Towards a Pan-Canadian Bridging Program for Internationally Educated Applicants

Transcription

1 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 Authored by: Keith Johnson & Nava Israel

2 Table of Contents Introduction... 2 Regulator Survey Methodology... 3 Questionnaire Themes and Findings... 3 Content and Scope... 3 Overall Demand... 6 Rationale... 8 Summary of Regulator Survey Findings... 9 Best Practices of Selected Bridging Programs Currently Operating in Canada Program Descriptions Bridge to Canadian Nursing (BCN), Alberta International Pharmacy Graduate (IPG) Program, Ontario Internationally Educated Dieticians Pre-registration Program (IDPP), Ontario Internationally Educated Physiotherapists Bridging (IEPB) Pre-registration Program, Ontario International Midwifery Pre-registration Program (IMPP), Ontario Bridging Program for Medical Laboratory Technology, Ontario International Accounting and Finance Professionals (IAFP) Program, Ontario The Overseas Nursing Programme, UK Survey of Bridging Programs Findings Recommended pan-canadian bridging model Works Cited Appendix 1: Regulator Survey Appendix 2: Survey of Selected Bridging Programs Appendix 3: Accepted language test scores for internationally educated pharmacists

3 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 Canada 1. 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

4 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, 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 3

5 Competency profile 2. 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 program 3. 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-topractice 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: 3 Paulette Blais, The Gap Analysis Project (The College of Respiratory Therapists of Ontario, June, 2010), pg

6 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 evident 4. 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. 4 These distinct applicant streams echo those described in the CRTO Gap Analysis report cited earlier. 5

7 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 ( ), 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 international applicants annually 5. 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). 6

8 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. 7

9 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, What existing mentorship placement programs/resources are available to Canadianeducated 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. May help to mitigate the shortage of respiratory therapists in certain parts of the country. 8

10 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-topractice of the applicant pool. As the 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 fulltime 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-topractice 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 9

11 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 Average number of applications, per year, from internationally educated practitioners (AB, MB, NS, ON, QC) Totals 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 15 10

12 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 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 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. 11

13 Bridging Program Survey Outcomes Program Descriptions Bridge to Canadian Nursing (BCN), Alberta 6 - 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 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 credentialbased and a demonstration-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 anadiannursing/ 12

14 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 Minimum score of 8 on the CLB 12 point scale for entry into BCN Level II and III 13

15 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, professionspecific 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 Degree studies Significant gaps identified Application for Registration with CARNA Some gaps identified Self-referral based on insufficient language proficiency Substantially Equivalent Competency (SEC) assessment including: Written Diagnostic Exams Clinical Judgment Assessment Triple Jump Assessment OSCE IEN Candidate Self-Assessment Language gaps identified (CLB 6) Courses: BCN Level I Common gaps Specialty based gaps as per need No gaps identified No gaps identified Sufficient language proficiency (CLB 8) Courses: BCN Level II + practical placement Specialty-based as per need Courses: BCN Level III (optional) CRNE Exam 14

16 International Pharmacy Graduate (IPG) Program, Ontario 7 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 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 7 Adapted from the IPG website; retrieved on Jan 10, 2011 from 15

17 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 Pharmacy Examining Board of Canada (PEBC) Evaluating Exam Proof of language proficiency Canadian Pharmacy Skills (CPS) I (onsite courses) Canadian Practical Experience (CPE) I (mentored placement) Canadian Pharmacy Skills (CPS) II (onsite courses) Canadian Practical Experience (CPE) II (mentored placement) Letter of Successful Completion to College Structured Practical Training approved by the College 16

18 Internationally Educated Dieticians Pre-registration Program (IDPP), Ontario 8 - 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 internationally educated dieticians apply for licensure each year across all provinces; 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 knowledge 9 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 from 9 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. 17

19 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. Program structure and flow are illustrated in Chart 3. Bridging components are greyed. Chart 3: Flow and Structure of Internationally Educated Dieticians Pre-registration Program (IDPP) Application (including documentation of education, training and work experience) Referral to courses Passed NO Applicant has been assessed by CDO; education and experience conducive to bridging YES Language test outcomes at the required level (CLB 8) YES NO Minor gap Documents screened by IDPP management for general comparability Evident gap Application put on hold pending CDO assessment Recommendations for remediation and/or referrals to other programs Failed Entry Assessment (Interview, case scenarios, simulation with client, teamwork) Compatible Individualized remedial plan Failed Failed Onsite courses Passed Supervised practicum (12-16 weeks) Passed Signed-off portfolio of competencies submitted to CDO Approved Temporary licence awarded; Write the registration exam 18

20 Internationally Educated Physiotherapists Bridging (IEPB) Pre-registration Program, Ontario 10 - 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 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. Program structure and flow are illustrated in Chart 4. Bridging components are greyed. 10 Adapted from the IEPB website; retrieved on Jan from 19

21 Chart 4: Flow and Structure of Internationally Educated Physiotherapists Bridging (IEPB) Program 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 Referral to language courses Recommendations for remediation and/or referrals to other programs NO Failed Language test outcomes at the required level YES Pre-Admission Assessment Recent professional experience NO Compatible Semester 1: Course: Prof. Communication Job shadowing (2 wks) NO Ramp to Bridging course (clinical skills refresher) Passed* Semester 2: 3 professional courses Basic internship (3 wks) Passed Semester 3: 3 professional courses + optional drop-in labs Clinical internship (5 wks) Re-assessment by The Alliance based on IEPB transcripts Optional Exam preparation workshop * Minimum pass grade: C+ or 67% 20

