The International Council of Nurses  has predicted an unprecedented global shortage of both clinical and academic nurses. Indeed, high income nations such as Australia, Canada, the United States and the United Kingdom have for several decades redressed deficits in the nursing workforce via recruitment of internationally educated (IENs) and trained nurses [2–4]. Strategies of this nature are fraught with ethical dilemmas . In summary, the mass movement and relocation of a highly skilled workforce has consequences for both the country of origin of the recruited nurses and the host community (both professional and lay). Most notably for the country of origin, are the profound effects on health care provision (in terms of nurse-to-patient ratios) that can occur when developing or low-income countries as a development strategy train large numbers of nurses who subsequently migrate .
Since health care systems are configured and evolve in relation to socio-economic, political, and cultural circumstances, there may be wide variation in the context of health care delivery and in the education and training of health professionals, including nurses . These variations may mean that the professional competencies, including ethno-cultural components, nurses achieve during core education may or may not be directly transferable to another health care context. Historically, issues faced when acquiring credentialing are the major barriers for IENs and other foreign-trained professionals hoping to obtain meaningful employment [8–10]. Indeed, the main challenge many IENs face is finding that their qualifications do not meet the standards in the destination country [10, 12–16]. While bridging/retraining/adaptation programs are available in some countries, these at present generally lack standardization and are often of suboptimal content. An often delayed licensure and registration promotes the "deskilling process" , consequentially IENs are forced to work lower level jobs and are retained within these positions for extended periods due to inconsistent training policies and both overt and subtle forms of discrimination [11, 13, 17]. Beyond limiting the potential of IENs to reach their full potential through competency recognition and promotion, deskilling and discriminatory practices may foster feelings of invisibility and marginalization with long-term effects including reduced self-esteem, confidence and possibly psychological health and well-being.
In addition to the credentialing issues that have been well-documented[10, 18, 19], new immigrant nurses may need considerable support in transitioning into new social and health care environments. Cultural displacement is frequently described and largely encompasses: language and communication barriers, feelings of being an "outsider", and differences in nursing practice. Nursing is a profession that highly depends on clear and accurate communication to ensure patient safety and treatment/care outcomes. Several international studies have reported that language is the most significant barrier to successfully gaining employment as well as integrating within the foreign country [12, 15, 20–22]. One study of overseas nurses in Australia found that nurses fluent in English as their first language were more likely to secure employment in their preferred specialty . A strong command of the language may also assist with cultivation of friendships and support from peers, both of which are predictors of assimilation. The psychosocial terms of cultural dissonance (characterized by extreme anxiety) and disillusionment have been used to describe the experiences of some IENs [7, 22]. Others whom have come from culturally-similar countries may fare better, since IENs are often expected to adapt to the host culture in a limited timeframe and without performance gaps .
Differences within the host countries nursing practice have been recognized as difficult during and beyond transition for many IENs. Limited knowledge of the health care system policies and practices (around confidentiality, documentation, patient care accountabilities, and interdisciplinary roles), tax laws, and social security rules among others can make the transition very difficult for nurses [20, 22, 25]. Differences in autonomy in nursing practice are noted by several authors, who have shown this can be country-specific and may cause a shift in professional identity [14, 25]. Ignorance of the health care systems technologies, and thus the overall practice of information management, has also been a finding which may be long-lasting for some IENs .
While the above discussion highlights research findings on IENs' experiences during transition in some countries, research in the Canadian context has been scarce, performed within its Eastern provinces,[10, 27–29] and largely focused on credentialing issues [9, 10, 12, 27–31]. Studies suggest that IENs articulate the confusion and subsequent disillusionment when told of their need for Canadian licensure [7, 10]. Many IENs have faced financial hardships as they endeavoured to obtain the necessary documentation of their education for entry into Canadian upgrading programs . Moreover, one study noted that there is no standard source in Canada where applicants may obtain information on educational requirements prior to entry into Canada . There are also limited support structures in place using a second language to aid IENs in gaining examination skills [29, 33]. In summary, IENs are experiencing frustration and disappointment with some leaving Canada prematurely which may create a financial drain on the host community and the individual nurse [19, 27, 34]. Recently in Canada, strategies have been established to enhance integration of internationally qualified health professionals into the Canadian health care system. At a federal level (but with key provincial contacts) the Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualifications, as conceptualized to aid recognition of foreign credentials and smooth the transition of individuals from key occupations including nursing, was implementation December 2010 . The strategy maps out a one-year time frame, from pre-migration to active participation in the workplace, during which assessment, recognition, and partial or non-recognition of credentials occurs.
During 2008-2009, a health authority in a western province in Canada undertook recruitment drives in Australia, India, the United Kingdom and the Philippines to address regional nursing workforce deficits, resulting in 800 contingent job offers. The first cohort of ten nurses arrived in early 2008, with the remaining nurses planned for arrival during the subsequent 12 to 18 months. This timeframe was therefore a critical juncture at which to conduct this research and harness vital data of relevance to federal and provincial decision makers.
The aim of this study was to gain an understanding of the transitioning experiences of IENs upon relocation to Canada, with the additional goal of creating some national and/or provincial policy and practice recommendations for improving the quality of their transition and their retention. Our primary research question was How do IENs transition into the Canadian health care system?
In order to gain a comprehensive understanding of this question a number of subsidiary research questions were proposed, these being grounded in the findings of international research studies exploring the experience of IENs [2
What are the motivations of IENs for relocation to western Canada?
What are the expectations of IENs in terms of their professional role in the Canadian context?
What are IENs' experiences of recruitment, reception and support on arrival?
How does their working life differ from that in the country of origin?
Have the IENs experienced racism and/or discrimination since arrival?
How is living in Canada experienced by IENs?
What strategies have IENs employed to overcome obstacles and barriers?
This focus on the Canadian context will not only assist those regulating, recruiting and training/supervising IENs in Canada, but will also provide some additional insights for regulatory bodies and health care managers and commissioners in other countries when recruiting IENs and implementing bridging/adaptation programs which will ensure successful transition of their IENs and thus their provision of health care.