Occupational Integration in Healthcare by French-speaking Immigrants Living in Minority Communities

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Table of contents

• Acronyms
• Abstract
• Executive summary
• Introduction
• Methodology, Analytical Approach and Limitations
• Research results: Quantitative Information
• Research Results: Interview Information
  • Foreign Credential Recognition
  • Interview based discussion
  • Education in Canada and Internships
  • Job Search and Hiring
  • Onboarding and Retention
• Conclusion
• Recommendations
• Appendix A: Avenues to Explore
• Appendix B: Bibliography
• Appendix C: Interview Guide for immigrants
• Appendix D: Quantitative Tables

Acronyms

CNFS

Consortium national de formation en santé

FMC

Francophone Minority Communities

IRCC

Immigration, Refugees and Citizenship Canada

IEHP

Internationally Educated Health Professionals

NNAS

National Nursing Assessment Service

Abstract

This report presents the results of a research project on the occupational integration of French-speaking immigrants in healthcare, in Francophone minority communities. Through interviews, this project examines the challenges faced by French-speaking immigrants working or pursuing a career in the health sector in Nova Scotia, Ontario and Alberta. Researchers also mobilized literature on the occupational integration of immigrants, data from the 2016 Census and the results of quantitative studies. The research shows that the need for English language skills constitutes a major obstacle at various stages of French-speaking immigrants’ occupational integration journey. The interviews also indicate that employment assistance services in French are not equipped to deal with the complex trajectories of internationally educated health professionals, or to help them identify alternative careers. During internships or at the start of employment, supports in French promoting the integration of immigrants (through mentoring, training workshops for employers, etc.) are very limited. Recommendations are addressed to the Department of Immigration, Refugees and Citizenship Canada and aim to improve supports offered to the study population from the start of their migration project to retention in their workplace.

Executive summary

Presentation of the study

This report, submitted jointly to Immigration, Refugees and Citizenship Canada (IRCC) by Mariève Forest of Sociopol and the Goss Gilroy Inc. team, presents the results of a research project on occupational integration in healthcare by French-speaking immigrants living in minority communities. The project was part of an IRCC research program studying immigration in Francophone minority communities. The research helps identify the challenges that particularly impact French-speaking immigrants living outside Quebec who work, or wish to pursue a career, in the healthcare sector. Another goal of the study is to draw up a list of promising practices adopted and implemented by various players, as well as potential solutions inspired by the accounts of French-speaking immigrants.

Methodology. The main analyses were performed on data produced from 35 semi-structured interviews with French-speaking immigrants trained in healthcare, as well as interviews with other stakeholders. Interviewees were residents of Nova Scotia, Ontario and Alberta. A large majority of the immigrants interviewed (29/35) have a diploma, granted outside of Canada, in a healthcare-related field. More than 40% of the foreign-trained individuals we met have abandoned the idea of working in their field and have found alternative employment, but most of these jobs are not consistent with their level of education and their previous work experience. In addition to these interviews, we interpreted data from the 2016 Census, used information drawn from other quantitative studies to describe the target population, and carried out a literature review.

Analysis of Interviews

Recognition of foreign credentials. For a number of foreign-trained healthcare professionals, limited English skills are a major barrier to the pursuit of their chosen careers in Canada. Language-related barriers are encountered at the various steps in the credentials evaluation and recognition process, as well as in mandatory English testing or when proof of work experience in an English-speaking setting is requested. Health regulators offer varying levels of French-language services, but these are often non-existent in Alberta and Nova Scotia. An additional drawback is the lack of a centralized database for Francophone resources in this field.

Training and internships. The 16 post-secondary institutions that are members of the Consortium national de formation en santé (CNFS) offer more than 100 healthcare training programs in French outside of Quebec. Interviewees who attended these programs felt it was positive – even necessary – for them to have the chance to study in a Francophone environment. Once again, people with limited English skills encountered pitfalls, for example, in the course of bilingual training programs at Campus Saint-Jean or with respect to language requirements set by professional bodies. Other issues emerged from the continued lack, or fragmentary nature, of programs adapted to immigrants in post-secondary institutions for Francophone minority communities. Examples include bridging or support programs for joining the workforce, during or after internships.

Job search and hiring. The healthcare job market generally seems conducive to hiring. Foreign trained healthcare professionals, however, have limited support for identifying alternative careers in this field, which makes occupational integration more of a challenge. Healthcare related knowledge is generally lacking in French-language employment assistance services for immigrants. Personal networks, which are often made up of immigrants, remain an important source of information. Interviewees living in Alberta and Nova Scotia found that potential employers did not seem to consider French an asset, and strong English skills were essential. A set of dynamics led to interviewees being in jobs with potentially difficult working conditions that do not match their level of education or expertise.

Onboarding and retention. Deskilling, and its impact on quality of life, is a key aspect of several interviewees’ lived experiences. Intersecting forms of discrimination should be considered at this point: people report being discriminated against because they belong to a visible minority and speak English with an accent, or are Francophone. An additional concern is the scarcity or absence of supports (mentoring, training workshops for employers, etc.) that promote the integration of French-speaking immigrants in their new jobs, although the value of these supports is recognized in the literature.

Recommendations

1. Strengthen support for pre-arrival service programs in French, by making them more visible and incorporating French-language services for occupational integration in the healthcare field.
2. Explore the possibility of implementing a French-language employment navigation service in healthcare and developing employment service capacities.
3. Assess the possibility of offering financial support for Internationally Educated Health Professionals (IEHPs) who seek to complete the credentials recognition process or wish to find a new career in a related field.
4. Assess the possibility of supporting development of bridge training and coaching, in French, for IEHPs.
5. Contribute to discussions about English-language barriers that reduce French-speaking immigrants’ access to the healthcare professions.
6. Contribute to discussions intended to improve supports for building employer awareness in the area of diversity management.

Introduction

Purpose of Research Project

This report, submitted jointly to Immigration, Refugees and Citizenship Canada (IRCC) by Mariève Forest of Sociopol and the Goss Gilroy Inc. team, presents the results of a research project on occupational integration in healthcare by French-speaking immigrants living in minority communities. The project was part of an IRCC research program studying immigration in Francophone minority communities.

The issues facing immigrants with respect to workplace integration in Canada are documented in a vast body of literature. The research helped identify the challenges that particularly impact French-speaking immigrants living outside Quebec who work, or wish to pursue a career, in healthcare. Another goal of the study was to draw up a list of promising practices adopted and implemented by various stakeholders, as well as potential solutions inspired by the accounts of French-speaking immigrants.

Workforce integration refers to several stages in an immigrant’s trajectory, each of which refers to different organizational environments and actors. We therefore set out to examine the barriers and factors facilitating occupational integration, focusing on credential recognition for internationally trained individuals, post-secondary education and internships, job search, hiring, and workplace integration.

Background and Problem

According to data from the 2016 Census, immigrants represent a larger proportion of the French-speaking population in Canada outside Quebec than in previous censuses. This proportion increased from 9.9% in 2006 to 12.8% in 2016 (Statistics Canada, 2017b).

The most recent literature reviews on the health of Francophone minority communities (Sauvageau, 2018; van Kemenade and Forest, 2015) report on Francophone and bilingual human resources issues in healthcare and the health issues of Francophone immigrants. Published research highlights the importance of Francophones receiving healthcare in their language and the fact that the language of service can have a real impact on their health and the effectiveness of care (Bowen, 2015).

Between 2005 and 2009, the Consortium national de formation en santé (CNFS) supported research projects (Lafontant et al., 2006; Belkhodja et al., 2009) and a series of consultations dealing specifically with the integration of Francophone immigrant professionals in the health sector. This work identified a series of promising initiatives, concluding that the offer of service is available in English, but much less in French; where employment services are available in French, they are rarely sufficiently specialized to assist health professionals (Belkhodja et al., 2009). This research describes issues that are still prevalent today, including the lack of clear information in pre-arrival and post-arrival services, the obstacle of credential recognition and the fact that it must be conducted primarily in English, the lack of opportunities (internship, mentoring, observation, work study, etc.) allowing immigrants to gain familiarity with the Canadian healthcare environment, financial issues, the limited availability of French-language or specialized training in healthcare for immigrants, and the few measures devoted to workplace integration and support. The research also notes the need for navigation services to guide Francophone immigrant professionals in a complex environment with which they may not be familiar.

Of the scientific literature recently reviewed in the healthcare sector concerning Francophones in minority communities (more than 140 between 2010 and 2016), none specifically addresses the pathway for integrating French-speaking immigrant professionals living in minority communities in healthcare sector jobs (Sauvageau, 2018). The most recent Statistics Canada report on official language minority healthcare professionals does not address variables related to immigration (Lepage and Lavoie, 2017). While Statistics Canada data acknowledge an increase in immigrant employment in healthcare, the language characteristics of immigrants are not known at this time (Statistics Canada, 2015).

Over the years, regulatory bodies, post-secondary institutions, different levels of government and other stakeholders have developed services and programs to meet the specific needs of these populations, but many barriers remain. Moreover, few recent sources are available to assess the impact of the measures implemented for French-speaking immigrant healthcare professionals who settle outside Quebec (Covell et al. 2017).

Occupational integration in the healthcare field often requires specialized training, as well as some knowledge of English for professionals in minority language communities. Although Health Canada’s investments over the past 15 years have made it possible to expand the availability of French language training in healthcare outside Quebec, several gaps remain when it comes to supporting immigrants – or foreign students as potential immigrants – and helping them succeed in these training programs (Forest, 2014).

At this juncture, the occupational integration of immigrants requires an examination of the hiring, workplace integration and job retention processes. Particular difficulties may emerge in terms of onboarding structures. To this end, the Société Santé en français has developed a number of tools to help administrators of health organizations become more open to offering linguistically and culturally adapted care to Francophone minority communities (FMC). However, these initiatives are often in addition to activities aimed at fostering openness to cultural diversity – both of which potentially involve different sociocultural realities and organizational adaptations. Still, in both cases, a broad resocialization experience where inclusion in and towards FMCs, in all their diversity, is emphasized. The subtleties, both cultural and systemic, of the double minority status experienced by Francophone immigrants in the workplace need to be better understood and better managed so that they can contribute more actively, and to the full extent of their skills, to the Canadian healthcare system.

Methodology, Analytical Approach and Limitations

This study was conducted using a mixed methodology combining quantitative and qualitative dimensions. On the one hand, we interpreted data from the 2016 Census and used information from other quantitative studies to better describe the target population. In addition, we conducted semi-directed interviews with Francophone immigrants trained in healthcare and living in the selected regions. The data collection also included interviews with stakeholders and a literature review.

Selected Regions

Given the many occupational integration contexts in Canada, especially in healthcare, the following geographic locations were selected: Halifax, Nova Scotia; Ottawa and Toronto, Ontario; and Edmonton, Alberta. These regions represent geographically diverse Francophone communities in the East, Centre and West. They also show differences in the density and number of Francophones or in the characteristics of immigration and socio professional environments, which provide a contrasting perspective. Moreover, in recent years, research in healthcare has focused a great deal on FMCs in Manitoba and New Brunswick (Sauvageau, 2018).

