We have already highlighted how there are similarities in the barriers, facilitators and recommended changes across the different professional groups we interviewed. Here, however, we try to pull together how, and along what dimensions, the IEHPS in their profession group experience the integration process differently. Briefly, although many similarities between professions were found, the logistical structure around licensing varied from one profession to another. While IMGs and ITMs reported the greatest difficulties around licensing, IENs also had their share of struggles, which varied in complexity according to their country of origin and their destination province.

IMGs: Although all IEHPs face challenges on the way to professional integration, IMGs probably face the most significant difficulties. The lengthy and complex licensing process for IMGs means that these professionals often take several years to complete all of the required steps. There is a timeframe between the end of active practice and eligibility for licensing in Canada within which IMGs are deemed acceptable candidates. Because the licensing process often takes longer than this allotted timeframe, many IMGs are effectively eliminated by the requirements of the process itself. This situation creates a great deal of frustration and outrage among the IMG community in Canada.

The strongest barrier to professional integration of IMGs is in the limited number of residency positions available to them. There is a general sense in the IMG community of not being in control of their integration and having to rely on fate rather than on their personal skills and abilities to get through the system. IMGs are also most likely to demand some retraining in the health care field that could give them the ability to integrate into the system in some other capacity than a physician (either on a temporary or permanent basis). At the same time, IMGs in general, have more social and financial capital than IENs and ITMs. Usually, they are coming to Canada as primary applicants under the category of skilled migrant. They usually have money to start the process of integration and to support themselves and their families financially, even if for a short period of time.

Thus, the case that most clearly represents the 'brain waste' issue is the issue of integration of IMGs. Indeed, recently available data from the Access Centre for Internationally Educated Health Professionals in Ontario, indicate three quarters of the over 10,000 clients that they have had since their inception in 2006, are IMGs.

IENs: It is generally true that nurses have higher chances of integrating into the system than do IMGs, in large part because they are more likely to be recruited from abroad than IMGs. IENs, who were recruited to practice in Canada, had the highest likelihood of being integrated into the Canadian health care system. But at the same time, they are most likely to be working in positions that are below their level of qualifications and experience. For example, some IENs who had experience and training as a Registered Nurse have been recruited to work as LPNs. Another factor which compounds the situation for IENs across Canada is the misunderstanding surrounding the different titles in nursing. Many countries have only one title for nurses and one job description. In Canada, there are three titles with three corresponding job descriptions and three pay scales.

ITMs: For ITMs, the different model of practicing midwifery in Canada posed the biggest challenge on the process of professional integration, followed closely with challenges associated with its newness, such as lack of developed programs, especially outside of Ontario, and capacity limitations. Once integrated, many ITMs felt that they were not ready to face the demanding schedule of Canadian midwifery practice.

In sum, despite those significant difficulties in the process of integration, successful professional integration for all three professions was highly related to availability and accessibility of bridging assessment and orientation programs for IEHPs. While IMGs were not able to obtain their license in Canada without attending a bridging program (i.e., residency), some IENs and ITMs did not feel ready to practice without attending a bridging program or orientation. Therefore, some of our respondents chose to attend a bridging or an orientation program even after passing their licensure exams. Many midwives and nurses who started practicing immediately upon their arrival to Canada, reflected on the enormous confusion and problems they experienced during this time.