22 International Midwifery Pre-registration Program (IMPP), Ontario 11 - 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 preregistration 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. Program structure and flow are illustrated in Chart 5. Bridging components are greyed. 11 Adapted from the IMPP website; retrieved on Jan from 21

23 Chart 5: Flow and Structure of International Midwifery Pre-registration Program (IMPP) Application (including documentation of education, training and work experience) 1.1. Referral to language courses NO Midwifery Language Profession Test + oral communication exam Referrals to other programs NO YES Pre-Admission Assessment (full day OSCEs) Compatible Onsite course 1: Prior Learning Assessment Passed Individualized remediation plan Failed Onsite course 2: Professional Communication Passed Onsite course 3: Clinical Knowledge and Skills Enhancement Passed Additional workshops and practice lab time Onsite course 4: Orientation to Midwifery Practice Passed Clinical Clerkship Placement (3 months) Passed Regulatory body 22

24 Bridging Program for Medical Laboratory Technology, Ontario 12 - 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 sectorspecific 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. Program structure and flow are illustrated in Chart 6. Bridging components are greyed. 12 Adapted from the program website; retrieved on Feb from 23

25 Chart 6: Flow and Structure of Bridging Program for Medical Laboratory Technology Write CSMLS Examination No Gaps CSMLS credential and prior learning assessment Language test (minimum CLB 7) Gaps identified Referral Planning the learning path with the applicant Semester 1: Courses (online and/or onsite) Courses Semester 2: Clinical placement Semester 3: Courses (online and/or onsite) + clinical placement Courses Partial studies as per applicant s decision Diploma in Medical Laboratory Technology 24

26 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 Canadianspecific 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 25

27 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. 26

28 Chart 7: Flow and Structure of International Accounting and Finance Professionals (IAFP) Program Application Credentials; individual consultation on relevance of bridging and expected outcomes Accounting Stream Financial Services Stream Orientation Workshop: Accounting Credentials Common to both streams Assessment of Workplace Communication in Canada Orientation Workshop: Employment in Financial Services Career Development for Accounting Professionals Prior Learning and Competency Portfolio Career Development for Financial Professionals Accounting and communication courses (minimum of 5 mandatory courses) Individual or group mentoring (optional) Selection of professional and communication courses (optional) Support workshops for IEPs Optional; pending demonstration of workplace readiness Optional; pending completion of 6-10 approved courses Optional; pending completion of 6-10 approved courses Certificate in Financial Management in Canada (6-10 courses as per individual plan) Optional; pending demonstration of workplace readiness Work placement (optional) 27

29 The Overseas Nursing Programme, UK 13 - 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: 28

30 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 oneday 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. Program structure and flow are illustrated in Chart 8. Bridging components are greyed. 29

31 Chart 8: Flow and Structure of Overseas Nursing Programme, UK Request denied Significant gaps Credentials and identity validated by centralized credentialing body; IELTS English test (achieve at least 7.0) Assigned facilitator/case manager Trained site mentor/ supervisor Some gaps identified 20 days Protected Learning PLUS Supervised Practice (minimum 16 wks) Minor gaps identified 20 days Protected Learning No gaps identified Registered on RCN Register 30

32 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. 31

33 Pharmacology Nursing Dietetics Physiotherapy Midwifery Medical Lab Accounting 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. 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 32

34 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 parttime 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. 33

35 All three programs offering an orientation course reported that they consider it an essential component of their program. Initially, it was offered as a short orientation workshop but was eventually expanded into a course. One of the three programs (dietetics) uses this intensive 84 hour course as an additional screening tool for the program, above and beyond their full day Entry Assessment. 3. Bridging-specific curriculum vs. mainstream courses All survey respondents stated that it is essential to design bridging curriculum specifically for its learner s needs vs. using mainstream degree curriculum, or at least provide specialized support workshop/modules if a mainstream course must be used. Bridging-specific curriculum is a need-based type of learning; it addresses specific gaps of IEPs even if those aren t defined as a professional core competency (e.g. computer skills). Three major justifications for a specific, bridging-specific curriculum were identified: The need for a much higher intensity of learning. In many cases IEPs may have been specialized in a single area for most of their career or have not practiced the profession for several years due to the immigration process so participants must build a significant amount of new knowledge/skills within a short period of time. Most mainstream courses aren t designed to serve this need; The varied nature of individual gaps that need filling/bridging. Program learners are coming from a vast range of experiences, levels of academic depth and breadth and levels/types of applied competency. Individual gaps may be at the higher levels of professional practice (e.g., competency to practice in a variety of settings at a high applied level of knowledge and skills), at the very basic levels of professional practice (e.g., mastery of profession-specific language and basic numeracy) and everything in between (e.g. culture-appropriate communication and soft skills). These gaps are reported to be unrelated of the learner s official level of education or professional experience but rather to the different ways professions are taught and practiced elsewhere. Fundamentally, when designing the curriculum, developers can t assume the existence of a direct relation between their learners experience, previous occupational level, educational level or even time in Canada and the actual extent and nature of gaps these learners would need to address. There is significant culture-based behavioural change that most IEPs need to undergo throughout a program. This type of bridging has to be threaded throughout all the bridging courses and tackled by learners often and intensively as it is a challenging transition for most. 4. Centralized curriculum development Most survey respondents believe in the importance of developing bridging curriculum using a collaborative/team approach to ensure consistency and threading. This collaborative approach requires substantial centralized coordination; it requires a longer development time (as compared to a mainstream, stand-alone course) but yields a 34