Interviews

Healthcare professionals. The non-probability sampling method was used to select the Francophone immigrant interviewees. In fact, recruitment was difficult since the size of this population is small and there is no obvious method to identify it. That said, for the initial recruitment, we turned to Francophone organizations active in healthcare and with immigrants, as well as CNFS member training institutions. The snowball sampling method was also used, as we asked respondents to identify potential subjects who matched our profile. Interviews with Francophone immigrants trained or being trained in healthcare were conducted through retrospective questioning. The interviewees were asked to talk about events in their past related to their professional and migratory trajectory. The interviews were about an hour long, which gave the interviewees time to subjectively reconstruct the events experienced and the obstacles encountered. When relevant, the interviews wrapped up with a broader projective reflection where the interviewee was asked to think about potential improvements to the socioeconomic fabric in relation to the issues they experienced. The interview guide is provided in Appendix C.

Stakeholders. Interviews were tailored to each stakeholder. The objective was to understand the interviewee’s organizational environment, lived experiences and the measures implemented to facilitate the workplace integration of Francophone immigrants, as well as projective reflections on how to improve the integration trajectories of these professionals.

Descriptive and Analytical Categories

The question of occupational integration is approached here as a series of tests in the sense of pragmatic sociology, i.e. as situations in which someone or something is confronted. While the event is always an individual experience, it also has a social dimension, as its description provides information about institutionalization patterns and cultural environments.

Occupational integration also involves juxtaposing openness to pluralistic values, attention to cohesiveness and integration of health professionals in their workplace. In considering the interviewees’ points of view, it was therefore a matter of highlighting elements affecting respect for cultural differences, the interdependence of professional relationships and inclusion within the profession. As such, the interviews sought to juxtapose information on diverse dimensions such as situations, traditions, values, organizational modes, regulatory frameworks and structures.

The population under study, the Francophone immigrant population in healthcare, is heterogeneous. In this regard, we recognize that there are several markers that significantly influence the trajectory of these individuals. Consequently, from an analytical point of view, we adopted an intersectional approach in that, where relevant, we sought to highlight the different forms of discrimination experienced by the interviewees, particularly with respect to their experiences as immigrants, Francophones, visible minorities and women.

Study Limitations

This study has many limitations, starting with the limited number of interviews in relation to the diverse social/community contexts, and the demographic profiles of the populations and professions studied. The healthcare sector is particularly complex in terms of work environments, occupational regulation and credential recognition processes. As a result, the following discussion does not allow for precise targeting of barriers and the measures to be put in place for specific occupations. This analytical difficulty arises to a lesser extent when isolating other important variables in this study, such as being a visible minority or living in a particular Francophone community.

Report Structure

This report has two main sections that present the research findings. The first is devoted to the quantitative results and the second to the results obtained during the interviews, which are compared to the literature. This second section is divided into subsections dealing with the various aspects of the occupational integration trajectory for Francophone immigrants: credential recognition, training, job search and workplace integration. The report also includes a list of “avenues to explore” drawn from the literature review, interviews and our analysis, including the identification of promising initiatives and models. This list is included in Appendix A and is also organized according to the stages of the occupational integration trajectory stated earlier. The report concludes by summarizing the important potential solutions into recommendations for IRCC.

Research results: Quantitative Information

Portrait of the Francophone Immigrant Labour Force living Outside Quebec

According to 2016 Census data, there were 885,195 Francophones^{Footnote 1} (4.0%) in Canada’s labour force outside Quebec.^{Footnote 2} Of these Francophones, 13.5% (119,295) were immigrants, half the proportion of immigrants in the overall labour force outside Quebec (27.9%). Francophones account for 1.9% of the immigrant population living outside Quebec. More detailed tables on the distribution of Francophone and immigrant populations across Canada and on the main birthplaces of the immigrant labour force are presented in Appendix D.

In each of the provinces selected for this study, the proportion of Francophones in the labour force and in the immigrant population varies significantly, as illustrated in tables 1 and 2. While immigrants accounted for only 5.4% of Francophones in Nova Scotia, they represented 16.3% of Francophones in Ontario and nearly 22.8% of Francophones in Alberta.

Still according to 2016 Census data, immigrants living outside Quebec were underrepresented among people working in healthcare. However, immigrant health professionals were slightly over represented in each of the three provinces studied, relative to the proportion of immigrants in the total labour force. This over representation does not apply to nursing but it does apply to the other health professions, particularly in Ontario and Alberta, and to assisting occupations in support of health services. We also note that the proportion of immigrants among Francophones working in healthcare is higher than the proportion of immigrants in the Francophone labour force in general (except in Nova Scotia).

We also note that a higher proportion of immigrants and Francophone immigrants (except in Nova Scotia) have healthcare training compared to the total labour force. It is important to note that some healthcare jobs, such as healthcare assistants, do not require training.

Outside Quebec in 2016, 9,625 Francophone immigrants had a diploma in healthcare, and 6,520 Francophone immigrants worked in this field.

Education-employment match

In Canada, within the labour force with a diploma in healthcare who were unemployed at the time of the 2016 Census, 33% were immigrants. This proportion was 9% in Nova Scotia, 39% in Ontario and 33% in Alberta – all higher than the proportion of immigrants in the overall labour force. The percentage of unemployed Francophones with a diploma in healthcare was similar to the percentage of Francophones in the labour force. However, the percentage of unemployed Francophone immigrants with a diploma in healthcare was higher than the proportion of Francophone immigrants in the labour force.

In 2011, according to a study by the Ontario Office of the Fairness Commissioner (Augustine, 2015), the difference between the employment match rate (or the match between education and regulated profession) for Canadian born and educated and foreign educated individuals was 27% in Ontario, 32% in Alberta and 23% in Nova Scotia for 17 selected regulated professions. The employment match rate for immigrants educated in a regulated health profession outside Canada was higher than for immigrant professionals in other sectors. A statistical exercise using 2011 data (Jantzen, 2015) indicated that the employment match rate of foreign educated nurses (economic immigration), particularly for nurses arriving after 2000, is one of the highest among the occupations examined, suggesting that access to this occupation has been facilitated.

That said, in our analyses of 2016 Census data, the estimated^{Footnote 3} employment match rate for non-immigrant individuals with a medical degree in Canada was about 71%, compared to 41% for immigrants. In pharmacy and dentistry, the same type of gap exists between non-immigrants and immigrants across Canada. The gap is also present for the three professions (medicine, pharmacy and dentistry) when we specifically compare the situation of Francophones with that of Francophone immigrants outside Quebec.

Interview-related Sociodemographic Information

A total of 35 interviews with Francophone immigrants were conducted as part of this research project: 14 in Alberta, 13 in Ontario and 8 in Nova Scotia. While these interviews are not a representative sample, they did make it possible to identify barriers and potential solutions, while adding an experiential dimension to the research as a whole.

The vast majority of the interviewees obtained a diploma in healthcare abroad and practised in their field outside Canada prior to immigrating^{Footnote 4} (29/35). A small number of respondents began their health education in Canada (n=6). Most of the interviewees identified themselves as a member of a visible minority (n=24) and were between 40 and 64 years of age (n=21). The sample consists of 19 women, 15 men and one person with a non-binary gender identity. The majority of respondents were born in East Africa, mainly in the Democratic Republic of the Congo or Congo Brazzaville, but the sample covers a total of 15 countries. The majority of participants (24/35) were Canadian citizens at the time of the interview and many of these individuals had arrived in Canada as refugees. Approximately half of the interviewees (17) had arrived in Canada less than 10 years ago, with 10 having arrived less than five years ago.

A majority of participants (20/35) confirmed that French is the official language in which they are most comfortable. Moreover, 14 people said they were as comfortable in English as in French, and one person who knew more French when he arrived in Canada said he was now a little more comfortable in English. The question of mother tongue is a complex one: Fifteen people identified French as their mother tongue, 8 respondents identified more than one (often including French) and 12 people indicated that their mother tongue was neither French nor English.

Table 4 distributes the respondents according to their first diploma in healthcare. Some of the foreign trained individuals have since studied in Canada in another profession. Of the sample of respondents, approximately 1/3 have a family medicine or general practice diploma. It should be noted that many of these individuals have additional and more specialized training, for example in research, public or community health, toxicology and pain management. Many held management positions before immigrating to Canada. The sample also includes six foreign trained medical specialists and seven nursing graduates, including one Canadian-trained and one student.

Among the foreign trained individuals we met, more than 40% (12/29) gave up practising in their field and found an alternative path more or less different from their previous profession. For example, some physicians have opted for nursing, health administration or community involvement. A small number of people have gone on to higher education.

Research Results: Interview Information

Foreign Credential Recognition

The Immigration and Refugee Protection Act and Canada’s immigration system support the permanentimmigration of people with strong human capital, including qualifications and work experience (Covell et al. 2017). The Express Entry program, for example, assigns a higher score to candidates with a university degree and extensive work experience. It is therefore not surprising that immigrant professionals, including those in healthcare, seek to join regulated^{Footnote 5} professions once they arrive in Canada.^{Footnote 6}

Individuals who wish to practise a regulated profession in Canada must take specific steps with the relevant regulatory bodies to obtain a licence to practise. The parameters of this approach are defined by the authorities responsible for regulating these professions in each province,^{Footnote 7} in particular according to the laws governing the practise of the professions. The regulatory process therefore varies from profession to profession, between sub professions and between jurisdictions. As a result, each profession deals separately with requests for requalification of foreign trained individuals.

This section of the report is not intended to be a comprehensive review of all credential recognition pathways for regulated health professions in Canada. Rather, we would like to provide an overview of these processes and the related challenges for Francophone immigrants. It bears mentioning that the issues raised in this section are very similar to those identified 10 years ago (Belkhodja et al., 2009).

Foreign Credential Recognition: General Discussion

The issue of foreign credential recognition has garnered more attention from the government and scientific community since the early 2000s. In 2005, for example, the Government of Canada launched an initiative targeting internationally trained workers that included a specific component for health professionals. This program ($18 million per year) supported a range of research projects and programs for Internationally Educated Health Professionals (IEHP) in Canada, including Francophone IEHPs living in minority communities through the CNFS.

The funding granted to the CNFS was used to conduct research on the factors that lead to the integration of internationally educated health professionals, and then to launch three pilot projects on occupational integration services in collaboration with Francophone post-secondary institutions in Manitoba, Ontario and New Brunswick (Socius, 2014) to offer information, support services and bridging options in French in the three target regions.^{Footnote 8} Overall, program participants were satisfied with the experience, and the CNFS established effective partnerships with stakeholders in the field to implement an innovative approach. However, structural obstacles, including resistance from professional orders, changes in immigration policies and the almost total lack of French language bridging programs, have limited the program’s impact in terms of requalification, integration and retention. Despite the positive conclusions of the evaluation report, support for these initiatives has not been renewed.

The pilot project evaluation findings were similar to those of previous studies on this topic (Lafontant et al., 2006; Belkhodja et al., 2009). All of this work had already identified the following aspects: the need for pre- and post-arrival information in French on the credential recognition process and occupational integration; the need for refresher training; the importance of job opportunities or job shadowing before obtaining full certification; the need for networking and mentoring; the importance of addressing cultural integration in the workplace; and the need for support during the certification process. The CNFS evaluation also revealed the lack of willingness or interest on the part of some regulatory bodies to help internationally trained Francophones, the challenges of reaching Francophones through settlement services, and the complex impact of the dynamics of labour shortages and cutbacks combined with changes in immigration policies (Socius, 2014). The results of our study are consistent with these findings.

