginning of the CPS II classes and laboratories).

Program structure and flow are illustrated in Chart 2. Bridging components are greyed.

Chart 2: Flow and Structure of International Pharmacy Graduate (IPG) Program

Letter of Successful Completion to College

Canadian Practical Experience (CPE) I

(mentored placement)

Pharmacy Examining Board of

Canada (PEBC) Evaluating Exam

Proof of language proficiency

Canadian Pharmacy Skills (CPS) I

(onsite courses)

Canadian Practical Experience (CPE) II

(mentored placement)

Canadian Pharmacy Skills (CPS) II

(onsite courses)

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17 Internationally Educated Dieticians Pre-registration Program (IDPP), Ontario8 - This program is offered through Ryerson University’s G. Raymond Chang School of Continuing Education; program development was funded by the Government of Ontario and the Government of Canada. This program has been designed to give internationally educated food-and-nutrition professionals information, advice, referral to career opportunities, language testing and training, and, for those who are qualified,

preparation for registration with the College of Dieticians of Ontario (CDO) and Dieticians of Canada (DC).

The practice of dietetics is regulated in all provinces. Approximately 60-80 internationally educated dieticians apply for licensure each year across all provinces; 20-25 of those are served by the IDPP program. Each province manages a separate system of credential assessment (document-based).

The IDPP features two main services:

 assessment and counselling for internationally educated food and nutrition

professionals who are exploring their education and work options (i.e. not eligible for registration with CDO or participation in the IDPP bridging to registration component) and,

 a pre-registration program designed to help internationally educated dieticians (IEDs) prepare for registration and practice in Ontario.

The bridging program is designed to familiarize internationally educated dieticians with the policies and practices of dietetics in Ontario and prepare them for the registration process with the College and become a member of Dieticians of Canada (DC).

The IDPP includes the following components: 1. Screening: a full day of assessments

2. Orientation: an entry-level course covering fundamental skills and familiarization with the profession.

3. Professional courses: during which participants must successfully complete seven program courses, and participate in all other mandatory activities. This component provides participants with the core knowledge9 and communication skills they need to practice as dieticians in Ontario, as well as familiarity with professional standards. 4. Supervised practicum: Once participants have successfully completed their coursework,

they must successfully complete a full-time supervised practicum (minimum total of 12 weeks in two different practice settings) and an administrative project. The practicum is

8_{Adapted from the IDPP website; retrieved on Jan 5 2011 from}

http://ce-online.ryerson.ca/ce_2010-2011/default.aspx?id=2352

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Note: identified content/knowledge gaps that are not covered through the bridging program courses must be completed externally, e.g. through courses offered by Ryerson’s School of Nutrition. All outstanding courses must be successfully completed throughout the time period of the bridging program as a condition for the practicum component.

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18 designed to help participants obtain hands-on experience in Canadian dietetic

professional practice; become acquainted with Canadian dietetic professional

guidelines, resources, and practice procedures; demonstrate competence for entry to dietetics practice; and document the successful completion of the practicum in order to meet CDO requirements. Supervisory Registered Dieticians attest to learners’ successful performance on the full range of professional competencies throughout the practicum component.

Chart 3: Flow and Structure of Internationally Educated Dieticians’ Pre-registration Program

(IDPP)

Minor gap Evident gap Approved YES Passed Failed Failed Passed Passed Compatible YES Failed NO NO Application (including documentation of education, training

and work experience)

Applicant has been assessed by CDO; education and experience conducive

to bridging

Documents screened by IDPP management for general

comparability

Application put on hold pending CDO assessment Language test outcomes at the

required level (CLB 8) Referral to courses

Entry Assessment

(Interview, case scenarios, simulation with client, teamwork) Recommendations

for remediation and/or referrals to

other programs

Onsite courses

Supervised practicum (12-16 weeks)

Signed-off portfolio of competencies submitted to CDO

Temporary licence awarded; Write the registration exam Individualized

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19 Internationally Educated Physiotherapists Bridging (IEPB) Pre-registration Program,

Ontario10

- This bridging program is offered through Ryerson University’s G. Raymond Chang School of Continuing Education and is funded by the Government of Ontario and the Government of Canada. The goal of the IEPB program is to help internationally educated physiotherapists (IEPTs) become licensed to practice and ultimately employed as physiotherapists in Ontario.

