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, as we outline in the facilitators section below, in most cases, it is imposed. This can be the source of much frustration and hurt:

Well it's personal for everybody. You know, it depends what everybody wants and how much they, you know, they're ready to [take on] It's very hard. It took me eight years before I started practicing. ...It's quite a long time and a lot of frustration, a lot of hard work, and a lot of times you, you know, you already achieved and it's not easy to achieve what you achieved in any other country. Like in any other country to become doctor is big achievement. It's big competition. ...Huge competition. And you achieved it. And suddenly [here in Canada] you become nobody. [British Columbia IMG #14, practicing]

The added dimension of being considered over-qualified for many positions makes the situation for IMGs particularly difficult. Degrees that were highly-valued social capital in their countries of origin can become a liability in Canada:

One thing that many people don't realize is that when you are an MD you cannot be anything else. ...Because for most things they consider you, what's the term they use in English? Over-qualified. In any case you don't have the skills to do anything else. Like even competing for a job. ... But I was just expressing that I was actually shocked when I tried to get a job. I was calling different companies, the private companies that are doing that home care, whatever, you know. And when I asked them they said to me 'No, we are sorry but you are over-qualified to do the job.' And I says 'Come on people. I need a job because I've got two kids. ... I need some kind of job. I'm ready to do whatever.' They said 'No. We are sorry.' And I tried to do that, maybe 20 times I tried to apply. They just simply say we are sorry, you are over-qualified. And I said I don't mind if I'm over qualified. I just need a job. [British Columbia IMG # 4, practicing]

We already noted above how the situation facing many IEHPs has led to frustration and indeed depression. The following participant had an ever more tragic story to tell:

And one of my colleague[s], he committed suicide and nobody even know about this thing. He was very much depressed. ... He was very, very upset, very, very depressed. He was 45 years old. He was having a one and a half year old child and six month old child. And he committed suicide because of this discrimination, injustice, and I mean all these things you know. And he was very knowledgeable, well experienced person... We are trying our best and still you know I am in the face of struggling. And I have courage to fight and I think I have so many harder and still I have only want harder to get into a system. Just not for the sake of money. Just for not the sake of the other thing. We have skills. ...like in paediatrics, obstetrics, gynaecology and working as a family physician I develop an advanced knowledge and skills and I passed all the exams here. I know about ethical emotional issues of the patient, each and everything, and I want to apply those skills. I want to educate the people in appropriate health because I love to make people well. I love to provide care to people. [Ontario IMG #4, in progress]

Although there is greater recognition of foreign credentials, in nursing or midwifery, than medicine, different forms of frustration remain. Formerly senior nurses find themselves in the position of new graduates:

The impression that I've got, um, that they want me to prove myself, that I don't have to go through any other critical care nursing education which I am not too excited about doing it over again. [British Columbia IEN #6, practicing]

Among midwives, even those with plenty of experience are confronted with conditions:

I've got quite a lot of experience as a midwife in the U.K. I've been a midwife for 12 years so I've covered a lot of what they wanted you to do so I've just got the minimum conditions." "...after I trained, there was no continuity of care that I could demonstrate and so lo and behold the College decided to give me 30 continuity of care requirements which is the highest number that anybody has to do even though I had been... I was the oldest trained midwife in Vancouver at the time. And I thought to myself when I found out 'What? This is absolutely crazy.' But I couldn't demonstrate to the College's satisfaction that I could meet any continuity of care requirements. [British Columbia ITM #6, no longer pursuing integration]

Others found work in the health care field, but in jobs which require a much lower skill level such as infirmières auxiliaire. Both the OSFQ, and many community organizations established to assist new immigrants, directed ITMs to these lower skill level and lower status jobs. Many immigrants had to spend time and money retraining for these positions.

Elle m'a dit oui, oui, après je lui donne le nom de l'école, donc elle m'a donné le nom de l'école, je devais payé 300 $, donc j'ai payé 300 $ et puis j'ai fait la formation des préposés.

[She told me yes, yes, then I gave her the name of the school, and so she gave me the name of the school. I had to pay $300.00, so I paid $300.00 and then I took the support worker training.] [Québec ITM #3, no longer pursuing integration].

While generally dissatisfied with this work, many ITMs do not feel they have any real alternatives, due to personal family and financial responsibilities, as well as the current systemic restrictions to midwifery.

In sum, while many of the barriers that individual IEHPs experienced were specific to their profession, many – including the skills-based language, cultural competency, and the structurally based financial, bureaucratic, and time constraints – were similar in nature even if not in scope. Although we only briefly touched upon the consequences here, it is important to note that their impact was great. In the next section we reorient the discussion to focus on facilitators which help us to better formulate policy and program recommendations that emerged from our discussions with these IEHPs.