In recent years, efforts to address the challenges faced by those seeking recognition of their foreign credentials have increased. That said, this issue remains complex and there are still many barriers, particularly for Francophone immigrants in minority communities, since the information and resources available to help them find their way and complete a credential recognition process are rarely fully available in French. For example, a recent report by the Ontario Fairness Commissioner (2018) on the registration practices of regulatory bodies reports that only 8 of the 40 regulatory bodies in Ontario reported offering all aspects of their registration practices in French. The 8 regulatory bodies include 3 of the 26 Ontario health regulatory bodies, all of which have a legal obligation to provide registration services in French. While the francisation efforts of regulatory bodies in Ontario and New Brunswick are limited, they are virtually non-existent in the other provinces and territories outside Quebec. The CNFS (2008) identified this issue more than 10 years ago, as well as the fact that there is no centralized database for Francophone resources in the field.

For IEHPs, the credential recognition process includes the following steps: identify the Canadian profession^{Footnote 9} and the pathway to credential recognition; have their academic qualifications and work experience assessed against Canadian standards (and, if applicable, take a competency test); meet language requirements; complete the necessary training; and pass all mandatory exams. The issue of language may arise at each step of this process, as illustrated in the two examples below.

Nurses. All internationally educated nurses who wish to work in Canada and have their foreign credentials recognized must, as of 2014, complete an application for the National Nursing Assessment Service (NNAS). Once the documentation is submitted, in either English or French, NNAS reviews the file and produces an assessment report, based on the occupational category and province of immigration. This report is then transferred to the regulatory body in the province where the applicant wishes to work. The process then becomes specific to each province. While the NNAS process can be conducted entirely in French, the regulatory bodies in each province do not necessarily offer this option. For example, the process can be completed in French in Ontario, but only in English in Nova Scotia and Alberta. The NNAS requires people wishing to work in Alberta and Nova Scotia to demonstrate English proficiency. This does not apply to applicants who have studied or worked (at least two years in Nova Scotia and at least 1,125 hours in Alberta) in that language. In the case of Ontario, the language criterion is not considered at the NNAS level, but when applying to the College of Nurses of Ontario, which requires applicants to demonstrate their ability in English^{Footnote 10} or French. Once declared eligible by the province, an internationally educated person must pass the licencing exam. The NCLEX-RN exam for practical nurses and the Canadian Practical Nurse Registration Examination (CPNE) for practical nurses are available in French. However, there are still issues with the translation of the NCLEX-RN exam, which is considered inadequate. In addition, preparatory material for these exams is not always available in French.

Physicians. In medicine, applicants with a degree from an educational institution recognized by Canada^{Footnote 11} must create an online file via “physiciansapply” in order to have their credentials assessed. This file can be created in French. Eligible applicants must then pass Part I of the Medical Council of Canada Qualifying Examination, which is available in French and can be taken outside Canada. In order to complete their residency programs, applicants must pass the National Assessment Collaboration (NAC) examination, which is not offered in French outside Quebec.^{Footnote 12} Part II of the Medical Council of Canada Qualifying Examination is a two day scenario based examination that is available in French, but only in Quebec. In addition to these Canada wide steps, applicants are required to complete a residency program, meet requirements specific to the province’s or territory’s medical school and take additional general practice or specialization examinations.

Interview based discussion

Respondents whose credentials are being or have been recognized

Of the 29 IEHPs surveyed, 27 were associated with regulated professions, with the remainder being osteopaths. A small number of these respondents were able to partially (4/27) or fully (6/27) complete a credential recognition process in order to allow them to practise in their field. Four other individuals were in the process of completing their recognition process or preparing for the licencing examinations. Two more recent arrivals to Canada were preparing to begin these processes.

Of the six licenced respondents, three are physicians, two are nurses and one is a pharmacist. Some of these individuals benefited from pre-established agreements concerning their country of origin or transit. For example, two individuals were able to benefit from a Saskatchewan program that provided South African physicians with a temporary licence for one year of restricted hospital practice. This arrangement allowed them to work and prepare for the exams to obtain a full licence to practise medicine in Canada. These two individuals subsequently moved to Ontario and Alberta.

Successful interviewees were given the opportunity to work in their own field or a related one before taking their final exams and obtaining their licence to practise, thus allowing them to gain experience in the Canadian healthcare environment. This was a benefit that all respondents found valuable. According to the literature, Canadian workplace experience, however brief, is indeed associated with better prospects for re qualification and employment (Covell et al. 2015). These individuals share other characteristics that facilitated their process: a mastery of English acquired prior to immigration, sufficient financial resources, a personal support network, good mastery of the process, and perseverance. The six interviewees who are now licensed studied in countries with stable socio political situations and had no trouble providing the necessary documentation for the credential recognition process:

Individuals who have experienced this type of trajectory have a positive view of their current work situation, which they consider to be comparable to that of their Canadian educated colleagues. Even as they understand the importance of the process to properly assess a foreign educated applicant’s competencies, these individuals also recognize the challenges associated with this type of approach:

In our sample, the profiles of the people who are in the process of having their credentials recognized are diverse. At one end of the spectrum, a recent arrival is taking full-time English-language classes to begin the credential recognition process, while at the other, a physician is in the process of completing his third and final licencing exam. A social worker was working to complete her refresher courses. In addition, two respondents were in special situations that allowed them to practise as physicians without having completed a credential recognition process because they were hired by a university.

Respondents who have not completed a credential recognition process

Twelve respondents abandoned the idea of completing a credential recognition process to practise their profession. The various scenarios explored below illustrate the main obstacles encountered. While most of these issues do not only affect Francophone immigrants in minority communities, the strict English language requirements clearly posed additional challenges for many of the interviewees.

The interviews reveal the importance of having clear information available as early as possible in the migration process, which has long been noted in the literature. For Francophone immigrants who wish to work in healthcare, this includes accurate information on bilingualism in Canada, and on the issue of regulated professions. Pre-arrival services provide this information to a minority of Francophone immigrants coming to Canada.^{Footnote 13} For example, a few study respondents admitted that they were surprised by the prevalence of English in Canada, which they had believed to be a bilingual country: “The first thing I was told is that we have to assess your English. But I said to myself isn’t Canada a bilingual country? I was told: “Of course, but you’re in Nova Scotia, and Nova Scotia is not a bilingual province”. Ideally, information on credential recognition and the Canadian labour market should be available to assist in decision making before an applicant chooses to come to Canada. Refugees who had to leave their country in a hurry or whose country is in conflict face considerable challenges in providing the documentation and evidence necessary to initiate an equivalency process.

For most respondents, lack of fluency in English was an obstacle in various ways. Some were stymied from the start because aspects of the process (service offer, information sessions, preparatory courses, etc.) and navigating the system require English proficiency. Other participants were able to proceed with the assessment of their credentials and managed to pass the theory exams, but encountered a language issue during the oral exams. These exams are challenging not only because of the language dimension, but also because some immigrants may not be familiar with the format (Blythe et al., 2009) and elements specific to the Canadian context:

Several respondents noted that these practice based exams require hands on preparation and preferably prior exposure to the healthcare environment. Respondents also addressed the issue of limited training resources, particularly in French. Respondents found it difficult to find these resources.

The financial aspect is also a major issue. Credential recognition is an expensive process that includes direct and indirect costs at several levels, not to mention the loss of income and financial pressures for individuals who cannot practise their profession and must spend time completing the process: “Preparing for exams is expensive and it requires full time study, but you have to live.” For individuals who have to provide for their family, this can be an insurmountable obstacle. Many of the people consulted for this research project also spent a lot of money before giving up because they did not have the financial means or encountered consecutive obstacles. Some individuals mentioned they were afraid of going into debt or had trouble accessing scholarships.

The length of the process is also of concern. Not only is recent practice a requirement of many regulatory bodies, applicants cannot practise their profession while waiting for approval, which can have a very negative impact on their confidence. The time required to complete the process is also an issue for older immigrants who come to Canada with dependent children. Although the immigration system values foreign experience, evidence shows that for IEHPs, extensive work experience abroad is associated with a lower likelihood of practising in Canada (Owusu and Sweetman, 2015).

Finally, several interviewees spoke of systemic obstacles that are more difficult to define and are tantamount to discrimination. For example, some interviewees received decisions from regulatory bodies that were unclear, negative and could not be appealed. Many failed to understand the reasons for their refusal while others saw these organizations as protecting their “territory.” Many people are surprised that the Government of Canada, which places importance on the qualifications of professionals in its immigration process, has so little control over the issue of regulated jobs compared to the bodies that regulate them. “The College of Physicians has more power than the government... I took steps and in the end I saw that I was wasting my time. Finally, someone... told us ‘the truth is that we have to protect these spots for our children’.” Some authors do indeed associate the handling of cases of internationally educated professionals with a supply control issue (Paul et al. 2017). Moreover, the sometimes limited resources of regulatory bodies for handling cases are also a factor in these issues (Bajwa and El-Assal, 2018).

Several professions have implemented changes to simplify or harmonize credential recognition processes, but these developments are recent. One can imagine that the experience of many of our respondents would have been different had they immigrated more recently. On the other hand, respondents testified that changes in processes (emergence or abolition of programs, changes in criteria and requirements, etc.) can have a negative impact on the fate of applicants.

Most of the interviewees took lengthy steps before they had to give up the credential recognition process. Many simply did not have clear information on the overall process to be followed, while others expected the process to be simpler, or at least consistent with Canada’s promises. Most of these individuals were very disappointed and frustrated with the way their professional capital was treated in Canada. “We came here to work. We don’t understand. We ask ourselves: what was missing on our CV? Why are they letting us in if we can’t find a job here? ... If you want to recruit street cleaners, just say so.” Some of these individuals are now using their expertise to help prevent health problems in their communities: “We’re here, we take care of newcomers and provide support to make sure they stay healthy.” Besides knowing the issues (for example, reluctance to use the healthcare system, or to seek help for mental health problems), these individuals have a relationship of trust with members of their community and can communicate in a culturally appropriate manner.

Education in Canada and Internships

Availability of health education programs in French

The CNFS has 16 post-secondary member institutions that offer more than 100 health education programs in French in eight provinces, at the college and university levels. These institutions also offer continuing education and distance learning options. The Action Plan for Official Languages plans to continue increasing this programming and the number of associated post-secondary institutions. In addition, the CNFS collaborates with health institutions to offer internships to its students. While the availability of health education in French is more extensive and diversified in Ontario, it is limited in Nova Scotia and Alberta, where Université Sainte-Anne and the University of Alberta are the only institutions to offer some French-language education programs.

It bears mentioning that some French-language education programs offered outside Quebec still require a candidate to demonstrate English-language proficiency. This is the case, for example, with the programs offered at Campus Saint-Jean in Alberta. Beyond the question of criteria, academic requirements in English can be a challenge for Francophones. For example, a Francophone immigrant in our study who enrolled in the bilingual program at Campus Saint Jean and who met the language admission criteria was unable to successfully complete courses requiring extensive writing in English. This participant had to leave the bilingual program and completed a nursing program at an English college where less written work was required. In addition, some institutions can encounter problems in maintaining the continuous availability of French-language programming, as illustrated below:

Several respondents who turned to graduate studies reported having trouble finding a research supervisor, let alone a French-speaking one.

Respondents’ testimonials illustrate a diversity of perspectives and preferences with respect to educational choices in Canada. For example, some individuals stated that they preferred or would have preferred to receive their technical training in French, while developing their English skills at the same time:

Others believe that Francophones benefit from pursuing their studies in English to kill two birds with one stone: “For those who have a better command of French, I would advise them to go directly to the (nursing) program in English, to improve their language skills. This implies flexibility in the language criteria for admission, as well as support for those whose first language is not English. Some respondents do not see the advantage of an education in French, given that they cannot work in French: “We’re in a predominantly English-speaking environment, it’s already restrictive. Unfortunately, continuing to hone our professional skills in French does not benefit us. It’s too bad, but as a Francophone, it’s in your best interest to be proficient in English.”

