Bridging programs aim to assist IEHPs in overcoming the perceived discrepancy between their knowledge and experience and Canadian standards of professional practice and knowledge so as to facilitate professional integration (Lum 2009). Bridging programs vary and can serve multiple purposes, including the assessment of existing education and skills to identify any additional training needs, and where possible, profession-specific language training; preparation for licensure exams; provision of both clinical or workplace experience; and improving familiarity with the social and cultural context of the Canadian health care system (Lum 2009). Completion of bridging education programs is usually one of the components necessary to secure licensure for IEHPs.

In each of the provinces we studied, and for each of the professions, there were bridging programs to assist in the professional integration process of IEHPs. We have already described (in Section 3) the Prior Learning and Experience Assessment programs and International Midwifery Preregistration Program (IMPP) that ITMs have to undertake, as they are both the ways in which ITMs become integrated and follow bridging programs simultaneously. For IENs, there are programs designed to upgrade their language, nursing skills and knowledge, and prepare for the licensure exams in BC at Kwantlen Polytechnic University, and in Manitoba, at Red River College in Winnipeg (CRNM 2010). The OIIQ requires that all IENs complete a 'professional integration program' which provides them with background on organizational, legal, ethical and socio-cultural aspects of nursing in Quebec, plus guidance regarding adaptation to the Quebec context and clinical skills (OIIQ 2006). In Ontario, the program is specifically called the Creating Access to Regulated Employment (CARE) for Nurses bridge training program. First announced by the Ontario government in May 2001, its aim is to provide profession-specific skills, including relevant English skills, along with education in nursing culture, to prepare IENs to meet the nursing baccalaureate degree requirements.

For IMGs, residency training acts as a form of bridging, but this is particularly the case for residencies that are specifically targeted to IMGs, such as those in Ontario and B.C. In Quebec, the only programs available to assist IMGs applying to obtain their license through the regular route are information sessions made available before each stage in the licensing process. Recently, the MICC in Québec joined forces with AMEQ to organize sessions to assistIMGs in their preparationm for the examination portion of the licensing process. For IMGs applying for licensure through the restrictive permit route, on the other hand, three months of orientation and evaluation must be completed. This clinical introduction to Quebec health care is undertaken by the teaching hospitals in the province, and acts as a bridging program of sorts. This program is not available to IMGs applying through the regular equivalency route (CMQ 2009a). Manitoba, for example, has a program for IMGs, the Medical Licensure Program for International Medical Graduates (MLPIMG) where they can prepare for future practice.

Benefits of Bridging Programs

Bridging programs were often regarded by our respondents as a facilitator for integration. This was perhaps most salient for IENs who were recruited and expected to enter practice quickly:

And actually in the courses, they were kind of going for all other nurses as well ... in that they were learning nursing that how you are going to deal with patients and lots of scenarios about this. So I really, that was very, very useful. And I was glad that they make me to not just write the exam. Take some courses. Some other people was [unintelligible] an eye opening. And I am so glad to the College allowed me to do that course [Ontario IEN #21, practicing].

Many commented on the benefits of the formal structure that a bridging program offered:

Like I could choose the courses I want to take. I just do the most important thing just to refresh my memory because it's no way I can just sit home and study everything on my own every day. It's no way. There's just so much information. Like I'm glad I did it. I'm glad I did it cause if won't take the program I won't pass the exam for sure. In my opinion everybody should take these course,s even if they are eligible to go and write the exam, cause ... your chances to pass the exam is so low without the proper preparation [Ontario IEN #1, no longer pursuing integration].

Others noted the important content of the course – such as ethics or culturally appropriate communication – but also how it provided information on the best way forward in the professional integration process. As one IMG in Manitoba mentioned:

In terms of medical training, I did not [know] where to go, because we did not know anyone and it was quite difficult. There was a very good program in Red River College CCPTA - communication for physicians trained abroad and it was a really good program, 'cause they taught culture and ethics and some language and it was very useful. Another thing is good about CCPTA that it gave a sense of direction on what to do next. It became clear where to apply and when. ... it was really good. [Manitoba IMG #2, no longer pursuing integration].

Challenges with Bridging Programs

When asked about existing bridging programs, our interviewees raised concerns about three major issues that need to be improved: (1) accessibility of bridging programs in terms of available spots, geographic availability and financial hurdles; (2) the coordination of those programs in terms of the design of the program and who is in charge, and (3) the content of the material in terms of a reqirement to be more adequately tailored to the needs of IEHPs.

Lack of Availability/Accessibility
There are bridging opportunities for professionals but unfortunately, the number of bridging programs is extremely limited. Not all health care professionals who are willing to participate in a bridging program can get access to one. This is due to three major problems that our respondents identified over the course of this study: (1) limited spots for participants, (2) accessibility of existing bridging opportunities; and (3) the financial burden that participation in the bridging program can create for the family of an IEHP.

