The experiences of migrant pharmacists: A phenomenographical study

Abstract

Objectives

To understand the experiences of migrant pharmacists in Ireland as they applied for recognition of their qualifications and registration with the national accrediting body.

Methods

Semi structured interviews were conducted with eight participants recruited using purposive sampling. Interview transcripts were subject to a phenomenographic study using a stepwise, inductive approach.

Results

Data analysis led to the development of a number of categories or descriptions of understanding that provided insight into the ways that participants experienced and conceptualised the phenomenon under study. Five categories of description were identified. These are (1) the migrator, (2) the navigator, (3) the student again, and (4) the registrant. For some, an additional category, (5) the mentee, was experienced. Within these categories, variation in participants' experiences was explored.

Conclusions

Participants reported a variety of reasons for migration, and upon embarking on the process, applicants were required to take on a variety of roles, with variation within each role dependent on a number of personal and external factors. Applicants faced personal, administrative, experiential and regulatory hurdles prior to registration, all of which should inform the development of future iterations of this and similar processes.

1. Introduction

Migration of healthcare workers is a global phenomenon of increasing importance. International migration has been defined as the movement of persons that change their country of usual residence and is a complex construct.¹ Recognition by the World Health Organization (WHO) of the importance of this issue is reflected in their Global Code on the International Recruitment of Health Personnel, urging Member States to observe fair recruitment practices and ensure equality towards both migrant and domestically trained health personnel.² The WHO predicted a shortfall of healthcare workers and the Pharmaceutical Society of Ireland (PSI), the Pharmacy Regulator, commissioned a Workforce Intelligence Report in light of this and the lack of robust data about the pharmacy workforce in Ireland and the absence of strategic planning. The report indicated that the number of pharmacists available to work could be increased by “receiving and processing increased numbers of registration applications from pharmacists who qualified from other countries” outside of Ireland and the European Economic Area. The report recommended streamlining the current process for migrant pharmacists.³

Attempts to explain drivers of migration have been widely reported in the literature, with particular emphasis on “push/pull” factors, labour demand, income differentials and migrant networks. There are interesting differences in experiences of healthcare workers with respect to profession and country of origin. A study by Austin described the experience of migrant pharmacists in Ontario, Canada, as they enculturated both personally and professionally, and highlighted the phenomenon of a ‘double culture shock’ experience, whereby individuals had to adapt to both a new national and a new professional culture simultaneously.⁴ A study of medical graduates by Wong et al. described a 3 phase process of loss, disorientation and adaptation in their integration journey.⁵ Sidebotham published a study examining the lived experience of United Kingdom (UK) migrant midwives practising in Queensland, Australia from which a central theme described as ‘finding a way’ emerged.⁶ In a 2018 review of migration motives and integration of various health professionals into the UK, Davda et al. noted that migration is determined by personal and professional factors, together with source and destination specific drivers.⁷ Integration experiences differed among nurses and doctors, with nurses reporting a wider knowledge and skills gap, more multi-level discrimination and less career progression compared to doctors. Migrants' integration experiences depended on their cultural awareness, discrimination exposure, English language proficiency, communication skills, social and professional support networks, social integration and personal attributes.⁷ Kalu et al. reviewed the experiences of internationally educated healthcare professionals (physiotherapists, occupational therapists, physicians and pharmacists) in their new country and mapped these experiences using a competency framework.⁸ Particular emphasis on the need to develop good cultural and communication competencies as well as confidence was highlighted across the studies.