Few programs for internationally educated individuals

Programs that enable IEHPs to return to their professions have a significant impact on their occupational integration. The benefits of bridging programs include reduced time to certification and employment, networking opportunities, a sense of community, and reduced feelings of isolation (Sattler et al. 2015). Many professionals seeking to practise their profession in Canada are looking for programs that would allow them to quickly upgrade their skills and build their professional confidence:

The cultural aspect of training is also fundamental for applicants who have been educated and worked in different environments before coming to Canada. It is essential for these individuals to understand and be able to adapt to the functioning of the healthcare environment, for example, when dealing with issues of gender, hierarchies and power relationships (Bourgeault 2013). Bridging programs also save professionals from having to start their training all over again, which can be challenging not only in terms of time but also financially and psychologically:

That said, there are many challenges associated with bridging programs, which are limited in number and restricted to major urban centres (Covell et al. 2017). Similarly, there is no standardized approach for these programs, which leads to a wide variation in content and formats between the programs themselves (Sattler et al. 2015). Supply also varies over time: many of these programs do not have consistent funding and are at the mercy of changes in enrollment, labour market demand, the mandates of regulatory bodies, and immigration policies (Sattler et al. 2015). Finally, there is a big language issue since few bridging programs are available in French. Of the three regions studied, only Ontario offered such programs.^{Footnote 14}

For foreign trained professionals, certification exams mean getting back into theory and reviewing basics they haven’t studied for a long time: “I think these tests are justified. But in terms of difficulty, while the concepts are basics that we have to review, it’s still a bit difficult.” As noted earlier, the courses and preparatory materials for the certification exams are offered primarily in English. Moreover, exam preparation cannot be limited to theory and many people need professional experience, internships or other ways to become familiar with the environment:

Few French language programs offer interesting alternatives for people who are not able to requalify in their profession (or not immediately), or who are interested in finding a job in healthcare. For example, several participants from Ontario who enrolled in Collège Boréal’s Health Navigator Bridging Program found that it helped them become familiar with the healthcare sector and increased their chances of finding a job in the field.

The importance of learning English for Francophones who want to work in healthcare

Given the criteria of the professional orders and the need to serve an English-speaking clientele, learning English is essential for Francophone immigrants in minority communities who want to work in healthcare. Some of the interviewees, particularly refugees, found themselves in their host province with very limited knowledge of English. Others, who felt they had a good level of English (some even published in that language) were unable to meet the strict requirements of the regulatory bodies. For these individuals, language was automatically an integration issue. Conversely, those who already had a good command of English were at an advantage at different stages of their trajectory.

Rapid language learning depends on the availability of resources, their cost, the quality of service offered and flexibility. In addition, while some people can afford to learn English intensively on a full time basis for a period of time, many have to combine this learning with their jobs and other obligations.

It may be difficult for a Francophone immigrant to identify the English-language training available specifically for health professionals. Existing programs also offer different levels of learning and do not necessarily allow immigrants to reach the levels required for certain requalification or employment processes. Some specialized and advanced courses are offered by private organizations and can be expensive. Collège Boréal offers free language training focused on communication and workplace skills, particularly for health professionals. This type of program has the advantage of offering both a certain level of language learning and familiarity with the healthcare environment. In class or remote learning is fundamental to learning English, but the interviews also reveal that workplace immersion accelerates this learning:

It is also important to keep in mind the costs associated with language learning, as well as the costs associated with registering for language tests that may be required for credential recognition, registration in training programs or by employers. At least two respondents mentioned that according to the language criteria, learners must achieve the required level in all test categories (writing, comprehension, oral communication), failing which the entire test has to be retaken, which is costly. A refugee who had taken a two week preparatory course prior to taking a workplace English test failed one of the three components, retook it three months later and failed one of the components again, narrowly failing. When her year of government funding expired, she was unable to retake the test and was forced to abandon the process.

Usefulness and issues related to internships and residencies

In addition to being a requirement of many health education programs, internships provide immigrants the opportunity to experience the workplace in which they wish to work, become familiar with workplace codes and practices, and understand the dynamics unique to Canada. For example, Covell et al. (2017) showed that practical – even brief – workplace experience is an indicator of success for internationally educated nurses.

All of the study respondents who had access to internships or even to informal shadowing, reported significant benefits. Generally, these were positive experiences. A few respondents noted the contrast between welcoming internship environments where interns have the opportunity to work under supervision, and environments where interns are less well integrated and less able to gain practical experience. Given that Ontario has a limited number of health services offered in French and that this type of service is almost non-existent in Alberta and Nova Scotia, few participants completed an internship in a Francophone or even bilingual environment.

Several individuals said they had trouble finding an internship when this task was assigned to them. Programs that organize and coordinate internships prevent the obstacles that immigrant students may encounter if they have to arrange their internship themselves. However, Sattler et al. (2015) indicate that it is difficult for bridging programs to obtain clinical internships because of “competition” with regular programs and resistance from some employers. In addition, supervisory staff must be equipped to support and assess an internationally educated applicant. Finally, several respondents raised the fact that internships are unpaid.

The requirement to complete a residency program in Canada poses a significant challenge for internationally educated physicians. Many of our respondents passed their medical exams but were unable to find a residency position despite considerable effort, a fact that is also documented in the literature (Bourgeault and Neiterman, 2013; Covell et al. 2016). “I took and passed my evaluating examination in 2000 in Quebec. But I had trouble finding a residency position. I spent more than two years trying without any luck.” A participant about to arrive at this stage acknowledged that there is no guarantee of finding a position. The study by the Ontario Office of the Fairness Commissioner (Augustine, 2015) identified this issue in 2011, when only 37% of internationally educated physicians were working as physicians in Canada. On the other hand, among internationally educated physicians who had completed their residency in Canada, the education and employment match rate was very similar (82%) to that of Canadian born and educated physicians (85%), indicating that obtaining a residency position is an important key to an immigrant physician’s career in Canada. For 2018, Canadian Resident Matching Service (CaRMS) statistics show that 77% of internationally educated physicians did not obtain residency positions for the R-1 main residency match.

Job Search and Hiring

As the previous sections suggest, the main obstacles for immigrant health professionals are upstream of the job search. In fact, the interviews show that the labour market is generally favourable to the hiring of health professionals. However, it was noted that experience related to relationship building, use of employment services and language skills present challenges and opportunities that influence pathways to employment.

A quest for appreciation

The issue of human dignity was a common thread underlying the hiring experiences recounted in several interviews. Indeed, many IEHPs who fail to work in the profession for which they were trained find themselves in low paying, undervalued, and unrewarding jobs far removed from their area of expertise. As a result, they feel unappreciated and unrecognized. Among the interviewees, IEHPs feel that their employment situation is worse compared to that of other Canadians with similar experience and education. Some of these individuals have found ways, besides their employment, to feel useful, for example, by supporting other newcomers or volunteering in connection with their foreign training.

A favourable labour market but with unequal opportunities

The labour market is generally favourable to employees, especially in the health sector, given the ageing population. As a result, for international students who have chosen a health profession, the prospects for hiring and retention in Canada are more favourable than in other fields (Covell et al. 2015). For example, nurses studying for their bachelor’s degree can, in principle, obtain employment as a nurse after two years of study, with the option of practising as a licenced practical nurse (college level) before practising as a registered nurse (bachelor’s degree). If they do not seem to have any difficulty finding a first job in their field during their studies, their transition to permanent or full time status is also quite easy: “After I finished, it was easy because I was already employed.”

On the other hand, internationally educated nurses who have not obtained their equivalency, or who have not sought it, are often not even allowed to work as patient attendants. In some cases, when they are allowed to do so, it seems that they earn less money than their counterparts who obtained their Patient Attendant certificate in Canada. It would seem that the rules could be relaxed to allow access to this occupation. Several interviewees found jobs as caregivers or support workers, either in private homes or retirement homes. These jobs pay less and working conditions (hours, stability, physical tasks) can be difficult.

A few respondents arrived in Canada with a job offer. One was an osteopath, an unregulated health profession in Canada, which is why an employer was able to offer the individual a job, who arrived as a temporary resident on a closed work permit. At the time of the interview, this individual was in the process of obtaining citizenship, having begun the process several years earlier. This delay had a negative impact on the individual’s career, as the closed work permit does not allow a person to change jobs. Generally speaking, closed work permits make professionals vulnerable because they must leave the country if they are fired. The other two people who came to Canada with a job offer are specialized physicians with an international reputation in their field.

For some people, the job search was more tedious. In some cases, over qualification was an issue: “I tried to get a job in pharmacies restocking shelves, but I was told I was overqualified.” In other cases, factors unrelated to education such as skin colour, accent or job search strategies, may have delayed hiring. Although being a visible minority is generally not seen as a decisive factor by respondents, their higher unemployment rates are a reminder that they encounter at least indirect hiring discrimination (Statistics Canada, 2019b).

Job search tools: Internet, networking, employment services and volunteering

In their effort to find a job, the interviewees mobilized the same resources typically used by the general population. Most often, especially if they have post-secondary education, people look for a job on the Internet, where they learn how to write their CVs, apply for jobs and ultimately get job offers; however, the Internet is rarely the only tool they use. Networks, whether personal, related to one’s education, volunteering or previous work seem to be very important: “I had a friend in Thailand. She put me in touch with a family here. And it was her family who found me a job.”

Thus, “word of mouth” is an essential tool, particularly for learning about the habits, norms and values associated with labour markets and job searches. People who are less supported by such networks take longer to fully grasp different dimensions of the job search, such as writing a cover letter or understanding cultural codes in job interviews. For people who are highly specialized in healthcare, informal networking becomes essential, especially since employment services are not able to offer sufficiently specific support to these individuals. Understandably, “opportunities” are missed in some cases, especially for recent arrivals whose personal networks in Canada are more limited.

While most of the interviewees did not use employment services, a majority of those who did found them useful, although some shortcomings were mentioned. On a few occasions, we noted that they were not aware of these services, particularly those in French: “It seems that the community health centre has an immigrant welcome centre, but I didn’t even know about it. I didn’t have any contacts. I learned what I know on the Internet.” Thus, the low visibility of these services is problematic for health professionals, as it is for other areas of employment (Traisnel et al., 2019). It was also pointed out that some educational environments used by future professionals, such as Campus Saint-Jean (University of Alberta), do not offer any real support or systematic job related resources. It would be a good idea to extend access to these services (Sociopol, 2019), for example, to refugees or even protected persons, who very often find themselves in very precarious economic situations (Statistics Canada, 2019a). In other cases, the issue is more that these services are not sufficiently specialized, even for more generalist professionals such as nurses, to properly guide health professionals to optimal educational and occupational pathways. This lack of specialization is probably accentuated in Francophone minority communities (FMC) because employment services for immigrants are often few and recent.

IEHPs appear to be the most penalized in this regard. For example, half of the respondents worked or were working at the time of the interview as patient attendants or support workers. Some of them had been advised by employment services to take this path. This advice seems legitimate since, for a majority of people, it was important to find work quickly. The six months of training – not mandatory in some cases – and the availability of jobs make this occupation interesting for people with a health background who want to learn about the Canadian healthcare environment.

