What this article is about
In brief
A mixed-methods study of internationally educated nurses (IENs) in rural and northern BC found four key themes, resourcefulness, rural life, mental health and identity, and registration-process challenges, and used a multi-stakeholder workshop to turn these findings into partnership-based strategies for improving...
For nursing students
Study summary
Internationally educated nurses (IENs) are nurses who trained outside Canada and now want to work here. Canada's health system depends on them, especially in rural and northern regions where staffing shortages are severe. But getting licensed in Canada can take years, cost thousands of dollars, and require moving away from family and support networks to access assessment centres or bridging courses that often only exist in large cities. This study, led by researchers at the University of Northern British Columbia, looked closely at what that process actually feels like for IENs living in northern BC, and what could be done to make it fairer.
The research team used a mixed-methods design guided by Equity Theory, a framework that looks at how people judge fairness by comparing what they put into a system (effort, money, credentials, time) against what they get back (recognition, employment, support). They gathered data in three ways: focus groups and interviews with 13 IENs, an online survey completed by 79 IENs, and a workshop bringing together 16 key partners, including nursing regulators, credential assessors, educators, a nurses' union, and health system leaders. Combining direct nurse experiences with the perspectives of the people who run the licensing system let the researchers see both sides of the same barriers.
Four themes emerged from the interviews and focus groups. The first, resourcefulness, described how IENs drew on personal determination, informal networks, and creative problem-solving to keep moving toward licensure despite obstacles. The second, rural life, captured the particular challenges of pursuing registration while living in small or remote northern communities, where the nearest testing centre, bridging program, or mentor might be hours away. The third theme, mental health and identity, reflected the emotional toll of prolonged waiting, financial strain, and the sense of having a professional identity put on hold or questioned. The fourth theme centered on the registration process itself, where participants described unclear steps, long delays, and a lack of navigational support to help them understand what to do next. Despite these struggles, participants also showed strong resilience and continued commitment to nursing as a profession. The survey of 79 IENs echoed these same barriers at a broader scale, suggesting the focus group findings were not isolated experiences.
The key partner workshop took these findings and turned them into a different kind of result: partnership-based strategies. Rather than treating licensure as something IENs must struggle through alone, participants worked together to identify ways regulators, educators, and employers could collaborate to improve educational access, streamline regulatory processes, and build clearer workforce pathways specific to rural and northern settings. This is where the study's title comes from: moving away from a system that acts mainly as a gatekeeper checking credentials, toward one that actively collaborates to support IENs into practice.
For nursing students and future colleagues, this research is a reminder that the nurses working alongside you who trained abroad have often navigated a long, financially and emotionally demanding path to get there. Understanding that path can shape how you welcome and support IEN colleagues in your workplace. The study's authors conclude that effective integration of IENs requires coordinated, equity-oriented partnerships across every part of the system, regulators, educators, unions, and employers together, not isolated fixes. Strengthening these collaborations, the authors argue, can shorten licensure timelines, improve retention of IENs once they are working, and directly increase healthcare capacity in the underserved rural and northern communities that need nurses most. As a Canadian Journal of Nursing Research article, this study adds northern-specific, partnership-oriented evidence to a growing body of work on internationally educated nurses in Canada.
Original publication
Source abstract and study details
Read the source abstract
Aim To examine the experiences, motivations, and perceived inequities of internationally educated nurses (IENs) residing in northern British Columbia and to identify systemic, geographic, and regulatory barriers to workforce integration. Background Although IENs are critical to Canada's health workforce, many face prolonged licensure processes and limited access to education and employment, particularly in rural and remote communities. Design Guided by Equity Theory and organizational perspectives, this mixed-methods study explored how perceived inequities influence motivation, engagement, and workforce participation. Methods Data were collected through three focus groups and interviews ( n = 13), an online survey ( n = 79), and a key partner workshop with regulators, assessors, educators, a union and health system partners ( n = 16). Results Four themes emerged: resourcefulness, rural life, mental health and identity, and challenges within the registration process. Participants demonstrated resilience and strong professional commitment but reported delays, financial strain, and limited access to local training and navigational support. Survey findings echoed these barriers. The key partner workshop translated findings into partnership-based strategies to improve educational access, regulatory collaboration, and rural workforce pathways. Conclusion Effective IEN integration requires coordinated, equity-oriented partnerships across regulators, educators, and employers. Strengthening these collaborations can improve licensure access, support retention, and enhance healthcare capacity in underserved regions.