The practice of physiotherapy is regulated in all provinces. Each year, over 300 internationally educated physiotherapists apply to become licensed to practice of which the IEPB serves 17-24. The Canadian Alliance of Physiotherapy Regulators (The Alliance) manages a centralized system of credential assessment (document-based) on behalf of all regulatory colleges in Canada with the exception of Quebec.

This bridging program is a relatively new, collaborative initiative. The enrolment to the program is limited to 50 IEPTs during the pilot phase (due to the dependence on external funding), therefore admission to the IEPB is competitive and not every qualified applicant is accepted.

This bridging program is designed to orient IEPTs to the health care system and to physiotherapy practice in Canada. The curriculum includes education in independent/autonomous practice, evidence based practice, inter-professional practice, professional conduct, standards of practice in Ontario and exam preparation skills.

The IEPB Program assumes that applicants have current knowledge of the fundamental domains of physiotherapy practice and that they can apply that knowledge in clinical scenarios. The IEPB curriculum focuses on the types of knowledge and skills that are unique to the Canadian context of practice. Applicants may apply to the IEPB Program before having their language test results but they must provide language scores before the beginning of the program.

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20

Chart 4: Flow and Structure of Internationally Educated Physiotherapists Bridging (IEPB)

Program

* Minimum pass grade: C+ or 67%

Re-assessment by The Alliance based on IEPB transcripts NO Optional Passed Passed* Compatible YES Failed NO NO Credential assessment (a centralized, national process

conducted by The Alliance)

Applicant’s gaps can be generally addressed through a one year bridging program: Referred by The Alliance to IEPB

Ramp to Bridging course (clinical skills refresher) Language test outcomes at the required level Referral to language courses Pre-Admission Assessment Recommendations for remediation and/or referrals to other programs Semester 1:

 Course: Prof. Communication

 Job shadowing (2 wks)

Semester 2:

 3 professional courses

 Basic internship (3 wks)

Semester 3:

 3 professional courses + optional drop-in labs

 Clinical internship (5 wks)

Exam preparation workshop

Recent professional experience

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21 International Midwifery Pre-registration Program (IMPP), Ontario11 - The IMPP is administered through Ryerson University’s G. Raymond Chang School of Continuing Education and funded by the Government of Ontario. It provides internationally educated midwives with skills assessment, information about how midwives practice in Ontario, clinical placements, mentoring and a final pre-registration exam.

Midwifery is the smallest regulated profession in Canada. It is regulated in six provinces, including Ontario. Approximately 25 internationally educated midwives are served annually in Ontario out of around 35 in total across provinces. The bridging program is the only pathway to registration of international midwives in Ontario.

The admission process is competitive as there are limited places available in the IMPP based on

limitations in clinical placements (up to 25 per year). The IMPP is intended for experienced international midwives, fluent in English, who have practiced midwifery within the past five years.

The program is designed to take 9 months to complete. Some components are individualized based on the outcomes of the Pre-Admission OSCEs; other components can be challenged by participants (for a fee). Therefore participants may finish the program more quickly or more slowly depending on the extent of their identified gaps. IMPP courses include Prior Learning Assessment for Midwives, Effective Professional Communication for Midwives, Clinical Knowledge and Skills Enhancement, Orientation to Midwifery Practise in Ontario, and Clinical Clerkship Placement.

Participants must pass each of the five courses in sequence (unless exempted) in order to enter the three month clinical clerkship placement offered as the final component of the IMPP.

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22

Chart 5: Flow and Structure of International Midwifery Pre-registration Program (IMPP)

1.1.

