Scoping review about the professional integration of internationally educated health professionals

General information about the types and sources of literature identified during the
charting process is presented below, followed by the numerical and qualitative thematic
analyses. The gaps in literature are highlighted within each qualitative theme.

Types and sources of literature

Of the 407 sources, 197 (48 %) are journal articles and 156 (38 %) are reports issued
by government agencies, professional associations, non-governmental organizations
or academia. The remaining 54 (13 %) sources are theses (n?=?15), conference papers (n?=?9), policy statements (n?=?5), book chapters (n?=?2) and online sources such as webpages, electronic articles, blogs and data sets
(n?=?23).

Almost half of the literature used an empirical method (n?=?189; 46 %). Nearly one half (48 %, n?=?91) used quantitative, 15 % (n?=?62) qualitative and 19 % (n?=?33) mixed methods designs.

The geographical distribution of the publications was primarily pan-Canadian (n?=?233; 57 %). Nearly one fifth (n?=?77; 19 %) of the literature was authored by individuals located in the Province
of Ontario. The literature was mostly focused on IMGs (n?=?196, 40 %) and IENs (n?=?126, 25 %). The remaining sources concentrate on allied health professionals (n?=?165; 33 %) or are about IEHPs in general and do not identify a professional group
(n?=?109; 22 %). An evident trend in an increase in the number of publications was present,
with 2008 as the peak year of publication (Fig. 2).

Fig. 2. Number of sources by year of publication (N?=?407)

Numerical thematic findings

As Fig. 3 demonstrates, the numerical analysis of the themes resulted in 496 extractions. The
findings reveal that the literature is primarily about professional recertification
(n?=?226, 42 %). The workplace integration (n?=?123; 25 %) and pre-immigration activities and programs themes were moderately represented
(n?=?79; 16 %). Considerably less information is available about early arrival activities
and programs (n?=?41, 8 %) and alternate paths to professional integration (n?=?27; 5 %). For the thematic coverage per paper, see Additional file 2: Table S2.

Fig. 3. Frequency of themes by profession (N?=?496)

Greater than one fifth (n?=?109, 22 %) of the extractions did not identify a specific professional group and
are coded as IEHPs. The frequency of the remaining thematic extractions varied by
profession. Nursing dominates the literature about pre-immigration activities and
programs (n?=?35; 44 %). The literature about early arrival activities and programs (n?=?17, 41 %) and professional recertification (n?=?96; 42 %) and workplace integration (n?=?53, 11 %) is dominated by medicine. Although the literature does contain some information
for IEHPs in the allied health professions (n?=?65, 13 %), the thematic analysis did not identify a clear trend.

Qualitative thematic findings

Findings were summarized according to the five themes: pre-immigration activities
and programs, early arrival activities and programs, professional recertification,
alternate paths to professional integration and workplace integration. Gaps identified
in the literature are presented per theme.

Pre-immigration activities and programs

The pre-immigration activities and programs literature discusses the activities IEHPs
undertake prior to migration and upon arrival to prepare for practicing their profession
in Canada. The literature details how the circumstances surrounding IEHPs’ immigration
influences the type of activities they undertake prior to immigration. The literature
indicates that some IEHPs have significant time and ability to plan their move to
Canada, and others, like refugees, move with little preparation. Of the 79 papers
that cover the theme, nearly one half (n?=?35, 44 %) were about IENs, followed by IEHPs (n?=?23, 29 %) and IMGs (n?=?20, 25 %).

Push and pull factors

Several papers explore the motivations behind IEHPs’ decisions to emigrate. Push factors
include broad political, financial and social problems in their home country; professional
issues such as lack of medical resources, poor working conditions or low remuneration;
and personal incentives such as a poor quality of life for their families and low
educational opportunities for their children 8], 9]. Many IEHPs describe a confluence of factors motivating them to emigrate and find
it difficult to identify specific push factors 10]. The reasons that pull IEHPs to Canada include positive views of the Canadian society
and governance, professional considerations and personal incentives 11]. An overriding motivation for selecting Canada is IEHPs’ perceptions that health
care workers are in demand and they will obtain preference in the immigrant selection
process 12].

International recruitment

The issue of international recruitment is particularly salient in the medical, nursing
and pharmacy literature. Although Canada does not actively recruit health professionals
at a national level, the recruitment of IEHPs for specific positions within the health
care systems has been carried out by private companies, placement agencies or through
focused provincial and territorial or regional health authorities. There is sizeable
amount literature addressing the ethics of international recruitment. Of primary concern
is the impact on “sending” countries and whether IEHPs are gainfully re-employed within
the Canadian health care system. Recruitment from countries with health worker shortages
is generally perceived as unethical practice 13]. Most literature does, however, recognize professionals’ right to migrate and suggests
attention should be directed towards improving the factors that push professionals
to emigrate rather than prevent emigration 14], 15].

