Social Science & Medicine 131 (2015) 74e81

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Professional integration as a process of professional resocialization: Internationally educated health professionals in Canada Elena Neiterman a, *, Ivy Lynn Bourgeault b, c, d a

Department of Sociology, McMaster University, KTH-633, 1280 Main St. W., Hamilton, Ontario L8S 4M4, Canada Telfer School of Management, University of Ottawa, 1 Stewart St. Room 227, Ottawa, Ontario K1N 6N5, Canada1 c Health Human Resource Policy, University of Ottawa, 1 Stewart St. Room 227, Ottawa, Ontario K1N 6N5, Canada2, 3 d Ontario Health Human Resource Research Network & Population Health Improvement Research Network (PHIRN), University of Ottawa, 1 Stewart St. Room 227, Ottawa, Ontario K1N 6N5, Canada4 b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 28 February 2015

This paper examines the process of professional resocialization among internationally educated health care professionals (IEHPs) in Canada. Analyzing data from qualitative interviews with 179 internationally educated physicians, nurses, and midwives and 70 federal, provincial and regional stakeholders involved in integration of IEHPs, we examine (1) which aspects of professional work are modified in transition to a new health care system; (2) which aspects of professional practice are learned by IEHPs in the new health environment, and (3) how IEHPs maintain their professional identity in transition to a new health care system. In doing so, we compare the accounts of IEHPs with the policy stakeholders' positions and analyze the similarities and the differences across three health care professions (medicine, nursing, and midwifery). This enables us to explore the issue of professional resocialization from the analytical intersection of gender, professional dominance, and institutional/organizational lenses. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Canada Internationally educated health care professionals International medical graduates Internationally educated nurses Internationally trained midwives Migration Professional integration Professional socialization

1. Introduction The global movement of internationally educated health care providers (IEHPs) has become one of the central topics for health researchers and social scientists alike particularly in the last decades (Joudrey and Robson, 2010). This literature seems to be nearly singularly focused on the individualistic “push” and “pull” factors that drive health professionals to emigrate and to choose a particular destination country (Buchan and Sochalski, 2004). The ethical issues related to recruitment of health care workers from the global south to the global west are also prominent (Buchan,  et al., 2006), but the actual process of integration 2006; Labonte into the health care system in the host country has received scant attention. When the integration process is under investigation, it tends to focus on the barriers and facilitators to licensure

* Corresponding author. E-mail addresses: [email protected] (E. Neiterman), ivy.bourgeault@uottawa. ca (I.L. Bourgeault). 1 http://www.health.uottawa.ca/healthsciences/. 2 http://www.ivylynnbourgeault.ca. 3 http://www.healthworkermigration.com. 4 http://www.rrasp-phirn.ca. http://dx.doi.org/10.1016/j.socscimed.2015.02.043 0277-9536/© 2015 Elsevier Ltd. All rights reserved.

neglecting to look beyond the attainment of a license to practice as the key indicator of integration. In this paper we focus on the integration process. The transferability of one's clinical skills is implied in the mobility of health professionals, but the cultural specificity of these skills can often be a barrier to successful professional integration. This has begun to be documented in the cases of immigrant nurses and physicians adjusting to the working environment in the U.K. (Cowan and Norman, 2006), Canada (Baumann et al., 2006; Bourgeault and Neiterman, 2013) and elsewhere (Bernstein and Shuval, 1998; Harris, 2011). We situate this examination in the context of the sociological literature on professional socialization. This literature provides useful insights into the process of learning a professional culture but it has almost exclusively focused on the process of socialization among neophytes to the profession (Becker et al., 1961; Haas and Shaffir, 1987; Olesen, 1968). Expanding the concepts of professional socialization to the case of the professional integration of IEHPs provides the opportunity to examine it as a form of professional resocialization. We describe this as the modifications made to the approach to professional work and professional identity in the process of professional integration, which includes both the universal and the culturally-specific aspects of being a professional,

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and the intersection of the professional identity with wider cultural norms and ideologies. 2. Professional (re)socialization Through the process of professional socialization, individuals e typically students newly enrolled in professional schools e learn not only to acquire the knowledge and skills necessary to the profession, but also to master the acquisition of a professional culture and the creation of their identity as professionals (Becker et al., 1961; Fox, 2000; Howkins and Ewens, 1999; Mackintosh, 2006). Classic ethnographies on medical socialization demonstrate how students internalize the norms of medical culture (Becker et al., 1961), learn to deal with medical uncertainty (Fox, 2000) and to present themselves as physicians through a cloak of competence (Haas and Shaffir, 1987). Similarly, studies of nursing socialization emphasize how nursing ideology and the ethos of care can be lost during the socialization process as neophytes transition from perceiving nursing as caring to nursing as competence (Mackintosh, 2006; Price, 2009). Accounts of professional socialization among midwifery students explore the role of informal sharing and personal communication in enculturation to midwifery (Ulrich, 2004). The vast majority of this literature focuses on the standpoint and experiences of students new to the profession, describing the process of identity formation and adaptation to professional practice. Cross-cultural, inter- or intra-professional transition e or resocialization e has been analyzed by researchers to a considerably lesser extent (but see Baj, 1997; Farnell and Dawson, 2006). In each case, there is not only new learning but also an unlearning to be accomplished, albeit to varying degrees. Any change in workplace setting, even from one medical ward to another, can require adaptation (Farnell and Dawson, 2006). There may also be resocialization needed to reflect changes in practice models within a profession, such as what Nimmo and Holland (1999) described of the pharmacy profession with the transition from more technical to more interpersonal models of pharmaceutical care. Even more profound can be the transition from one profession to another because each has its unique culture which is acquired during the process of socialization and clinical training (Hall, 2005). There are also vast differences among the cultural models of professional practice, since local culture, ideology, and health care organization shape the cultural capital that is acquired during professional training (Kingma, 2006; Khokher et al., 2009). Analyzing the transition of pharmacists into physicians, Austin et al. (2007), for example, described a similar “culture shock” akin to geographically moving from a middle power (e.g., Canada) to super power (e.g., the US). Transitioning to a sometimes entirely new health care culture, IEHPs can experience cultural shock requiring the learning of the local aspects of practice, including dynamic hierarchies of authority in the workplace, protocols of care, and the management of treatment (Baj, 1997; Harris, 2011). Although IEHPs may have several years of professional experience prior to immigration, there may be significant differences in the models and culture of professional practice in the host and home country. Baj (1997) points out that nurses trained in the former Soviet Union faced unique challenges in integrating themselves professionally in the United States, challenges which stemmed partially from their lack of familiarity with the local health care system and different cultural expectations connected to the nursing role. Adjusting to the local culture of practice, IEHPs have to learn the new professional landscape simultaneously with learning the cultural norms of the host country (Erel, 2010; Elias and Lerner, 2012; Bourgeault and Neiterman, 2013). This process is compounded by the salience of

