From margins to mainstream: Incorporating internationally educated health professionals’ skills into primary care

Introduction

More than 6 million Canadians don’t have access to comprehensive primary care. ¹ At the same time, Internationally Educated Healthcare Professionals (IEHPs) face what can seem like insurmountable barriers to returning to practice. A 2023 Statistics Canada report estimates there are almost 260,000 working-age IEHPs in Canada. ² Within this population, 76% are employed, but only 58% of them work in healthcare, and an even smaller percentage of those work in the fields that they are trained in. As health leaders consider how they will meet the health workforce challenges that keep them from providing the levels of care that Canadians need, they should be looking into this underutilized pool of talented healthcare professionals as a valuable resource. As we face persistent shortages of nurses, as pharmacists take on more responsibilities in community-centred care, as the Canadian Dental Care plan unfolds, and as family physicians retire without replacements, it behooves us to be highly focused on utilizing the skills of IEHPs.

In this case study, we provide an overview of the collaborative efforts to integrate the skills of IEHPs undertaken by a non-profit workforce development organization, ACCES Employment, in collaboration with a range of health systems partners as a part of Team Primary Care.

Our analytic approach involved a review of program activities, program reports, policy documents, and interviews with key actors to highlight strategies, partnerships, and outcomes. In our analysis, we centred feedback from IEHPs, incorporating their evaluations of support systems available to them to contextualize our readings of relevant documents. A broader review of partnerships between non-profit organizations serving IEHPs and health systems actors was also conducted. Given the relatively small number of these partnerships, we also used our interviews with key actors to explore barriers to partnership. These processes highlighted recurring themes in the development, implementation, and longevity of workforce development supports for IEHPs that are detailed in the case study. Through the examination of ACCES Employment’s integration into the Team Primary Care initiative, the article demonstrates the importance of coordinated efforts in overcoming longstanding barriers faced by IEHPs.

Settlement agencies and workforce development non-profit organizations play an important role in supporting the settlement and career development of IEHPs. Professional associations and regulatory bodies engage with IEHPs who are pursuing licensure, and many are experimenting with changes to their processes to increase licensure while still protecting public safety. This problem has been tackled in silos for far too long, though, with non-profits, professional associations and educational institutions going it alone trying to improve the rate that IEHPs can contribute to their communities.

If workforce development non-profits and health system actors could find more ways to work in partnership, they could significantly expand their capacity to make real and meaningful progress in integrating IEHPs into the Canadian health system. To make this more possible, Canada’s healthcare workforce development initiatives could be built upon enhanced and expanded funding mechanisms that purposefully engage non-profit workforce development organizations in working closely alongside regulatory bodies, professional associations and health systems employers. While there are moves towards increased collaboration between non-profits and these groups, this collaboration is not embedded into the systems of support for IEHPs.

Health workforce could follow promising collaborative practices from other sectors

Workforce development non-profits play an important role in supporting internationally educated professionals as they navigate challenges posed by complex regulatory requirements, cultural differences, and systemic barriers. Their approaches involve being responsive to local communities, job seekers, employers, and other partners to continuously improve. In bridging services for internationally trained engineers, human resources professionals, information technology professionals and others, professional associations, and regulatory bodies are typically embedded directly within program activities to consistently inform and support the labour market success of internationally educated professionals in their fields. Funders such as the Ontario Ministry of Labour, Immigration, Training and Skills Development purposefully embed collaboration with the sector into their funding requirements, and consistent success breeds ongoing support. Why should health workforce development be so different?

Health workforce development initiatives that are designed to help IEHPs overcome the barriers they face are funded by a variety of federal and provincial ministries as well as through charitable organizations. ACCES Employment has leveraged funding from government funders, including Immigration, Refugees and Citizenship Canada and from the Ontario Ministry of Labour, Immigration, Training and Skills Development, to support more than 700 IEHPs, with a clear focus on helping IEHPs secure high quality non-licensed employment in the health sector that supports their pathways to licensure. Other non-profits offer a diverse mix of services, ranging from health sector English language courses to retraining initiatives that aim to move IEHPs into high demand, but typically lower skill level, health professions.

