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.

Language Skills:

Not surprisingly, language is seen as the biggest barrier for many IEHPs when it comes to professional integration. The practice of all of the professions studied requires extensive communication skills. Our respondents faced difficulties in preparing themselves for communication with clients and co-workers. While this is faced by all immigrants, regardless of occupation, this is particularly salient in a health care context where often intimate information needs to be shared:

Not surprisingly, language is seen as the biggest barrier for many IEHPs when it comes to professional integration. The practice of all of the professions studied requires extensive communication skills. Our respondents faced difficulties in preparing themselves for communication with clients and co-workers. While this is faced by all immigrants, regardless of occupation, this is particularly salient in a health care context where often intimate information needs to be shared:

You can't ask people about all the intimate things that you need to ask them about, not just about the physical side of it but, you know, psychological aspects and all that sort of thing, you couldn't have a proper discussion with a woman and establish what was really going on for her unless you're fluent in that language. It's hard enough to communicate with people who do speak English never mind [British Columbia ITM #4, in progress]

To obtain their professional license, applicants whose education was in neither of Canada's official languages are required to pass one or more language tests. A number of our interviewees, however, challenged the assumption that passing a language test makes them ready to communicate in their workplace. Language differences, even among native English or French speakers coming from outside Canada, had been defined as a barrier to effective workplace communication:

There is still a language barrier even though we speak the same language... One thing I've noticed here there's an awful lot of abbreviations for things which in the U.K. has been stopped over the last 10 years. We don't abbreviate stuff. So you know, you'll hear a lot of people within the work force talking about certain abbreviations and you're kind of like 'Well what does that mean?'...The drugs are different here. Different names for the same drugs but completely different names... Language, I mean it must be even harder for people that don't have English as their mother language [Manitoba ITM #1, practicing).

Language barriers are an issue for all IEHPs, but are a particularly tricky problem for ITMs in Québec, where proficiency in both French and English is required.

It has already been suggested (Baumann, Blythe, Rheaume, & McIntosh 2006) that language is one of the biggest barriers to professional integration and that current tests used by professional colleges may not accurately evaluate the knowledge of professional language. We found that IEHPs overwhelmingly felt unprepared for the communication taking place at the workplace, even once they passed or were exempt from the language exams. This was especially true among nurses, who are usually integrated into the system more quickly than IMGs and ITMs:

From a cultural standpoint, um, sense of humour was a little bit different. ... that took a little bit of getting used to. ...and another thing I found that was kind of a little hard was, um, the way certain things were pronounced was different ... even medication names we pronounce a little differently. Like rocephin in South Africa it's called 'rossefin' and so you would say it and it sounds like you're saying it wrong to somebody who says it differently which then almost makes you look like you don't know what you're talking about. So I found that a little hard. And then when you start to adjust your language and your spelling, like you know we spell certain words like paediatric is spelled with an 'a' in it and words like dysmenorrhea, diarrhea they have an 'hoea', um, on the end. So having to drop letters and then change the way I pronounce stuff ... that took me a bit of getting used to [Manitoba IEN #3, practicing].

J'apprends les expressions drôles avec des fois je dis des trucs aux enfants qui me regardent avec leurs grands yeux, ils ne comprennent pas ce que je leur dis. On leur explique c'est comme je ne sais pas moi, je vais appuyer un peu sur ton ventre puis il regarde sa mère mais non on va peser sur ta bedaine, c'est rien. C'est des petites expressions.

[I learn funny expressions and sometimes I say things to the children and they look at me with their eyes wide open. They don't understand what I'm saying. We tell them, I don't know, like I'm going to put a little pressure on your stomach and then he looks at his mother but no, I'm going to press on your tummy, it's nothing. It's little expressions.] [Québec IMG #1, practicing].