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the professional identity among immigrants who see their occupational status as core to their sense of self (Bernstein and Shuval, 1998). The literature on resocialization more broadly can also be instructive. Traditionally focused on the impact of total institutions in “fixing” the deviant social roles and behaviors of criminal offenders or individuals suffering from mental health problems (Bereswill, 2004; De Hert et al., 1997), the process of resocialization was perceived as completely erasing the previously held identity, substituting it with the one crafted by social institutions which take on a role of socializing agents (Thornton, 1984). Some studies, however, challenge this assumption highlighting the contingency between the old identity and the one acquired during the process of resocialization (Daly, 1992; Freyberg and Ponarin, 1993; Golden, 2002; Thornton, 1984). Focusing on resocialization of Russian immigrants in Israel, Golden (2002) shows that the adoption of new identity e that of an Israeli citizen e does not erase migrants' previous identity completely, but rather modifies and adjusts it to fit the expectations of belonging to Israeli nation. In short, resocialization necessitates learning and unlearning of certain aspects of identity, but some elements persist. 3. Immigration and integration of IEHPS in Canada The context of the immigration and integration of IEHPs in Canada is bifurcated. On the one hand Canadian immigration policies encourage highly skilled migration, including of IEHPs (Kapur and McHale, 2005). This has created a large pool of immigrant health professionals seeking professional integration in Canada but one which has not kept pace with the provincial regulatory infrastructure to integrate them into professional practice (Bourgeault et al., 2010). On the other hand, Canada, like many other western countries, has a long history of reliance on IEHPs (Bourgeault, 2008). In the past decades, close to 25% of Canadian physicians (approximately 17,600) were born and trained internationally (CIHI, 2012a). Between 2007 and 2011 about 7% of Canadian 360,000 nursing workforce had been trained abroad (CIHI, 2012b). Since formal midwifery education was not established in Canada until the 1990s, it is not surprising that the internationally trained midwives have dominated the Canadian midwifery workforce. Although IEHPs have always played a vital role in the Canadian health care system, the recruitment and integration of IEHPs has become a more controversial policy issue (Bourgeault, 2013). Canadian health workforce policy is focusing more on self-sufficiency and domestic production of health professionals, in part due to growing concerns with the ethics of South to North migration of health workers. The increase in domestic production has still left significant distribution issues with rural and remote areas remaining medically underserved and some provinces and health regions recruiting from abroad (Bourgeault, 2008). This creates one path of entry into the Canadian workforce, i.e., those who are recruited directly are eligible to work largely immediately under a provisional license agreement. This path is restricted to those IEHPs who are deemed “practice ready” in Canada based on their education and skills, such as those trained in the U.S., for select nurses from the Philippines and (until most recently) doctors from South Africa (Grant, 2006; Joudrey and Robson, 2010). The second path taken by IEHPs who are not recruited (i.e., those who come to Canada through its selective immigration process) can take considerably longer to enter practice. Many IEHPs are perplexed by the paradox of gaining points for immigration application for their credentials and what they regard as a cumbersome and complicated process of obtaining licensure (Bourgeault et al., 2010). Although there are some differences between provinces in the licensure process of physicians, nurses, and midwives, generally, all

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are required to provide credentials for verification of their education, demonstrate language proficiency in English or French, and successfully complete professional licensure exams. International medical graduates (IMGs) must also compete for a limited number of residency positions to complete their licensure process; thus many remain unable to practice medicine even after passing all the required exams. Throughout this process, IEHPs may participate in bridging programs which aim to integrate and upgrade the skills of IEHPs. These programs vary in structure and duration, but generally, involve refresher courses, profession-specific language training, and preparation for licensure exams. In this paper, we apply the concept of professional resocialization to the transition of internationally educated physicians, nurses, and midwives to the Canadian health care system to capture how they re-evaluate internalized culturally specific professional identity, but in some cases also resist the change. The inter-professional comparison that we are afforded across three professions enables us to explore which aspects of professional resocialization are shared and which are unique. Also, given that professional culture is informed by cultural and gender norms (Witz, 1992), comparing traditionally male- and female-oriented professions provides an opportunity to explore how professional culture is shaped by gender ideologies and how the gendered nature of these professions affect the process of professional resocialization. Our goal is to examine (1) which aspects of professional work need to be modified in transition to a new health care system; (2) which aspects of professional practice are learned by IEHPs in the new health environment, and (3) how IEHPs maintain their professional identity in transition to a new health care system.