These services are designed to help IEHPs navigate the complexities of licensure and employment within the Canadian healthcare system, but they have historically operated distinctly apart from professional associations and regulatory bodies. While these groups do occasionally access funding to better engage with IEHPs, community-based non-profits play a central, yet often disconnected, role in health workforce development. Despite their best efforts to support IEHPs, non-profits face limitations in addressing systemic barriers independently and require collaboration with health systems actors to drive meaningful change.

Seeing IEHPs as a potential part of comprehensive primary care teams

Team Primary Care decided at its outset to actively integrate the contributions of non-profits serving IEHPs into the overall project. Through this inclusion, it created space for all project partners to view IEHPs as parts of their teams, and it provided ACCES Employment with a framework through which it could enhance the training made available to IEHPs, aligning it more closely with what the health sector was identifying as critical skills for success in the workplace.

At the core of this training was a recognition that incorporating Equity, Diversity, Inclusion and Access (EDIA) into health skill sets was a necessary precondition to IEHPs effectively communicating in interprofessional teams that served highly diverse communities. This aligned well with Team Primary Care’s principles of interprofessionalism, EDIA, truth and reconciliation, psychological health and safety, and social accountability. In recognition of the serious psycho-social barriers that IEHPs face when they are unable to practice post-immigration, support services geared towards addressing IEHPs’ identity loss and status anxiety were created and implemented alongside training focused on building resiliency skills to support both personal and organizational success.

Within the short period of the case study, high levels of support were provided to a large number of IEHPs. Given the limited timeframe of Team Primary Care, IEHP supports will continue beyond the end of the project through leveraging other funded programs to help IEHPs reach their employment goals. Of clients who have completed the supports available to them, results have been very strong, as detailed in Table 1.

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Table 1.

Supporting IEHPs in putting their skills to use in primary care environments.

Type of IEHP support	EDIA and interprofessional communications training	Building social capital	Further training and licensure supports	Securing employment	Client success rate (%)
Number of IEHPs who completed supports	117	117	10	98	92

Through engagement with other Team Primary Care partners, a wide range of small initiatives to support IEHPs at health systems actors surfaced, often comprised of only a few interested leaders or faculty members trying to make a difference. With the College of Family Physicians of Canada (CFPC) and other trusted health systems actors at the table, individuals’ efforts and ad hoc initiatives were able to coalesce and be imagined in systematic and sustainable ways. Collaborative, mutually beneficial partnerships were built that catalyzed innovative solutions to healthcare workforce challenges. By leveraging the expertise and resources of both non-profits and the health sector, these partnerships reduced the distance between IEHPs and primary care employers, creating opportunities to actively address systemic as well as structural and cultural barriers to health sector integration.

The active engagement of employers in health sector workforce development programming is critical to realizing success for IEHPs, but healthcare employers have traditionally been difficult to engage. Through engagement with the range of partners taking part in Team Primary Care, many of the barriers that are typically faced when engaging with health sector employers were reduced, and IEHPs were supported in moving into positions such as General Manager, High Priorities Community Health Ambassador, Director of Operations, Mental Health Worker, Medical Office Administrator, Clinical Research Coordinator, and many other positions. In addition to these non-licensed roles, participants were supported in actively advancing their licensure processes, getting them closer to fully using their skills in the health sector.

Building partnerships for long-term change

ACCES Employment used opportunities available through Team Primary Care to deepen its collaboration with the Health Commons Solutions Lab at Sinai Health, a publicly funded, not-for-profit innovation lab that challenges leaders in health and social systems to think differently about their work and the people that they serve. IEHPs often arrive in Canada with significant expertise in conducting health research but have difficulty in securing research positions within teams that often recruit from pre-defined networks. With funding from Team Primary Care and the active partnership of the Health Commons Solutions Lab, ACCES facilitated the inclusion of IEHP researchers in multiple Health Commons research projects, ensuring that IEHPs’ experience leading innovative health systems work outside of Canada could be incorporated in leading edge research. Their skills and voices contributed to research on creating adaptive career pathways for IEHPs in comprehensive primary care environments, personalizing health exploration using health technology platforms, and developing resources for Ontario Health Teams who are considering implementing Hepatitis C elimination strategies locally.