Failed Passed Passed Passed NO Passed Compatible YES NO

Application (including documentation of education, training and work experience)

Midwifery Language Profession Test + oral communication exam Referral to

language courses

Pre-Admission Assessment (full day OSCEs) Referrals to other

programs

Onsite course 1: Prior Learning Assessment

Clinical Clerkship Placement (3 months)

Individualized remediation plan

Onsite course 2: Professional Communication

Onsite course 3: Clinical Knowledge and Skills Enhancement

Onsite course 4: Orientation to Midwifery Practice

Additional workshops and practice lab time

Passed Regulatory body

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23 Bridging Program for Medical Laboratory Technology, Ontario12 - This initiative is offered by Mohawk College and funded by the Government of Ontario and recently by the Government of Canada. This diploma program is intended for internationally educated medical laboratory technologists who wish to work in this role in Ontario.

Medical Laboratory Technology is regulated in seven Canadian jurisdictions. Approximately 300 internationally educated medical laboratory technologists are assessed by the Canadian Society of Medical Laboratory Science (CSMLS) annually on behalf of provincial regulators. Although the majority of the internationally educated practitioners reside in Ontario, the bridging program can only serve 30 applicants a year as it is limited by the number of the clinical placements that can be secured for

program students. CSMLS manages a centralized system of credential assessment (document-based) on behalf of participating regulatory colleges. CSMLS requires applicants to demonstrate a minimum language proficiency of CLB 6 to start the credential assessment process and a minimum of CLB 8 at the time of writing the registration exam.

Admission to the bridging program requires applicants to submit the outcomes of their Prior Learning Assessment conducted by CSMLS. Applicants, for whom English is a second language, must pass the English assessment test (CanTest or equivalent) and demonstrate language proficiency of CLB 7. The program is 9 months in length divided into 3 semesters and consists of classroom theory and laboratory sessions at the College, coupled with clinical experience. The program also includes sector-specific language courses and preparation for the CSMLS competency-based exam. Participants, in consultation with the Program Manager, may take select courses in support of an individual learning plan (instead of the full program). Program curriculum consists of 660 hours (intensive, equivalent to full time) focusing on content and language and 675 clinical experience hours focusing on knowledge application.

The distance education (online learning) format offers IEPs on-line availability of five main program theory courses, hands-on laboratory opportunities, networking with professionals in the field,

interactive learning platforms, and simulated clinical placements. This virtual component is facilitated via interactive components, a webcam in the classroom and online chat capability.

12

Adapted from the program website; retrieved on Feb 2 2011 from http://www.mohawkcollege.ca/continuing-education/bridging-medical-laboratory.html

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24

Chart 6: Flow and Structure of Bridging Program for Medical Laboratory Technology

No Gaps Write CSMLS Examination Gaps identified Courses Courses Referral

Semester 2: Clinical placement CSMLS credential and prior

learning assessment

Language test (minimum CLB 7)

Planning the learning path with the applicant

Semester 1: Courses (online and/or onsite)

Semester 3: Courses (online and/or onsite) + clinical placement

Partial studies as per applicant’s

decision

Diploma in Medical Laboratory Technology

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25 International Accounting and Finance Professionals (IAFP) Program, Ontario – The IAFP program is administered by Ryerson University and funded by the Government of Ontario and the Government of Canada. The program is designed to serve bridging needs of internationally educated professionals in the field of accounting or finance. Although not a healthcare profession, this bridging program was selected for the survey based on its bridging strategy which differs from the other programs surveyed in this report. This may provide an alternative perspective and/or complementary bridging methodology to consider.

While professions in the area of accounting and finance are not regulated in the same way most of the health professions are, it is still a highly regulated practice area. IEPs face multiple barriers accessing employment in their field, such as language and cultural barriers, a ‘No Canadian experience – no job’ phenomenon, complex and unfamiliar professional practice, difficulty communicating the value of one’s previous experience, and employment requirements for certification or professional designation. In that sense, bridging is as crucial for these professionals as it is for individuals in regulated healthcare

professions.

The IAFP includes the following two Program Streams and one certificate program:

 Stream 1 – Bridge to Accounting Credentials. This stream serves professionals whose goals are certification, employment, or career advancement in accounting. If all the program components are taken this stream typically takes one year to complete.