Place of Origin/Practice Differences

Another one of the strengths of our approach which was inclusive of IEHPs from various source countries is that we were able to examine the impact of ethnicity across professional groups. What is typical of the experiential research in this domain is the tendency to look at one particular group – like the South Africans (Collinds 2004; Flynn 1998; Giri 1998). What we found was that the place of origin or education of IEHPs played a significant role in successful or unsuccessful professional integration. It is often assumed that the fluency in an official language of Canada plays the most significant role in successful professional integration. While our findings do not deny the importance of language, it is not the only factor determining success. Racial and ethnic background continues is also viewed as posing barriers to professional integration.

Among IMGs, it was often the case that the South African physicians are the fastest to integrate into the system. Although in all provinces under the study, the process of obtaining medical licenses was streamlined, many IMGs claimed that South Africans have better chances to do better on the personal interview and to be offered a position. Those IMGs who immigrated from Iran, on the other hand, were, for the most part, fluent in English, but they often felt that they ethnicity was seen as a barrier for professional integration. Many felt that "being non-white" decreased their chances of receiving a placement or doing well on a residency interview. In Quebec, the racism among employers was considered to be even more prevalent from the perspective of our IEHP participants.

The system of education (especially for nurses and midwives) in the country of origin was yet another important factor. Many IENs coming from Eastern European countries, for example, had a different model of nursing and a different model of education and therefore had difficulties in adjusting and having their credentials meet Canadian standards.

Another component was the variations in professional practice in different countries. IEHPs coming from a different model of practice, understandably, had more difficulties in practicing their profession here in Canada. It would take these professionals the greatest amount of adjustment to align their practice routines and habits with those of Canadian professional.

Finally, the transferability of credentials was often evident in comparing the responses of IEHPs coming from different countries about their perceived chances of practicing their profession. While IENs from Philippines, the UK and Australia, and IMGs from South Africa were directly recruited to come to Canada, IEHPs from other jurisdictions were often actively discouraged from seeking professional integration in Canada.

Thus, place of birth and of professional education placed some IEHPs at advantage, while they made the process of integration especially challenging for others. Lack of communication skills, and discrepancies in education and credentials, but also racism and cultural intolerance, all played a role in the process of integration of IEHPs.

Financial difficulties

Another big barrier that cut across the professions we studied is the financial demands of preparations for professional examinations and class and course attendance. Although many of our respondents arrived in the country as skilled workers with a certain amount of money to spend on preparations for the exams, they very soon realized that their resources were insufficient. The amount of money spent on examinations in many cases went well into the thousands of dollars:

I think in all the process for me probably to get my license, and this is nothing compared to what the physicians pay, probably from start to finish was about $15,000. And I know physicians can pay hundreds of thousands. I honestly think it's a money making process for some of these provinces, 'cause I mean there's a lot of immigrants who want to come here. I mean Canada is not easy to get into. We've often laughed about it and said 'You know what? If we'd been refugees we would have got in a lot easier than if we'd been, than being skilled workers.' You know. It seems to me they make it as difficult as they can, almost so they can make more money out of you. [Manitoba ITM #1, practicing]

The inability to get a student loan was also mentioned by our respondents. While Canadian students can receive loans with good borrowing and repayment terms, expecting to repay the bank once they finish their education, the vast majority of IEHPs have to apply for general bank loans, which often demand high levels of interest, related to their lack of a Canadian financial history, and require them to make monthly payments while they are studying:

We ended up paying about $3,300. every month for our loans... And those were not student loans because we were international medical graduates and we had no security that we'll become doctors so nobody will give us any student loans... In our case our future is, you know, it can be very bright and it can be very dark. So we have no guarantees there so nobody will give us any kind of student loan because they don't know where we will end up. So we have to take regular loans with high interest rates, 18.5 and things like those [Manitoba IMG #2, practicing].

As a result of the costs involved, many IEHPs had to work while preparing for the exams. They were not working in their profession, instead having to take positions which often did not pay well. This ultimately affected their examination success which in turn, affected their chances of receiving a professional license.