36 much more powerful curriculum for IEPs. 5. Gradual/scaffolded curricular structure Implementing a high-level curriculum at the outset proved to be most challenging for many of the learners in four of the interviewed programs. This was mostly due to the scattered gap phenomenon (e.g., culture-based gaps in analytical/clinical reasoning and decision making skills, lack of familiarity with competencies, adhering to a different professional scope and frameworks). Initially, the program would offer too much too soon, making it too overwhelming for learners. The gradual or scaffolded approach introduces concepts to learners in an iterative manner, using step-by-step learning. This curricular strategy starts with basic concepts (i.e. no assumptions are made on learners prior knowledge or skills), gradually moving to more advanced applications. Activities are broken down into smaller, more manageable components to ensure progressive, frequent feedback to learners as well as to provide them with manageable components. 6. Supplementary curriculum in support of mainstream courses When program development resources are limited or when there are other organizational reasons for utilizing existing mainstream courses for the bridging program, a strategy of support/supplementary workshops was reported to be useful (e.g. Accounting) in addressing the specific learning needs of the internationally educated cohort. These workshops can be offered onsite or online. They are developed based on the content of the mainstream course and designed to break it down into more manageable components while integrating language supports and culture-based activities and elaborations. 7. Profession-specific language and communication courses Five of the seven surveyed programs offer courses that enhance professional language and communication skills as part of the program. Each of these employed a slightly different approach. Dietetics and physiotherapy programs developed profession specific courses focusing on communication and soft skills using simulations and scenario-based learning. Med laboratory science and nursing programs developed courses that focus on professional issues (e.g., core knowledge, ethical and current issues) that are delivered mainly for the enhancement of language while teaching relevant content. The accounting program uses the courses of another bridging program within the university that focuses specifically on the development of soft skills and cultural competency of IEPs. These courses are not profession specific but are staged within a workplace environment. 8. Threading language and communication into content courses All respondents from the seven surveyed programs discussed the importance of supporting the development of language and communication skills throughout the program, and not only through specific language courses. Language and culture-bridging supports are normally embedded in all education and training activities of the surveyed bridging programs through ongoing individual feedback. Most programs report that the main challenge of offering a standalone communication course as part of a profession-specific program is that while individuals may improve on their communication skills within the Canadian context, they may still lack clinical knowledge and skills. That often 35

37 creates a situation where an individual communicates well with a client/patient but provides the wrong content or applies faulty techniques. Integrating explicit, facilitated development of culture-based communication skills in all content courses was reported to be vital to the bridging process. 9. Threading multiple culture-based competencies into professional content courses All respondents discussed the pedagogical value of threading multiple concepts and competencies throughout courses content. Among the major concepts listed were client-centred care, reflective practice, self directed learning, time management, evidence based practice, documentation skills, initiative taking, analytical thinking (clinical reasoning), formal and informal interpersonal communication, professional behaviour etc. These skills are often difficult to develop and take time to understand and master 10. Focus on application and integration of knowledge The importance of focusing on the application and integration of knowledge vs. the mere delivery of pure knowledge was a common understanding among all seven surveyed programs. Some of the programs restructured existing mainstream courses and others developed from the ground up to address the kinds of applied knowledge and skills that are required within the Canadian context of practice. 11. Highly experiential delivery and assessment strategies For all seven programs it was critical to combine theory and application through highly experiential instruction and assessment strategies (e.g., simulations, OSCEs, case studies, projects, teamwork). 12. Extensive, ongoing, individual feedback All survey respondents stressed the value of providing learners with extensive, ongoing, individualized feedback as part of the intensive learning process. Feedback is provided by instructors, placement supervisors and program management. 13. Additional learner supports Providing learners with additional supports such as individual meetings with a learning strategist, supplementary lab-time, a variety of supports provided by Student Services, access to a library, access to a computer lab, external mentoring etc. was deemed important for all seven surveyed programs. 14. Online components Six of the seven programs reported using online learning components to one extent or another. Cited advantages included improved access to the program for learners (especially IEPs who live far from the training site), and a self-paced, self-managed learning process. 15. One-size-fits-all curriculum with minimal individualized components Four of the seven surveyed programs offer a pre-determined bridging program in which all participants are 36