The need to develop resources to foster and retain migrants has also been widely reported. Humphries et al. studied the reasons why migrant doctors in Ireland plan to stay, return home or migrate onwards to new destination countries.⁹ In a separate publication, the same group reported that many doctors felt that their hopes for career progression and postgraduate training in Ireland had gone unrealised and that they were becoming deskilled, thus driving onward migration.¹⁰ Other authors have commented on the need for investment and development in the training needs of international graduates upon migration. In a study of non UK qualified doctors working within the regulatory framework of the General Medical Council (GMC) document Good Medical Practice, Slowther et al. reported clear differences in the ethical and legal framework for practising medicine between the UK and their country of qualification.¹¹ In contrast, Legido Quigley et al. used interpretative approaches to study the experiences of EU qualified doctors working in the UK, with overall enjoyable experiences being reported.¹² Challenges regarding support structures in nursing were noted by Moyce et al. regarding migrant nurses' experiences, noting that nurses' experiences included licensing barriers, difficulty with communication, racism and discrimination, skill underutilization, acculturation, and the role of the family.¹³ Within the pharmacy profession, Ziaei et al. explored the work experiences of internationally trained pharmacists in Britain.¹⁴ Key negative findings concerned workload, working hours and lack of employer support. In particular, EEA pharmacists felt largely excluded from the professional network and sensed that colleagues saw them as ‘foreigners’, while some non EEA pharmacists had to deal with a level of hostility from patients. Similar observations were reported in Portugal by Cavaco et al..¹⁵

Noting the challenges detailed by migrant health professionals in the published literature, we considered it important to understand the experiences of migrant pharmacists in Ireland as they applied for recognition of their qualifications and registration with the accrediting body. The PSI is responsible for the registration of any person wishing to practise as a pharmacist in Ireland. Migrant pharmacists must undertake the so called “Third Country Qualification Route” (TCQR) to register in Ireland. Under the direction of the statutory instrument,¹⁶ TCQR candidates must satisfy the PSI of their standard of training by completing an ‘equivalence’ examination and/or an ‘adaptation’ period of training, after which they must pass the Professional Registration Examination (PRE), the examination taken by Irish graduates for entry to practice. All candidates taking the TCQR route to certification in Ireland since its inception in the current form have been evaluated by RCSI faculty and associated faculty assessors. Depending on the individual applicant, the length of time from initial application to issue of an appropriate certificate to practice in Ireland can vary significantly and has been described as “lengthy” by the PSI.³ I. The experiences of this cohort have never been formally studied. In this work, we aimed to explore the experiences of TCQR applicants who have successfully completed the process of recognition. This has the potential to add to the literature on migrant pharmacists and inform the streamlining of the process in Ireland and other countries.

2. Material and methods

A phenomenographic qualitative study design was used in this study. Phenomenography allows researchers to map “the qualitatively different ways in which people experience, conceptualise, perceive, and understand various aspects of, and various phenomena in, the world around them”.¹⁷ Originally developed by educational researchers, it has been applied more broadly, including by health professionals, to study approaches to learning, teaching, healthcare delivery and continuing education.¹⁸ It fits within the interpretivist paradigm and assumes a non dualist ontological position, with the object of phenomenographic research being to explore how a particular phenomenon is experienced by different individuals.¹⁹ By employing a phenomenographic approach in this study, we aimed to gain insight into the diversity of TCQR candidates' experiences. Data collection was collected via semi structured interviews conducted using an interview guide, as is usual for phenomenographic studies. Ethical approval was obtained prior to commencement of data collection through the RCSI Ethics Committee (Record ID 212559311).

2.1. Participants

Purposive sampling was used to identify potential participants, as is usual with phenomenographic studies. Participants were considered eligible if they had completed registration via the TCQR route at the time of the study and were willing and able to take part in a semi structured interview. With the assistance of the PSI as gatekeepers, pharmacists registered in Ireland who had completed certification via the TCQR route at the time of the study were invited to take part via an email (n = 53). The team aimed to recruit approximately ten participants.²⁰ No participants who initially indicated they would take part subsequently withdrew. No credit or incentive was offered for participation in this study. Written informed consent was obtained from all participants, who were advised that participation was voluntary and that they could cease their participation at any time. Participants were also informed that the data collected would be anonymised post transcription, handled confidentially throughout the study, and that nothing they shared would impact their relationship with the research team or regulatory body.