Figure 4.1: Family Status (i.e., having children) and Marital Status of IEHPs by Profession

Financial difficulties and the problem of finding time to prepare for exams were especially salient for these IEHPs who immigrated to Canada with families, which was the case for many of our participants (see Figure 4.1). On one hand, our respondents often commented that immigrating with family was an advantage, since it often provided emotional support that was not available to single people. On the other hand, immigrating with the family meant spending more time and money to integrate family members, straining already limited resources:

One of my friends, he's my classmate, so he passed the three exams and he ... is doing part time job in some clinic, some walk-in clinic. So he is just making I think three days a week or two days making one thousand dollars of income doing that. So he is managing just to care take. So I thought... and he's dependent, like his in-laws supporting him. Like he live with his wife but in his in-laws' basement so he is not paying rent and his wife is working. ...So she is supporting the kids and so the kitchen and the rent, everything he is not worried about. But my situation was totally different. I had to support my family hundred percent. Like no chance someone would support me. [Ontario IMG #5, in progress].

Gender Differences

We found that the gender of the immigrant health care professional could play a significant role in the process of integration. Interestingly, gender played a significant role in the integration of female physicians. Even in the case of IENs and ITMs who immigrated with their families, they were usually either regarded as primary breadwinners by their family members and partners, or were following their husbands and looking for professional opportunities near their the husband's job:

Actually it was hard because, um, ... he's qualified as an electronic engineer. That was what he did in South Africa. But coming over, um, there's no sort of shortage necessarily in his field so we were relying on me to get my work visa and then he could work as my dependent. Then he could work anywhere. So we did need to get my visa first. He, because we were so remote, um, it was hard for him to get anything in his field. He ended up working at Canadian Tire eventually just to have something to do but that ended up doing really well for him. ... So that ended up working out okay, but no, it wasn't easy for him to get work [Manitoba IEN #3, practicing].

He has been supportive and the decision was for him to be at home while I worked ...So he stays home and that has been a blessing. Like I wouldn't be doing this job at all if he wasn't willing to do that because I have no desire to put my baby in child care. People do it and that's fine but it's expensive... It has not been easy to be a mother, a full time midwife, and now pregnant [Manitoba ITM #3, practicing].

On the other hand, female IMGs were often discouraged by their partners and family members to pursue professional integration:

My family did not support me in this process. My husband is an engineer and he did not really want me to go through all this. It's been 10 years now. We did want to have more children, but we were waiting and waiting, and it is too late. And now, it is more coming, this feeling that I am struggling for nothing. [Ontario IMG #3, practicing]

Age Differences

Integration can be particularly difficult for those who come to Canada later on in life. Not only do they face complications due to their immigrant status, but also to their age. Some respondents reported being discriminated against on both of those fronts.

Ah c'est différent d'une place à l'autre, c'est différent avec chaque personne, c'est vrai qu'il y a beaucoup de racisme, c'est vrai qu'il y a des préjugés par rapport à l'âge. Je me suis fait dire plusieurs fois qu'est-ce que tu fais ici, à ton âge, combien d'années tu penses travailler avant la retraite. Je me fais dire ça comme étudiante, je me fais dire ça comme professionnelle, comme infirmière auxiliaire. Il y a beaucoup de préjugés par rapport à l'âge et il y a aussi beaucoup de racisme.

[It's different from one place to another and it's different with every person. True, there is a lot of racism. True, there is age-related prejudice. I've been asked many times, "What are you doing here, at your age? How many years are you still planning to work before you retire?" I get asked that as a student, as a professional, as a licensed practical nurse. There is a lot of prejudice about age, and a lot of racism.] [Québec IEN #3, in progress].

