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Originally published in French by Symposium+, this article is now presented in its English version.
Bianca Briciu
Lorraine Ste-Marie
Saint Paul University
In response to the underutilization and de-skilling of immigrants in health-related occupations in Canada (Hou & Schimmele, 2020), Saint Paul University has started a collaboration with the National Newcomer Navigation Network (N4) in 2022 to design and deliver an on-line professional program to support the integration of internationally educated health care professionals into the Canadian healthcare system. We had 2 English speaking cohorts with 60 participants each and 1 French speaking cohort with 46 participants and we will continue to offer the program in the fall of 2023 in both languages.
The intention of this program is to accompany Internationally Educated Health Professionals as they navigate the challenges involved in meeting the requirements for certification by their respective credentialing bodies. The program is specifically designed to strengthen their non-clinical skills and knowledge to support their successful integration into the Canadian healthcare system. The overall aim is to engage them in a transformative learning process for gaining deeper self-awareness, knowledge, and skills for mobilizing their expertise. In the program participants gain greater awareness of their own strengths, weaknesses and vulnerabilities through reflective practice and dialogue. This allows them to also critically assess the role of worldviews and assumptions in their attempts to transition into a new social, political, economic and professional culture (Tilburt, 2007). Throughout the program, participants are invited to participate and contribute to a learning community, which plays an important role in their own learning and sense of belonging. While each module instructor has expertise in their particular field of study and practice, they recognize their role as facilitators of learning, more as co-learners with the participants in this program. For this reason, we refer to our instructors as “lead learners.” (Fullan et. 2015). Through their live sessions, video capsules, selected resources, and reflection exercises the lead learners facilitated a welcoming approach to learning.
The disorienting dilemma of immigration and re-professionalization for IEHPs
Immigration is an experience that creates disorienting dilemmas of examining one’s values and decisions, uncertainty about the future, grieving, negotiation of one’s cultural and professional identity, all of them involving emotional aspects and the continuous effort to make meaning.
The process of adjustment to life in Canada for the IEHPs who participated in this study has been described as a disorienting journey that tested their resilience, determination and self-confidence. They face many contradictions: gaining immigration points for credentials in contrast with a long and difficult process of getting licensure (Neiterman & Bourgeault, 2010, p.75); the insufficient medical personnel in the Canadian healthcare system in contrast with the lack of recognition of their license and experience (Goodfellow et al., 2023); the promise of a multicultural, welcoming context in contrast with prejudice and the assumption of Canadian cultural and clinical superiority (Neiterman & Bourgeault, 2010, p. 79).
The greatest difficulty they talked about was not culture shock or the need to adapt, nor the loss of one’s homeland, but rather the diminished self-confidence with every failed exam, every rejection after an interview, every silence to inquiries about licensure that led to a generalized confusion. A recent study conducted by N4 expresses the troubling paradox between the lack of medical personnel in the Canadian healthcare system and the lack of recognition of the medical competencies of IEHPs (Goodfellow at al., 2023).
The impact of a welcoming approach to learning-restoring self-confidence, hope and agency
In 2023 we obtained permission to conduct research about participants’ experiences. 23 of them gave us access to their end-of-module reflection and 11 of them participated in a focus group. The transformative learning aspects of program surprised many participants habituated to a different way of learning without self-reflection and sharing. Here they were asked to share their life stories, reflect on their traumas, emotions and worldview, engage with their so-called soft skills. The experience of being met exactly where they were in their life journey, being listened to, sharing one’s struggles with a learning community was life-giving and empowering.
Three approaches of transformative learning in particular had a big impact on the experience of being seen, of being welcome and accompanied, which had a strong impact on restoring their self-confidence, hope and agency, as they moved through the disorienting dilemma of cultural and professional adaptation. These approaches were self-reflection, sharing one’s story of trauma and resilience and the conversations that created a learning community.
Self-reflection
20 participants reported that writing their own stories and reflecting on their experiences helped them to affirm their gifts, skills, competencies and purpose in the healthcare setting. Seven participants shared that they became more hopeful and confident in their resilience and ability to navigate challenging circumstances, including their licensing pathway as a result of self-reflection.
Self-reflection increased awareness about the role of one’s culture in creating worldviews and behavior, leading to a more tolerant an open attitude towards other cultures. Cultural humility is an essential aspect of intercultural sensitivity that increases adaptation and openeness (Bennett, 1986).