2.2. Data collection

Semi structured interviews were conducted with participants to explore their experiences and understanding of the TCQR registration process. The interview guide was developed specifically for this study based on the aims of this study. It contained eight open ended questions aiming to elicit descriptions of participants' experiences and probing questions were used to seek additional clarification when necessary. The interviews were conducted by the corresponding author (JB, a male Senior Lecturer who is a pharmacist with a PhD and previous experience conducting qualitative research), from 01/09/2022 to 28/11/2022. None of the participants were known personally to the interviewer. The interviews took place online via either Zoom or Teams platform, as preferred by the participants, and lasted between 21 and 39 min. No person apart from the interviewer and the participant was present during the interview. At the beginning of the interviews, the participants were reminded of the reason for the study and invited to ask any questions. The interviews were audio recorded and subsequently transcribed verbatim before being anonymised. Audio recordings were deleted as soon as transcription was completed. Data collection continued until all participants who had volunteered had been interviewed and further reminders yielded no additional expressions of interest to participate. At this point, consideration was given as to whether the sample size was adequate. Drawing on Malterud et al.'s model,²¹ it was identified that with the narrow study aim, high sample specificity, strength of dialogue, and research approaches used, eight participants was adequate and within the range of six to ten identified for phenomenographic studies of this kind.

2.3. Data analysis

Interviews were transcribed and anonymised by JB. Transcribed interviews were independently coded by two team members [JB and MF] using a stepwise, inductive approach based on the seven steps described by Dahlgren and Fallsberg.²² MF and JB met regularly during the analysis process to discuss progress. Steps completed included (1) familiarisation, which involved reading through the transcripts to become familiar with the detail in the transcripts; (2) compilation of answers by question using Microsoft Excel; (3) condensation of answers where the most significant statements were selected; (4) grouping similar answers; (5) comparing categories; (6) naming the categories with descriptive titles; and (7) contrastive comparison to examine how the categories were similar and differed. Where differences in opinions arose during coding, the original transcripts were again consulted, and agreement was reached through discussion. Using a phenomenographic approach to analysis allowed the team to explore how different participants experienced the same phenomenon (TCQR process) and develop a broader understanding as to how it may be experienced by different people.

To ensure study quality, several steps were taken during the research. Interviews were conducted by one researcher (JB), who kept field notes where necessary. Member checking was conducted during the interviews where necessary to ensure interviewer understanding was correct. This included summarising and paraphrasing participants' responses to verify interviewer understanding. Data analysis was conducted by two researchers following a set process as outlined above, who reflexively considered the impact of their own beliefs and experience on their analysis as part of regular meetings (see Section 2.4 below). Additionally, the COREQ guidelines were used to structure the reporting of this research.²³

2.4. Reflexivity statement

This research study was prompted based on the collective experience of the authors in encountering TCQR applicants within their professional roles. Although aware that while TCQR applicants ultimately sat the PRE in the same way as MPharm students in Ireland, their journey to this exam was different. We had a shared interest in learning more about their experience, and as health professions' education researchers we aimed to conduct this research both to learn more and add to the evidence base. All team members have experience conducting quantitative, qualitative, and mixed methods research and adopted an ontologically/epistemologically pragmatic approach to the identification of the methodological approach to the study, choosing a phenomenographic approach to match the study aims of exploring TCQR participant experiences. We carefully considered how our experiences might influence the process and reporting while conducting this research.

3. Results

A total of eight participants volunteered to take part and were included in the study. Data analysis led to the development of a number of categories or descriptions of understanding that provided insight into the ways that participants experienced and conceptualised the TCQR process. Five categories of description, representing key aspects of the variation in meanings and experience were identified. These are (1) the migrator, (2) the navigator, (3) the student again, and (4) the registrant. For some, an additional category, (5) the mentee, was experienced. Within these categories, variation in participants' experiences is detailed below.

3.1. The migrator

The TCQR process began for all students with a decision to move to Ireland and apply for recognition of their qualifications as pharmacists. This decision to move country was associated with a variety of factors that were personal, variable, and generally pragmatic. Some participants reported being influenced primarily by pull factors (factors that pull them to a certain country) or a combination of push (factors that push people away from a country) and pull factors. For example, some participants had family links with Ireland (pull factor), while others were seeking to advance their careers in a country with more advanced pharmacy practice (push and pull factors). Pull factors included citizenship and established links with Ireland.

