Alternative routes to utilize health professional skills can serve as a personal bridging program, that is, a possible facilitator to professional integration or possibly professional redirection. To facilitate integration into their future work environment, many IENs choose to work in a lower skill level position in health care before obtaining their license to work as a nurse in Québec. For instance, in Québec, many IENs work as patient care attendants or préposés aux bénéficiaires (PAB) while going through the licensing process, and numerous IENs in the other provinces work as Personal Service Workers (PSW).

Respondent: Yes. After three months and a half I found this job. At the McGill Health Centre, and I start work.
Interviewer: What are you doing again? I'm sorry, I forget what you said? What are you...
Respondent: I'm a patient care attendant.
Interviewer: Patient care attendant. So you're at least getting familiar with how hospitals work here in Quebec....
Respondent: In the same time I learn language, medical language, that type of thing. It's a good practice for me. [Quebec IEN #1, in process]

When the prospects of getting employment in their own profession seem slim, many IEHPs consider getting into health care in Canada by finding some other position which would offer a way into the system, but which would be easier to obtain. For example, the inability to get into residency motivates IMGs to look at other options of gaining employment in Canada. Others travel to other provinces to work as clinical assistants (in Manitoba) or medical assistants. This way, they hope to get Canadian medical experiences and thus to become more attractive candidates for provincially run bridging programs for IMGs. Indeed, one of the biggest concerns raised by IMGs is that they could not get a position in Canadian health care, which would be (at least partially) related to their medical past:

I am also making some alternative arrangements. Not too far from medical practice. Because there is an area I am quite interested in. That is biotechnology. Very, very interested in it... While I am in this process [of getting medical license] if I get opportunity [to work in biotechnology] I have to move on. [Manitoba IMG #1, in process].

Many choose to apply to research programs where they can work as research associates:

And I'm looking forward just, you know, maybe if there's something worth it to maybe start a new career in something like related to health field. As I mentioned the CRA, like a research associate, I would love to because like I'm very organized. I can find myself doing this... So I might consider this path [Ontario IMG #20, practicing].

Other IMGs decide to retrain as nurses, because nursing is a shorter program than medicine. In this way, they will be integrated into the health care system, but not as physicians.

Oui, oui, je ne suis pas le seul donc dans ma formation il y a je ne sais pas, il y a nous sommes 4, 5 médecins étrangers, il y a deux femmes qui viennent d'Algérie, un du Liban, il y a une dame qui vient de la scène des pays soviétiques. Donc il y a la dame qui vous avait donné mes références qui venait de la Roumanie. Donc nous sommes nombreux puis nous ne sommes pas les seuls au cégep à avoir fait la médecine.

[Yes, yes, I'm not the only one in my training program. There are, I don't know, there are four or five foreign doctors, two women from Algeria, one from Lebanon, a woman who comes from the Soviet countries. There is the woman who referred you to me, from Romania. There are a lot of us, and we are not the only ones in Cegep who studied medicine]. [Quebec IMG, no longer pursuing integration].

But those initiatives are taken by IEHPs individually. Many think that the system could offer retraining programs in order to utilize IMGs in other health care related positions:

I wasn't expecting to get directly into the medical system [in Canada]. [I thought that if] I am not able to work right away in the medical system I can work as let's say a paramedic. I can work as an instructor for a tourist training center. I felt I can work for biomedical companies... I felt I can get into the universities and do my PhD or Masters which was something that I was interested in as well. After getting into Canada I figure out that all this paths are much more complicated than what I thought and some of it is considerable... Immigration in Canada is not a new phenomenon and you're expecting the system... to be much more organized and widely designed. This part was a little far from expectations [Ontario IMG #1, in process].

Therefore, one of the recommendations given to us by IMGs is to establish bridging programs which would allow them to practice in a health-related field:

You cannot bring people from overseas to here and make them go through the system which is absolutely designed for people who are trained and who have been living here, you know what I mean? You cannot take people as immigrants to Canada and right after arriving in Canada asking them to offer Canadian experience and Canadian credentials. It doesn't make sense. If the system believes immigration is contributing in any ways to the society it's supposed to do something to fix these problems... As an immigrant you have to get out of the square sometimes... This is the responsibility of the government and the high rank[ing] decision makers are supposed to fix these problems. They have to make bridges based on different sectors. And they know what's the impact of immigration on these different sectors. But somebody in a higher position needs to look from higher position [how] to bridge the systems, bridge these gaps. A physician if he is not able to get in practicing medicine could do something useful instead of driving cab [Ontario IMG #1, in process]

There should be some kind of programs. Even a lot of people are so desperate they are like I also did some work, I worked with some doctor in Toronto for some time for no money you know. Volunteering. And my husband did for at least six months in Winnipeg for some time. This is not right. There should be something for the doctors you know [Manitoba,IMG #1, practicing].

In sum, our participants overall felt that they should have more information about the Canadian work environment, the structure of the health care system and other things which are unique to Canada. This knowledge would also help them once they are integrated into the local health care force. But before we turn to mapping out some of the key policy recommendations that emerged from our discussion with IEHPs, it is important to turn to a theme which began to emerge from our data analysis: this is the question of whether the success of an IEHP is due to being proactive or just to fate.

Some of our participants who were ultimately successful in their professional integration process identified two activities key to their success: professional networking and personally being proactive. Being "proactive" denotes self-initiative, determination, and self-confidence. One IMG summarized the situation succinctly:

From the beginning I understood that it's the most important thing is to have connections, the networking. I know many people took the workshops. Nothing. I mean other people, you know, help them to find a job but it's not through the government. [British Columbia IMG #9, no longer pursuing integration]

I called people. I sent my resume. I met with people who agreed to meet with me. I spoke with them and everybody understood, ... And finally, finally when I think that somebody already know that there is such guy here and he is looking for work, they called me. [British Columbia IMG #1, in progress]

Others, however, when asked why did you get the job, obtain the residency, or make it through, did not answer "luck" or "a miracle", citing many examples of people who were highly proactive yet they still didn't make it through. So for many it was really more of a question of "fate" (i.e., I was just lucky to get in touch with person, to meet a person, to get into a program). It was a like a miracle, like winning the lottery. Thus, being proactive was seen as being necessary but insufficient – because many who were not yet integrated exhibited a great deal of initiative and proactive measures.

In the next section, we expand upon this discussion of facilitators with some clear recommendations and promising practices highlighted by the IEHPs we interviewed. Table 5.1 provides a summary of the barriers and facilitators discussed and provides an outline for the recommendations and promising practices of the following Sections.