to be eligible to practice in Canada. The interviews lasted 60e90 min and were recorded and transcribed verbatim. The interview guide focused on the experiences of IEHPs' professional integration, following the chronological process of migration e the decision to choose Canada as a country of destination, preparations to come to Canada, the experiences upon arrival, the process of professional integration, and workplace experiences for those who were in practice. The interview guide was pilot tested with nine IEHPs at the beginning of the study. The questions flowed organically and were modified to reflect the comments that we received from these participants. Overall, 179 individuals were interviewed in four different Canadian provinces (British Columbia, Manitoba, Ontario, and Quebec) of whom 69 were international medical graduates (IMGs), 71 were internationally educated nurses (IENs) and 39 were internationally trained midwives (ITMs). About half (n ¼ 35) of IMGs were female, comparing with disproportionally female distribution of IENs (n ¼ 59) and exclusively female profile of ITMs. The majority of our IMG respondents came from Eastern Europe followed by the Middle East and South America, East Asia and Western Europe in equal numbers. The most common regions for IEN participants were U.K., other countries of Western Europe, and Eastern Europe. Most of the immigrant midwives came from Western Africa and Western Europe with the U.K. close behind. About 1/3 in each professional category self-identified as members of a visible minority group. About 1/3 of IMGs, 2/3 of ITMs, and more than half of IENs were practicing their profession while the rest were in the process of obtaining professional license. 4.2. Participants & data collection e stakeholders

4. Research design and methodology This paper evolved from a larger study on international migration of health care providers which examined the experiences of IEHPs who came to Canada in the past ten years with the intent to practice in their chosen profession. The research received approval from McMaster University Research Ethics Board. A qualitative methodological approach was employed to enable participants to openly share their views on the migration and professional integration process in Canada. Two types of participants were interviewed for the study e internationally educated health care professionals (international medical graduates, internationally educated nurses, and internationally trained midwives) and federal and provincial stakeholders (members of federal and provincial organizations involved with professional integration of IEHPs).

Short, semi-structured interviews were conducted with 70 federal, provincial, and regional stakeholders who are involved in integration of IEHPs in Canada. Members of professional associations, regulatory bodies, and government officials were chosen based on the role of their organization in the process of integration of IEHPs. These interviews were conducted exclusively over the phone, lasted from 30 to 60 min and were recorded and transcribed verbatim. The semi-structured interview guide focused on the role of the stakeholder's organization in the process of integration of IEHPs, the barriers and facilitators for professional integration of IEHPs, and the policy initiatives that are being considered to facilitate the integration of IEHPs. The questions were derived largely from a scoping review that was conducted prior to the interviews and the analysis of policy documents and government reports pertaining to integration of IEHPs.

4.1. Participants & data collection e IEHPs 4.3. Data analysis The IEHP participants were recruited through a variety of means including immigration offices, local programs designed to facilitate the process of professional integration among newcomer health workers, and using snowball sampling. The participants were included in the study if: (1) they were in the country for ten years or less; (2) they were internationally educated physicians, nurses, or midwives; (3) they were planning to obtain professional license when they arrived in Canada; and (4) they spoke English or French. The interviews were conducted between 2007 and 2008 in person, or on the phone in cases where it was preferred by the interviewee or where the interviewees resided in geographically remote areas. All provided their informed consent to participate in the study. The interviews were conducted in English or French, and while it may seem as a limitation of our research design that we did not interview in other languages, we felt that this shortcoming is justifiable, given that IEHPs who are seeking professional integration need to demonstrate proficiency in one of the Canadian official languages

The interviews with IEHPS and stakeholders were analyzed as two separate datasets, though there ensued an overlap of thematic codes. The analysis was largely inductive, but it was also somewhat informed by the literature and the semi-structured interview guide. First, the interviews with stakeholders were analyzed using “free” unstructured coding and largely descriptive codes. Later they were modified into structured, “tree” coding mapping out the relationships between themes and allowing for emergence of analytical categories. During second stage, the interviews with IEHPs were analyzed as a new set of data to allow the emergence of new themes using the unstructured “free” coding. Upon completion of free coding, we conducted thematic analysis of the data derived from the interviews with IEHPs. The emergent themes of cultural competence, workplace integration, and professional (re)socialization were particularly prevalent in both datasets, warranting concentrated analysis. In the third and final stage of analysis, we