38 required to take all program components. This approach was supported by the following arguments: Based on program experience, all IEPs require all offered components; the program reduces redundancies and addresses all major gaps typically identified in the assessment process. The regulatory body requires IEPs to demonstrate the full set of professional entry to practice competencies as a condition for writing the registration exam. This can only be achieved through taking a meticulously designed program as opposed to an ad hoc gap remediation approach. 16. Individualized bridging pathway based on initial assessment Four 14 of the seven surveyed programs offer a flexible, individualized bridging program in which participants are able to either select their own bridging pathway or challenge parts of the program through demonstration of knowledge/competency. This approach was supported by the following arguments: A centralized credentialing body has already pre-determined the courses applicants should be taking; therefore an individualized approach better suits learners. Individuals should have the liberty to decide whether they want full bridging to licensing or a partial learning path that would better suit alternative purposes. 17. Remedial program components Three of the seven surveyed programs include remedial components to learners who had failed one or more program components. It is important to clarify that remedial components are different from the mainstream approach of repeating courses upon failure; rather these are individualized components designed to address individual gaps. Remedial components may include a written project, a practical/applied project, additional lab time or additional practical placement all specifically selected for/with the learner. This approach was supported by the following arguments: An individual who had failed the existing format of learning (a course or a placement) might not benefit from going through more of the same. Another bridging approach needs to be devised/offered to help the learner internalize the content, concept or skill. The identified gap might not require repeating a whole course/placement segment. Specific challenges need to be identified and addressed, therefore requiring individualized remediation. Involving the participant in identifying and planning their own remediation activity enhances his/her reflective competency which is an integral part of professional practice. 14 The program for medical laboratory technicians offers an alternative flexible path in addition to a streamlined program and is therefore counted twice. It is important to note, however, that the flexible program doesn t lead applicants to a diploma and therefore may not fit a bridging category. 37

39 18. Constant evaluation and revision of the curriculum All seven surveyed programs conduct a continuous process of program and curriculum evaluation and revision, including programs that have been running for nearly 10 years. Revision is based on learned experience from working closely with the IEPs, the instructors, the placement advisors/supervisors and other stakeholders. 19. Practical experience/clinical placement Supervised placement is provided to learners in all seven programs. All surveyed respondents agreed that this is a vital component for any type of bridging program, especially in the health sector. Practical experience may vary in duration, format and in the stage of the program it is offered. Programs may offer orientation/observation days in different practice environments, participatory placements for practise purposes and a clinical internship with a competency assessment component. How is success measured? Survey findings suggest that bridging programs measure success in two major ways: Short-term measures of success including the following: o Sufficient/steady annual number of applicants o Rates of successful completion of each of the program components o Attrition rates o Rate of graduates getting licensed/passing the registration exam o Rate of graduates gaining employment in the field o Outcomes of external program evaluation Long-term measures of success including the following: o Effectiveness and success of graduates within the profession (e.g. number of formal complaints to the regulatory body) o Range of employing organizations and occupational levels available to program graduates (i.e. assessing whether graduates have equal employment opportunities to those of Canadian educated graduates with similar professional experience) What are the major challenges faced by the participants in the bridging program? Multiple challenges were reported by each of the surveyed programs. The following participant challenges were reported across the board, regardless of the profession or of program formats: Access challenges: Many of the participants struggle financially to cover fees associated with regulatory and bridging assessments and courses. 38

40 Most bridging programs are very demanding and intensive in order to complete the required curriculum in the shortest time possible. Even in part-time programs, participants are required to dedicate time equivalent to a full-time program and beyond. This prevents participants from committing to full time employment; even a part-time job may be too demanding which, in turn, creates financial challenges. Participants who work throughout the program need their employer s support and accommodation, especially during practical placements. This can often be challenging as they are at risk of losing a much needed job. Participants who need to relocate for a clinical placement often find it most challenging both financially and family-wise. Professional/study-related challenges: Language and culture-appropriate communication are some of the more common challenges faced by participants, even by those trained in the English language in another culture (e.g. India, Philippines, South Africa). Language acquisition and adaptation to the Canadian professional communication style requires the greatest investment both of the program and of the participant. Some of the learners have gone through professional de-skilling due to lengthy periods away from practice. This creates undocumented gaps (if the assessment is based on credentials alone) and significant challenges throughout the program. Three out of the seven surveyed programs either refer such applicants to refresher courses prior to admission to the bridging program or deny registration altogether (dietetics, midwifery and physiotherapy). The cut-off for these programs is five years away from practice. All survey respondents reported challenges with participants clinical reasoning abilities. These skills are not related to one s level of intellect but rather to culture-based critical thinking. In many of the immigration source countries, clinical reasoning skills were not developed due to highly hierarchical, expert-driven environments of practice. While these skills can be developed through a well-designed bridging program, participants often struggle to understand what exactly is required of them and why. Many participants who have immigrated from hierarchical, expert-driven environments also struggle with the concept of client-centred practice. Having to adapt to the Canadian educational system can be challenging to most learners who are used to book-learning versus practical, experiential, self driven or reflective learning. Personal challenges: Life commitments and distracters IEPs are post-immigration adult learners who are often still dealing with a variety of issues that detract from the amount of time they are able to devote to a bridging program and motivation to focus on academic studies. Issues in this category typically include: 39

