Although our health care system heavily relies on the support of IEHPs, we know surprisingly little about their experiences during and after their integration into Canadian workforce. The vast majority of research dealing with international migration of health care providers concerns itself with outflows of health care workers from developing countries and analyzes motifs and patterns of migration of health care professionals as well as assesses the impact of their migration on global and local health care economies (Connell 2008; Grant 2006; Kapur & McHale 2005; Labonte, Packer, & Klassen 2006). Some literature addresses the reasons why health care providers migrate, highlighting the traditional push and pull factors. "Pull" factors include better and more comfortable living and working conditions, higher wages and opportunities for advancement (Aiken et al. 2004). Overall, poor wages, economic instability, poorly funded health care systems, the burdens and risks of AIDS, and safety concerns are factors that "push" health care providers to leave developing countries (Aiken et al. 2004; Kronfol et al. 1992; Phillips 1996; Robinson & Carey 2000). Although this model is often used in migration literature, the relationship between "push" and "pull" factors and the dominance of some factors over others are yet to be determined. It was noted, for instance, that "pull factors" (although a list of attractive features of the destination countries) do not solely account for mass exodus of health care professionals from the developing world (Kingma 2006).

While the push-pull factors model combines political, economic and personal motives for migration, there have been theoretical attempts to link migration of individuals (and health care workers in particular) to economic forces. In this realm, the opponents of migration of IEHPs usually highlight the losses to the developing countries of their highly qualified health care personnel (Ahmad et al. 2003; Buchan 2004; Jeans 2006; Kapur & McHale 2005; Labonte et al. 2006), while the proponents of such movement highlight the economic benefits that remittances of migrant health care workers return to their countries of origin (for discussion on the role of remittances in the economies of sending countries, see Guarnizo 2003). Similarly, the cost-benefit analysis of the use of the imported health care workforce in the countries of destination, has demonstrated how the recruitment of health care workers from abroad helps developed countries to save millions on the training of health care personnel (Labonte, Packer, & Klassen 2006).

The drain of capital from the developing nations to the developed world can hardly be seen as a new phenomenon. Some researchers link these flows to the colonial nature of the relationship between countries. Indeed, the historical analysis of the colonial past of the Philippines explains the current pattern of migration of Filipino nurses into the English speaking world (Choy 2003). In a similar vein, Ishi (1987) stresses the importance of demands of the service economy in high income countries, their cultural, political, military, and economic hegemony over low income countries, and immigrants' experience of uncertainty over their futures in their homeland. Drawing on the post colonial theory, McNeil-Walsh (2004) seeks to explain the movement of South African nurses to UK. The historical context in which migration of health care workers was established from the colonies to the first world cannot be reduced to simple economic explanations. For instance, scholars found the culture of migration to be firmly rooted in Nigerian and Ghana physicians' visions of their medical future, who expect to move to the West upon completion of their education (Hagopian et al. 2005, p. 1754).

Generally, the studies looking at migration of health care professionals are interested in a large-scale analysis, and pay little attention to the experiences of individual migrants (Aluwihare 2005; Brown & Connell 2006; Cooper 2005). In the past decade researchers also became interested in the experiences of health care workers in their countries of destination. The majority of these studies deal with the racism and discrimination that health care workers face in the country of destination (Alexis & Vydelingum 2004; Calliste 1996; Collinds 2004; Flynn 1998; Giri 1998; Hagey et al. 2001; Larsen 2007). Qualitative studies often explore how immigrant health workers are being discriminated against according to race and denied career opportunities (Allan, Larsen, Bryan, & Smith 2004; Dicicco-Bloom 2004; Turrittin, Hagey, Guruge, Collins, & Mitchell 2002). The instances of discrimination and racism at the workplace are especially evident in the nursing literature. Dicicco-Bloom (2004), for instance, explores how Indian nurses are discriminated against in US health care facilities. IENs of colour in the UK also report discrimination based on racial identity (Allan et al. 2004). Similarly, nurses from African countries interviewed in Quebec and Ontario, reported racist and discriminatory experiences (Calliste 1996; Hagey et al. 2001). Evidently, racial discrimination of immigrant nurses is a problem faced by nurses of all ethnic backgrounds coming to different countries (Kingma 2008). A study looking into the experiences of South-Asian women physicians working in Canada reported instances of racism and discrimination faced by the newcomer doctors (Giri 1998).