The time-consuming nature of the process

Exacerbating the financial difficulties experienced by the IEHPs interviewed, were complaints about the length of time required to obtain a license to practice their profession in Canada. Whether because of wait times between steps in the lengthy process, lack of availability of residency or stage placements, or length of updating or preparatory courses, the length of the integration takes between one to two years for some ITMs and IENs and five or more years for some IMGs. During this time, IEHPs feel that they become out of practice and lose the edge in some of their technical skills. For all the professional groups we studied, it was necessary to stay in practice. Some, who could, had to go back to their home country to practice so that they would remain eligible. The following quote comes from an interview conducted in December 2008:

On nous a classés comme date d'inscription comme je vous ai dit que je me suis inscrite dans l'Ordre depuis 2005, alors j'étais la sixième dans la liste pour avoir mon stage. Pour le moment on ne sait pas quand est-ce que moi personnellement je dis je ne sais pas quand est-ce que je vais commencer mon stage, à partir de février, selon la disponibilité. Et normalement trois mois de stage, au moins trois mois de stage. On va encore, je ne sais pas à partir de février ou c'est pour l'été, on n'est pas au courant encore

[They categorized us by registration date, as I told you, I registered with the Ordre in 2005 and I was sixth on the list to get my practical training. For the moment we don't know when, I personally don't know when I'm going to start my training, beginning in February, depending on availability. And there is usually three months of training, at least three months of training. We're still going, I don't know starting in February or in summer, we don't know yet.] [Québec ITM #8, in progress].

While waiting for integration, many IEHPs resort to working outside of the health care field altogether. As one IMG related:

J'attends mon stage, alors. Pour m'occuper, je fais du soutien scolaire. J'aide les enfants à... des petits cours. Je surveille un petit peu les enfants. C'est pas loin de l'endroit où j'habite. L'école est sympathique, les enfants, je connais bien.

[I'm waiting for my training, so to keep busy, I do school support work. I help the children ... little classes. I monitor the children a little. It's not far from where I live. The school is nice, I know the children well.] [Québec IMG #1, in progress]

In an attempt to increase their chances of eventual integration, some IMG respondents decided to accept work in the health care field that does not require them to have their license as a physician but allows them to work in the system and be integrated to some extent.

You know, if you want just to stay at home, they say they don't like the person just stay at home and not taking part in any activities, any scientific activity. So the best option – and they are so sensitive about it – and so the best option that some persons try is ...to have the kind of, I say health job, I call it health job because it can be, I don't know, the research, medical research or science research or anything that tries to afford the families. .... We were not far from the science, we are not far from the medicine. [Québec IMG #1, no longer pursuing integration]

When IMGs work in other health care fields, their employers and co-workers, who are aware of their medical background, sometimes take advantage of it. For instance, one IMG, who does not yet have his license to practice medicine in Canada, was hired by a long-term residence as a nursing coordinator. On top of his duties in the capacity as coordinator, he unofficially uses his knowledge and skill as a physician to make things run more smoothly in the facility:

Yes. The doctors appreciate, because I go there and assess the patient. And I know what to look for. So when I'm talking with a specialist, ... I already know the way he thinks, the way a doctor thinks. So, sometimes they ask me what do you think the patient has? Because I already assessed the patient. [or] Sometimes they'll bring a nurse in for needles and, because they are old, they have tiny veins, they cannot set IVs and the patient needs an IV because he's dehydrated. So then they call me and they told me, sorry, but they cannot do it because, and I go there and I cannot do it myself, because it's not legal. I don't have the licence to do that, but I go there and I look for a bigger vein and I told them, look, I think you can do it with this ...So they feel more confident and they do it and then it works for them. [Québec IMG #2, in progress]

Eligibility for obtaining a license often expires before the process is completed (e.g., in most jurisdictions in Canada, IMGs must have practiced for twelve consecutive months within the past three to five years, which is a similar requirement for IENs and ITMs). Some IMG respondents observed the experiences of colleagues who waited years and spent thousands of dollars to only to find out that they were refused a residency spot.

I passed the test and I think with good grades and with my experience and my age, I know that I'm young and I thought that, yes, there is no way because I saw that my friends with the same situation, maybe a bit more, a bit less, they couldn't enter the system so I tried not to waste my money and my time. So I didn't participate for the last part. ...It's making a logical and make a wise decision. [Québec IMG #1, no longer pursuing integration]

As a result, these respondents chose to give up before even finishing their equivalency process, and thus will never be integrated as practitioners in the health care system.