The problem of limited spots was especially salient among IMGs who are looking at the possibility of getting into medicine through existing bridging programs. Usually, the spots available for IMGs in provincial bridging programs are far lower than the actual numbers of IMGs eligible to participate. As noted earlier, for instance, MLPIMG – a bridging program in Manitoba – on average recruits 25 to30 IMGs, but applications number over 150. In Québec, an IMG with a sponsoring employer waiting in the wings (the best case scenario possible for an IMG) may wait as long as 18 months before getting access to the orientation and evaluation program.

While programs for IMGs exist in all four of the study provinces, there are fewer bridging opportunities for nurses, other than those in Québec. Nurses from Manitoba, for instance, constantly complained about the lack of bridging opportunities available for IENs who entered the province. In fact, the local Filipino Nurses Association in Manitoba started to offer courses for IENs to improve their chances of finding work and address the lack of refresher courses. The IENs themselves took the initiative to actually establish bridging opportunities for local immigrant nurses:

When I was in Manitoba and I was preparing for this examination [CRNE] there was a shortage [of nurses] here in Manitoba... So what happened is there are lots of Filipino nurses here in Manitoba that are not licensed but they are already Canadian citizens. They live here in Manitoba. So what we did is we looked for somebody, like we approached some politicians here and asked for their help: "You know what, you are short of nurses here. We have lots of nurses who are in Winnipeg right now and they are willing to do extra review courses or study more so that they can get their license and practice as nurses." ... So anyways we were lucky enough that [they said] "okay, let's see what you can do". We had a meeting with the Red River College. We had a meeting with the licensing body. We had a meeting with the Minister of Health to get some money and recruitment and retention and things like those. But anyway in short sentence we were able to acquire... these nurses were able to get the licensure because they offered them some review courses. [Manitoba IEN #1, practicing].

IENs even had concerns with the model CARE program:

The time wasn't really, uh, it wasn't suitable for me. It was at night and since I have a family to look after myself, my husband is very busy, I didn't consider it. [Ontario IEN #9, no longer pursuing integration].

The availability of bridging programs is especially limited for people coming to cities which are far from the provincial "centres" of concentration of immigrants. Availability of courses online was regarded by our respondents as an excellent opportunity to gain access to information. Finally, availability of financial assistance for IEHPs participating in bridging programs is a crucial factor: there is a need for loans, bursaries and scholarships to allow IEHPs to study and to prepare themselves for the licensure exam instead of working as health care aids, waitresses and gas station workers.

Program Coordination
Another problem that IEHPs identified is the manner in which the bridging programs were coordinated or administered, the lack of navigation inside each program, and the inability of IEHPs to raise concerns or to complain about unfair treatment. A number of concerns were raised about the IMMP program which provides bridging opportunities to midwives in Ontario. For example, some of our participants felt that the assessment of their eligibility for the program was not based solely on an objective assessment of their qualifications, and their progress in the program was sometimes unfairly evaluated. Instances of unfair treatment while attending the bridging program were also reported by nurses and physicians. Usually IEHPs do not know how to navigate through the educational system and are unaware of how (or even if) they can make complaints. In the bridging programs designed for IMGs, for instance, the success of a physician can be evaluated by a mentor assigned to an IMG by a program coordinator. If, for any reason, the communication between the IMG and their mentor is disrupted, there is little can they can do to complete the process:

The only reason I think I survived this assessment [part of the bridging program] was because there were two doctors who were assessing me. I worked with [one of them] for just two days, and then she went on vacation. In the first four hours she observed me and I didn't know that she was my boss... And suddenly she introduced herself to me and she said 'Okay, my name is this and you are working under me.' And, you know, I said okay. And she said that 'I have seen you working and I just want to tell you that you will have no problem passing this assessment. You are very good.' ... And then my bad luck that she went on her vacation just two days after. Now I had no choice but to work with other doctor who had a lot of personality issues... Now what should I do? You know... I thought that I will not pass this [assessment]. So I called my program director and I said 'I am going to lose it not because I am not competent. I'm going to lose it because somebody just don't like me.' ... So the human error thing is there. The remedy is that they should have two or three assessors. [Manitoba IMG #2, practicing].

The bridging program for nurses in Québec requires that some IENs undergo between six months and two years of retraining. As indicated below, some respondents feel that they were pegged for failure before even finishing the bridging program. Furthermore, they believe that the program was designed to test their capacity to endure stress more than to teach them how to work in the Québec health care system.