Professional Integration Experiences

While experiences of racism and discrimination of health workers have been documented by researchers, little is known about the process of establishing practice in a new country. Indeed, much of the literature on health labour migration neglects the psychosocial experiences of health care immigrants and how they negotiate the labyrinth of policies and procedures to practice their profession. A great deal of what we know comes from the studies undertaken by Shuval and her colleagues (Bernstein & Shuval 1998; Shuval 1995, 1998, 2000) of the massive emigration of physicians from the Soviet Union to Israel when it had an open, non-selective migration policy. Not surprisingly, these studies found that, those IMGs working as physicians had significantly higher well-being scores than those not working as physicians. For those physicians who were working, however, many were dissatisfied with their allocation to less prestigious practice settings, the lack of recognition of their professional backgrounds, and the questioning of their authority by patients. Gender also has an impact. Some researchers have found that women physicians seem to adjust to a new system better than men (Remennick & Ottenstein-Eisen 1998), but others have noted psychological distress among female health immigrants (Factourovich et al. 1996).

There are several insights that we can garner from the Canadian health policy literature regarding integration experiences. First, there is no typical or usual way in which health care providers who are trained elsewhere enter into the Canadian health care system. As noted by the Barer and Stoddart (1991) study of physicians, internationally trained health care providers can include Canadians who pursue training elsewhere, graduates who enter Canada as refugees or who otherwise meet immigration requirements, trainees who pursue post graduate position in Canada and providers who are recruited (often through temporary visas) to meet the needs of particular geographic and specialty areas where shortages are most severe. Their ability to practice their profession here in Canada is dependent on these entry factors, the province into which they intend to become integrated, and a whole host of other factors.

Several barriers to the integration of internationally trained health care providers have been noted in the policy literature including: 1) poor information available to prospective immigrants overseas, especially with regards to what they must do to legally practice their profession in Canada; 2) a lack of information available in Canada about professional standards and registration that is clear, transparent, and understandable for a newcomer; 3) difficulty in having educational credentials recognized due to, for example, difficulties in getting official transcripts from institutions outside of Canada; 4) difficulty in navigating through the policies, practices and procedures for licensure/registration; 5) a lack of adequate bridging programs which candidates may be referred to once gaps in competencies or education are identified in assessments; and 6) the amount of time and cost associated with being assessed (Martin 2004).

Specific barriers experienced by IMGs that were noted in several of the documents include the following:, "While some lack the required preparation, knowledge and skill, others have been unable to confirm or demonstrate their skill levels due to tight workforce policies, limited access to assessment and/or training opportunities and lack of support to understand the licensure requirements in Canada" (Report of the Canadian Task Force on Licensure of International Medical Graduates 2004, p. 1). One of the key barriers is the above noted limitation in the number of residency training positions (Yelaja 2000; Immen 2004).

In 2004, the Canadian Nurses Association (CNA) established the Diagnostic for the National Assessment of International Nurse Applicants Project called IEN-DP. In the report, published in 2005, the IEN-DP identified the major barriers for IENs wishing to become licensed to practice in Canada as language and culture. A lack of coordinated policy and examinations has been identified as another culprit with regard to the successful integration of IENs. In a press release in 2005, Lisa Little, Chair of the Steering Committee of the Diagnostic Project for the International Educated Nurses (IEN-DP) explained:

Navigating through the maze of licensure is complex. We know, for example, that there are no fewer than 25 regulatory bodies for the three regulated nursing groups. While most are similar in their assessment approach, the subtle differences cause a number of inefficiencies. We need to find a way to better integrate IENs into the Canadian health system, starting with a national, coordinated, responsive and centralized assessment process that is part of a larger pan-Canadian health human resources strategy (CNA 2005 p. 2)

Some of the key policy responses called for, in such documents as the recommendations of the Canadian Task for on the Licensure of IMGs, include: 1) increase the capacity to assess and prepare IMGs for licensure; 2) work toward standardization of licensure requirements; 3) expand or develop supports andprograms to assist IMGs with the licensure process and requirements in Canada; 4) develop orientation programs to support faculty and physicians working with IMGs; 5) develop capacity to track and recruit IMGs; and 6) develop a national research agenda, including evaluation of the IMG strategy Such policy reaponses would include the evaluation of the IMG licensure recommendations and the impact of the strategy on physician supply. Similarly, the national IEN "Diagnostic Project" (2005) recommended: 1) the establishment of a national assessment service to create an evidence-based standardized approach to the assessment of IENs; 2) the establishment of nationally standardized and flexible bridging programs to ensure IENs have the competencies required to meet Canadian nursing standards; 3) the development of strategies to address the financial challenges incurred by IENs who enrol in bridging programs; and 4) the development of a central source of information such as a Web site specific to IENs to access complete, clear and easily understood information related to immigration and nursing licensure/registration.

Beyond this policy research, there is little theoretically informed literature that addresses IEHPs' professional integration experiences.