The bureaucratic nature of the process

A frequently expressed frustration concerns the level of bureaucracy in the professional integration process, which is experienced in addition to the frustrations of the immigration process. One of the ITMs we interviewed said, "I can totally get that they have to be very sort of, um, careful...but sometimes it feels like they're just downright obstructive." [British Columbia ITM #4, in progress]. Another one recounts her experiences with the integration process:

The individuals in the College have been very helpful, very friendly, very supportive, but the overall College rules, I mean that was just ridiculous ... [someone from the College] called me up and saying 'Oh you know, the documents didn't get sent up properly.' And I said 'Well I'm sorry. The school didn't realize. They sent it to me and I sent it on to you.' And she goes 'Oh well, you'll have to do it again.' And I said to her 'Look. You know what? I don't even need to do this. So you either accept what I've given you or I'm done.' [laughs] And it was 'Well let me look into that. Let me look into that.' Next thing you know 'Oh no, it's fine. Don't worry about it. It's fine. But that was the kind of stuff that they were pulling. [British Columbia ITM #5, in progress]

Many respondents complain that there is a lack of communication between different stakeholders and a lack of transparency in the integration process. Some of our participants noted a lack of communication between employers and the regulatory bodies, and in turn a lack of communication with the IEHPs. For example, in the Québec stage placements, an IEN described the confusion and misunderstanding:

Respondent : Par exemple quand j'ai appelé le ministère, le ministère au départ donc pour avoir des renseignements pour immigrer, etc., au départ on ne m'a pas parlé d'examen de l'Ordre. On m'a dit si vous avez un permis en France et que vous avez un permis ici il n'y a pas de problème. Moi je pensais qu'au début j'allais avoir un temporaire d'un an puis qu'après hop.
Interviewer : Automatiquement.
Respondent : Très vite je me suis aperçu que ce n'était pas ça. Autre chose aussi on m'avait dit, on m'avait dit que vu le niveau d'études que j'avais, j'aurais mon niveau académique serait reconnu comme un baccalauréat en sciences infirmières. Ça n'a pas été le cas, on m'a reconnu une technique en soins infirmiers

[Respondent: For example, at first when I called the Department, the Department to get information about immigrating, etc. in the beginning no one mentioned Ordre examinations. I was told if you have a licence in France and a licence here, there is no problem. In the beginning, I thought I would have a one-year temporary licence and after that, away we go..
Interviewer: Automatically.
Respondent: I soon realized that it didn't work that way. Another thing I was told, I was told that given my level of education, my academic standing would be considered the equivalent of a bachelor of nursing science. That wasn't the case; I was recognized for vocational nursing.] [Québec IEN #4, practicing]

A following section outlines barriers that IMGs have experienced from the residency matching process. This also speaks to the issue of a seemingly overly bureaucratic process.

The challenge of cultural competency

While Canada provides a multicultural environment, it has its own unique cultural dimensions and colloquialisms. According to some respondents, the opportunities open to IEHPs can depend on the individual's fit with the implicit, tacit, and even inchoate aspects of what comes to be recognized as Canadian culture. Indeed, "cultural competence" is emphasized in the bridging program discussed more fully below. This section explores how a lack of understanding of cultural subtleties in reading people and situations can pose a barrier to the ease with which and IEHP is able to integrate into their chosen profession:

I've seen the full spectrum. But actually I've seen lots of extremes. I've seen people that really want to embody this country and, you know, become Canadian and maintaining maybe their culture but, you know, adopt this country. And some people that basically were very resistive and they want to, you know, retain their own culture at all costs and kind of impose their culture on the Canadian system. Those are the ones that I've seen least successful, most aggressive, and I have to say a small number [British Columbia IMG, practicing].