However, given the difficult working conditions in this occupation, particularly because of the very low wages and variable working hours, other options could be considered by those responsible for employment services. In fact, while some people see this type of employment as a temporary recourse, for others there are few opportunities for professional development. Moreover, as mentioned earlier, people who have already held important responsibilities in healthcare find it upsetting to be in a position where there are few opportunities for taking initiative.

It was mentioned in the interviews that specializations in healthcare can be transferred to environments where the requirements in terms of credential recognition are less rigid, such as pharmaceutical research, biotechnology or social services. The most successful employment service experiences are those that are accompanied by personalized programs such as mentoring, case management or job navigation. Some form of guidance is considered necessary given the complexity of the trajectories.

At least four respondents reported volunteering in the healthcare field after coming to Canada. These experiences were all considered very positive, as they helped them learn the Canadian way of doing things. This learning may have helped them succeed academically and in their job search. It appears that these individuals decided on their own to volunteer: “I started volunteering at a retirement home. Right now, I am taking full time classes, but I spend my weekends doing this. If I want to look for a job, I’ll apply there.” Internships and volunteer experiences are two of the natural breeding grounds for jobs. In fact, according to de Moissac et al., “many participants admit that doing an internship had a big impact on their decision to work there after obtaining their certification or diploma.” (2014, p. 43)

The limited importance of French and the need for English

The issue of language skills plays a role in the job offer, the skills valued by the employer and the individual’s performance during the interview.

First, for the vast majority of healthcare jobs in Ontario, and for all jobs in Alberta and Nova Scotia, English proficiency is essential. In addition to the many English-language courses taken by the interviewees, the first few odd jobs, for example in fast food restaurants, were considered useful to improve their language skills: “The big challenge in my first job was my language skills. But I wanted to practise and to learn. And at work, I could talk and get help to improve my language skills.”

When it came time to get a job in healthcare, French was sometimes valued, but little used in the workplace. For example, for a person working with clients in healthcare, a very good command of English was essential, while knowledge of French was considered positive, but not essential, by employers: “I think the fact that I speak French was considered a plus.” Those interviewees who had to find their own clients, either through independent clinics or as self-employed workers, did not appear to have had any difficulty in building their clientele; however, they were all fluent in English before coming to Canada.

The fact remains that many of the interviewees would have preferred to work in French or in a bilingual environment because they were more comfortable speaking French or felt more attached to the Francophone community. It was more important for individuals who received their training in French to work in their own language. This was the case for our interviewees and for the study by de Moissac et al., where 31 immigrant health professionals were interviewed (2014).

Onboarding and Retention

To be able to provide for one’s material needs, to grow, to feel useful, to learn: there are many reasons to love one’s work and to feel included. In this case, from an organizational perspective, workplace integration includes the measures implemented to facilitate onboarding and retention. According to the literature, obstacles to professional fulfilment continue to characterize immigrants’ workplace integration trajectory. The interviews also illustrate that issues of indirect or systemic discrimination arise: “Finding a job is easy.... It’s in the workplace that things get complicated.” That said, the experiences of the interviewees vary greatly in terms of integration assessment and success. Although most people see their work environments in a positive light, some testimonials reveal that these environments are not necessarily conducive to full inclusion.

Professional deskilling

Deskilling is the most striking aspect of many people’s work experience after they come to Canada. This phenomenon is defined as “accepting a job that has lower educational and training requirements than the applicant’s actual qualifications” (Chicha and Grill, 2018, p. 59). While some people find job satisfaction in their new responsibilities, others remain bitter, even very bitter, about the situation. It bears mentioning here the trajectory of IEHP interviewees who gave up on the idea of continuing in their chosen profession.

• A pharmacist who became a security guard
• A physician who became a community development officer
• A physician who became a nurse
• A physician who became a telemedicine assistant
• A nurse who became a patient attendant

A study using data from the 2011 Household Survey (Augustine, 2015) found that in Ontario, foreign trained registered nurses not working in their profession work primarily as practical nurses’ assistants or housekeepers, while Canadian educated nurses in other professions work primarily in healthcare management or as head nurses. These data serve as a reminder that a variety of jobs can be considered based on specific vocational training, but that IEHPs are instead directed to jobs for which they are overqualified. Some people are very disappointed as the job they have does not correspond at all to their expectations: “It’s a long way from where I wanted to be.” It appears that female IEHPs face more obstacles, particularly because of their bigger share of family commitments and responsibilities: “In the interest of our family, one of us had to stay home and I let my husband advance professionally so that we could keep our family together.”

In some cases, the magnitude of the challenges encountered has provided an opportunity to get involved to help develop organizations and resources for Francophone immigrants to facilitate, for example, information sharing concerning the medical profession or mental health support. That said, while these initiatives can be considered very positive for FMCs the fact remains that people working in this field see, above all, the slow pace of change in the processes associated with credential recognition and workplace integration and the persistence of mental health issues for immigrants.

In fact, while immigrants report better mental health than their Canadian born counterparts when they come to Canada, their mental health deteriorates thereafter (Poullos 2019). The issue of financial resources appears to be the biggest stress factor. In socio demographic terms, being a woman or a member of a visible minority are significant health indicators.

Other IEHPs manage to find value in their work and note a variety of positive aspects, such as “excellent relationships with co-workers and supervisors.” Those who were in the credential recognition process at the time of the interview were more positive when working in low paying jobs. For example, a telemedicine assistant, who was a physician in her home country, appreciated the responsibilities and learning associated with her position: “I perform a physical examination of the patient, obtain a history and profile and then the doctor checks what I’ve done and writes the prescription. For me it’s good, it’s much better than shadowing, which is not even offered.”

Routine discrimination

While the experience of professional deskilling refers to systemic barriers, some forms of indirect discrimination are also described, whether it is a question of relationships with co-workers or with clients. According to the data, belonging to a visible minority is associated with lower incomes (Evra and Kazemipur, 2019) which can be tied to hiring discrimination, but also to more limited access to promotions or other career development opportunities.

On a daily basis, the question of professional status is important in the relationship with colleagues or patients. Individuals with more highly valued jobs and greater responsibilities, such as physicians or pharmacists, describe certain privileges associated with their professional status: “In Quebec, I started as a technician. But being a pharmacist gives you status.” Still, one physician reports that it is common for patients to be reluctant to deal with a black professional. The same respondent felt that this is most noticeable when a professional is just starting out, but that the reaction of patients becomes less pronounced over the years, either because of some form of acclimation or because of strategies developed by the professional:

On the other hand, the accounts of racialized individuals in low level jobs, such as patient attendants, suggest that they experience more discrimination, although this was often downplayed in the interviews. The situations of racism or discrimination are so frequent as to be routine: “They say there’s no racial segregation, that’s on paper. But practically speaking, this is the life that we live, that we live every day.” Another person adds, speaking of employees from the black community: “We’re the last ones hired and the first ones fired.”

Beyond the more difficult relationships with some patients or colleagues, the interviews reveal the ghettoization of immigrants in some jobs. For example, it was noted that there are more black people among the patient attendants. It was also suggested that in one Edmonton hospital, “The patient attendant and nursing staff is 100% Filipino and the administration is white.” According to the respondents, these employment situations tend to create a negative atmosphere, reinforce prejudices, and reduce the opportunities for immigrants to flourish in their jobs. A few respondents describe a double standard in terms of discipline, as they feel more supervised and vulnerable to reprimands, even for minor mistakes. Many mentioned that immigrants face barriers to career advancement. Some of the stakeholders and immigrants interviewed for this study emphasize the importance of informing immigrants about labour law.

No formal coaching process

Few specific integration measures, such as mentoring and on the job training, seem to have been put in place for immigrants in the work environments of the interviewees. For example, one respondent explained that he felt left to his own devices when he started a job where his superiors assumed that because of his previous experience he would have no trouble using the computer tools. “The Electronic Medical Record, ... you really need to sit down with someone who can explain how it works. It shouldn’t be taken for granted that the person knows.” This perception reflects the reality of the labour market (Woodbeck, MacMillan and Kelso, 2015). Where coaching was provided, it was usually informal and provided by the interviewees’ supervisors. The participants would have appreciated coaching adapted to immigrants and measures aimed at career development.

At all stages of workplace integration, the presence of friends and diverse relationship networks are cited as having positive impacts (Ramji, 2016; Evra and Kazemipur, 2019). Extensive social capital, such as having friends in Canada, has an upward effect on immigrants’ employment income, for example. It will be recalled that professional isolation seems to be a reality for many professionals in bilingual or Francophone positions in minority communities (Savard et al., 2013).

Several of the interviewees noted the presence of generally positive relationships in their jobs. Some stated the important role their colleagues played in their integration process as they took the time to explain the procedures to follow, what to do as well as what to say. The presence of staff and patients who support and value immigrants affects their sense of acceptance: “There were different attitudes. But after six, seven months, people saw how I work and they saw that I’m honest and that I’m kind. There’s one person whose attitude towards me changed 180 degrees.” The attitude of managers is also important: “I faced a lot of obstacles... with some colleagues who were prejudiced because I was from Africa. It’s no longer a problem. I was fortunate to have a department head who was open and objective.”

Lastly, it should be noted that both personal and professional relationships are generally easier and more common between people of similar ethnic backgrounds (Evra and Kazemipur, 2019). In this regard, the interviews show that it is difficult for some people to feel welcomed and supported in the workplace, but also in the Francophone community in general.

English as a recurring barrier and French as a resource

Although less pronounced than at the other stages of workplace integration, issues related to English language proficiency can and do arise in the workplace, but they are more technical: “The most difficult thing is to express my certainty on my findings to my clinical colleagues. I had to learn to express words of confidence: I’m sure of....” This difficulty is a reminder that English language skills are necessary, even in organizations where French language services are more widespread, particularly in Ontario: “Professionals unanimously agree that good knowledge of English is essential, since we have to be able to communicate the needs of residents to professionals in other healthcare institutions, most of whom are Anglophone" (De Moissac et al., 2014, p. 44).

However, apart from language, it seems that beyond English-language skills, other aspects of identity, such as being Francophone or belonging to a visible minority, or speaking with an accent, pose a challenge in terms of workplace relationships: “As a Francophone in Alberta, it’s difficult. Some people are really allergic to French. They put a lot of emphasis on accents. This is true for both patients and colleagues.”

Still, many people cite their pleasure in offering services in French, or the pleasure of patients receiving services from a French-speaking professional: “Not many Francophones will come to the walk in clinic as they tend to go to the community health centre. But I speak French, and you should see the sigh of relief on their face!” However, beyond the personal pleasure of occasionally offering services in French, the interviewees, especially in Alberta and Nova Scotia, did not receive any particular appreciation for practising their profession in French. In addition, the Francophone community was not very visible and often not well known by the immigrant interviewees.

Conclusion

This research project identifies various barriers to the occupational integration in healthcare by French-speaking immigrants living in Francophone minority communities, ranging from credential recognition (often difficult) to the lack of openness to cultural diversity in the workplace.

This project – like many others dealing with the occupational integration of immigrants to Canada – emphasizes the importance of providing clear, detailed and honest information to immigrants before they arrive in Canada. This study reminds us of the importance that this information be available in French and that it be sufficiently detailed to allow individuals to plan their healthcare careers in Canada.

The language barrier arises at every stage of the trajectory of a Francophone immigrant seeking to work in health care in FMCs. Reducing these barriers would contribute both to enhancing the vitality of FMCs and mobilizing the extensive skills of immigrant health professionals.