Pre-immigration testing or verification

The literature emphasizes the importance of immigrants having access to information
prior to immigrating to help them adequately plan for re-establishing practice in
their professions upon arrival to Canada 16]. The literature also recommends IEHPs gather all relevant documents before emigrating,
especially IEHPs from politically unstable countries or from countries that have poor
record keeping 17]. Completing the credential assessment and verification process, perfecting their
language skills and taking the professional examination for licensure before immigrating
are also recommended 18], 19]. Yet despite some examinations being offered overseas, only small numbers of IEHPs
take the examinations prior to becoming permanent residents of Canada 20].

In summary, migration is a complex and complicated process that occurs in the context
of personal factors and social and structural conditions (e.g. push and pull factors,
international recruitment). While it has been known for some time that this is so,
we have yet to identify the most dominant or least dominant factors in the push-pull
model of migration. We also have less literature about the ethics of international
recruitment of allied health professionals. In the Canadian context, specifically,
it is noted that IEHPs do not always fully prepare to migrate, which has not been
fully explored. Some possible explanations could be the lack of information or access
to exams when overseas and misinterpreting the immigration point system as a measure
of their ability to become registered and employed immediately upon arrival. Lack
of preparation before migrating can have a negative effect on IEHPs’ ability to acquire
employment in their profession once in Canada.

Early arrival activities and programs

The activities IEHPs undertake upon arrival and the programs available to prepare
them for practicing their profession in Canada. Eight percent (n?=?41) of the literature about IEHPs centres on the activities IEHPs undertake upon
arrival and the programs available to prepare them for practicing their profession
in Canada. The literature primarily focuses on the challenges IEHPs encounter and
the policy solutions and support available to them upon their arrival. While this
literature does speak to IMGs (n?=?17, 41 %) and about IEHPs in general (n?=?14, 34 %), there is an absence of literature that focuses on the early arrival
activities and programs for IEHPs in the allied health professions.

Challenges experience by IEHPs

The literature recognizes the greatest barrier to professional recertification for
newly arrived immigrants is a financial one. The tension between the resettlement
costs and the fees required to have their credentials assessed and verified can be
significant. Many IEHPs are forced into non-professional jobs to meet their immediate
needs, which can have negative consequences for professional integration. Johnson
and Baumal who investigated the professional integration of IEHPs found when IEHPs
began working in “survival” jobs, it became far more difficult for them to re-enter
their profession in Canada 21].

The second most frequently identified barrier is IEHPs’ lack of knowledge of how to
navigate social and professional resources in their new country. IEHPs often lack
information about the programs and resources available to initiate the credential
verification and assessment process, how to secure housing that permits easy access
to the available programs and resources, and initiate contact with the ethnic or cultural
resources within their communities 22].

Policy solutions to ameliorate these challenges

The literature identifies both federal and provincial initiatives to support IEHPs
during the early arrival period. For example, federal and provincial loans are available
to help IEHPs offset the costs of having their credential verified and assessed 23]. Several provinces and territories have implemented microcredit programs to assist
newcomers 24]. Provincially based IEHP specific settlement programs are available to provide information
about the licensing process 25]. Jablonski found the use of a case management approach that provides support to IEHPs
who are eligible, as well as those that are not yet eligible to practice, as effective
for helping IEHPs navigate the professional integration process during the early phases
of their resettlement period 26].

Role of professional associations

The review identified several professional associations that provide support and services
to IEHPs 27]–29]. There are many large professional associations for nurses and physicians and as
such have the infrastructure to support the integration of IEHPs through various initiatives
30], 31]. The Canadian Society for Medical Laboratory Science provides information to assist
internationally educated medical laboratory technicians (IEMLT) traverse the professional
integration landscape 32]; however, there is less literature that describes the role of the professional associations
for other allied health professions.

In summary, what is known from the literature about early arrival activities and programs
is the importance of providing system navigation assistance and access to various
forms of support. The use of a case management approach towards helping IEHPs navigate
recertification landscape is promising practice. The literature does not fully explain
the process or address the range of services offered by immigrant settlement organizations
and for IEHPs in allied health professions. There is also very little information
about whether the programs are successful in addressing the needs of IEHPs.