“So, my father is actually Irish, so I am in this sort of privileged category that I have dual citizenship of both Australia and Ireland...Umm and I decided it would be kind of nice to not have winter and be able to kind of move between the two”. (Participant 2).

“My mum's an Irish citizen born and bred and my dad is a medical doctor that qualified [in Ireland]. So, we have very close ties to Ireland and I've been coming up and down since I was a child. And anyways when I qualified, I always wanted to move to Ireland and you know, try and live in Europe and experience the other side of things”. (Participant 6).

For most, the decision was more complex and based on a combination of factors that pushed them away from their own countries and others that pulled them towards Ireland. Examples of push factors included keeping family together, professional advancement, and political circumstances in their home country. Employment availability and more advanced standards of practice were pull factors mentioned.

“When you graduated as a pharmacist, and when you do all this stuff, and you find very limited jobs … you can not say jobs, very limited options of work, and you don't have… so much resources in the country, so you will look for to improve yourself, to pursue your career in an advanced country. Ireland one of the advanced countries, that we are looking up, Ok, so this is why we choose Ireland”. (Participant 4).

“The political and safety situation in [home country] became... basically a major concern for us as a family.... from talking to people, they said there's a big shortage of pharmacists in Ireland…I started doing a bit of... in fact, my wife did... I think I was 55 at that time, 56, 55 I think, and lots of other countries have age limits, like Australia and New Zealand, it's a points based system, so you start losing points. So, I said to my wife, listen, I'm not doing anything until you find out about the age thing so... She did and she found out that there was no age limit which I'm very grateful for...I didn't really know very much about it, but it looked like a good country to come to, it looked like pharmacists were pretty well respected and it looked like the process was reasonably straightforward”. (Participant 6).

3.2. The navigator

For all participants, their experience with the TCQR process included an initial engagement with the PSI to commence and navigate their application. At this time, they were required to submit documentation to commence the process. For several participants, navigating this process proved difficult, with complications including communication challenges, time delays, and logistical issues relating to travel.

“Once I got into it, it was not as straightforward as it kind of purported to be […] I had to keep going back to the university and asking them for more stuff. […] I had to come in for an interview. When could it be? Can you come next week? No, I'm in [Country x]. That's like on the other side of the world. And they said, oh, OK, well, we could organize it for… And it was …for two or three months' time. And yeah, I can do that. That was fun. Had the interview they said, oh yes, everything looks fine. Like, it was literally a meeting that could have been an email...... at that point they said Oh, now the exam will be next week and I'm like guys, we've already had this discussion about how I'm on the other side of the world and I cannot just pop over”. (Participant 2).

“There was a lot of admin work required and it's a bit difficult to tie in what they need...There was one part of the documentation that I felt it was a little tedious to do, so they requested your syllabus and the breakdown of the syllabus. And then separately they requested, I think a certificate of good standing from the university, which could have gone together to the PSI. But they requested that two different couriers come and collect it”. (Participant 7).

Others had a more straightforward experience of the process and did not experience significant challenges.

“Like it took me some time to understand the process and how long it could take and... and when I contacted them, they were, I'd say, helpful at ...at that time… It looked like there are a few steps I have to go through, but I didn't think it would take that long. I thought like maximum it would be something like two years”. (Participant 1).

3.3. The student again

After navigating initial engagement with the regulator, study participants described a subsequent phase of establishing equivalence that moved them back into the role of a student. For many, it had been a long time since they had studied for exams. All participants experienced challenges preparing for the equivalence exam, reporting a lack of defined syllabus and resources. For some, the challenges were compounded by lack of familiarity with the exam format used (Objective Structured Clinical Examination (OSCE)), cost, and pressure to do well. Some applicants had connections with other students who were currently undertaking or who had completed the TCQR process and found the peer support helpful, while others who didn't reported feeling isolated. For all participants, the exams were a stressful experience.