It is difficult for a Francophone immigrant to fully grasp the rules of the sector and the occupational options available. Offering broad French-language navigation support to Francophone immigrants wishing to practise in healthcare would be an important starting point. In addition, financial barriers were also identified in the case of Francophone immigrants who wish to requalify, pursue their studies, or who are overqualified. Finally, given the situations of discrimination brought to light in the interviews, workplace integration and the commitment of employers are crucial issues.

The following recommendations are aimed directly at IRCC and suggest ways to more closely support the workplace integration trajectories of Francophone immigrants living in minority communities. In addition, we recommend the development of cooperative efforts with Health Canada and Employment and Social Development Canada.

Recommendations

1. 1. Strengthen support for pre-departure service programs in French by making them more visible and incorporating French-language services for occupational integration in the healthcare field.

   For IEHPs, there is still a gap between their expectations of practising their profession in Canada and the reality of the credential recognition process. Although information, cooperation agreements and support are more extensive for certain professions, there are still gaps, especially in terms of serving Francophones.

   A component of pre-departure services in French should be devoted to guiding IEHPs or future Francophone health professionals. This requires more cooperation with regulatory bodies, employers in the field and certain departments, particularly Employment and Social Development Canada. IRCC can implement this recommendation in three important ways:

   • Deliver more pre-departure services in French with a view to providing better information to future immigrants about the language used in the healthcare workplace and the credential recognition processes for IEHPs;
   • Work with Employment and Social Development Canada to identify alternative career options in healthcare and ensure that these options, and the associated steps, are promoted by pre-departure services in French;
   • Assess the possibility of working with regulatory bodies to expand the presentation of information and the provision of French language services and resources abroad.

2. 2. Explore the possibility of implementing a French-language navigation service for jobs in healthcare and developing employment service capacities.

   The data gathered in the field underscore the importance of having specialized employment services for the healthcare sector. They also highlight the need to approach workplace integration on a case management basis, where individuals are supported throughout their journey, both in terms of credential recognition and job search and integration. The research also shows the need for Francophone immigrants to be proficient in English at various stages of the credential recognition and job search process.

   A Francophone service with a pan-Canadian perspective could be set up – through online resources and telephone or videoconference support – so as to help people navigate the various stages of credential recognition; develop, identify and refer people to French language resources; help develop the capacity of local employment services, etc.

3. 3. Assess the possibility of offering financial support for IEHPs who are completing the credential recognition process or wish to find a new career in a related field.

   Lack of financial resources – combined with delays, particularly in learning English – is one of the main reasons IEHPs abandon their credential recognition efforts. While to date, most scholarship programs have been offered by Employment and Social Development Canada or Canadian Heritage, IRCC could assess the possibility of offering financial support to IEHPs who are completing their credential recognition process or who wish to move to a related field. IRCC could thus initiate a dialogue with the above mentioned departments to assess the most effective ways of financially supporting Francophone immigrants trained in healthcare so that Canada can benefit more from their expertise.

4. 4. Assess the possibility of supporting development of bridge training and coaching, in French, for IEHPS.

   Bridge training programs and coaching measures help to ensure that the expertise of IEHPs is recognized and promoted. However, little is known about the impact of such support in Francophone minority communities. For example, the impacts of initiatives such as Collège Boréal’s Health System Navigator Bridging Program could be measured to assess its scope and how it could be adapted to other situations. Coaching measures and tools, particularly in the context of clinical training, could be developed for immigrants and foreign students. More broadly, research emphasizes the importance of programs (mentoring, sponsorship, networking, shadowing, internships, etc.) that allow immigrant professionals to become familiar with and create contacts in the healthcare environment.

   Although the field of vocational training does not fall under IRCC’s jurisdiction, the department could consider mobilizing its expertise to develop training initiatives aimed at immigrants.

5. 5. Contribute to discussions about English-language barriers that reduce French-speaking immigrants’ access to the healthcare professions.

   Given the requirements for English proficiency, it appears that the opportunities for French-speaking IEHPs and immigrants to work in healthcare are more limited than for their English speaking counterparts. Although improvements have been made over the years, challenges persist for Francophones. In general, the aim would be to reduce the possibility of exclusion from the profession for reasons related to the mastery of English by Francophones. Specifically, our suggestions are as follows:

   • Evaluate the possibility of developing pathways where French training in healthcare can be aligned with English-language training, both for Francophone immigrants and foreign students;
   • Engage in a dialogue with regulatory bodies to provide temporary licences based on language to allow Francophones with limited English-language proficiency to begin practising their profession sooner. Quebec’s advances in this area, particularly with the Ordre des infirmières et infirmiers du Québec,^{Footnote 15} can serve as a model or forge new partnerships;
   • Re-evaluate the relevance of current language proficiency benchmarks specifying the levels required for health professions with a view to making the language requirements for entry to professional bodies fairer and more transparent;
   • Consider the possibility of splitting the competencies assessed in language tests (listening, reading, speaking and writing) so that persons who fail a single competency do not have to be retested on all the competencies.

6. 6. Contribute to discussions intended to improve supports for building employer awareness in the area of diversity management.

   The risks of ethnic and language stigmatization are still very much present in the workplace. Efforts should be made to determine how initiatives aimed at managing diversity, developing cultural competency and offering services in French can be more closely aligned from a theoretical and practical standpoint, both in the workplace and in training environments. The Department of Canadian Heritage could be invited to take part in the discussions, which aim to contribute to the workplace integration of immigrants, their retention, and the vitality of FMCs.

   The French-language Health Networks, the Francophone Immigration Networks and the partners of the Réseau de développement économique et d’employabilité already have mandates to raise awareness among and provide support to employers. This support could be expanded and the collaboration between these groups strengthened. In addition, the support could include spending more time on deploying best practice based transformative approaches aimed at, for example, recruiting and supporting employers, supporting new employees and building employee teams. Ultimately, this reflection and the resulting initiatives would seek to help create sustainable inclusive workplaces for Francophone immigrants.

Appendix A: Avenues to Explore

This section presents possible solutions based on the literature and interviews and highlights initiatives that can serve as examples. These avenues can be implemented by a range of stakeholders in the field.

Credential Recognition

Emphasize comprehensive, clear and available pre-arrival information in French about credential recognition and offer specialized individual post arrival support.

The following organizations have developed initiatives in this direction:

• Funded by IRCC, CARE for Nurses was created in Ontario in 2001 and provides a range of pre- and post-arrival services relevant to internationally educated nurses. The Pre-Arrival Supports and Services (PASS) program was created in 2016 in collaboration with the Canadian Nurses Association and is reserved for individuals who have graduated from a Canadian recognized nursing program and are in the process of becoming permanent residents. The PASS program is free and offers specific services for internationally educated nurses (webinars, sponsorship program, online communication courses, case management). Unfortunately, the program does not offer services in French, but the resources are relevant to nurses wherever they wish to practise in Canada. This type of initiative and collaboration between professional associations and immigrant serving organizations has the advantage of offering specialized services and valuable personalized support to help immigrants navigate the process. CARE’s post arrival program also offers a variety of resources for internationally educated nurses. More than 4,000 people have used CARE’s services since 2001. That said, CARE does not offer any services or information in French. The Immigrant Services Association of Nova Scotia offers an orientation program for internationally educated nurses (in English) that includes pathway information, study groups, online resources, information on alternative careers, mentoring, etc.
• There are a few programs to support the integration of Francophone immigrant professionals in the healthcare field. For example, French language resources and services are offered by Health Force Ontario, through the Access Centre for Internationally Educated Health Professionals and the Health Force Integration Research and Education for Internationally Educated Health Professionals (HIRE IEHPs) project, which offers integration tools specific to IEHPs.

Provide French-language resources for credential recognition processes administered by regulatory bodies including orientation, self-assessment and alternatives.

For example, the Canadian Society for Medical Laboratory Science (CSMLS) operates a bilingual one stop shop for internationally trained applicants to complete their forms online. The online platform includes self-assessment resources, a comprehensive component dedicated to alternate careers, and a bilingual services telephone line. Professionals can take the certification exam in French. The CSMLS exempts applicants who have completed their education in English or French from taking a language test, but the provinces ultimately retain their language level criteria. It should be noted that the self-assessment offer available online is also a good way for individuals to orient themselves by identifying their knowledge gaps and the options that are available. Thanks to funding by EDSC, CSMLS comprehensively reviewed and developed its alternate career component.

Grant temporary licences to practise.

The medical regulatory authorities in some provinces, including Alberta and Nova Scotia, offer licencing assessments that allow international graduates to obtain a temporary licence, which may be accompanied by a service agreement that requires the applicant to practise in a specific location at the end of their training. Engineers also offer applicants the opportunity to practise their profession in a supervised manner, which has been identified as an effective way to allow internationally trained professionals to quickly integrate into the workplace and gain Canadian experience. These programs have English proficiency requirements.

Enhance the offer of financing and financial support.

Some financial assistance programs are available through various organizations to facilitate credential recognition and bridging^{Footnote 16} pathways. ESDC’s Foreign Credential Recognition Program was recently expanded to allow organizations to set up loan programs for individuals wishing to complete the credential recognition process. Even if eligibility for this type of resource is defined in strict terms, financial support is essential given the cost of the process and the needs to be met during the process. These services should be well publicized and accessible to Francophones.

Support the development of concrete programs and initiatives; support harmonization efforts through stakeholder discussions and concrete initiatives.

Initiatives such as those spearheaded by the CNFS or developed by collaborative working groups to help with the occupational integration of IEHPs are important. Resources should continue to be provided so that innovative approaches can be introduced, but in a manner that is both sustainable and allows for the measurement of results. In part, this is what the ESDC Foreign Credential Recognition Program does. In general, there is a need to support discussions among provincial and territorial regulatory bodies on better credential recognition mechanisms and consider the provision of information and services in French.

Training and Internships

Inform and facilitate access by Francophone immigrants to English-language learning options for professional purposes in the healthcare field.

The language courses offered by the CNFS are designed to help health professionals serve a French-speaking clientele, with a view to improving the active offer of health services in French. Under its “Culture and language in the health sector” component, the CNFS therefore offers French second language training for health professionals, modules that enable participants to practise or maintain their French, or to become familiar with the culture and language used in certain Francophone communities. It would be beneficial to complete this table with English-language learning resources for Francophones. The resources developed at McGill University for health professionals wishing to learn English could be widely used.

Assess the possibility of easing language criteria for training programs and offer “probationary” or conditional admission options.

Such a measure would allow applicants who want to take their training in French to develop the necessary level of English concurrently with their studies. This means that educational institutions must be able to offer pathways that include English courses so that graduates acquire the necessary language level to meet the requirements of regulatory bodies or employers in the field. It also means being flexible so that language learning can be integrated into the training process for students without penalizing them.

Support a consistent supply of training programs for internationally educated individuals.

Several of these programs exist, but mainly in English.

• For example, the Nova Scotia College of Nursing refers internationally educated nurses to the Registered Nurses Professional Development Centre and the Nova Scotia Community College for the Practical Nursing program. The University of Ottawa’s Bachelor of Nursing program offers a bridging option for the integration of internationally educated applicants in 3rd and 4th year.
• As of 2016, the Canadian Culture and Communication for Nurses programming developed by the Manitoba Nurses Union was available online to applicants from across Canada (although funding for this initiative ended in March 2020). It would certainly be possible to develop similar French language resources that could be offered online and shared in all provinces and territories to meet Francophone demand in particular.
• Some programs have been developed specifically to meet the needs of health professionals who cannot requalify in their field. For example, the Catholic Centre for Immigrants in Ottawa offers a free career transition program that provides targeted training to internationally trained physicians who are fully or partially unemployed and seeking employment in unregulated areas of the healthcare system. These programs are available in English only.