 Stream 2 – Bridge to Employment in Financial Services. This stream serves professionals whose goal is employment or career advancement in their area of direct or related expertise or experience. If all the program components are taken, it typically takes 6 months to complete this stream.

 The Certificate in Financial Management in Canada – Based on the IAFP intake assessment process, qualified participants in either of the program streams can simultaneously register for the Certificate in Financial Management in Canada. The certificate is structured to participants’ individual needs and allows them to complete courses that can also be applied to one of several professional credentials in the fields of accounting and financial services. The certificate addresses IEPs’ need for a Canadian-specific knowledge base and professional communication competencies in order to market themselves effectively to employers and to practice confidently. Potential participants are typically adults in mid-career who currently work in or are hoping to enter the accounting profession or financial industry in Canada and want to obtain a formal Canadian qualification in the field to advance their career.

Utilizing existing courses in the Ted Rogers School of Business Management as well as courses currently offered through The Chang School, the Certificate in Financial Management in Canada is configured to be of maximum benefit to its students. The curriculum (6-10 courses) is appropriately flexible in that it has a clearly defined structure which includes multiple choices and allows course substitutions and/or

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26 transfer credits, all based upon the participant’s assessment and individualized academic plan. This flexibility enables participants to complete a program shaped to their specific needs and to complete courses that can also be applied to one of several professional credentials in the fields of accounting and financial services.

The program is designed to be modular and address the skills and competencies required by local employers and professional bodies. Applicants’ program/course schedule is finalized in a meeting with the IAFP Program Admissions Committee based upon their assessed needs. On-campus courses for the Accounting stream include Orientation Workshop for Accounting Credentials, Assessment for IAFP (Workplace Communication in Canada), Prior Learning and Competency Portfolio, Career Development for Accounting Professionals, Content courses (Business Law; Taxation Law) accompanied by support workshops for IEPs, and Workplace Communication in Canada (WCC) program components as assessed and recommended by WCC, and agreed to by the participant (training in profession-specific language, communication, soft skills, and cultural competence).

Program courses for the Financial Services stream include Orientation Workshop for Employment in Financial Services, Assessment for IAFP (Workplace Communication in Canada), Prior Learning and Competency Portfolio, Career Development for Financial Professionals, and Workplace Communication in Canada (WCC) program components as assessed and recommended by WCC, and agreed to by the participant.

Off-campus components (common to both streams) include mentoring (available to participants who have completed core courses) and work placement. The placement is provided as available to those participants who are deemed eligible and work placement ready through the WCC assessment, and who require this component to complete their individual program plans.

Applicants may enrol in individual courses without completing the WCC Entry Assessment. However, the Work Placement component requires a passing grade on the assessment to ensure placement readiness. Program structure and flow are illustrated in Chart 7. Bridging components are greyed.

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27

Chart 7: Flow and Structure of International Accounting and Finance Professionals (IAFP)

Program

Common to both streams

Optional; pending completion of 6-10 approved courses Optional; pending completion of 6-10 approved courses Optional; pending demonstration of “workplace readiness” Application

Credentials; individual consultation on relevance of bridging and expected outcomes

Accounting Stream Financial Services Stream

Assessment of Workplace Communication in Canada

Orientation Workshop: Employment in Financial Services

Prior Learning and Competency Portfolio Orientation Workshop:

Accounting Credentials

Career Development for Accounting Professionals

Career Development for Financial Professionals Support workshops for IEPs Individual or group mentoring (optional)

Work placement (optional)

Selection of professional and communication courses

(optional)

Certificate in Financial Management in Canada (6-10 courses as per individual plan)

Optional; pending demonstration of “workplace readiness”

Accounting and communication courses (minimum of 5

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28 The Overseas Nursing Programme, UK13 - Offered throughout the UK by a privately held company (JSC Training) on behalf of Manchester Metropolitan University. The program was designed to bridge overseas nurses into practice. Nursing is a regulated profession in the UK. This program serves hundreds of applicants a year.