41 o o o Settlement-related challenges, e.g., finding a place to live, a school for the children, where to buy familiar food, how to commute, how to deal with the weather etc. Increased home and family responsibilities due to losing support previously provided by extended family members and friends. The need to work in survival jobs throughout the program. The process of cultural bridging/transition is an ongoing progression of push and pull that requires a deep and challenging learning process. Participants are constantly moving between cultures (home and outside) and the change itself often creates personal stress and even family challenges. Many of the learners are dealing with loss of all sorts, including the loss of friends and family, the loss of their own culture, their professional confidence and authority, and sometimes their very identity. Participants are not always participating by choice. Many choose to participate because it is their only pathway into the profession, not because they believe they really need it. More often than not, IEPs have little or no awareness of their own bridging needs; immigrants who have never practiced the profession in Canada don t know what they don t know and therefore have little grasp of the difference in role and scope of practice. This leads to lack of motivation to participate in a bridging program or to antagonism and resentment upon admission. In many cases, participants are unaware or don t appreciate the value of a practical placement. If it is offered as an option, many participants will elect not to take it. What are the major challenges faced by the administrators of the bridging program? Multiple challenges are faced by each of the surveyed programs. The following issues were most commonly reported: Designing the program: Determining what learners need beyond knowledge-based content. New programs invest a significant amount of time on trial-and-error in the attempt to identify the most appropriate content, pace and required supports. Designing the program in a way that provides maximum access to participants. Most programs currently offered are delivered primarily in a classroom setting. Even programs which have partial online components require a full-time placement at a given point in the program. Participants must therefore be able to commute daily to the program site or to the clinical placement. Most programs continually attempt to expand online components and to accommodate clinical placements that are within a reasonable commuting distance for applicants but the latter is not always possible. Supporting learners and learning: 40

42 The need to employ an individualized approach given great diversity in educational and practice backgrounds. The need to support participants who are unprepared for the time and personal commitment required for the bridging program. Administrators indicated that some learners hold unrealistic perceptions of their own professional capacity in the context of the Canadian practice; dealing with participants lack of understanding and acceptance of their need to further develop language and culture-based soft skills. The ability to support the professional development of participants who aren t very flexible or adaptable. Some participants arrive from cultures where they had a superior position with embedded entitlement. Administrators reported an inherent difficulty in identifying the optimal spot between program flexibility and rigor; the difficulty in determining how far the program should go in supporting its participants, and at what point a participant is beyond remediation and should be released from the program. Sustaining the program: In all programs there is a systemic need for continuous evolution and refinement, which requires continuous investment of human and financial resources. In some cases there is difficulty recruiting suitable instructors from the field mainly due to: o the need to train individuals (instructing international professionals requires significant orientation to learners unique needs and a strong cultural competency on the part of the instructor), and; o the significant time investment instructors are expected to put in (mainly for individualized coaching and extensive feedback). The challenge of securing practicum placements in a saturated and competitive environment where locally educated applicants have the competitive edge over the internationally educated. The need to facilitate relationships and negotiate with multiple stakeholders (professional/credentialing body, regulatory body, participating universities/colleges, employers providing clinical placements) to ensure that all are satisfied with the structure, content and outcomes of the program. The natural fluctuations in the pool of qualified candidates for the program impacted by immigration rates, program affordability, individual readiness, etc. The difficulty of program management to accept that the program can t bridge everyone; that some participants will not successfully complete the program. The need to deliver courses to a small number of learners at a time (up to 25 students per course in most bridging programs; about half a typical full-time cohort) while remaining financially viable. 41

43 Financial sustainability six out of the seven surveyed bridging programs require higher financial resources than could be obtained through reasonable tuition fees. This creates a need for ongoing reliance on external funding. Reliance on the labour market, especially when it comes to securing funding for the program or clinical placements. Are there parallel bridging initiatives for the same profession in other provinces? If so, what are the major commonalities and differences among these programs? Two of the surveyed professions (midwifery and medical laboratory technology) reported that there are no other bridging programs in the country. The following two professions reported some form of bridging in other provinces: o Dietetics - one program in British Columbia; isolated to the practicum component with no bridging courses or other supports. o Physiotherapy - an online extended exam preparation is offered in British Columbia but it doesn t replace the need for bridging. An independent bridging program used to be offered in Alberta but was shut down as it wasn t well aligned with the regulatory body and with university programs. The following three surveyed professions reported similar bridging programs in other provinces: o Nursing - there are bridging programs for nurses in all provinces. Most programs have similar components; some have less bridging components than others (i.e. only offering access to mainstream courses; no bridging content and no practical placements). o Accounting there are other bridging programs in Ontario and some other provinces offered by settlement agencies and colleges. The main difference is that none of them offer university level courses or a university certificate program and not all of them offer job placements. o Pharmacology - there are several very similar bridging programs in other provinces; all programs share resources and communicate regularly. Have there been efforts to harmonize bridging/mentoring initiatives across provinces? What have been the programs challenges and successes in this regard? No significant attempts have been made by three of the surveyed programs (physiotherapy, accounting and medical laboratory technology) to harmonize bridging/mentoring initiatives across the country. Some initial dialogue on harmonization was reported by the following three programs: 42