Reviewed findings
Main findings
- Four themes emerged from IEN focus groups and interviews: resourcefulness, rural life, mental health and identity, and challenges within the registration process.
- IENs in northern and rural BC reported prolonged licensure delays, significant financial strain, and limited access to local bridging education and navigational support.
- Participants demonstrated strong resilience and sustained professional commitment to nursing despite the barriers they described.
- Survey findings from 79 IENs echoed the barriers identified in the qualitative focus groups and interviews, corroborating the thematic findings at a broader scale.
- A key partner workshop with 16 regulators, assessors, educators, a union, and health system partners translated study findings into partnership-based strategies for improving educational access, regulatory collaboration, and rural workforce pathways.
For teaching and learning
Education implications
- Nurse leaders and educators in rural and northern settings should anticipate that IEN colleagues may be managing significant financial and logistical strain related to ongoing licensure or credential-recognition steps, even after they begin working.
- Health organizations may improve retention of IENs by providing local navigational support (a named contact or mentor who can explain registration steps) rather than assuming IENs will independently locate this information.
- Because rural geography compounds registration barriers (distance to assessment centres, limited local bridging programs), rural employers and regulators should consider region-specific supports rather than applying urban-designed pathways uniformly province-wide.
- The study's emphasis on mental health and identity as a distinct theme suggests IEN-supportive workplaces should attend to psychological safety and professional-identity recognition, not only technical credentialing steps.
- Because the study explicitly moved from problem identification to partnership-based strategies involving regulators, educators, and unions together, meaningful improvement in IEN integration likely requires coordinated cross-sector action rather than isolated employer-level initiatives.
For educators
Teaching and appraisal notes
This mixed-methods study by Sanders, Haggarty, Friesen, McKellar, Clyne, Schiller, Agoston, and Roots, published in the Canadian Journal of Nursing Research, examines the licensure and workforce integration experiences of internationally educated nurses (IENs) in rural and northern British Columbia. The research team, based at the University of Northern British Columbia, is well positioned for this inquiry: the lead author is herself an internationally educated nurse who relocated to northern BC, and the broader project has partnered with Northern Health and the Provincial Health Services Authority to document IEN experiences and pathways in the region.
The study is framed by Equity Theory and organizational perspectives, which allow the authors to interpret IEN accounts not simply as individual hardship stories but as reactions to perceived imbalances between the effort, cost, and time IENs invest and the recognition, employment, and support they receive in return. This framing is useful for faculty introducing students to workforce-integration literature, since it links lived experience to a testable organizational construct rather than leaving findings at the level of anecdote.
Methodologically, the study triangulates three data sources: qualitative focus groups and interviews with 13 IENs, a broader online survey of 79 IENs, and a key partner workshop with 16 regulators, assessors, educators, a union representative, and health system partners. This design lets the authors compare individual narrative depth against survey-level pattern confirmation, and then move findings into a solutions-oriented space by convening the system actors who control licensure and employment pathways. Four qualitative themes were identified: resourcefulness, rural life, mental health and identity, and challenges within the registration process. These themes describe both the resilience IENs bring to a difficult process and the structural friction points, geographic isolation, financial strain, unclear navigation, and identity disruption, that the process imposes. The survey data are reported as corroborating these themes rather than contradicting them, which strengthens the credibility of the qualitative findings, though the abstract does not provide the specific survey statistics or effect sizes that would allow independent verification of that alignment.