The program includes two elements: theory and practice. There is a strong focus on the integration of theory and practice and participants undertake both elements simultaneously, on a full time basis. The 20 day Protected Learning contains study specifically relevant to the practice of nursing in the UK (e.g., the structure of the UK health care system, the Code of Professional Conduct and personal

accountability of a registered nurse). The program contains competencies designed to ensure fitness for practice in the UK. Through this program, applicants achieve competencies within the field in which they are qualified to practice.

Program stages and components include the following:

1. Prerequisites and admission

 a work permit/visa

 a current decision letter from the national nursing credentialing body (NMC), which confirms the applicant's suitability to undertake the Overseas Nursing Programme

 Applicants from countries where English is not the first spoken language, are required to undertake the IELTS (language test) and achieve the Academic Standard at 7.0 or above

 All overseas students must have achieved mandatory training/work experience in their home countries.

2. Program structure - The length of the program and period of supervised practice varies greatly depending on the applicant’s previous training, experience, and competence. Applicants who have had educational and practice experience in their home country that closely matches UK requirements for entry to practice are only required to take the 20 Protected Learning days as a bridging process. Others also require supervised placements as part of the program. While the minimum period for supervised practice is determined by the NMC decision letter, the program itself offers a minimum of 16 weeks and a maximum of two years depending on personal circumstances. This approach enables internationally educated nurses to acquire the competencies required for professional registration at a pace that meets individual needs and abilities.

The delivery of the program incorporates a number of modes:

13

Adapted and retrieved on January 2, 2011 from Overseas Nursing Programme website: http://www.jsctraining.co.uk/onp_programme.htm

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29

 Twenty mandatory (protected) learning days offered throughout the programme.

Participants must attend ten days of facilitated learning at a local delivery centre organized by the program leader plus ten days of self directed learning. The sessions are led by centre tutors and supported by a range of professionals. A theoretical learning log is recorded by the participants to ensure the 20 protected learning days have been achieved throughout the program. This component of the program is additional to the clinical practice (i.e. not counted as part of the minimum 16 weeks).

 Clinical placement - The program must be taken on a continuous full time basis with a

named mentor throughout that offers a minimum of two full days a week of direct supervised clinical practice. Assessment of competence is performed by the mentor utilizing the prescribed NMC competencies for entry to practice. Mentors are required to satisfy the NMC requirements for mentorship. A private company provides a one-day mentorship development workshop annually. Mentors are then continuously supported through the company’s Quality Monitoring Strategy. Each participant is also supported by a designated facilitator/case manager.

3. Learning Resources - Participants are registered as external students with Manchester Metropolitan University and have access to a range of e-learning facilities. Resource boxes containing reference materials are offered onsite and a range of open learning materials are used to support learning activities. Additionally, participants are encouraged to join the Royal College of Nursing to facilitate access to the library and resource centres.

On successful completion of the Overseas Nurses Programme, applicants are entered into the NMC Register as a nurse.

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30

Chart 8: Flow and Structure of Overseas Nursing Programme, UK

Some gaps identified Significant gaps Minor gaps identified No gaps identified Registered on RCN Register

Credentials and identity validated by centralized credentialing body; IELTS English test (achieve at least 7.0)

20 days Protected Learning 20 days Protected Learning PLUS Supervised Practice (minimum 16 wks) Request denied Assigned facilitator/case manager Trained site mentor/ supervisor

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31

Survey of Bridging Programs – Findings

In addition to providing baseline program information, key informants were asked a series of qualitative questions related to the development and administration of their respective bridging program. This information will be of value when designing a program structured to the specific needs of the respiratory therapy community and its applicants. A summary of these key points are set out below. What is the level and type of involvement of the regulatory body and other professional stakeholders with the bridging program?

Six out of the seven surveyed programs reported high-to-very high involvement of regulatory/certifying bodies in program design, administration and maintenance. All surveyed programs reported the involvement of multiple stakeholders such as national professional bodies, university departments and employers providing job/clinical placements. The more established programs described a natural decline in direct involvement of stakeholders in bridging programs from providing input on program

conceptualization and curriculum design during the pilot phase to a less-involved role of providing referrals and clinical placements in the post-pilot phase. One program (dietetics) reported a trend of growing partnership with the regulator throughout the period of the program, to the point where the College is now driving internal policy changes to improve access for IEDs.