“Ok, yes, the exam, you can say, so... we didn't do any OSCE exam, so we don't have any experience when we go to the equivalence exam, this was very tough for us, I will say to you that... They are very tough, so if you don't do something like that for the first time and you are not in your country, you are in a different country, so it's very tough...You're feeling you are doing something very big, you know, so all these feelings, you are doing very odd exam, didn't do it before, so it's very tough.. the paper thing its very good, no problem, you can do it no problem”. (Participant 4).

“To be honest, I didn't know at that time anyone who sat this exam or went into that process like I did it completely on my own, you know […] They gave me some at list of something like 10 books recommended, or maybe a little bit more. So, it's it was a little bit... To be honest, tough for me. Difficult. Like I didn't know where to start. Or anyone to ask you know. So, it was tough for me. I didn't prepare well, or I didn't know what to expect, so it was a bit overwhelming for me... Like I found the calculations were so specific […] I found them to be tough”. (Participant 1).

“I said there's no way I could go through all these textbooks […] I had a family I had a commitment I was working so it wasn't the same me back then in undergraduate pharmacy school. But I tried my best. So, we got some materials, you know, and there's a group of… third country trained pharmacists that formed a WhatsApp group, so they were sending some materials like this, this and some information […]. we realised there wasn't any past questions, like past questions are not released. But the questions we saw were those questions that people that had gone through it, remembered immediately after the exam”. (Participant 8).

Some applicants who achieved the required standard in the equivalence exam and satisfied the PSI's requirements with their documentation were permitted to move straight to the PRE. Others required an adaptation period (see below), after which they were eligible to sit the PRE. At this stage, TCQR candidates sat the national licence exam alongside MPharm students. Many applicants reported drawing on the experiences of the pharmacy students preparing for the exam to help guide their study. Participants reported finding the PRE challenging but well organised.

“Yeah, I wasn't working at that time. So, I had the time to prepare in that month. I met a few Irish students that were studying in RCSI. And… umm before sitting the exams... I think they helped me a lot with them directing me in the right way how to prepare and how to study ...Like I focused more mostly on the you know, the rules and regulations of Ireland. I think that helped me a lot”. (Participant 1).

“I was trying to familiarize myself with what goes on in Ireland as well... after a while the PSI kind of sent us a link from [University X] to see how the OSCEs would be like, but there was just loads and loads of information, it wasn't particularly structured into one way ..you have to start searching, as opposed to what they did for the students here, which would be.. because I work with interns and they tell me about their experiences preparing for the PRE and all that, so like, it was just loads and loads of information and we just have to kind of look through”. (Participant 2).

“To me it was a good experience. Like of course I was very nervous and… But, yeah, everything went well. I think. Like the calculations part, I felt that I didn't have enough time for it, it went so quick. But the OSCEs were OK. Although they were a bit like too long for me, too many, I don't know whether there were 12 or maybe more. But maybe 16 I'm not sure. I forgot it. There were too many. But yeah, like, of course, I... I like. I got out of this exam like exhausted for days. But yeah. It was organized, I'd say”. (Participant 1).

3.4. The mentee

As already mentioned, some applicants progressed directly to the PRE, while others were required to undertake an adaptation period. The TCQR applicant bore the responsibility of securing a placement for the period required by the PSI. All participants reported challenges with identifying and securing a placement.

“I was told that I need to do one year adaptation period. And I had to apply for a place and like I'd say it, it was one of the most difficult parts. Of that process like I could…I couldn't find any… like I contacted […] I'd say something like 50 pharmacies. But uh, at the end I… like only one pharmacy accepted me […] I think it was at that time the problem was that they couldn't pay me or something like that. That's why they refused…So I… I asked him, how about if I do it without… without getting paid like for free. You know, I just want to finish that training. And he was like, OK, you can start tomorrow”. (Participant 1).

“I even go to every... I go to west of Dublin, east of Dublin, south of Dublin, you know... The people they are... you can say that they are looking at you, and saying ‘Who is he? Why is he doing that?’ […] I think about June and July. People in this time, they already recruited the trainee from the... the Irish trainee, that graduated this year, back in February and January.” (Participant 4).

