We employed a largely qualitative approach to this study, as it was deemed most appropriate for the experiential and comparative research questions under investigation. A qualitative design allows for a greater appreciation of embedded and multifaceted nature of the phenomena under investigation and the contextual influences on these phenomena. In addition to the comparative dimension of professions, we also chose to examine the experiences across four key provinces.

Selection of Comparative Provinces

Given that professional regulation in Canada is a provincial jurisdiction, it was important to include more than one province, and some variability in migration policy, practices and experiences, in the data gathering process. The provinces of Ontario (with a very high number of IEHPs, many of whom are not (yet) integrated); Quebec (with a unique system of immigration policy and language issues affecting migration); British Columbia (another province heavily saturated with IEHPs – but from somewhat different source countries than other provinces); and Manitoba (a regionalized health care system that actively recruits internationally trained providers) were chosen as the provincial referents for this study. All four provinces encompass variability in the policies for IMGs, IEN and ITMs and all four provinces have regulated forms of midwifery. For each of these provincial case studies, data were collected through key policy documents and interviews with IMGs, IENs and ITMs who were pursuing professional integration, had achieved it or had decided to redirect their efforts.

Data Collection

The study started by analyzing policy documents and mapping out the system that health care professionals have to navigate to obtain licensure in Canada. For each province, we identified the major stakeholders that facilitate or regulate the process of integration of IEHPs. In addition to the reliance on the analysis of policy documents, our research team also worked on learning to navigate the system of regulation in the same way as IEHPs. We collected the information about professional integration by visiting the websites of regulatory Colleges and professional associations for medicine, nursing and midwifery. We collected documents and information brochures available for IEHPs in each province, analyzed them and built a model of step-by-step integration process for each profession in each province. We also consulted the information provided by provincial professional associations, to gain a better understanding of the experiences of IEHPs and identify specific difficulties that they may face on the way to integrating into the system. This information proved to be invaluable during the interviews with IEHPs. For instance, armed with knowledge about a particular bridging program or about a particular organization that was designed to facilitate the process of integration for IEHPs, we could directly inquire into the experiences of IEHPs who attended the program or joined the organization.

We secured interviews with 176 IEHPs in the provinces of British Columbia, Manitoba, Ontario and Quebec. To recruit these professionals, we advertised our study in local immigration centres, newspapers, immigrant community centres, and other locations with high proportions of newcomers. We also used snow-ball sampling, recruiting participants from the networks of our respondents. The interviews were conducted in person and on the phone and usually lasted between one and two hours. The interviewees could choose to be interviewed either in English or in French. We acknowledge that this strategy limited our access to IEHPs who were relatively fluent in one of Canada's official languages, but because we were largely interested in the experiences IEHPs who were seeking or who had sought integration in health care system in Canada, we felt this limitation appropriate. The interview guide was designed to address the following research areas: 1) the decision to immigrate to Canada and navigation through the immigration system; 2) the process of gathering information and navigating through professional integration; 3) the input of IEHPs on gaps in the system of integration; and 4) their recommendations on how this system can be improved. For the vast majority, the interviews were transcribed verbatim for analysis. We also had participants fill in a short demographic survey so that we could better understand their personal and professional background. Figures 3 to 7 provide a profile of the study participants.

Figure 3: IEHP Participants by Profession and Province

Figure 4: IEHP Participants by Profession and Status

Figure 3 reveals that we had a larger number of participants from Quebec and Ontario. This is largely reflective of the national distribution of IEHPS. Figure 4 highlights how many more IENs are in practice when compared to ITMs and especially IMGs. This may be reflective of the broader population, but there are little data to which we can compare our participants, to substantiate this theory. It is important, however, to keep this in mind when interpreting our findings across profession as it may be reflective of status.

Figure 5: Age Distribution of IEHP Participants by Profession

Figure 6: Gender Distribution of IEHP Participants by Profession

Figure 5 shows the age distribution of our IEHP participants by their profession. This indicates that our IMGs participants are slightly older than IENs and ITMs in this study. Figure 6 shows the gender distribution with roughly equal distribution of men and women for IMGs, a disproportionate distribution for IENs and an exclusive distribution of women ITMs. This is largely reflective of the population, but perhaps the study sample has an exaggerated proportion of males in the IEN category and females in the IMG category. Finally, Figure 7 outlines self-identified visible minority status by profession. Across all professions our participants were more likely to state that they were not a member of a visible minority group.

Figure 7 Self Identified Visible Minority Status by Profession

Data Analysis

Data collected through the documents and interviews were analyzed sequentially using typical procedures of thematic and constant comparative analysis. This involves an iterative process of going back and forth between documents and interviews to produce a multi-layered description of the context and experiences of IEHPs in the each of the provinces. We began with the analysis of the documentary data to help frame the context. Then the transcribed interview data were entered into QSR-NUD*IST 6 for analysis. Our research team developed a preliminary coding scheme which highlighted the major themes discussed in the interviews and emerging from the contextual analysis. The coding scheme was then distributed among research assistants to use as a guide in developing a more detailed coding scheme. Each research assistant analyzed five interviews using "free coding," identifying major themes emanating from the interviews. These themes were then categorized and developed into a comprehensive coding scheme that was used during the analysis. To test the scheme, each research assistant recoded three interviews originally coded by other team member, to ensure that the codes used in the analysis were consistent among the team members. In the second stage of the analysis, the interviews were analyzed using the new, comprehensive coding scheme. In the process of the analysis, the research team made additions to the existing coding scheme but overall, all interviews were coded under the same categories. Key segments from the documents were excerpted according to this final scheme to help flesh out and form the backdrop for the experiential data from the IEHPs we interviewed.

In the sections that follow, we trace the experiences of the internationally educated physicians, nurses and midwives that we spoke to. We begin with their decision to come to Canada, the process they undertook to get here, and the barriers and facilitators to their professional and labour market integration. We conclude with some of their recommendations for policy to improve the situation for others who follow their path.