Provide intercultural training for healthcare administrative and management staff.

The CNFS offers French-language courses for trainers and internship supervisors, including a workshop on cultural skills via the CNFS – University of Ottawa Component. Since 2008, the CNFS has been offering intercultural training in French to stakeholders working with French-speaking internationally educated health professionals.^{Footnote 17} The program aims to make stakeholders aware of the intercultural realities of Francophone health professionals and international health graduates and to work more effectively with them in their workplace. The courses have been available online since 2011. In April 2012, the CNFS launched a second intercultural training site, this time aimed at health professionals themselves. These resources would benefit from being mobilized more.

Job Search and Hiring

Create incentives to hire healthcare staff.

Quebec’s Employment Integration Program for Immigrants and Visible Minorities (PRIIME) and the Employment Integration Project for Foreign Trained Persons Referred by a Professional Order (IPOP) support the occupational integration of skilled immigrants through financial incentives to employers and support for immigrants. Such programs can be particularly useful for people whose credentials and experience are not officially recognized or whose English-language skills still need to be improved. Indeed, such profiles involve closer support in hiring and this type of program can encourage employers to provide support or take “hiring” risks.

The Atlantic Immigration Pilot also provides a form of incentive for hiring potential immigrants, including international students, by facilitating the matching of skills, the hiring process and language training for international students.

Raise awareness among and provide support to employers to increase immigrant recruitment.

Employer awareness continues to be relevant, both to increase immigrant recruitment and to facilitate their integration. For example, a study of immigrant hiring in Northern Ontario showed how simple focus groups between employers on this topic can break down barriers to hiring (Woodbec, MacMillan, Kelso, 2015, p. 28). Employer awareness sessions have also been beneficial under the Atlantic Immigration Pilot (Oliphant, 2017). This involves both sharing successful hiring experiences, but also supporting employers by providing coaching and refresher training – for example, in English when skills are limited.

Create a hub for specialized employment services in healthcare in French.

French language employment services for immigrants are now available in all provinces and territories. However, the previous comments speak to the limitations of such services when they cover all areas of employment. Issues related to career reconversions, credential recognition or job searches as part of a broader professional development strategy would be better addressed through a hub where the entire offer and staff are focused on the healthcare field in order to optimize the resources and advice offered. A few relevant examples are provided below:

• The Catholic Centre for Immigrants in Ottawa appears to be one of the few places outside Quebec where such services are partially offered in French. Their services focus on career reorientation and involve, beyond the usual job search support services, participation in workshops on different themes, such as transferable skills. Mentoring and volunteering, which have proven to be promising practices, are also offered by the Catholic Centre for Immigrants.
• Also noteworthy are the activities of the Career Mentoring Program of the Ottawa Community Immigrant Services Organization, which provides support to internationally educated professionals through mentoring by a professional working in the same or a related field. This program has the advantage of closely monitoring mentoring activities by providing, for example, an orientation session for mentors and ensuring that weekly meetings take place. In fact, when mentoring is not accompanied by structure, participants may more often be overlooked by their mentors. However, the disadvantage of this program is that it is offered exclusively in English and is not geared specifically to the healthcare field.
• Campus Saint-Jean at the University of Alberta recently joined forces with community partners to launch a volunteer mentorship program for immigrant women who want to work in the healthcare field.

These initiatives would benefit from being aligned with those for recognition of prior learning, given that a great deal of knowledge and expertise is transferable at any stage of these trajectories.

Offer subsidized French-language daycare services for job seekers.

A well planned and coordinated job search generally leads to a more relevant and challenging job. As such, subsidized child care provides valuable support to future professionals. Employment services for immigrants in large cities often have this type of service, but few offer it in French. As demand is lower, home care services could be favoured or childcare reimbursement options could be considered.

Onboarding and Retention

Establish bilingual health human resources strategies where diversity management is taken into consideration.

The Société Santé en français and the French Health Network of Central Southwestern Ontario have developed a Health Human Resources Strategy that presents “concepts and courses of action for improving access to French-language health services across Canada, and supports the vision and strategic directions set out in Health Canada’s Health Human Resource Strategy.” This initiative offers a structured framework, customizable HR planning tools for bilingual staff, language resources in English and French, examples of promising practices and video testimonials. In addition to online resources, advice is provided by the project sponsors. Moreover, participants are invited to complete online modules. Participants receive a certificate for each completed module and ultimately a Certificate of Completion from the Canadian College of Health Leaders, which is associated with Maintenance of Certification (MOC) credits.

The disadvantage of this resource is that it does not address the issue of intercultural relations to any great extent. However, our work shows that a cross sectoral approach has the advantage of simultaneously addressing the cross effects of language and racialization on workplace integration. Moreover, this resource still seems little known, which limits the social acceptability and promotion of French in Canadian health services outside Quebec.

Develop cultural competencies in the workplace.

Cultural competencies are now recognized as essential in a majority of health professions’ codes of ethics, but strategies for their implementation in the workplace would benefit from being expanded. Cultural competence is defined as the set of skills needed to provide safe and effective healthcare to clients from diverse cultural backgrounds (Campinha-Bacote, 2002). The Strategic practices for hiring, integrating and retaining internationally educated nurses: employment manual (Baumann, et al., 2017) suggests that workplace integration should focus on job specific skills, knowledge, and workplace culture. The latter is especially important to ensure immigrants’ optimal professional development and confidence in their abilities. In general, within health organizations, onboarding is not always supported by a strategy and systematic application of this type of good practice, given that, for example, there is not enough time to implement a one year strategy, involving different phases – from process, to support, to follow up. However, while all employees benefit from a continuous onboarding strategy, the growing presence of immigrants and IEHPs means that specific strategies are needed where workplace integration initiatives are linked to practices aimed at disseminating cultural competencies among all employees. This manual reminds us that various practices can be systematically adopted and implemented in a concerted manner through the allocation of funds, the adoption of mandates and visions that include diversity, the formation of a committee dedicated to the issue of diversity, the recognition of senior employees as diversity leaders, extensive orientation and mentoring practices. Although intended for internationally educated nurses, the principles contained in this manual can be adapted and extended to all IEHPs and immigrant health professionals.

The Communication Matters program is offered partially in French in Ontario and aims to support the workforce integration of IEHPs by offering online courses for employers and professionals. Courses for employers aim to provide human resource management strategies to better welcome and integrate health professionals.

Establish French language networking and communities of practice.

The value of bilingualism for health professionals and its requirements are still poorly understood in the workplace. According to the literature, strategies to promote bilingualism in the workplace would benefit from incorporating recurring opportunities for language training and dialogue among colleagues (Drolet et al., 2014). Indeed, it is important for employers to develop a work culture where the French fact refers to added value rather than to forms of discrimination or overwork. As such, the work led by de Moissac suggests that discussion clubs be set up in healthcare institutions: “In order to encourage mutual support, professionals could organize discussion clubs or dinners to make greater use of this newly learned language, whether French or English” (De Moissac et al., 2014, p. 47). Such clubs foster greater confidence on the part of healthcare providers to speak French, while ensuring the maintenance and development of their French-language skills. Indeed, opportunities to maintain French-language skills may be limited in a predominantly English-speaking environment.

However, when there are few bilingual professionals, it may be more beneficial to rely on broader online communities of practice. The organization Public Health en français, supported by the Ontario government since 2013, has set up a community of practice to promote information exchange and networking for the benefit of French-language health services. This community of practice, which brings together public health stakeholders involved in providing health services to Francophones, has mobilized some 100 people to date. However, this community does not seem to mobilize enough people to ensure that French truly takes hold in the workplace.

For immigrant health professionals, such initiatives have the advantage of potentially helping to break down their professional isolation and reduce some stress, particularly in the early stages of their practice. They are also opportunities to better understand the social and health realities of FMCs. For the time being, the initiatives identified to enhance the value of French in the workplace do not seem to incorporate practices that ensure the hiring of immigrant and ethnocultural minority professionals.