Professional recertification

The most prolific theme in the literature is about the processes IEHPs engage in to
meet the requirements for registration with a professional regulatory body in Canada
(n?=?226, 46 %). Forty-two percent (n?=?96) of this literature was about IMGs and 21 % (n?=?47, 21 %) was about IENs. The professional recertification literature is organized
into two main subthemes: barriers and facilitators to professional recertification
and programs and policies to facilitate IEHP professional recertification.

Barriers and facilitators of professional recertification

The first step in the process of professional recertification is having one’s credentials
verified and assessed by a regulatory body. This process can be complicated by the
fact that IEHPs often are not familiar with the system of professional recertification
(particularly the division of responsibilities between federal and provincial bodies),
may not have all necessary documentation or may not know where to send the documents
for verification and assessment. The process of professional recertification can also
be time consuming and costly. The amount of time it takes to qualify for examinations,
study and pass can be considerable with the time away from the profession being a
critical factor that will influence IEHPs’ ability to recertify.

Language fluency plays a significant role in IEHPs’ ability to traverse the professional
recertification landscape. Without language fluency, IEHPs are unable to thoroughly
understand the professional recertification process or benefit from the resources
created to facilitate their recertification. Language fluency also plays a significant
role in IEHPs’ ability to prepare and pass licensing examinations. Passing a language
test is a standard requirement for licensure, although the test may vary and require
different passing scores 33]. There is considerable debate in the literature about the best methods for testing
IEHP language fluency and their ability to competently communicate when in the professional
environment 34], 35]. Lafontant highlights the importance of providing opportunities for francophone IEHPs
to become professionally recertified as they are in a good position to provide services
to francophone minority communities 36].

Cultural competence, or familiarity with the culture and specifics of practice within
a new country, has been found to be important for IEHPs to achieve success on professional
examinations, complete professional training and communicate with patients 37]. While the issue of cultural competence may be more pressing for the diverse group
of IEHPs whose cultural heritage is markedly different from the North American culture,
Bourgeault and colleagues found that even those IEHs who arrive in Canada from countries
with similar health care practices (e.g. United Kingdom, United States and South Africa)
often find it difficult to immediately adjust to the Canadian way of professional
practice 10]. Despite the literature’s recognition of IEHPs’ lack of cultural competence as a
barrier to professional recertification, there is very little discussion in the literature
about the potential benefits of the diverse cultural heritage and knowledge of additional
languages IEHPs may bring with them or how these attributes can positively influence
patient care and the Canadian health care system.

Programs and policy initiatives to facilitate professional recertification

The literature suggests that various stakeholders and policy makers are fully aware
of the many challenges that exist in the process of credential verification and assessment
process. It also identifies the work of various organizations that ensure IEHPs have
timely access to accurate information about the process and support. For example,
there are a number of “credentialing agencies” that provide the initial equivalency
information for regulatory colleges or certification bodies across the country. Additionally,
corresponding programs have been developed to provide the opportunity for IEHPs to
demonstrate they have acquired the appropriate skills and knowledge through experience,
as opposed to formal education 38]–40]. There are two types of programs presented in the literature that are instrumental
in facilitating IEHPs’ professional recertification: IEHP bridging programs and residency
training programs for IMGs.

Bridging programs have been established to ameliorate the various barriers to professional
recertification for IENs and internationally educated allied health professionals.
The bridging program literature represents 4 % (n?=?21) of the IEHP literature and is primarily focused on IENs (n?=?8, 38 %). Some bridging programs assist with preparations for the national licensing
or certification examinations whereas others truly bridge the competencies that IEHPs
have with Canadian requirements. Other bridging programs prepare “practice-ready”
IEHPs for immediate work integration. A small proportion of the bridging literature
(n?=?15, 3 %) focuses on the bridging programs and residency training available to immigrant
physicians. Despite wide variation in the content and structure of bridging programs,
they are often identified as promising practices for facilitating the integration
of IEHPs.

Major barriers raised in the literature are the limited delivery of bridging programs
outside of major urban centres, low enrolment capacity of many programs and isolated
or temporary funding dedicated to these initiatives. Many professions have been able
to increase both class size and accessibility through development of distance education
modules 41], 42]. IEHPs also experience financial barriers to successful completion of a bridging
program. Most programs are not covered by provincial post-secondary student loans
schemes, and when funding is provided, it is usually limited to direct program costs
(such as tuition, book and equipment costs) with no supplements for daily living expenses
(such as rent, transportation, childcare, food). Upon completion of bridging programs,
IEHPs have report a better knowledge of the culture of health care in Canada practice
and improved communication skills. This draws attention to the need to better integrate
bridging programs both within the professional infrastructure as well as inter-professionally.