Respondent : ... la première session que j'ai réussi et après il m'informait que j'avais réussi, la prof m'a dit [nom] je crois que tu dois travailler comme préposée [PSW]... À la deuxième session j'avais monté un peu de catégorie, parce qu'à la deuxième session quand j'avais réussi, la prof m'a dit [nom] tu as réussi mais je te recommande fortement d'aller travailler comme infirmière auxiliaire [LPN], parce que tu es excellente comme infirmière auxiliaire. Mais madame qu'est-ce que vous faites ici, vous êtes supposée de former des infirmières, ça veut dire que vous ne réussissez pas votre travail, votre tâche. Non j'ai pas dit, non je ne pouvais pas dire ça mon Dieu...C'était parfait mais non j'ai juste dit on dirait mais on n'est pas, on n'est pas capable de dire rien parce que c'est une formation, je dis maintenant, je peux le dire après six sessions, basée sur la porte...En cinquième session, la prof m'a dit qu'il faut que je parle de l'Ativan, parce qu'elle m'a dit [nom] tu as pas fait ça, oui, pourquoi si tu sais comment le faire. Je sais comment le faire mais le stress ne me permette pas de le faire.
Interviewer : Donc elle vous recommande de prendre un anti-anxiété?
Respondent : Mais c'est une pratique commune, il y a beaucoup de collègues qui ont commencé à prendre l'Ativan pour arriver à réussir le stage.

[Respondent: ...I passed the first session and after they told me that I had passed, the teacher said, "[name], I think you should work in personal support [PSW]"... In the second session, I moved up a notch because in the second session, when I passed, the teacher said, "[name], you passed but I strongly advise you to work as a licensed practical nurse [LPN] because you would make an excellent licensed practical nurse." But lady, what are you doing here? You're supposed to be training nurses, and if not, you aren't doing your job, your duty. No, I didn't say it; I couldn't say that, my God. It was fine. No I'm just saying, but we aren't, you can't say anything because it's a training program. I say it now, after six sessions based on how things went ...In the fifth session, the teacher told me that I had to talk on Ativan because she said [name] you didn't do that. Yes. Why, if you know how to do it? I know how to do it but the stress stops me.
Interviewer: So she advised you to take anti-anxiety medication?
Respondent: But it's common. A lot of my colleagues started taking Ativan to get through the training.] [Quebec IEN #3, in progress].

Thus, many of our participants felt that the assessment process developed by their bridging program was in some cases poorly managed or poorly coordinated.

Program content and target
Finally, some IEHPs also raised concerns with of content of bridging programs, in terms ofits variability and what kind of target it had in mind. This was a challenge not prevalent among all the professions, because of the variability in the IEHPs that came to Canada. As was noted in the report, Navigating To Become A Nurse In Canada (2005, p. 6), "Some provinces offer specific bridging programs for IENs but they are not all similar in content, length or cost and only some incorporate language and communication training."

The following ITMs argue that this variability in bridging program participants made it redundant for some, although appropriate for others:

I think it's aimed at people like me [ie. with degree]. I think it's for people who have clinical skills and just need a little bit of like okay, you know, this is how the relationships are different, this is how you have to approach the doctors. [Ontario ITM #1, practicing]

And in that way actually the IMPP program that we did is very poorly designed for us. It was designed for the immigrants. Fair enough. ... and have more time to be developing their cultural awareness and language skills... [Ontario ITM #2, in progress]

Many felt that bridging programs should pay more attention to the culture of Canadian practice rather than to the care issues:

Respondent: Childbirth is not different from country to country. It's not maple syrup is coming out of the breast here and that we need to know then what breastfeeding is all about. I'm sorry, but that's just how it comes across... I made those jokes. I said, like 'What? Canadian women deliver upside down? So we need to learn the skill again?' Honestly, give me a break.... I've worked in different settings and different hospitals and I know that protocols can be different and I said, pharmacology's completely different and I think it is fair that people from other countries go through that ...
Interviewer: Would a program that focused on working in the Canadian context be more interesting?
Respondent: Yes, absolutely. And, I think, don't make it a seminar, make it part of that process of becoming licenced... That's very fair and I think I would have really enjoyed that. I really would have enjoyed to hear more about the history of midwifery, for example. These were things that I learned in my placement. How the Association worked and how the college worked and so on and so on, how we can be protected as midwives. [Ontario ITM #5, practicing].

Since many of bridging programs are just in their early stages of development and delivery, there are often inconsistencies or ambiguity about some parts:

I think there are some gaps in between. I have my personal example. It was obvious that IMGO and Royal College didn't have proper negotiations about this particular new stream that I got enrolled in and almost admitted this in conversation with me that they sort of didn't have time to discuss this because they really wanted to start one of them... they were in a rush to do it in Spring 2004. They didn't want to delay it for half a year. And I agree they did a good job but there were some drawbacks in particular. They didn't negotiate it properly with Royal College and as a result I am doing the residency longer. [Ontario IMG #2, practicing]