Appendix B: Bibliography

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• Bajwa, A. and El Assal, K (2018). Strengthening Canada’s Immigration System. The Conference Board Report.
• Baumann, A., Ross, D., Idriss Wheeler, D. and Crea Arsenio, M. (2017). Strategic practices for hiring, integrating and retaining internationally educated nurses: Employment manual. Nursing Health Services Research Unit (NHSRU), McMaster University.
• Belkhodja, C., Forgues, É., Gaboury, I., Guignard Noël, J., Bahi, B., Nkolo, C., Tawil, N. (2009). L’intégration des diplômés internationaux en santé francophones dans les communautés francophones en situation minoritaire [integration of French-speaking international health graduates in Francophone minority communities]. Report prepared for the Consortium national de formation en santé.
• Blythe, J., Baumann, A., Rhéaume, A., McIntosh, K., (2009). Nurse Migration to Canada: Pathways and Pitfalls of Workforce Integration, Journal of Transcultural Nursing, 20 (2), 202-210.
• Bourgeault I., Neiterman E. (2013). Integrating international medical graduates: the Canadian approach to the ‘Brain Waste’ problem. In: Triadafilopoulos, P. (Ed.), Wanted and Welcome? Policies for Highly Skilled Immigrants in Comparative Perspectives Policy. Springer, Toronto, pp. 199-217.
• Bowen S. (2015). Impact des barrières linguistiques sur la sécurité des patients et la qualité des soins: Rapport final pour le compte de la Société Santé en français (French only; PDF, 1.18 MB) [impact of language barriers on patient safety and quality of care: final report for the Société Santé en français],
• Campinha Bacote, J. (2002). The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care. Journal of Transcultural Nursing. 13(3), 181-184.
• Chicha, M. T., Gril, É. (2018). “L’interminable course à obstacles” [the never ending obstacle course]. Revue Gestion, 1(43), pp. 58-61.
• Consortium national de Formation en santé (2008). L’équité linguistique en matière d’évaluation des diplômes et compétences des professionnels francophones de la santé formés à l’étranger (French only; PDF, 0.6 MB), [language equity in evaluating diplomas and competencies of French-speaking internationally educated health professionals], Consortium national de formation en santé.
• Covell C., Neiterman, E., Bourgeault, I. (2015). “Forms of Capital as Facilitators of Internationally Educated Nurses’ Integration into the Registered Nursing Workforce in Canada,” Canadian Public Policy 41(1), S150-S161.
• Covell C., Neiterman, E., Bourgeault, I. (2016). “Scoping review about the professional integration of internationally educated health professionals,” Human Resources for Health, 14 (38).
• Covell. C., Primeau M D., Kipatrick K., St Pierre, I., (2017) “Internationally educated nurses in Canada: predictors of workforce integration,” Human Resources for Health, 15 (26).
• De Moissac, D., Savard, S., Ba, H., Zellama, F., Benoit, J., Giasson, F. and Drolet, M. (2014). Le recrutement et la rétention des professionnels de la santé et des services sociaux bilingues en situation minoritaire (French only; PDF, 1.3 MB) [recruitment and retention of bilingual health and social service professionals in minority communities]. University of Saint Boniface and University of Ottawa.
• Drolet, M., Dubouloz, C. J., Benoît, J. (2014). L’accès aux services sociaux et de santé en français et la formation des professionnelles et des professionnels en situation francophone minoritaire canadienne. [access to health and social services in French and training for professionals in Canada’s Francophone minority communities]. Reflets, 20(2), 11-34.
• Evra, R., Kazemipur, A. (2019). Insights on Canadian Society. The role of social capital and ethnocultural characteristics in the employment income of immigrants over time.
• Forest, Mariève (2014). La formation linguistique des immigrants et des étudiants étrangers d’expression française dans les établissements postsecondaires de la francophonie canadienne: état de la situation et pistes d’action [language training for French-speaking immigrants and foreign students in post secondary institutions in the Canadian Francophonie: status report and courses of action.] Prepared for the Consortium national de formation en santé and the Association des universités de la francophonie canadienne.
• Immigration, Refugees and Citizenship Canada (2018). Evaluation of Pre-Arrival Settlement Services
• Jantzen, L. (2015). Do Economic Principal Applicants Work in Their Intended Regulated Occupation? Introducing the National Household Survey and Immigration Landing File Linkage Database, Canadian Public Policy, doi:10.3138/cpp.2015-010.
• Lafontant, J., Forgues, E., Belkhodja, C., Sangwa Lugoma, G., Meridji, T., Pietrantonio, L., Tremblay, A., Kayirangwa, C. (2006). La reconnaissance des diplômés internationaux francophones en santé: un potentiel pour les communautés francophones en situation minoritaire au Canada [recognition of Francophone international health graduates: a potential for Francophone minority communities in Canada]. Report submitted to the Consortium national de formation en santé, Canadian Institute for Research on Linguistic Minorities.
• Lepage, J. F. and Lavoie, É. (2017). Health care professionals and official language minorities in Canada, 2001 and 2011. Statistics Canada, Ethnicity, Language and Immigration Thematic Series, No. 89-657-X-2017002
• Newton, S., Pillay J., Higginbottom, G. (2012). “The migration and transitioning experiences of internationally educated nurses: a global perspective.” Journal of Nursing Management, 20(4), 534-550.
• Office of the Fairness Commissioner of Ontario (2018). Rapports sur les services d’inscription en français (PDF, 42 KB) [reports on French language registration services].
• Oliphant, R. (2017). Immigration to Atlantic Canada: Moving to the Future. Ottawa, House of Commons.
• Owusu Y., Sweetman A. (2015). “Regulated Health Professions: Outcomes by Place of Birth and Training.” Canadian Public Policy 41(1), S98-S115.
• Paul R., Martimianakis M., Johnstone J., McNaughton N., and Austin Z. (2017). “Internationally Educated Health Professionals in Canada: Navigating Three Policy Subsystems Along the Pathway to Practice.” Academic Medicine, 92(5), pp. 635-640.
• Poullos, Nicholos (2019). Immigration et santé: où en sont les francophones? Une enquête sur l’état de santé des immigrants francophones en Colombie Britannique [immigration and health: where are the Francophones? A survey on the health status of Francophone immigrants in British Columbia]. Prepared by RésoSanté Colombie Britannique.
• Ramji, Zubeida (2016). Beyond Transition: Understanding Workplace Integration of Internationally Educated Nurses A Qualitative Case Study. Doctoral thesis, School of Nursing, University of Ottawa.
• Sattler et al. (2015). Multiple Case Study Evaluation of Postsecondary Bridging Programs for Internationally Educated Health Professionals. The Higher Education Quality Council of Ontario
• Savard, S., Arcand, I., Drolet, M., Benoît, Savard, J. and Lagacé, J. (2013). “Les professionnels de la santé et des services sociaux intervenant auprès des francophones minoritaires: l’enjeu du capital social” [health and social services professionals serving Francophone minorities]. Francophonies d’Amérique, 36, pp. 10-29.
• Sauvageau, Marie-Michèle (2018). La Recherche en santé et en services sociaux auprès des populations francophones en situation minoritaire au Canada: revue de littérature et analyse des thèmes de recherche (French only; PDF, 0.4 MB) (2014-2016) [health and social services research on Francophone minority communities in Canada: literature review and research theme analysis], for the CNFS.
• Société acadienne du Nouveau-Brunswick (2018). L’immigration francophone au Nouveau Brunswick. Constats et priorités [Francophone immigration in New Brunswick. Findings and priorities]. White paper on immigration. Moncton.
• Sociopol (2019). Les ressources et les besoins des organismes du secteur francophone de l’établissement [needs and resources of Francophone settlement organizations]. Report prepared for the Fédération des communautés francophones et acadienne du Canada.
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• Statistics Canada (2015). Analysis of the Canadian immigrant labour market, 2008 to 2011.
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• Statistics Canada (2017b). Census in Brief: English, French and official language minorities in Canada.
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• Woodbeck, C., Macmillan A., Kelso B. (2015). Exploring Immigrant Hiring in Northwestern Ontario. Report. A Pathways to Prosperity Project.
• Yssaad, L., and Fields A. (2018) The Canadian Immigrant Labour Market: Recent Trends from 2006 to 2017. Publication 71-606-X.

Appendix C: Interview Guide for immigrants

Occupational Integration in Healthcare by French-speaking Immigrants Living in Minority Communities

Integration and Retention in Employment

Objective: To understand the context of being employed in healthcare at the time of the interview. To understand the workplace integration trajectory for the position. To understand the effect of the Francophone immigrant experience – and to a lesser extent the visible minority and female immigrant experience – on the employment situation.

1. Tell us a little bit about your current position? Title? Employer? Organization? Relationships with colleagues? Supervisors? Since when?
2. Do you feel that you have all the skills required for this position? Explain.
3. Work environment or atmosphere for immigrants and visible minorities?
4. As an immigrant/visible minority/Francophone, did you feel that you had to “adapt” to your work environment? With respect to patients/colleagues? Explain. Initiatives that helped you adapt?
5. Your employer’s commitment to cross cultural awareness, diversity, etc.?
6. Obstacles since you’ve been working caused by a lack of cultural sensitivity? Francophones?
7. What qualifications did you need to obtain your current position?
8. What was your onboarding process? First days? Obstacles?
9. What could have been done to make your onboarding easier?

Job Search

Objective: To understand the different job search experiences, the resources mobilized, the facilitating factors and the obstacles encountered. To understand how the experience of Francophone immigrants – and to a lesser extent the visible minority and female immigrant experience – affects the job search experience.

10. Tell me a little bit about how you went about finding your current job?
    • Was it easy to find a job?
    • How has being a Francophone immigrant affected your ability to find work?
    • What networks have you mobilized?
    • What resources (website, organizations, applications, etc.) did you use?
    • What training have you taken: EN/FR language training, CV development, interview preparation, labour standards workshops, networking experiences, etc.?
      • Were these trainings offered in French? Why did you choose them over others?
      • Were they accessible? Useful?
      • How could they have been improved?
    • Did you encounter any obstacles?
11. (If applicable) How were these approaches different from your initial job search experiences when you first came to Canada?
12. Can you think of other resources that could have been useful in your job search?
13. What were your biggest challenges in finding a job?
14. Do you feel that your English language skills were (or have been) a problem in finding or integrating into a new job? Explain.

Training

Objective: To understand the history of post-secondary degrees/diplomas obtained, if applicable, in Canada and abroad. To identify factors facilitating training experiences in Canada and related issues. To understand how the experience of Francophone immigrants – and to a lesser extent the visible minority and female immigrant experience – affects the training experience in Canada.

15. Can you show me the post-secondary diplomas you’ve obtained in chronological order? For each diploma/degree obtained, specify the field of study, level of study, place, year, language of study.
16. How have these credentials and trainings been helpful when looking for work in Canada?
17. Please specify if you have changed career plans due to Canadian labour market requirements.

For IEHPs or International Educated Professionals (IEPs):

18. How many years of experience did you have in your profession before coming to Canada?
19. Have you sought recognition of your diplomas/degrees in Canada?
20. If so, could you explain to me how your credential recognition or recognition of prior learning took place? Courses taken, costs, exams, individuals who provided support and information, etc.
    • Did you have to take bridge training? If so, how would you characterize this experience?
    • Did you have to write an exam? If so, how would you characterize this experience? Do you feel you were well prepared?
    • What has been your biggest challenges/obstacles?
    • What was the most important support you received?
    • Were any internships part of your training?
21. Please indicate whether you thought the training costs in Canada were appropriate? Or posed a challenge?

For international students:

22. (If applicable) were you already planning to immigrate to Canada when you began your studies?
23. What resources (readings, programs, organizations, consultants, etc.) did you mobilize when you began your immigration process?
    • Were these resources easy to find?
    • Are there any additional resources you feel would have been useful?
24. Do you think we could have done a better job of supporting you in your training? And/or your immigration project? How?

Internships

Objective: To understand the internship experience in Canada’s healthcare sector. To understand how the experience of Francophone immigrants and to a lesser extent the visible minority and female immigrant experience affects the internship experience in Canada.

25. Can you tell us about your internship experience(s)?
26. Were there any initiatives, organizations or individuals that facilitated your internship experience? Explain.
27. How was being a Francophone an enabling factor or an issue in your internship experience?
    • Did you note the presence of an active offer of health services in French in your internship setting? What effect did this presence/absence have on your internship experience?
28. How was being an immigrant an enabling factor or an issue in your internship experience?
    • Did you notice any cultural sensitivity among the internship coordinators or in your internship environment? What effect did this presence/absence of cultural sensitivity have on your internship experience?
29. Did the internship experience raise any particular financial issues?
30. In hindsight, can you imagine tools, ways of doing things or coaching that could have improved your internship experience?

For international students (IEHPs or others):

31. Did you encounter any particular issues because you were an international student? (Application processing time, understanding of procedures, etc.) If so, can you explain the nature of these issues?

Migration Plan

Objective: To understand the migration pathway before and after arrival in Canada. To understand the issues and enabling factors of this pathway.

32. Under what circumstances did you begin your settlement process in Canada?
    • What country were you born in?
    • Had you lived in other countries before coming to Canada?
    • What made you come to Canada?
    • How did you hear about Canada’s immigration policies?
    • In hindsight, do you think you had all the information you needed to make an informed decision about your migration project?
      • What diplomas? What additional training? Functioning of the labour market? What costs?
33. Did you come to Canada as a permanent or temporary resident?
    • If permanent: Was it through economic immigration, family reunification or as a refugee?
    • If temporary: were you a worker, student, visitor?
34. What were the immediate post arrival activities in Canada that were most helpful to your workforce integration?
    • What other post arrival activities in Canada might have been useful to you?
35. For IEHPs:
    • Were the language levels required for recognition of degrees/diplomas problematic? In English? In French?
    • Did you know what to do to ensure recognition of your degrees/diplomas?
36. Once in Canada, have you lived in provinces/territories other than the one in which you are currently living?
    • If so, what made you move to another province?
37. Today, what is your status: Canadian citizen? Permanent resident? Temporary resident?

Appendix D: Quantitative Tables

Note: If the proportion of immigrants in the Francophone population was comparable to the proportion of immigrants in the total population, the percentages in columns C and D would be similar, as would the percentages in columns E and F. Lower percentages in columns C (compared to D) and E (compared to F) indicate a deficit of immigrants in the Francophone population compared to the proportion of immigrants in the total population of the province, territory or region.

Statistics Canada (2019). Data Tables, 2016 Census, Product No. 1b_j4069646

Statistics Canada (2017). Data table, 2016 Census, Catalogue No. 98 400 X2016086