“I was really aiming for the six months cause I knew that you have to adapt to the process with legislation and stuff. So, I was OK with that. So, I ended up with a six month adaptation. So, then I went about the process of trying to find a pharmacy, which is difficult when you are 10,000km away from the place. But what I did was essentially... I literally just used Google Maps and I pinpointed forty pharmacies within a 5 or 6 kilometre radius of the place. And I said I will phone everyone on this list, and I phoned a lot of pharmacies. Many of them were not... not many of them, all of them were not willing to help and they didn't understand what the third country route was or why I was phoning and stuff”. (Participant 7).

A smaller number of participants experienced significant challenges in their placements that were difficult to address due to lack of formal support structures and availability of alternative placements.

“So, I came to that place... Now, it didn't work for me like I had to leave after two months and find another placement...Like I wasn't really comfortable from the beginning at this place. Like I think like there was an, there was some issues with that place… when we talked, he was like. If you want me to train you. Oh, and or sign these papers. I need to give you few papers. To sign first… Like, to be honest, I was... It was very difficult times for me because I didn't want to leave that place. I know that there are... there is nowhere to go and what pharmacy will accept me, you know? And after I planned everything, and I got accommodation beside that place. And so, it was very tough for me”. (Participant 1).

“I did not have a very good process. I must say… I asked if I could get a contract in terms of what my pay would be, what my time would be, what my hours would be, time off, etcetera. And I wasn't given this. So initially she said no she'd get to it. Then it became a month and two months and three months, and it didn't come to fruition. And I also started noticing irregularities…I don't think I've ever been called a foreigner so much in my entire life…. I wasn't getting the support from the pharmacy that I was working in. And every time I asked about it, I was met with a lot of aggression…called me very, very unsavoury words in… with regards to my dressing, with regards to my body shape with regards to where I come from…I did explain to XXXX that listen, there is a problem and I don't know how to fix this. And all I was met with was. If you can't stick it out, you need to leave and you will have to start again...told me that if I do not keep my mouth shut and my head down, she would make trouble for me. And the only options I had was to either continue... So shut up and continue...I flagged that I needed help. Nobody helped me and I don't know what to do...I spoke to a representative at [professional representative group] who explained to me that this has never been done before and they cannot help me because there's no protection for 3rd country pharmacists or third country entry pharmacists”. (Participant 7).

3.5. The registrant

For most TCQR applicants, the final process of registration once they had passed the PRE was straightforward. However, some reported additional unexpected challenges specific to their own circumstances e.g., language requirements.

“I think that was like the smoothest process, by then I've gone through every other thing, so the registration part was just... Get the registration done and that was it, as opposed to the first processes I had gone through it didn't take long at all and because I passed the PRE I could start applying for jobs”. (Participant 3).

“It was really straightforward at that time. Everything was very well explained in emails [...] The group that does the CPD [continuing professional development] for pharmacists... [...] I got an email from them as well. Everything in the post. So no, again, everything is really well organised”. (Participant 5).

“When I passed my registration exam, I was told that I have to do the... There's only one thing left. The English exam, so I was like no, but I was told such and such. But they were like no, everything changed...So I was a bit to be honest, upset about it. But then what they told me that maybe because their official language is English. So, like it really upset me at that time, but like, there was nothing I could do. I tried all the possible ways. They were like, no, just the regulations have changed and now you know, you have to do the English exams so. I just... went and applied for that English exam and I dedicated one month to study for it. as soon as I passed English exam, and I sent them the... the results, I think I got my registration number or something like one week after”. (Participant 1).

4. Discussion

This study used a phenomenographic approach to explore the experiences of individuals who applied via the TCQR process to become registered pharmacists in Ireland. As research conducted with other groups of migrant healthcare workers has indicated that many encounter significant challenges with such processes,²⁴ we aimed to understand the experiences of pharmacists aiming to register in Ireland. The five qualitatively different categories of experience developed during the study highlight how TCQR applicants are required to take on a variety of roles during the process, with variation within each role dependent on a number of personal and external factors.