44 o o o Dietetics - There has been some discussion about sharing supports and materials but because of the limited size of the profession, the smaller provinces have insufficient pools of applicants to sustain a program. There is now recognition of the IDPP program by some of the other provinces and initial dialogue has begun on the need for a more centralized or otherwise transferrable approach. Midwifery Although there has been some initial discussion in this regard, there is currently no agreement on the appropriate approach. The standards for professional development in midwifery vary across provinces, a fact that makes it almost impossible to reach meaningful collaboration in this area. Pharmacology Programs in British Columbia and Alberta are the only participants in the discussion on harmonization. Although there is some initial discussion, professional/internal politics prevents any substantial harmonization to occur at present. Theoretically, some harmonization is expected to take place in two years. Nursing was the only profession that reported ongoing collaboration among programs towards harmonization. A new project lead by the Canadian Association of Schools of Nursing (CASN) aims to create shared guiding principles for bridging programs for nurses in Canada. This, however, will not lead to the complete fusion of existing programs under a centralized/unified delivery model; rather it will provide common standards for existing programs. What are the barriers to long-term sustainability of the bridging program? Some of the barriers reported were common to all programs, others were profession-specific. Major barriers included the following: Barriers related to professional stakeholders: Collaboration with respective regulatory bodies this is an essential component for the success of the program in terms of referral and recognition of program outcomes. In some of the professions regulation is inconsistent across Canada. This limits the possibility of the program to offer services in other provinces and therefore achieve long-term sustainability. Most programs struggle with securing clinical placements; this creates a bottleneck in the program which ends up limiting the number of applicants a program is able to serve. Program credibility, both on the part of regulators and on the part of participants. This is especially challenging for newly developed programs that have no track record of success. The need to maintain a delicate balance between bridging programs and mainstream academia. A bridging program needs to be associated with academia for ongoing update but not governed by it (e.g. the professional school within the university or college) since participants require an educational environment that brings maximal flexibility and strong expertise in bridging. These are more likely to exist within continuing education than within faculties. Financial sustainability barriers 43

45 Most surveyed programs are funded by the province. Such funding usually covers development and pilot stages but not ongoing operation. Since tuition fees must be maintained at an affordable level for participants, program costs in small professions that bridge individuals a year cannot be fully covered on a cost-recovery basis. This creates a situation where programs either need to keep applying for new development funds (dietetics, midwifery, physiotherapy, accounting) or be fully integrated into the college/university infrastructure (pharmacology, nursing, medical laboratory technology) which requires significant systemic change. The need for additional funds for ongoing redevelopment of the program above and beyond operational costs, for example: o Moving some of the program components online to increase accessibility and therefore the number of participants. o Redeveloping the program based on changes in professional standards, competencies and scope of practice. Labour market and provincial priorities Most bridging programs depend on provincial funding and therefore on provincial priorities. Political changes (either at the federal or provincial level) might therefore create unforeseen instability of programs. For example, in the past year, the stated need for nurses in Alberta dropped from thousands to nearly none based on provincial re-prioritization (versus actual need). Such labour market shifts in supply and demand impact the will of stakeholders to provide supports and the interest of funders to allocate ongoing funding for the program as they are directly related to talent shortages. 44

46 Recommended pan-canadian bridging model Recommended pan-canadian bridging model A successful pan-canadian system of bridging international applicants needs to account for the specific characteristics of the respiratory therapy profession. As mentioned above, the practice of respiratory therapy, as it is understood in Canada, is not practiced in many jurisdictions outside of North America. As such, a significant proportion of international applicants worked in a different but related profession before immigrating to Canada (physicians, anaesthesia technicians and general medical technicians). The result of this trend is great variance in the learning/skill gaps and ultimately readiness-to-practice of the applicant pool. According to the survey of Canadian respiratory therapy regulators conducted as part of this project, a relatively small number of applicants (typically from certain schools in the Philippines and US) have education and skills fairly comparable to Canadian entry-to-practice requirements. These individuals, have a few, minor gaps which need to be remediated before gaining licensure and are the target group for a pan-canadian bridging program. Based on the research conducted into the structure and best practices of other bridging programs a number of key drivers of success were identified. These are set out below and have been incorporated into the proposed model which is described in the following section. 1. Pre-bridging supports: including consistent, and often centralized, credential assessment, identification of specific content-gaps and a clear decision tree for referral to professional prebridging, bridging, degree studies or alternative careers. 2. Rigorous admission process: including assessment of language skills, profession-specific communication skills (mainly in client-facing professions), and assessment of personal readiness for a bridging program. 3. Curricular components: including courses/modules on professional communication and Canadian culture of practice; orientation to the Canadian healthcare system; professional content addressing major common gaps; and, supervised practical practice. Curriculum should be designed to include bridging-specific courses as opposed to using mainstream courses to maximize relevance and support for participants. Instruction should focus as much as possible on practical application of content in a simulated environment. 4. Remedial opportunities: bridging is a very personal and often emotional process that can take varying periods of time irrespective an individual s starting point. An opportunity for remediation within the program should be included for learners. 5. Exit assessment: administration of some form of assessment of professional competency prior to entry to the profession. 45

47 Most of the surveyed bridging programs are currently funded provincially and administered through a local university or college. This model proves to be geographically limiting for participants and therefore less accessible. Online components have been added to many of the programs as a partial solution for accessibility but none are fully web-based and onsite components are still geographically limiting. Although, theoretically, a locally-developed bridging program should be transferrable across organizations and provinces, in reality none of the surveyed programs has been transferred due to a variety of reasons. Conversely, components that were developed under a centralized system to begin with (e.g., credentialing and testing services), have been made available across the country and are reported to be successful models. Based on our research findings and the unique needs of the profession, we recommend the following model for bridging internationally educated respiratory therapists into practice in Canada (see illustration/flow chart of proposed program components and associated descriptions below). Where possible, the administration of the program is centralized and made available online. This type of model affords improved administrative efficiencies, economies of scale and overall consistency of service and information to learners. Based on the typical gaps identified in the survey of respiratory therapy regulators, it was felt that a clinical practice component was also necessary to acclimatize international learners to the nuances of the Canadian workplace and expose them to technology and equipment they might not be familiar with. As such, the only non-centralized component of the process is the laboratory simulation and clinical placement in which the input and coordination of provincial regulatory colleges will be required. As mentioned earlier, the proposed model of bridging does not meet the needs of all applicants; it is specifically designed for those applicants with limited deficiencies relative to Canadian standards who can meet entry-to-practice requirements with a year or less of bridging. It is our recommendation (reflected in the proposed model) that applicants with significant gaps identified in the credential assessment phase are not suitable for a bridging program and should be referred to/integrated into a full-time Canadian respiratory therapy program with advanced standing where possible. Finally, the majority of professions surveyed as part of this research were able to secure third-party funding (typically from federal and/or provincial governments) to develop and pilot their respective bringing programs. As such, it is also recommended that the NARTRB prepare a proposal directed to potential funders based on the bridging model described herein. 46