Theoretical Inspirations

Traditionally, immigration studies concentrated on the assimilation of immigrants into a local community (Levitt & Jaworsky 2007). While the degree to which immigrants had successfully integrated into a local community varied between developed nations (i.e., Canadian cultural mosaic vs. the United States melting pot), the assumption that the measurement of successful assimilation should be somehow developed within the hosting community remained. In the past several decades, this approach to immigration had changed (Anderson 2001; Joppke 2004; Levitt & Jaworsky 2007; Sana 2005). Since more and more people maintain ties with their homeland, the migration studies had been slowly transformed into transcultural studies inquiring into patterns of communication between migrants and, both their home countries and the countries of destination (Landolt 2001; Sana 2005; Takacs 1999). Currently, the debates are formed around the practices of transnational communication and the impact of migration on the home and hosting countries' economies and cultures (Landolt 2001; Levitt 2007; Morawska 2004; Orum 2005; Smith 2006).

While transnational studies incorporate many aspects of inquiry to better capture the dynamic of the relationship between migrants, hosting countries, and the countries of origin, scholars continue to engage in methodological and theoretical debates about what constitutes "transnationalism", as well as how it should be studied and measured (Levitt & Jaworsky 2007). Although the definitions rendered by researchers of the transcultural movement vary, it seems that vast majority of scholars came to a consensus that the research on migrants should contextualize the agency of migrants in the structural and institutional dynamics of both countries. Defined as transnational living, this analytical approach suggests that:

While transnational living foregrounds migrants' agency, it also involves relations initiated by nonmigrant - individual and institutional - actors aimed at establishing and maintaining multifaceted cross-border engagements that help shape migrants' living conditions abroad. Transnational living signifies an active, dynamic field of social intercourse that involves and simultaneously affects actors (individuals, groups, institutions) located in different countries. Transnational living is shaped by the historically determined social, economic, political, and cultural micro and macro structures of the societies in which the lives of migrants are embedded (Guarnizo 2003, p. 670).

This new approach is reflected in many works looking into the experiences of immigrants in their countries of destination. Scholars often link migrants' personal experiences to the structural forces in their home countries and modes of communication that shape their experiences as newcomers in their countries of destination (Ajrouch & Kusow 2007; Behnke, Taylor, & Parra-Cardona 2008; Calavita 2006; Lewin 2005; Waldinger, Lim, & Cort 2007).

In looking at the experiences of migrants in their countries of destination, however, researchers usually have to concentrate on a particular ethnic group or a particular country which hosts immigrants (Behnke et al. 2008; Gallo 2006; Lewin 2005) leaving the global patterns of migration to large-scale, macro studies. Those studies usually link the global movement of migrants to political and economic relationships between developing countries and the developed world. Although such studies cover a wide range of topics, researchers have found general trends in global movement of human capital (Castles & Miller 2003). According to Castles and Miller (2003), for instance, the differences between traditionally studied migration and the current, globalized movement of migrants, can be summarized as: 1) the globalization of migration (more countries participate in migratory movements and they are more affected by it); 2) the acceleration of migration (reflected by large volume of migrants and controlled by nation-states); 3) the differentiation of migration (skilled workers, refugees, visa workers, etc.); 4) the feminization of migration; and 5) the growing politicization of migration (reflected in bi lateral agreements and security policies of nation-states) (pp. 7-9).

In researching these avenues, critical race theory and post colonial studies contributed tremendously to the analysis of movement of human capital from the global east and south to the global west and north (Ball 2004; Clark, Stewart, & Clark 2006; Romero 2008). This is especially true in the context of migration of health care providers, whose migration is reflected not only in remittances sent back to their countries of origin but also in poor health conditions and the drain of health care systems of developing nations (Buchan 2006; Chen & Boufford 2005; Kapur & McHale 2005). This phenomenon, as alluded to earlier, has become known as "brain drain" in professional and academic literature and one of the dominant issues in the literature on migration of internationally educated health care providers (Ahmad et al. 2003; Aiken, Buchan, Sochalski, Nichols, & Powell 2004; Aluwihare 2005; Astor et al. 2005; Buchan 2006).

In sum, we suggest that successful analysis of migration patterns of health care workers should include the analysis of economic, cultural, and individual factors leading to migration and to be contextualized in a larger socio-political context. In other words, "the satisfactory theoretical account of international migration must contain at least four elements: a treatment of the structural forces that promote emigration from developing countries; a characterization of the social forces that attract migrants into developed nations; a consideration of the motivations, goals, and aspirations of people who respond to these structural forces by becoming international migrants; and a treatment of the economic structures that arise to connect areas of out-and in-migration" (Hirschman, Kasinitz, & DeWind 1999, p. 50).