What is your admission policy as related to internationally educated professionals who were not educated or practiced in this profession in their home countries and are now interested in entering the profession in Canada?

Three major approaches were identified through the survey:

1. Case-by-case (dietetics) – each case is assessed separately. Credentials and relevance of experience are reviewed for gaps.

2. Referred post-assessment by regulator (physiotherapy, pharmacology, medical lab)

3. Require proof of prior education and practice in the profession (midwifery, nursing, accounting)

Despite the different approaches, all three methods are attempting to answer a single question: “Is this program sufficient, in both time and content, to bridge this individual from his/her current state of knowledge and skills to competent and safe professional practice in Canada/the province?” If the gaps identified indicate that the answer is “no”, applicants are referred to alternative education/career pathways.

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32 What are the specific pedagogical and programming design characteristics that make this program effective?

Multiple strategies were described and discussed by the surveyed programs. A summary of the most reported and effective strategies are listed in the table below. A brief description of each of these strategies follows. Ph ar mac o lo gy N u rs in g Di eteti cs Ph ys io th er ap y M id w ife ry M ed ic al L ab Acc o u n ti n g

1. Assessment-based admission process       _

2. Formal orientation to the profession and to the program

  _

3. Bridging-specific curriculum vs. using mainstream courses

      _

4. Centralized curriculum development      5. Supplementary curriculum in support of

mainstream courses 

6. Gradual/scaffolded curricular structure     7. Profession-specific language and

communication courses

    _

8. Threading language and

communication into content courses

      _

9. Threading culture-based competencies into content courses

      _

10. Focus on application and integration of knowledge

      _

11. Highly experiential delivery and assessment strategies

      _

12. Extensive, ongoing, individual feedback       _ 13. Additional learner supports (learning

strategist, lab-time, student services)

      _

14. Online components      _

15. One-size- fits-all curriculum with minimal individualized components

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33 16. Individualized bridging pathway based

on initial assessment

   _

17. Remedial program components (addressing student’s failure)

  

18. Constant evaluation and revision of the curriculum

      _

19. Practical experience (supervised placement)

      _

1. Assessment-based admission process – All interviewees stated that establishing an IEP’s readiness for the program is essential. Applicants who have greater bridging needs than the program can offer will not only be disserved by admission to the program but also take the place of, or interfere with the progress of other, more suitable candidates. Admission assessments range from a basic process of credentialing and language testing through to more elaborate experiential assessments of knowledge, professional communication, professional skills, critical thinking and personal readiness for the program. The more advanced assessments range from one full day (dietetics, physiotherapy, midwifery and accounting) to five full days of assessments (nursing). Assessments most often include individual interviews, written case studies,

simulations, OSCEs, knowledge exams, teamwork and self appraisal/reflection activities.

2. Formal orientation to the profession and to the program – Three of the seven surveyed

programs offer orientation courses to applicants either as optional or as mandatory components of the program. The specific goals of orientation courses differ among programs but in general terms formal orientation aims to help applicants:

 gain deeper understanding of the profession in Canada (scope, depth and characteristics of professional practice);

 introduce the concept of culture-driven professional standards (e.g., reflective practice; critical/clinical reasoning; client-centred care);

 orient to the legal and ethical basis of the profession and the academic environment (e.g. self driven learning, academic integrity);

 enhance basic skills to ensure success in program courses (e.g., math skills, computer skills related to research and communication, information research and analysis skills, reading peer reviewed literature);

 better prepare for the high expectations and intensity of the bridging program (all participating programs noted that even when a bridging program is offered as “part-time” it requires applicants to invest time and effort that go far beyond main-stream programs that are offered as “full-time”); and,

 make a final, well informed decision about accessing the profession in Canada in general and joining the bridging program in particular.

Towards a Pan-Canadian Bridging Program for Internationally Educated Applicants