One participant noted: “Effectivement, l'autoréflexion peut mener à l'humilité culturelle. L'humilité culturelle est la capacité de reconnaître que notre propre culture et notre propre expérience ne sont pas les seules valables et de respecter les cultures et les expériences des autres.” (EoLM_FR_Winter_2023_P5).
Sharing stories of trauma and resilience
One module in the program opened the space for sharing the stories of participants’ migration and invited them to reflect on previous experiences of trauma and resilience. Many participants also appreciated the vulnerable sharing of some of lead learners’ stories. Being seen and heard both in one’s vulnerability and strength reinforced their self-confidence and the courage to continue.
The opportunity to share one’s story with others who could relate and understand, shifted the perspective on one’s emotions, helping to reframe and ease the pain of displacement.
Learning community
Proximity and connection to others, a sense of solidarity and trusting relationships are crucial aspects of transformative learning because they restore a sense of safety, power and hope (Taylor, 2009).
One participant experienced a sense of relief and safety in being “held” by the learning community through the distress of feeling lost in a system difficult to navigate. “Soulagement, je me sens pas seul Ça transforme que de se voir isolé, comme perdu dans un ocean” (FG_FR_Winter 2023_P8).
Another participant shared the self-affirming experience of being seen and heard after feeling invisible. “Because we know how sometimes we feel like nobody is seeing us here and having a program like this it's kind of important because we feel that they know we are here and they can help us and they want to help us” (FG1_ENG_Fall 2022_P3). It makes a big difference to know that they have allies in Canada, that there are people and agencies who care about their success.
Participants derive strength and confidence from the discovery of a larger community sharing the same struggles. This strength is the dawning of a collective consciousness, a shared identity as health professional newcomers to Canada.
“I am strengthened with the understanding that the journey of professional integration is not a lonely journey and there is a community of people on the same track. I want to say, that support of people is very important. Especially for newcomers, because of the stress and trauma, that we all have” (EoLM_ENG_Fall 2022_P8).
The program had a welcoming ethos in its invitation to participants to share who they were, in the curiosity, listening and reflection experience, in its support and encouragement based approach.
If Canada abides by its ideal of integration, this means not only that newcomers adapt to the new culture (assimilation), it means that culture itself adapts to create conditions for dynamic processes of “mutual acquaintance, accommodation and understanding” (Canadian Council for Refugees, 1998). There is a large system of support for integrating newcomers but less infrastructure for turning integration into an experience of mutuality and cultural transformation. Settlement agencies in Canada accompany newcomers in their process of cultural adaptation and integration while N4 strengthens their network and creates opportunities for learning and collaboration across the sector, contributing to more mutuality.
What would it take to create more welcoming contexts of mutual acquaintance for highly trained medical professionals who enter Canada? To answer this we can ponder the question of one of the participants: “Je me demande est ce que le Canada a suffisamment confiance à tout le potentiel humain qu'il a sur son sol?” (EoLM_FR_Winter_P9)
References
Bennett, M. J. (1986). A developmental approach to training for intercultural sensitivity. International journal of intercultural relations, 10(2), 179-196.
https://doi.org/10.1016/0147-1767(86)90005-2
Canadian Council for Refugees (1998). Best settlement practices. https://ccrweb.ca/sites/ccrweb.ca/files/static-files/bpfina1.htm
Fullan, M., Hord, S. M., & von Frank, V. (2015). Reach the highest standard in professional learning: Implementation. Thousand Oaks, CA: Corwin.
Goodfellow, C.; Zohni, S.; Kouri, C. (2023). A Missing part of me: A Pan-Canadian report on the licensure of internationally educated health professionals [Final Report]. Ottawa, ON: National Newcomer Navigation Network.
Hou, F. & Schimmele, C., (2020). Adults with a health education but not working in health occupations. Statistics Canada: StatsCan COVID-19: Data to Insights for a Better Canada.
https:// www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00004-eng.htm
Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA:-Oxford Jossey-Bass.
Neiterman, E. and Bourgeault, I.L. (2015). Professional integration as a process of professional resocialization: internationally educated health professionals in Canada. Soc. Sci. Med. 131,74-81.
Taylor, E.W. (2009). Fostering transformative learning In Mezirow, J., & Taylor, E. W. (Eds.) Transformative learning in practice: Insights from community, workplace and higher education (pp. 3-18). San Francisco, CA: Jossey-Bass.
Tilburt, J., & Geller. G. (2007). Viewpoint: The importance of worldview in medical education. Academic medicine. 82(8), 819-822.
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