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compared the data pertaining to these themes in both datasets and identified similarities and differences between the respondents from different professions, and among stakeholders and IEHPs. Specifically, we examined how the process of professional socialization is perceived by IEHPs and stakeholders, both in general and within the professions of medicine, nursing and midwifery. The analysis was performed by three members of the research team. All three participated in the development of the coding scheme. To ensure inter-coder reliability, each member independently coded five interviews; the discrepancies in the coding were discussed and the coding scheme was modified. During the second stage of the analysis, the themes derived from the data were discussed among all the members of the research team to validate the findings. The triangulation of data collection and analysis (interviews with IEHPs, interviews with stakeholders, and policy documents/literature) ensured the robustness of the findings. In what follows, we examine the process of professional resocialization in transition to a new health care system. We contrast the aspects of professional integration that both stakeholders and IEHPs themselves consider to be most challenging, and describe how IEHPs embrace and resist certain elements of resocialization. Comparing the accounts of IEHPs and policy stakeholders across three health care professions allows us to explore the issue of professional resocialization from the analytical intersection of gender and professional dominance. 5. Findings 5.1. Status, rank and authority: stakeholder's view What are the gaps in cultural readiness of IEHPs entering practice? Reflecting on this question, federal and provincial stakeholders identified a number of challenges facing IEHPs during professional integration. Although language proficiency and educational background were mentioned in the accounts of our key informants as key challenges for successful integration, they also believed that IEHPs were unfamiliar with the status, rank and authority of their profession in Canada: People who have trained in very hierarchical systems have a great deal of difficulty dealing with nurses and other allied health professionals … The other issue is that it extends to the interpersonal relationships with patients. If you come from a situation where you're the doctor and if the doctor tells you to do ‘x’, you do ‘x’, and you come into Canada and the patient appears for their appointment with a printout from the internet … and the doctor says ‘Well do x’, and the patient says ‘Well, I know you want me to do x, but what about y and b and q?’ Doctor says ‘I am the doctor. You do what I say.’ Doesn't go over too well … (Medical Regulator) IMGs in particular were sometimes portrayed as socialized in more authoritarian models of medicine, where the physician has almost absolute power over patients and other members of health care team. This often implicated gender. Citing anecdotes about IMGs who refuse to attend to a female patient if she is menstruating, or find it difficult to communicate with nurses on a more equal footing, stakeholders constructed an image of a ‘typical’ IMG as overly domineering with non-normative understandings about lines of power and authority. Gendered and racial prejudices were often engrained in this image of IMG, which tended to reflect IMGs coming from non-Western nations. Gendered and racial ideologies also shaped the view of cultural readiness of IENs and ITMs for Canadian practice. According to many of our stakeholders, immigrant nurses and midwives needed to learn to be more independent, assertive and pro-active:

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I believe that Canada has one of the highest standards of nursing education and nursing practice in the world and so part of that is because nurses can function and have authority and scope to function at an independent level in a collaborative team and the individuals that come to us from other countries for the most part do not do that. They're not an equal player in the health care team. And so that is the biggest challenge we have found and the biggest lesson is that while they can have all the nursing skills you want, they don't have necessarily the skills to be able to challenge a physician if they know something is wrong … The biggest challenge is that they, for the most part, automatically assume a subservient role in the health care teams (Educator of IEHPs). It takes some learning to navigate the culture of the Canadian health care system, the culture of the maternity care system, and then to integrate into the model of practice the way midwifery is practiced in Canada … For some midwives coming from some cultures, just the culture of the status of women is significant because if you come out of a system where it's not just the health care system but where women are expected to do what they're told or fit into a very hierarchical structure [it is difficult to adjust].... (Regulator) Cultural and gender norms of the country of origin were seen by the stakeholders as engrained in the professional practice of IEHPs. A ‘typical’ midwife or a nurse in the accounts of stakeholders tended to not be socialized to speak up and to advocate on behalf of the patient. Our respondents generalized this image to the “majority” of immigrant nurses and midwives, despite significant variation in the imported cultures of professional practice among the diverse population of IEHPs. Rank and status of the profession define the roles within the workplace, and without this orientation that comes through socialization IEHPs can experience difficulties in the presentation of their professional selves. Although those IEHPs who arrived in Canada from health care systems with similar structures of professional hierarchy in the workplace (e.g. US or the UK) were not seen as facing this challenge, for other immigrant health care professionals who were trained in the health care systems with different organization of relationships in the workplace, learning the rank and status of their profession in Canada became an essential part of their professional resocialization.

5.2. Roles, responsibilities and professional status: IEHPs' view Entering the workforce, IEHPs had to learn “on the go” how their profession is practiced in Canada. Some tasks seemed to be performed in a familiar way, but others were done or described differently. A major challenge faced by IEHPs in adapting to Canadian professional practice was to understand who does what. The IEHPs were often unsure about their scope of practice and the division of labor in the workplace. This was especially evident in conversation with nurses who were recruited to practice in Canada and often started working immediately upon their arrival. One of the nurses, for example, recalled: There's definitely a difference [in practicing]. One of the things I noticed the most is that Canada has much more clearly defined roles. Like back in South Africa if I was in the ward and a patient was discharged and the bed needed to be cleaned, I would grab the stuff and clean the bed because the next patient needs to come in; whereas what I found [here] was that everybody's role was very much the role you stick to. If I did that [change the sheets] in [Canada] they would say ‘No, no … It's not your role’ … And that

