Authors: Ivy Lynn Bourgeault, Elena Neiterman, Jane LeBrun, Ken Viers & Judi Winkup

Canada has historically relied on internationally educated health professionals (IEHPs) to address shortages in rural and remote locations and hard to fill positions within its health care system. It continues to do so and, while this has been true for medical and nursing labour in the past, this is now also true for midwives. At the same time, we hear of numerous accounts of IEHPs who are not able to practice their profession in Canada. The barriers to practice for IEHPs – what some have labelled the 'brain waste' problem – have recently become a significant concern for Canadians. The difficulties this causes are not limited to the Canadian context – in terms of lost labour, and possible solutions to its human resource crises – there are important implications for the countries from which health care providers migrate.

This study was designed to fill some of these gaps in our knowledge by examining:

• the experiences of internationally educated physicians, nurses and midwives who were pursuing professional integration, who have achieved it, and who have decided to redirect their efforts; and
• the barriers and facilitators they experienced along the way that they feel influenced their relative success at becoming integrated into provincial health care systems in Canada.

From the outset we decided to gather the perspectives of the IEHPs. This was intended to supplement the policy recommendations that have been made through stakeholder consultations, because the issues that have come to the attention of Canadian stakeholders may or may not be a true reflection of IEHP experiences. The analysis took a comparative approach between professions, as it allowed us to contrast the process and outcomes of various models of integration across professions. We conducted interviews with 67 international medical graduates (IMGs), 70 internationally educated nurses (IENs) and 39 internationally trained midwives (ITMs), recruited through a variety of means in four provinces – British Columbia, Manitoba, Ontario and Quebec - and in two languages. Based on these conversations, we traced their experiences, from their decision to come to Canada, through the process they undertook to get here, and then examined the barriers and facilitators to their professional and labour market integration. We include some of their recommendations for policy to improve the situation for others who follow their path.

Deciding to Leave and Come to Canada

The majority of our IMG respondents came from Eastern Europe, followed by the Middle East and South America, East Asia and Western Europe in equal numbers. The three most common countries of birth for IENs were Western Europe, Eastern Europe and the U.K. Most of the ITMs we interviewed were born in Canada – a fact which largely reflects of the relative lack of Canadian educational opportunities for midwives – followed by Western Africa and Western Europe and then the U.K. close behind.

It is difficult to tease apart the 'push' and 'pull' factors that cause IEHPs to emigrate from their home countries to Canada. Most, however, choose Canada as a country of destination as it 1) has a relatively easy process of immigration; 2) has the reputation of a country with political and economic stability; 3) has fair international politics; 4) promotes multiculturalism; and 5) gives the impression that health care providers are in demand.

Immigration to Canada

The first step for most health care providers is the national system of immigration, although for some, this is a second step, following recruitment. While there are tremendous differences in immigration preparations undertaken by our respondents, it is possible to categorize them into having followed one of four different routes: 1) independent immigration, through one of two possible immigration entry points (economic or family class); 2) immigration to Canada through recruitment agencies (largely economic class), 3) immigration to Canada with the help of agencies that solely provide assistance with immigration per se, without helping immigrants find work (which could be either economic or family class); and 4) entry to Canada as refugees. The largest proportion of respondents came as skilled workers but this proportion is far greater for the IENs and IMGs than for the ITMs. There were almost as many ITMs who came as family as who did so as skilled workers; far fewer IENs and IMGs came as family class than as skilled workers. Those who found it most difficult to integrate into their profession were those who came as refugees, followed by those who came independently. Those who were recruited were most likely to have largely positive labour market outcomes in the health care sector.

Barriers to Professional and Labour Market Integration

There are number of barriers which IEHPs face while seeking to integrate into the Canadian workforce. Some are unique to their individual profession, some are similar across health professions, and some are similar to the migration of highly skilled workers generally. All of the IEHPs we interviewed faced very similar barriers in terms of: their English or French language skills, particularly those which are profession-specific; financial difficulties related to the requirements for licensure which is compounded by the time-consuming and seemingly bureaucratic nature of the process; and the challenge posed by the lack of opportunity to gain Canadian cultural competency.

Our IMG participants described two key barriers specific to their professional integration process. The first relates to the three standardized MCC examinations. The other, more challenging, barrier is the relative lack of access to residency training programs. Many also felt that they were unable to find a temporary position during their transition to practice medicine. Many respondents complained about lack of positions which would allow them to utilize their health care skills working in a related field. Many IMGs felt that since the chances of them getting into medicine were very low, the time that they spent on preparing for the exams would be less likely to feel wasted if they could have found a job in a health care setting.

In additional to the language and cultural competency barriers that were salient for IENs, and the problems with the perceived culturally laden nature of CRNE exam, an additional barrier unique to this profession is related to level of education – degree or diploma. IENs often have to decide which process of accreditation (LPN, or RN) to take without actually knowing the difference between different levels of nursing in Canada. Another barrier to satisfactory integration cited by IEN respondents is a lack of full recognition of education and work experience.

ITMs in Canada identified two unique barriers to integration: 1) the challenges of the relative newness of the profession, which results in both a low number of available preceptors to date, and, until most recently, a lack of availability of integration programs; and 2) the difficulties posed by the primary care model of Canadian midwifery and its requirement to offer midwifery services in home settings.

There are a number of consequences that directly result from these professional integration barriers for the IEHPs we interviewed. For many, it means downward professional mobility. Although some of this may initially be a strategic choice on the part of the IEHP themselves, in most cases, it is imposed. The added dimension of being considered over-qualified for many other positions in health care makes the situation for IMGs particularly difficult.

