In additional to the language and cultural competency barriers that were particularly 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. In some countries – and indeed institutions within countries – the title of nurse is earned with a college diploma, whereas in others, it requires a university degree. Thus, the title of nurse is awarded to one level of education in some countries and a different level in others. Beyond level, some respondents argue that nursing training is not equivalent in all countries:

They were saying 'We're not going to accept your education. You have an associate degree in nursing and that's not equivalent to anything here, you know, a college degree. And so I said 'Well I have 15 years of nursing practice and I'm not going to go back and sit for the exam so we need to figure out how to come to agreement on this.' So once I got an advocate and I just, you know, sent them all the information about all the different courses that I'd gone to over the years and my certification as a clinical research associate and also as a certified case manager in the States and the baccalaureate degree which was not in nursing but it was in biological sciences as well as the biomedical writing degree then they did decide that they would do a reciprocity so I did not have to sit for the exam. [Ontario IEN #3, practicing]

Others highlighted how IENs can have advanced knowledge in comparison to Canadian nurses. For instance, nurses in the Ivory Coast have extra training in tropical diseases, yet when they come to Canada they nevertheless must undertake a minimum of six months of updating courses.

Abidjan c'est la capitale de la Côte d'Ivoire, c'est un pays de l'Afrique de l'Ouest. J'avais, donc moi j'étais responsable clinique et j'étais responsable de 25 personnes dont 20 infirmiers. Ils ont de très bonnes connaissances par exemple. Mais moi je dirais que leur formation académique ne correspond pas à la formation académique des pays comme le Canada ou la France ou l'Angleterre. Donc ils sont très bons dans les maladies tropicales par exemple mais dans le diagnostic infirmier je pense que j'ai pas, je ne suis pas allée fouiller ou chercher vraiment le programme d'études de l'infirmière ivoirienne. Mais je suppose que dans le programme il voit y avoir des lacunes.

[Abidjan is the capital of Ivory Coast, a country in West Africa. I was the clinical lead and responsible for 25 people, including 20 nurses. Their knowledge was very good, but I would say that their academic training was not the same as academic training in countries like Canada, or France or England. They are very good with tropical diseases, for example, but in nursing diagnosis, I didn't, I didn't go and look into it or really research the Ivory Coast curriculum, but I suppose that there are gaps in the curriculum.] [Québec IEN #12, practicing].

IENs often have to decide which process of accreditation (LPN, or RN) to take without actually knowing the difference between different levels of nursing that we have in Canada.

Another barrier to satisfactory integration cited by IEN respondents is a lack of full recognition of education and work experience. Often, IENs are led to believe that the level of education obtained in their home country will be recognized in Canada. A university degree in their home country may only be recognized as a technical college level education here, often leading to a demotion in status and salary:

Respondent : Mais dans le sens qu'en arrivant j'ai été reconnu comme une, vous avez deux formations au Québec. Celle de l'université puis du collège. Alors j'étais reconnue comme une infirmière qui venait du collège et puis enfin mais j'avais déjà une idée de me spécialiser d'une façon ou d'une autre et puis là j'ai vite compris qu'il fallait que je refasse deux ans d'université si je voulais avoir le statut d'une universitaire pour avoir accès à d'autres choses.
Interviewer : Même si votre formation était de quatre ans.
Respondent : Exactement.
Interviewer : Et non le trois ans qu'on exige ici [au niveau universitaire].
Respondent : Voilà

[Respondent: I mean that when I arrived, I was recognized as one, you have two training programs in Quebec--the university program and the college program. I was recognized as a nurse with college-level training, but I had already thought of specializing in one way or another, and I soon realized that I would have to do another two years of university if I wanted to obtain university status to open the door to other things.
Interviewer: Even though you had taken the four-year program?
Respondent: Exactly.
Interviewer: And not the three years required here [at the university level]?
Respondent: That's right.] [Québec IEN #2, no longer pursuing integration].

In Québec, many IENs had difficulty finding a clinical placement. A stage (or minimum 40 day orientation period) is required by the OIIQ, but finding a placement in a teaching hospital is left up to the IEN. Places are not always easy to come by, and IENs have no means to evaluate their options before beginning.

Là où j'ai trouvé que c'était difficile c'est que c'était à moi de trouver l'établissement qui aurait bien voulu m'accepter en tant que stagiaire, ça aussi ça a été très difficile parce que j'ai envoyé des lettres de demande de stage à tous les hôpitaux de Montréal, il n'y en a pas un qui m'a offert de me prendre en stage...donc je pense qu'il y a un trou entre le devant de l'Ordre et le service offert par les centres hospitaliers. Là je pense que l'Ordre normalement, je pense à mon avis, j'aurais beaucoup apprécié que l'Ordre m'aide à trouver l'établissement peut-être qu'elle soit en convention avec des établissements qui acceptent les infirmières que l'Ordre exige qu'on fasse des stages. Moi je ne demande pas à faire le stage, l'Ordre exige de le faire.

[What I found difficult was that it was up to me to find an establishment that would agree to take me on as a trainee--it was also very difficult because I sent training application letters to every hospital in Montreal and not one offered to take me on as a trainee... So I think there is a gap between the Ordre and the services offered by hospitals. I think that the Ordre normally, in my opinion, I would have appreciated the Ordre's help in finding an institution, maybe if it had agreements with establishments that will accept the nurses that the Ordre requires to take training. I'm not the one asking to take the training--the Ordre is the one that requires it.] [Québec IEN #12, practicing].

Those nurses who were integrated quickly through the recruitment agencies usually found that their orientation process was often too short or overwhelming and did not give them a chance to actually get to know the Canadian health care system:

That one [orientation] I cannot even remember a single thing. All I remember is the pills are on racks and they're in bubble packs. That's all I remembered. And then I remembered that if there is a fall you have to report, and if there is anything that you are not sure of you have to report. That's all. We started [to work] after four days... Like we came on November 26th. December 1st we were working [Manitoba IEN # 2, practicing].

Those IENs who went through the process of finding work on their own in Canada, on the other hand, struggled to find the place that would agree to hire them:

When I came, first came and I was looking for a job they were asking me 'Do you have Canadian experience?' I said 'Where do you expect me to get Canadian experience? I just got my license, you know. You want me to have the Canadian experience? No. You people just have to give me an opportunity. I just need somebody to start me off.' And they were like 'Okay, okay, we'll get back to you.' And they never did [Manitoba IEN #2, practicing].

IENs' experience of profession specific barriers varies considerably by whether they are recruited overseas or not. Nevertheless, there are some commonalities which include concerns with the CRNE exam and recognition of their experience despite the level of their education.