48 Proposed Bridging Framework for Respiratory Therapists Guided Exploration of RT Practice in Canada (online) Application Degree studies/ Language training Significant gap Credential assessment No gap Incompatible Minor gap Admission process: Assessment of personal readiness for bridging (interview; province-based/centralized) Assessment of profession-specific language and communication (online; centralized) Mandatory for all participants Bridging courses (online; centralized) Orientation to RT in Canada Professional Communication for RT Applied RT Practice Individualized; based on identified gaps Content courses (online; centralized) Successful completion Learner and mentor supported by a central coordinator (centralized) Mentor supported by online modules and a network of peer mentors (centralized) Remedial plan Failed Online and onsite lab simulations (centralized + provincial) Successful Practical placement with a trained mentor (provincial) Successful CBRC Exam Preparation Course (centralized; optional) Write CBRC Exam Online, fully centralized service Centralized coordination; provincial implementation 47

49 1. Orientation to the profession: Based on the survey of well established bridging programs, it is well advised to create a powerful orientation process to the practice of respiratory therapy in Canada to create transparency and align applicants expectations. This online, non-facilitated orientation can be offered through the program website and include scenario-based introduction that will feature a variety of practice areas and allow potential applicants to actively engage and test their professional skills. 2. Pre-bridging processing/evaluation of applicants: As per findings stemming from the Towards a Pan-Canadian Framework for the Assessment of Internationally Educated Respiratory Therapists report, it is recommended that the assessment of international applicants be centralized in one or two locations in Canada. a. Credential assessment: performed by trained credential assessors, all applicants will be evaluated against the same set of standards. These standards can be set by an Evaluation Committee comprised of representatives from participating regulatory colleges and administered by a central body or bodies. b. Decision making: referral based on identified applicant gaps. The conditions for referral to the bridging program should be pre-established and standardized. A referral structure can be based on a step approach: o In the case of substantial equivalence (i.e. where an applicant meets prescribed entryto-practice standards), referral to either a registration examination or another type of assessment that verifies professional competency. This step is recommended based on limitations related to the credentialing process which often fails to assess an individual s current professional capacity to practice. o In the case of small gaps (the scope of which should be pre-established) that can be addressed through a single year of bridging, and therefore referral to the bridging program. This referral should include specifics regarding content gaps. o In the case of significant content/experience deficiencies, referral to a degree program (potentially with recommendations on advanced standing). Significant can be qualitatively described as requires significantly more extensive transitional education and training than the RT bridging program can offer. However, quantitative measures of significant need to be put in place to ensure transparency, consistency and fairness. 3. Admission to the bridging program: As gleaned from the survey of existing Canadian bridging programs, this stage of the process should optimally include two major components: a. Assessment of profession-specific language and communication skills this assessment can be developed and delivered centrally to enhance accessibility, transferability and long-term sustainability. Although a number of generic language assessment are readily available to applicants (TOEFL, IELTS, etc.) they have many drawbacks when it comes to professional qualification. These exams focus mostly on language proficiency rather than professional communication and soft skills. Other detractors of using these tests in the context of regulated health professions may include: their level of transparency is most limited (little information 48

50 about the test itself; limited information provided to the participant in the outcome report); participants perceive these tests to be of little relevance to them based on their generic nature; and finally, some of the applicants may have high language scores (e.g., were educated in English) and yet are ineffective communicators within a professional environment having immigrated from countries with significantly different professional, linguistic and cultural contexts. A profession-specific assessment of language, fully relevant to the applicant, valid, reliable, transparent and helpful to the applicant, rigorous, secure and accessible. This assessment can be developed and delivered centrally and offered fully online. b. Assessment of personal readiness and expectation setting for the bridging program can be performed through a structured interview with the applicant. This interview can be conducted provincially (i.e. by the regulatory body) or centrally by the coordinating/managing body of the bridging program (via electronic communication). 4. Curricular bridging components: It is recommended that the following components be integrated into the curriculum of a bridging program suited to the needs of internationally educated health practitioners seeking licensure and respiratory therapists in Canada. a. Course/integrated modules on professional communication and Canadian culture-of-practice specific to respiratory therapy. These components should include an in-depth exploration of: Canadian cultural values, norms and related workplace legislation Critical analysis and communication of information Client-centred (vs. expert centred) framework of practice Client-centred interpersonal communication Working in multidisciplinary teams Reflective practice Persuasive communication b. Orientation to the Canadian healthcare system and to professional jurisprudence. c. Courses covering professional content (usually up to five courses over 6-8 months) addressing major common gaps) integrating multiple applied components that touch on professional culture and communication in Canada. d. Online and onsite lab simulations. e. Supervised clinical practice component. Apart from the onsite lab simulations and the supervised clinical practice (in which specific sites, instructors and mentors will need to be sourced across the country to ensure adequate access), all the curricular components can be developed and offered centrally, fully online. A centralized coordinating body 15 will be responsible for retaining instructors to teach remotely and case-manage the participant roster. This delivery structure will improve the potential for long-term financial 15 Program coordination may be covered by a single FT position supported by a volunteer advisory committee, possibly NARTRB members. 49