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was one thing that took a bit of getting used to … (practicing female IEN). Learning which tasks are and are not performed by nurses in Canada and which are delegated to other members of the health care team was often seen as a first step in professional integration and resocialization. Indeed, certain elements of this division of labor could be seen as reflecting the relatively higher status of nursing in the Canadian context. Almost every one of our participants recalled a situation where they stepped outside of what were considered to be their professional responsibilities, and many consequently received a reprimand from a fellow colleague or a nursing manager. While nursing practice in Canada was seen as different from the standards that IENs had back home, for many IENs, and especially those who came from similar health care systems, these differences were not perceived as a major challenge for professional practice. That was not the case with internationally trained midwives (ITMs) who often had to adjust to a very different way of practice. In Canada, midwives are primary care givers who oversee pre-, intraand postpartum (up to six weeks) care for women and infants with no medical complications. Depending on the choice of their clients, midwives assist women requesting either home or hospital birth. This model of care is unique and many midwives had difficulties to adjust their skills to the broad scope of Canadian practice. One of our respondents, a nurse-midwife from the UK who came initially to Canada as a nurse but decided to become a midwife, compared the differences between the two processes of professional integration: Coming here as an RN was easy. That was a simple, stress free process of coming and writing the exam, getting your license, and boom e you're done. That I didn't find hard. The midwifery was the real stumbling block for me. In Canada the model of practice is very much based on us being a community midwife within the community as a primary health care provider, like a GP … So if you come from the U.K. and you haven't worked in the community apart from doing your training and you've had no clinic based experience, [your] community based experience was very minimal (practicing female ITM). For midwives, therefore, the gap in professional socialization was perceived in terms of a lack of training and experience working in a particular setting eat home e and with a broad scope. Although the set of professional skills of incoming midwives may match the standards of midwifery practice in Canada, the status as a primary care provider, and the responsibility that came with this status was seen as a barrier. Moreover, coming from more biomedically oriented models of midwifery, many ITMs struggled to adapt to the more holistic, low-tech kind of midwifery practiced in Canada. The setting in which the birth is managed and the style of providing care required ITMs to make significant adjustment to their professional culture. Learning their new professional status and the way their profession is practiced in Canada was also a challenge for some IMGs: In Philippines, the doctors are much more involved in the care of their patients … They come every day even though they are specialists. They also rely less on labs and only do them when they are really needed. The doctor and patients are closer there than here. Here also the nurses have much more responsibilities and they also can “manage” a doctor. They really may cause him trouble (male IMG, in process of obtaining the license).

Echoing the responses from other immigrant doctors, this IMG identified three major differences between the Canadian and a foreign model of medical practice. First, the lack of technologies and the cost of diagnostic tests in many developing countries made immigrant physicians more reliant on direct communication with the patient in diagnosing and identifying the medical problem. Thus, many IMGs suggested that Canadian doctors seemed to be more ‘remote’ from the patient and less in touch with the ‘art’ of the clinical encounter in arriving at a diagnosis. Consequently, communication between the doctor and the patient in the Canadian health care system was perceived by IMGs as fragmented and less ‘personal’. The third difference between Canadian practice and the medical training brought from abroad was seen in the professional status of physicians in communication with other members of the health care team, most commonly, nurses. As this respondent suggested, nurses in Canada were often seen as a ‘threat’ to physician's authority. Not only did IEHPs have to learn what tasks were within their scope, our respondents also reflected on how they had to learn the “Canadian way” of doing these tasks from taking medical history or ordering diagnostic tests. Those IEHPs who came from developing countries, sometimes felt that they were not familiar with the technology available to Canadian health professionals, and had to learn how to use it. Another challenge faced by IEHPs was learning how to communicate using a “Canadian style” with patients and other health care professionals. Immersed in a new professional environment IEHPs had to adjust to the cultural differences. As an IEN from Philippines noted, respect for elderly patients is displayed differently in Canadian and Filipino cultures. He recalled: I was born in a culture where the respect with elders is, you know … It's a big deal if you don't respect an elder in my country, it's a very big deal. So here I came to Canada and I heard, ‘Hey, John!’ And John is like 80 years old … You know, you want to adjust to the environment and slowly fit into that population, you should also do what they are doing, you know. As they said, do what the Romans do. But this is not what I am doing sometimes. Sometimes I greet them like, ‘Hey, John how are you?’ And then, ‘Oh Mr. McKenzie, I am sorry!’ And then they will tell you, the patient will say, ‘It's okay, you can call me John.’ You know. But it's not okay with me … (practicing male IEN) The cultural adaptation to professional practice was not limited to what is happening in the workplace but often required adaptation to the general culture of interpersonal communication in Canada. Thus, entering the Canadian workplace IEHPs had to learn new skills, roles and responsibilities, and develop an appreciation for how the status of their profession in Canada may be different from what they are used to. To adjust to the Canadian way of practice, immigrant nurses, physicians, and midwives modified their practice to fit Canadian standards and in so doing reframed their professional identity. The status of their profession, the authority that they held in the workplace, the language used for communication, the technology and availability of different clinical tests were all a novel experience for these IEHPs. They had to learn wider Canadian culture which is engrained in the professional practice and communication with patients. This process of learning required reevaluation of the familiar patterns of communication, re-learning the role of their professional cadre in the workplace, and adapting to the way their profession is practiced in Canada. It also required adjusting their imported identity as a professional to the Canadian work environment. This process of learning new skills and unlearning “old ways” of