We did not identify bridging programs specifically for IMGs, but rather the literature
called attended to the difficulties IMG can have when attempting to access to residency.
Although the number of residency positions allocated for (or occupied by) IMGs grew
substantially in the past decade. IMGs are still considerably less likely to secure
a residency position than Canadian Medical Graduates.

In summary, the professional recertification literature encompasses two general themes.
First, there are a number of publications that describe how the professional recertification
process is seen as confusing and opaque by IEHPs. Second, the literature points to
a number of policies and programs that have been put in place to respond to these
concerns; however, they mainly focus on IMGs and IENs. What is known about the bridging
programs available to IEHPs in the allied health professions is limited. We also do
not know if the available programs are fully addressing the identified concerns, as
there is very limited information about their effectiveness.

Alternate paths to professional integration

There is very little literature (n?=?27, 5 %) that examines the alternative paths IEHPs take to achieve professional
integration. The literature is mainly focused on alternate paths for IMGs (n?=?10, 37 %) or is not profession specific (n?=?8, 30 %). The literature centres on discussing alternate roles for IEHPs, such
as IMGs becoming physician assistants 43] or IENs as unregulated live-in caregivers 44], 45]. No literature could be found that described programs or policy initiatives specifically
designed to facilitate IEHP profession integration by way of alternate professions.

In summary, there is a gap in the literature about the alternate paths to professional
integration. Given that we have many IEHPs that cannot professionally recertify due
to the various barriers, more information about how IEHPs access their profession
by ways of other professions is warranted.

Workplace integration

Workplace integration is the process of IEHPs becoming members of a workgroup within
an organization where they can use their professional knowledge and expertise. The
thematic analysis revealed one quarter (n?=?123) of the IEHP literature focuses on workforce integration. Three quarters of
the workplace integration literature concentrates on IMGs (n?=?53, 43 %) and IENs (n?=?36, 29 %). It is organized into three main themes, practice profiles of IEHPs,
barriers and facilitators to workplace integration and the role of employers.

Practice profile of IEHPs

IEHPs tend to reside and work in urban areas where they are closer to well established
immigrant communities and can access integration and professional support services
46]. When IEHPs are recruited to fill the geographical gaps in the health workforce,
long-term sustainability is negatively affected 47]. IEHP migration follows the same patterns as their Canadian counterparts, as they
often move from less to more prosperous provinces and from rural to urban areas of
the country 48].

Barriers and facilitators to workplace integration

IEHPs continue to experience challenges once they are employed. Language barriers,
developing trustful relationships with patients and colleagues and adapting to new
technology and professional culture are cited in the literature 21]. IEHPs also continue to experience discrimination in the workplace 49], 50]; however, it is unclear if this is because they are visible minorities or because
they have foreign credentials. The literature suggests that formal leadership roles
are not readily available to some IEHP groups, such as IENs. Communication challenges
and marginalization of immigrants are reasons given in the literature 51].

The literature also contains information about the facilitators of IEHPs’ workplace
integration. In addition to direct to work bridging programs, employer-sponsored orientation
programs, collegial environments, mentoring and social support are cited as important
factors that assist IEHPs with integrating into their workplaces 52], 53].

Role of employers

The literature reveals employers view IEHPs as both beneficial and unfavourable additions
to their workplaces. For example, some authors highlight how IEHPs can assist with
the provision of linguistically and culturally sensitive patient care 21], while others 18] report employers are uncertain if IEHPs have the knowledge and skills needed to be
successful in the workplace. No literature could be located that compared IEHPs’ work
performance to Canadian-educated health professionals.

In summary, the workplace integration literature mainly focuses on IEHP practice patterns,
including location and sector of practice and does not provide information about what
they do. As a result, the number of IEHPs who are unemployed or to what extent they
are underemployed is unknown. The literature also reveals IEHPs experience another
layer of barriers and discrimination on top of those identified in the professional
recertification literature, but does not fully discuss the reasons why this occurs.
Information about IEHPs after they have professionally integrated and their opportunities
for career advancement is also lacking. The literature does include reports of many
promising practices to facilitate IEHP workplace integration. It does however indicate
employers can play a critical role in IEHP professional integration, yet very little
information is available about employers’ hiring decisions as they related to IEHPs.
Additionally, little information is available about the workplace integration of IEHPs
in the allied health professions.