One of the first instances where IEHPs face the limits of their cultural competency is in the licensing exams. While language is a challenge for many nurses, the biggest difficulty is not the language of the CRNE, or the OIIQ in Québec, but its cultural dimensions. According to many of our respondents, the failure of IENs to pass the exam is not attributable to their lack of nursing skills. In their opinion, it is the questions related to the Canadian nursing environment and culture that make it difficult for IENs to pass the exam:

The short answer was sort of crazy because you just have to present the sentence they have... and some of those things from my home nursing, some of them were like off limits. ... In Nigeria you don't advise the physician. You just inform. Advise and inform, they are two different things. In Canada you have to put 'advise'. Whereas in my home nursing, the physician you just inform. You can only advise your colleagues, nurses just like you... You inform the physician patient's results. You inform and not advise. Advise is like you being the authority. [Manitoba IEN #2, practicing].

IENs also told us that they are expected to know how to navigate the administrative system. In their opinion, it was not fair to evaluate their knowledge of system navigation prior to their actually working in it:

They have too many cultural questions [on the] exam. For example ... they asked me about the Jehovah Witnesses. It's the religion and I knew that they don't do the blood transfusions. [It's] against the religion and they say well like if you had a patient and they are Jehovah Witnesses and this is their kid and they have to do the transfusion and the parents have refused and what are you going to do about that? Are you going to do the transfusion or are you going to the Child Aid? Like [there are] too many questions when you have to really understand the culture to know how to answer these questions [Ontario IEN #1, no longer pursuing integration].

The biggest concern of IENs, however, had to do with culturally biased questions that, in their opinion, had little to do with nursing:

They test different areas of knowledge and I think that the answers, I think it's just a cultural barrier. ... For example I'll never forget, I had this question about what toy would be more appropriate for a child with autism, toy or game. Merry-go-round, jack-in-the box, and a couple more things like this, okay? I didn't know what to answer because I didn't know what any of those games were, toys, were so I just randomly picked whatever. I had no idea. So I mean that is an insensitive question. They really should not ask a question like that because it pretty much is designed to weed out people who never heard of those toys so what would be the purpose of that? They should have rephrased the question and explained do you want an interactive game, do you want, you know, a game where he plays a role or things like that. So that wasn't fair. And there are many questions like that [Ontario IEN #1, practicing].

While bridging programs and preparation courses can teach IENs how to navigate the system, some IENs believed that the culturally biased questions in the exam put them at a unique disadvantage: unless they had an exposure to North American culture, they would have difficulty answering these questions and in turn, have difficulty in becoming licensed.

The problems of obtaining cultural knowledge unique to the Canadian health care system were widely acknowledged by our interviewees. IENs, for example, became integrated quickly via bridging programs available for nurses. Not all IENs go through this process and not all bridging initiatives fully cover the cultural uniqueness of the Canadian health care sector. Usually, it is up to the employer to decide, whether a nurse should go through orientation prior to the start of practice and (if so), how long this process should take:

Every place is different. So if the hospital or any place that it is if they give more opportunity [to] extend probationary period or orientation period it's better for an international nurse. Because we don't know Canadian culture. [Manitoba IEN #3, practicing]

As this nurse suggests, it is up to the employer to determine the length of the orientation given to a nurse. Some of our respondents, however, told us that they did not have any orientation at all. Others suggested that this orientation took one to two days which meant that they started working within a week of their arrival in Canada. Knowledge of his type of limited orientation experience motivated some of our IENs to seek the position of health care aide in the hospital in order to get acquainted with local hospital culture before pursuing their nursing career:

I started working as a health care aide in different hospitals here and trying to learn the kind of nursing here in Canada, you know, while I am working. That's why I decided to work as a health care aide. At least I am in an environment where I can see how the nurses are working and what kind of work do they do. [Manitoba IEN #1, practicing]

Establishing cultural competency was also important for IMGs and ITMs, but because their integration processes typically took longer than for IENs, they had the opportunity to become acculturated prior to practicing. The IENs who integrated more quickly typically had to acquire cultural competency while on the job.

This section has reviewed the difficulties that IEHPs face when entering practice across different professions. We found that language barriers, financial difficulties, the time consuming nature of the process, Canadian bureaucracy, cultural competence, the inability to obtain health care experiences, and a lack of alternative routes for practice, all become barriers for health care workers. In what follows we describe profession-specific barriers that make it difficult for IEHPs to start practice.