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practicing was more profound for IEHPs coming from non-western health care systems, but those who came from the health care systems that are similar to Canadian system (e.g. US, UK, Australia and France) also did report cultural shock during the process of professional integration. They had to learn local abbreviations for medications and tests, new protocols of care, and, in the case of midwifery, how to adjust to a different status of their profession. But they were more familiar with the wider cultural and social norms, including gender relations, than their counterparts from global south. 5.3. Managing professional identity: accommodation & resistance in IEHPs' views What makes IEHPs different from the neophytes described in the professional socialization literature is that learning how to be a professional in Canada takes place within a context where these practitioners already have established professional identities that they acquired in their countries of origin. The vast majority of our respondents had been in practice for five to 15 years prior to immigrating to Canada. Moreover, many IEHPs had gained entry into Canada demonstrating that their qualifications and skills meet Canadian standards. Therefore, modifying their professional identity to meet Canadian standards of practice meant balancing the need to present themselves as “competent” to be practicing in Canada while at the same time ascertaining in what ways they needed to adjust in the presentation of their professional selves in order to fit in. Our respondents dealt with this challenge by adopting two strategies e minimizing the differences between professional practice in Canada and their home country, and in some cases, by asserting the superiority of their professional approach. Many IEHPs suggested that their Canadian-trained colleagues overstated the differences between local practice and the model of practice from their home countries: My major problem with it is that it sort of comes across that midwives in Canada are like the top, the super midwives, like that's really a little bit how I felt … Childbirth is not different from country to country. It's not maple syrup [that] is coming out of the breast here and that we need to know then what breastfeeding is all about. I'm sorry, but that's just how it comes across (practicing female ITM from Western Europe). While learning local professional culture was welcomed by the vast majority of our respondents, many IEHPs also suggested that their professional readiness and skills were often unnecessary questioned by their colleagues and educators. The presumed inferiority of IEHPs in professional practice was often assumed in the comments of the fellow colleagues, in some topics covered in bridging programs, and it was evident in some of the stakeholder interviews we conducted. Another strategy employed by IEHPs in maintaining their professional identity and status was to assert the superiority of some of their approaches to care by way of contrast to Canadian health care professionals. This theme was evident in the accounts of respondents who came from the developed countries with levels of technology similar to Canada and those who came from countries with less technological advancement and had to rely on their personal skills in assisting the patients: I kind of had a higher expectation of what I would think nurses trained in Canada should have and I'm very sad to say that I honestly do find it very substandard to what I've been trained … And I just find that horrifying. What are they actually being trained

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to do? … Their training … that is shocking … I'm sounding very snobbish but our [IENs] training is so much more intense, so much more extensive.’ (practicing female IEN) As this nurse, trained in middle income country, suggested, IENs saw some of their skills as exceeding Canadian standards. Many years of experience and knowledge of not only Canadian but also tropical and other diseases which are uncommon in Canada made the IENs, in their opinion, more knowledgeable and more skilled than their Canadian-trained colleagues. At the same time, they had to content with the image of Canadian training as ‘ideal’. The theme of superiority was even more strongly pronounced in the interviews with IMGs. Many highlighted their advanced knowledge, skills, and training in comparison to Canadian-trained colleagues: Down there [in my home country] … you make more use of your brain because when you don't have the facilities to make a diagnosis, your brain is only place to rely upon … (male IMG in training from Middle East) The work of the doctor's ‘brain’ in making the diagnosis, something that one of our respondents was referring to as ‘art’ in medicine, was, in the opinion of IMGs, lost in the Canadian medical practice because of its heavy reliance on diagnostic tests. Comparing Canadian medical education with the systems in their own home countries, many IMGs portrayed their home training as more challenging. These accounts of IMGs have to be understood in relation to the difficulties experienced by IMGs in trying to obtain a license to practice medicine in Canada. The requirement of regulatory colleges to have Canadian training as a necessary step for obtaining medical license, and the handful of available training positions, were often perceived by IMGs as intentional barriers to entry set up by locally trained doctors. Explaining this perceived unwillingness of locally trained doctors to accept IMGs, some of our respondents believed that it was the IMGs' professional superiority that posed a challenge for Canadian trained doctors to allow IMGs to enter the system: We [IMGs] have more knowledge than these [Canadian] doctors … We have more knowledge.... more experience … We use more our clinical [skills] cause they don't use that. So … there is a fear from the doctors, Canadian doctors, they want to protect [themselves]. … They don't want to be challenged [by IMGs] (male IMG in training from South America) Portraying themselves as professionals whose skills and qualifications are comparable to, if not superior to, Canadian standards, IEHPs maintained their professional identity during their retraining in Canada. Rather than learning to become a professional, they saw themselves as already professional, though needing to adjust the enactment of their role as professionals in a way that conformed to Canadian culture and standards. Their professional identity was often firmly engrained in their sense of self and navigating through the Canadian health care system they maintained it while learning a new culture. This tension between the need to maintain the existing professional status and the need to learn the Canadian way of practice is at the core of the process of professional resocialization. 6. Discussion and conclusion Professional practice is always embedded in wider cultural and

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political ideologies (Tuohy, 1999; Witz, 1992); thus the process of professional integration of IEHPs should be understood as a transition that requires adaptation to new ways of practicing and learning a new set of skills, responsibilities, and professional relations. We have showed that like neophytes to the professions, IEHPs need to learn how to enact their role as professionals in their new workplace, how to communicate with patients and other members of the health care team, and which roles and tasks comprise locally bound professional practice. Unlike neophytes, however, our respondents did not need to acquire the identity of professional. They came to Canada with already well-formed professional identities reflecting the context of their training abroad. Seeking professional integration in Canada, they had to demonstrate their clinical competency e the equivalency of their previous training and education to Canadian standards e but had to change their cultural competency to reflect a new practice context. The transition to the Canadian health care system, therefore, was not simply a process of adaptation to a new workplace; it was often a transition to a new culture of practice, combining ‘old’ skills with new skills and new patterns of communication. Moreover, struggling to gain access to the Canadian workplace, our respondents felt that their already well-formed professional skill set and identity was questioned by their Canadian colleagues. The very process of the evaluation of IEHPs' skills and qualifications in accordance with the Canadian standards presupposes that the Canadian education and training is the norm, to which other (e.g. foreign) training and education must be compared. Dealing with this potential threat to their professional sense of self, IEHPs sought to maintain their professional status by minimizing the differences between and in some cases showing the superiority of their skills in comparison to their Canadian colleagues. It will be interesting to see in future research how these resocialization processes are experienced for the growing cohorts of Canadian-born students studying medicine abroad. The identity of a doctor has been revealed to be a prominent identity among IMGs, firmly embedded in their sense of self (Neiterman and Bourgeault, 2012; Remennick and Shakhar, 2003). Stripping themselves of their previous professional identity may be especially painful for immigrants who had high social status in the professional hierarchy of their home country (Remennick, 2002). Although physicians who participated in our study were more vocal about their professional superiority, we also found similar motifs in the accounts of nurses and midwives. For all three groups of professionals that we examined, acquiring the license to practice in Canada was a long and cumbersome process, although physicians faced relatively greater challenges than nurses or midwives. In cross-cultural transition, the process of professional resocialization is situated in the context of struggle over professional recognition in a situation where immigrant professionals also face institutional and interpersonal discrimination. Future research may shed more light on how the degree of difficulty in entering professional practice shapes the management of foreign professional identity during the process of workplace integration. Gender and cultural ideologies often made the transition to Canadian practice particularly challenging for the IEHPs who come from more hierarchical health care systems. The gender and racial stereotypes held by local professionals, evident in our stakeholder interviews, are also important to deconstruct. Portrayed as subservient and lacking advocacy skills, IENs and ITMs were seen as in need of learning how to take initiative, and thus they did not pose significant threat to the professional hierarchy of their cadre. The interlocking power of gender, ethnic and professional ideologies made IENs and ITMs to be perceived as too nurturing, feminine and subservient reflective of broader post-colonial ties between source and destination country (Choy, 2003). IMGs, on the other hand,