Facilitators to Professional and Labour Market Integration

The key facilitators to integration that were most salient to the IEHPS included making as many arrangements for integration as possible prior to immigration. Several of the IEHPs also felt that appropriately targeted information sessions available at the outset and throughout the immigration and integration process facilitated their success. The primary facilitator identified was the various bridging programs that have been established, which not only help to upgrade skills, but also assist with the amorphous cultural competency problems. They nevertheless had some concerns with the accessibility of bridging programs in terms of available spots, geographic availability and financial constraints; and the coordination of those programs, in terms of the design of the program and who is in charge and, in some cases, the content, which they feel should be more adequately tailored to fit the needs of IEHPs. Finally, they described how alternative routes to utilize health professional skills can be both a facilitator to integration, as well as an end in and of itself, for those deciding to redirect their efforts.

Policy Recommendations

Our participants suggested the following general recommendations for changes to policies or programs:

• Improve access to health sector and profession-specific language training;
• Address financial difficulties through a IEHP-targeted loans program and counselling to improve the labour market positions of IEHPs during the professional integration process;
• Make information available from multiple sources and at multiple points in the integration process – but with a consistent message about the process and likely outcomes; and
• Increase opportunities to gain cultural competence both formally and informally.

The IMGs specifically suggested that there be a higher likelihood of a residency position for those who pass MCC exams, approximating chances of Canadian medical graduates who successfully pass exams. IENs suggested that an approach that focuses on competency, rather than 'one-size-fits-all' examination and credential-based approach be considered. ITMs suggested that the range of modalities for midwifery practice be expanded but, in the mean time, allow for some on-the-job shadowing to gain insight into the Canadian primary care model.

Comparisons & Conclusions

Many of our findings and recommendations are consistent with earlier research and policy briefs. This is an indication of the stability of some of the key issues, and that our participants are not unique in any particular way that would limit the transferability of our findings. Our comparative approach, however, does allow us to make some important and unique contributions to this policy literature. With respect to interprovincial differences, although all provinces we studied had relatively similar requirements for obtaining a license, IEHPs immigrating to each of these provinces had somewhat different experiences. The availability of bridging opportunities, the perceived willingness of health authorities to integrate IEHPs, and the availability of informal social networks, made each province different in its perceived readiness to accept IEHPs and integrate them into the local workforce. IEHPs both recognize and denounce some of these jurisdictional differences. They call for simpler, standardized and nationally based licensing requirements. With respect to interprofessional comparisons, although many similarities between professions were found, the logistical structure around licensing varied from one profession to another. While IMGs and ITMs reported the greatest difficulties around licensing, IENs also had their share of struggles, which varied in complexity according to their country of origin and their destination province. Interviewing IEHPs at different stages of the process of integration gave us a unique opportunity to assess the differences in the experiences of IEHPs at these different stages.

Take Home Messages

• Most of the internationally educated health professionals (IEHPs) that we spoke to approached their migration to Canada with a sense of optimism and hope of being productive members of Canadian society and bringing their skills and knowledge to their new home.
• Most found it difficult to tease apart the 'push' and 'pull' factors that cause IEHPs to emigrate from their home countries to come to Canada. They typically choose Canada as a country of destination as it: 1) has a relatively easy process of immigration; 2) has the reputation of a country with political and economic stability; 3) has fair international politics; 4) promotes multiculturalism; and 5) gives the impression that health care providers are in demand.
• Knowledge of the perceived shortages in health care creates a great deal of confusion to these IEHPs when they face insurmountable barriers to obtaining a license to practice and respond to the health care needs of the Canadian population. Receiving points for their education in their immigration application process further compounds this confusion.
• Those who found it most difficult to integrate into their profession were those who came as refugees, followed by those who came independently in either the economic or family class; those who were recruited – and this was more likely for IENs - were most likely to have largely positive labour market outcomes in the health care sector.
• All of the IEHPs we interviewed faced very similar barriers in terms of their English or French language skills, particularly those which are profession-specific; financial difficulties related to the requirements for licensure which is compounded by the time-consuming and seemingly bureaucratic nature of the process; and the challenge posed by the lack of opportunity to gain Canadian cultural competency. The strongest barrier for IMGs is the lack of residency positions; for IENs it is the level of education; and ITMs are confronted with the small size of their profession, its relative newness and the primary care model of practice.
• Key facilitators to integration include: encouraging IEHPs to make as many arrangements as possible prior to immigration; making appropriately targeted information sessions available at the outset and throughout the immigration and integration process; the creation of more and expanded assessment and bridging programs; and clarifying routes to alternative employment options to utilize IEHPs at their highest skill level.
• Key recommendations for changes to policies or programs include: 1) Improve access to health sector/profession-specific language training; 2) Address financial difficulties through an IEHP-targeted loans program and counseling to improve the labour market positions of IEHPs during the professional integration process; 3) Make information available from multiple sources and at multiple points in the integration process and ensure that this information conveys consistent messages about the process and likely outcomes; and 4) Increase opportunities to gain cultural competence, both formally and informally.
• Many of our findings and recommendations are consistent with earlier research and policy briefs. This should be taken as an indication of the stability of some of the key issues, and that our participants are not unique in any particular way that would limit the transferability of our findings. Our comparative approach does, however, allow us to make some important and unique contributions to this policy literature.