Another barrier that non-profits often face in IEHP workforce development initiatives is getting buy-in from key sectoral actors to mobilize support in professional communities. Despite the desire of many in the health sector to contribute to IEHPs’ return to practice, there are very few formal and consistent ways to volunteer. Through Team Primary Care, ACCES Employment was introduced to Dr. Eva Grunfeld, a renowned expert in primary care for cancer patients. Dr. Grunfeld had helped an IEHP that was interested in moving into midwifery develop the health language skills she needed to succeed and was interested in contributing to the broader development and rollout of a project that would mobilize other physicians in making similar connections. In partnership with Dr. Grunfeld, ACCES Employment is now piloting Health English Language Pro (HELP), pairing immigrant physicians with practicing or recently retired Canadian physicians to develop the highly nuanced health sector communications they need to succeed in Canada’s health system.

Grant funding to support IEHPs runs in cycles, and this often presents barriers to creating projects that have sufficient longevity to move beyond outputs and outcomes and into impact. From the outset of this case study, ACCES worked closely with a developmental evaluator to focus on impact and longevity, contributing to a clear focus on creating change for the long term. To ensure that the collaboration carefully fostered in this initiative will continue to effect change in the labour market integration of IEHPs, a series of partnerships with health sector actors were developed and integrated into funding proposals to support IEHPs. These partnerships will reduce IEHPs’ distance from the health sector while at the same time ensuring that their training reflects their unique needs. Partnerships have been developed with the Mental Health Commission of Canada, the Equity in Health Systems Lab, and the Centre for Advancing Collaborative Healthcare and Education to incorporate industry-leading training into services for IEHPs. Other key health systems actors, including the CFPC and the Canadian Pharmacists’ Association have extended support for enhanced services for IEHPs, showing significant leadership in unlocking IEHPs’ potentials to contribute to resolving the health human resources crisis.

Scaling up change to meet immediate demands

The partnerships fostered within this case study represent a much-needed start in the move towards more collaborative, coordinated approaches to health workforce development. They are a response not only to the needs of IEHPs, but also an important component in helping health leaders address Canadians’ lack of regular access to care. To make a broader impact on the health workforce crisis and to drive sustainable change in integrating IEHPs into the healthcare workforce, though, a scaled-up systems-thinking approach is imperative. Workforce development funding that purposefully incorporates the expertise of non-profits that serve IEHPs alongside professional associations, regulatory bodies and health systems employers is needed. To be truly effective in bringing the skills of IEHPs to bear in building healthier Canadian communities, funding must emphasize collaboration, innovation, and continuous improvement.

It must also ensure that full labour market integration of IEHPs is a goal that is achieved through a continuum of services that start as soon as an IEHP is approved for permanent residency and continues through to their entering Canadian practice. A commitment to funding pre-arrival services for IEHPs could significantly accelerate their labour market integration and their return to practice. Taking the opportunity to support IEHPs prior to their arrival in Canada opens up opportunities to accelerate their transition into the health sector at a time when their skills are desperately needed.

There’s no doubt that this work will be complex, but this complexity provides even more reason for an integrated collaborative systems approach. Limitations to the view of how this work could proceed include potential biases that are inherent in the case study approach we’ve used, but the lack of coordinated, collaborative training options available to IEHPs is not a new phenomenon. By fostering cross-sectoral partnerships and incorporating diverse perspectives, partners can develop wholistic solutions to integrating IEHPs into the Canadian healthcare workforce.

The future Canadian health workforce will need to include IEHPs’ skills in comprehensive, community-centred, team-based primary care environments if it wants to meet the challenges of providing the care that Canadians will increasingly need. To reach this point, collaborative partnerships between non-profits and health systems actors will need to be the norm rather than the exception. These partnerships can deploy complementary sets of expertise while building solutions for complex workforce problems, and this purposeful collaboration will regularly drive innovation in healthcare workforce development. As health leaders explore how they can address the health workforce crisis, our findings underscore the transformative potential of scaling these collaborative integration efforts in building a more inclusive and resilient healthcare workforce through supporting IEHPs’ returns to practice, ultimately enhancing access to quality primary care for all Canadians. By leveraging the strengths of both sectors, these partnerships will overcome structural, cultural, and systemic barriers to IEHP integration, ultimately leading to a more inclusive and resilient healthcare workforce.