51 sustainability. The supervised practicum should be offered locally within a given applicant s province. Local partnerships with training providers can be set up with the support of the regulatory body. The practicum can consist of a single or of several placements, depending on availability and the requirement of the regulatory bodies. While in practicum, both participant and professional mentor/placement supervisor will be supported by the program coordinator. In addition, an online training and networking system can be developed to provide ongoing support for mentors throughout Canada. Access to this system can potentially be perceived as a professional benefit for program mentors. It is highly advised to create some sort of professional acknowledgment for participating mentors to help the program recruit placements (usually the major challenge and bottleneck of all bridging programs). 5. Remediation: It is also recommended that an applicant who requires remediation (based on failure in courses or placement) can be offered an individualized learning and improvement plan. This plan can be collaboratively developed by the participant, the program coordinator and the instructor/mentor depending on the stage in the program. 6. Exit assessment: The final demonstration/proof of professional competency can be achieved in several ways. Overall entry-level competency can be demonstrated through a single, experiential, centralized and standardized assessment (preferably onsite); through the collection of a participant s demonstrated competency throughout the program (portfolio of attested competencies); or, through a provincial registration examination. Whichever method is selected, it is important to maintain consistency to ensure full transferability and defensibility. 50

52 Works Cited Blais, Paulette. The Gap Analysis Project. The College of Respiratory Therapists of Ontario, June, Blais, Paulette. Access Issues Regarding Internationally Educated Health Professionals and the Respiratory Profession in Canada. National Alliance of Respiratory Therapy Regulators, February, Johnson, Keith. Towards a Pan-Canadian Framework for the Assessment of Internationally Educated Respiratory Therapist. National Alliance of Respiratory Therapy Regulatory Bodies, JSC Training. Overseas Nursing Programme (ONP). (accessed January 2, 2011). Mohawk College. Bridging Program for Medical Laboratory Technology. (accessed February 2, 2011). Mount Royal University. Bridge to Canadian Nursing. ms/bridgetocanadiannursing/ (accessed January 10, 2011). National Alliance of Respiratory Therapy Regulatory Bodies Respiratory Therapy National Competency Profile. Ryerson University. Internationally Educated Dietitians Pre-registration Program (IDPP). (accessed January 5, 2011). Ryerson University. Internationally Educated Physiotherapists Bridging (IEPB) Pre-registration Program. (accessed January 5, 2011). Ryerson University. Midwifery Education Program. (accessed January 5, 2011). University of Toronto. International Pharmacy Graduate (IPG) Program. (accessed January 10, 2011). 51

53 Appendix 1: Regulator Survey Respiratory Therapy Regulator Questionnaire (Name Org ) Bridging Program Due Diligence (November, 2010) 1. What is the professional/educational background of your international applicant pool? 2. What are the academic and non-academic deficiencies that are typically identified in a credential assessment of international applicants? 3. What existing mentorship/placement programs/resources are available to Canadian and/or internationally educated respiratory therapy professionals towards professional accreditation? 4. What existing mentorship/placement programs/resources are available to Canadian educated respiratory therapy professionals who wish to re-enter professional practice after a break (i.e. how are gaps currently identified and remediated)? Approximately how many individuals re-enter the profession annually? 5. Do applicants have to prove official language proficiency to meet entry-to-practice requirements? What tests are accepted? What is the minimal level/score required? 6. Are there certain types of disciplinary issues that are endemic to the internationally educated cohort post-registration? 7. What do you see as the potential benefits of a bridging/mentorship program? 8. How many individuals would you expect to refer to a bridging/mentorship program annually? 9. What source countries do you typically receive applicants from? Number of international applications Number of inquiries from international applicants (not including official applications) 52

54 Appendix 2: Survey of Selected Bridging Programs Bridging Program Due Diligence (November, 2010 February, 2011) 1. Describe the overall structure and flow of the program. 2. How many IEPs are served annually by the program? 3. What is the level and type of involvement of the regulatory body and other professional stakeholders with the bridging program? 4. What is your admission policy as related to internationally educated professionals who were not educated or practiced as physiotherapists in their home countries and are now interested in entering the profession in Canada? 5. What are the specific pedagogical and programming design characteristics that make this program effective? 6. How is success measured? 7. What are the major challenges faced by the program in the bridging process? 8. What are the major challenges faced by the participants in the bridging program? 9. Are there parallel bridging initiatives for the same profession in other provinces? If so, what are the major commonalities and differences among these programs? 10. Have there been efforts to harmonize bridging/mentoring initiative across provinces? Challenges and successes? 11. What are the barriers to long-term sustainability of the bridging program? 53

55 Appendix 3: Accepted language test scores for internationally educated pharmacists (Retrieved on March 15, 2011 from 54