were often seen as overly dominant and this may create additional intra-professional tension between them and locally trained doctors. Gender also influenced the voices within the professional group of IMGs e female doctors were less likely to voice the claims of professional superiority, and when they did, they did not frame it as a basis for intra-professional conflict with locally trained doctors. Due to nature of our sample, we were not able to identify gender differences within the group of IENs and ITMs in presentation of professional self. Future research may further contribute to our understanding of the interplay between gender and professional socialization. Given that IEHPs who come to Canada are a diverse group, coming from variety of countries with different cultures and different organization of health care systems, our analysis does pose a challenge in identifying similarities across a group of individuals of diverse cultural, ethnic, and professional backgrounds. Immigrants from Global South or Eastern Europe, for instance, may have more challenges integrating into the system than their counterparts from Western Europe or the United States because of unfamiliarity with the western medical/nursing/midwifery practice, cultural differences, or language barriers. Another challenge of such comparison lies in the length of time that IEHPs spend in the country before they begin professional practice. For someone who begins to work immediately, learning new culture happens “onthe-go” while those IEHPs who had a chance to learn about Canadian professional world while attending bridging programs or refresher courses may feel more “prepared” to enter the Canadian health care system. We contend, however, that across all cases, IEHPs are required to modify their professional identity, unlearn some skills and adopt others (although for some IEHPs this will signify more profound change than for others). Interestingly, this process is not only relevant to those who do not have English or French language as a mother tongue. In sum, because the process of professional socialization occurs through the education process (i.e., four or more years), it is important to recognize that professional resocialization also takes time. While the reliance on IEHPs will most likely remain a feature of the majority of health care systems of the developed world, various stakeholders need to recognize the cultural specificity of professional practice in the IEHPs' integration process. We offer here a lens on this dynamic drawing upon and expanding the notion of professional resocialization to show its impact not only on clinical competency but also on professional identity and the processes of acceptance and resistance of new models of practice. The insights garnered from this analysis not only apply to cases of resocialization across cultures as we have explored here, but also across professions and across different cohorts within professions socialized in unique ways. Acknowledgment This research was funded by Social Sciences and Humanities Research Council of Canada (SSHRC). We would like to thank Dr. Dorothy Pawluch for her helpful comments on the earlier version of this paper. The authors would also like to thank Jane LeBrun, Ken Viers, and Jude Winkup for their help in collecting and analyzing the data. References Austin, Z., Gregory, P.A., Martin, J.C., 2007. Negotiation of interprofessional culture shock: the experiences of pharmacists who become physicians. J. Interprofessional Care 21, 83e93. Baj, P.A., 1997. Evaluation of a programme to train Russian emigre nurses. Int. J. Nurs. Pract. 3, 40e46. Baumann, A., Blythe, J., Rheaume, A., McIntosh, K., 2006. Internationally Educated