For teaching purposes, this article is well suited to seminars on health workforce policy, equity-oriented qualitative design, or Canadian health human resources. Useful discussion angles include: how Equity Theory operationalizes fairness perceptions in a licensure context; the methodological value of pairing a stakeholder workshop with participant data collection to move research toward actionable, partnership-based recommendations rather than recommendations directed only at IENs themselves; and the tension between individual resilience narratives and structural critique, since celebrating IEN resourcefulness could inadvertently normalize a system that requires excessive resourcefulness to navigate.
Limitations for classroom discussion include the study's regional specificity to northern BC, which may limit transferability to urban or other provincial contexts with different regulatory bodies and labour markets; the qualitative sample size of 13, typical for focus-group-based designs but modest for theme saturation claims; and the abstract's lack of detail on survey response rate, sampling method, or demographic breakdown of participants, which limits appraisal of survey representativeness. The study's practice and policy value lies in its explicit move from problem identification to partnership-based strategy generation involving the actual regulatory and educational bodies responsible for change, a design feature students should be encouraged to notice and compare against studies that stop at documenting barriers without engaging the institutions that could address them.
Critical appraisal
Limitations
- The qualitative component drew on a relatively small sample of 13 participants across three focus groups and interviews, which may not capture the full diversity of IEN experiences in the region.
- The study is geographically specific to northern and rural British Columbia, and findings may not generalize to IENs in urban BC or other Canadian provinces with different regulatory bodies and labour markets.
- The abstract does not report the online survey's response rate, sampling method, or participant demographics, limiting independent appraisal of how representative the 79 survey respondents were of the broader IEN population.
Classroom use
Discussion Questions
- How does Equity Theory help explain why IENs might perceive the licensure process as unfair, even when regulators are applying the same rules to everyone?
- Why might combining focus groups, a survey, and a key partner workshop produce more actionable findings than a purely qualitative or purely quantitative study alone?
- What specific features of rural and northern geography (beyond simple distance) could make licensure and bridging education harder to access for IENs?
- How can 'resourcefulness' as a theme be read two ways, both as evidence of IEN resilience and as a sign that the system currently demands excessive individual effort to navigate? Which reading do you find more useful for policy discussions, and why?
- What kinds of navigational supports (mentorship, single points of contact, plain-language guides) do you think would most reduce the confusion IENs reported in the registration process theme?
- Why did the researchers convene a workshop with regulators, assessors, educators, a union, and health system partners rather than making recommendations directly to IENs or to employers alone?
Knowledge check
Quiz
1. What theoretical framework guided this study's exploration of IEN experiences?
- Social Learning Theory
- Equity Theory and organizational perspectives
- Health Belief Model
- Diffusion of Innovation Theory
Show answer and rationale
Rationale: The abstract states the study was 'guided by Equity Theory and organizational perspectives' to explore how perceived inequities influence motivation, engagement, and workforce participation.
2. How many internationally educated nurses participated in the focus groups and interviews?
- 7
- 13
- 22
- 79
Show answer and rationale
Rationale: The abstract reports 'three focus groups and interviews (n = 13)' as one data source.
3. How many IENs completed the online survey component of this study?
- 13
- 16
- 79
- 104
Show answer and rationale
Rationale: The abstract states data were also collected via 'an online survey (n = 79)'.
4. Who participated in the key partner workshop described in the study?
- Only internationally educated nurses
- Regulators, assessors, educators, a union, and health system partners
- Only hospital administrators
- Only nursing students
Show answer and rationale
Rationale: The abstract describes 'a key partner workshop with regulators, assessors, educators, a union and health system partners (n = 16)'.
5. Which of the following was NOT one of the four themes identified from focus groups and interviews?
- Resourcefulness
- Rural life
- Interprofessional teamwork
- Challenges within the registration process
Show answer and rationale
Rationale: The abstract lists the four emergent themes as 'resourcefulness, rural life, mental health and identity, and challenges within the registration process'; interprofessional teamwork is not among them.