E. Neiterman, I.L. Bourgeault / Social Science & Medicine 131 (2015) 74e81 Nurses in Ontario: Maximazing the Brain Gain. Nursing Health Services Research Unit, Toronto: Ontario Government. Becker, H.S., Geer, B., Hughes, E.C., Strauss, A.L., 1961. Boys in White: Student Culture in Medical School. University of Chicago Press, Chicago. Bereswill, M., 2004. Inside-out: resocialisation from prison as a biographical process. A longitudinal approach to the psychodynamics of imprisonment. J. Soc. Work Pract. 18, 315e336. Bernstein, J., Shuval, J.T., 1998. The occupational integration of former Soviet physicians in Israel. Soc. Sci. Med. 47 (6), 809e819. Bourgeault, I.L., 2013. Health professional migration. In: Monahan, L., Gabe, J. (Eds.), Key Concepts in Medical Sociology, second ed. Sage, London, pp. 169e174. Bourgeault, I.L., 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. 199e217. Bourgeault, I.L., 2008. On the move: the migration of health care providers into and out of Canada. In: Singh Bolaria, B., Dickenson, H. (Eds.), Health, Illness & Health Care in Canada. Nelson Education, Toronto, pp. 76e98. Bourgeault, I.L., Neiterman, E., LeBrun, J., Viers, K., Winkup, J., 2010. Brain Gain, Drain & Waste: the Experiences of Internationally Educated Health Professionals in Canada. University of Ottawa, Ottawa. Available at: www. healthworkermigration.com. Buchan, J., 2006. The impact of global nursing migration on health services delivery. Policy Polit. Nurs. Pract. 7 (3), 16Se25S. Buchan, J., Sochalski, J., 2004. The migration of nurses: trends and policies. Bull. World Health Org. 82, 587e594. Choy, C.C., 2003. Empire of Care: Nursing and Migration in Filipino American History. Duke University Press, Durham, N.C. CIHI, 2012a. Regulated Nurses: Canadian Trends, 2007e2011. Canadian Institute for Health Information, Ottawa. CIHI, 2012b. Supply, Distribution and Migration of Canadian Physicians, 2011. Canadian Institute for Health Information, Ottawa. Cowan, D.T., Norman, I., 2006. Cultural competence in nursing: new meanings. J. Transcult. Nurs. 17 (1), 82e88. Daly, K.J., 1992. Toward a formal theory of interactive resocialization: the case of adoptive parenthood. Qual. Sociol. 15, 395e417. De Hert, M., McKenzie, K., Pieters, G., et al., 1997. Rehabilitation and resocialization for the long-term mentally ill in Belgium: description of services and history of their development. Int. J. Ment. Health 26, 86e97. Elias, N., Lerner, J., 2012. Narrating the double helix: the immigrant-professional biography of a Russian journalist in Israel. Qual. Soc. Res. 13, 1e22. Erel, U., 2010. Migrating cultural capital: Bourdieu in migration studies. Sociology 44, 642e660. Farnell, S., Dawson, D., 2006. ‘It's not like the wards.’ Experiences of nurses new to critical care: a qualitative study. Int. J. Nurs. Stud. 43 (3), 319e331. Fox, R.C., 2000. Medical uncertainty revisited. In: Albrecht, G.L., Fitzpatrick, R., Scrimshaw, S. (Eds.), Handbook of Social Studies in Health and Medicine. Sage,

81

Thousand Oaks, California, pp. 409e425. Freyberg, M., Ponarin, E., 1993. Resocializing teachers: effects of graduate programs on teaching assistants. Teach. Sociol. 21, 140e147. Golden, D., 2002. Belonging through time: nurturing national identity among newcomers to Israel from the former Soviet Union. Time Soc. 11, 5e24. Grant, H.M., 2006. From the Transvaal to the Prairies: the migration of South African physicians to Canada. J. Ethn. Migr. Stud. 32 (4), 681e695. Haas, J., Shaffir, W., 1987. Becoming Doctors: the Adoption of a Cloak of Competence. JAI Press, Greenwich, Connecticut. Harris, A., 2011. In a moment of mismatch: overseas doctors' adjustments in new hospital environments. Sociol. Health Illn. 33 (2), 308e320. Hall, P., 2005. Interprofessional Teamwork: Professional Cultures as Barriers. Howkins, E.J., Ewens, A., 1999. How students experience professional socialisation. Int. J. Nurs. Stud. 36 (1), 41e49. Joudrey, R., Robson, K., 2010. Practising medicine in two countries: South African physicians in Canada. Sociol. Health Illn. 32 (4), 528e544. Kapur, D., McHale, J., 2005. Give Us Your Best and Brightest: the Global Hunt for Talent and its Impact on the Developing World. Center for Global Development, Washington, D.C. Kingma, M., 2006. New challenges, emerging trends, and issues in regulation of migrating nurses. Policy Polit. Nurs. Pract. 7 (3), 26Se33S. Khokher, P., Bourgeault, I.L., Sainsaulieu, I., 2009. Work culture within the hospital context: professional versus unit influences. J. Health Organ. Manag. 23 (3), 332e345. , R., Packer, C., Klassen, N., 2006. Managing health professionals migration Labonte from sub-Saharan Africa to Canada: a stakeholder inquiry into policy options. Hum. Resour. Health 14, 4e22. Mackintosh, C., 2006. Caring: the socialisation of pre-registration student nurses: a longitudinal qualitative descriptive study. Int. J. Nurs. Stud. 43 (8), 953e962. Neiterman, E., Bourgeault, I.L., 2012. Conceptualizing professional Diaspora: international medical graduates in Canada. J. Int. Migr. Integr. 13 (1), 39e57. Nimmo, C., Holland, R., 1999. Transitions in pharmacy practice, part 4: can a leopard change its spots? Am. J. Health Syst. Pharm. 56, 2458e2462. Price, S.L., 2009. Becoming a nurse: a meta-study of early professional socialization and career choice in nursing. J. Adv. Nurs. 65 (1), 11e19. Remennick, L., 2002. Survival of the fittest: Russian immigrant teachers speak about their professional adjustment in Israel. Int. Migr. 40 (1), 99e121. Remennick, L., Shakhar, G., 2003. You never stop being a doctor: the stories of Russian immigrant physicians who converted to physiotherapy. Health 7 (1), 87e108. Thornton, W.P., 1984. Resocialization: Roman Catholics becoming protestants in Colombia, South America. Anthropol. Q. 57, 28e38. Tuohy, C., 1999. The dynamic of change in the health care sphere: the United States, Britain and Canada. Health Aff. 18 (3), 114e134. Ulrich, S., 2004. First birth stories of student midwives: keys to professional affective socialization. J. Midwifery Womens Health 49 (5), 390e397. Witz, A., 1992. Professions and Patriarchy. Routledge, London/New York.