Like studies of other migrant healthcare professionals, participants in this study reported a variety of reasons for coming to Ireland, with some reporting political and safety concerns as being the primary driver and others coming because of personal ties to Ireland. In a systematic review of 107 studies, Toyin Thomas et al. explored drivers of migration of healthcare workers from low/middle income countries.²⁵ Remuneration and security problems were the key macro level factors driving migration/intention to migrate, while career prospects, good working environment and job satisfaction were the major meso level drivers. The constancy of these drivers was noted over five decades. In this work, navigating the challenges of identifying and supplying relevant documents to the Regulator was a lengthy and uncertain process for TCQR applicants, reflecting challenges reported for migrant healthcare professionals elsewhere.^26,27 All applicants were required to revert to the role of students for the equivalence and PRE exams, and some reverted to mentees, if an adaptation was required. Challenges were described by some participants concerning engagements with potential employers, notably concerning the status of entry permits on arrival in Ireland. A related hurdle in this regard concerned securing an adaptation site. Other studies have noted the substantial financial and organisational difficulties in this regard.²⁸ The challenges reported here relating to finding information about examination content and being required to sit exams in new formats have been encountered by other migrant healthcare workers and have been associated with a heightened state of anxiety.²⁴

The most concerning findings related to participants' reports of inappropriate treatment during their adaptation periods, with no official channels through which to obtain support during this time. TCQR applicants undertaking periods of adaptation reported being faced with the choice of putting up with unacceptable treatment or having to restart their adaptation period from the beginning. This, alongside the challenges in identifying a placement in the first instance, meant that they were particularly vulnerable. While migrant healthcare workers being subjected to overt or subtle racism, discrimination, and marginalisation is sadly reported in several other studies, it is not acceptable and indicates a need for change and enhanced diversity, equity and inclusion training for all involved.²⁹ Of particular concern in this research is the fact that when applicants sought help for their situation due to their lack of formal status as a student or registered pharmacist, there was no formal route available. Of note, while this research was being conducted, the PSI commenced a review of the TCQR process and identified a number of changes to be implemented. We hope that our findings act as advocacy for the cultivation of a more inclusive and supportive environment within pharmacy placements in Ireland. A guiding principle of the WHO Global Code of Practice on the International Recruitment of Health Personnel is to promote and respect fair labour practices for all health personnel. Further, all aspects of the employment and treatment of migrant health personnel should be without unlawful distinction of any kind. We posit that adapting core principles such as this within the frameworks governing the training of personnel would add strength.

4.1. Strengths and limitations

When compared to the literature on migrant doctors and nurses, the literature on migrant pharmacists is limited, and this research will add to the evidence base on this important topic. To our knowledge, this is the first study of its kind relating to the study of pharmacists aiming to register via the TCQR route in Ireland, and it is therefore the first research to report on their experiences. The phenomenographic approach enabled the researchers to identify a range of experiences that comprise the overall experience and variation therein. While it is generally considered optimal to have ten participants in a phenomenography study, only eight participants took part in this research. Although this is fewer than aimed for, the richness of data and the variety of experiences reported means that the findings are still valuable.

Our study design included only participants had all successfully completed the TCQR process due to ethical considerations, and the experiences of those who are in the process or did not complete it may have been different. Future research should focus on the experiences of those who do not complete the process, and on the further professional integration of successful candidates, as little is known in this regard within allied health professions, including pharmacy.³⁰

4.2. Implications

The findings highlight the need for regulatory bodies to consider how best to develop a process that ensures participants are supported and treated fairly during their adaptation periods, and that provides clearer guidance in terms of curriculum and assessments. As many participants reported challenges identifying placements and managing challenges arising, particular focus should be placed on ensuring there is a process for securing placements and supporting candidates to manage issues arising. The planned changes to the TCQR route will address some of these issues, however consideration as to how practical, cultural, and pastoral support can be provided to applicants is also important.

5. Conclusions

This study explored the experiences of pharmacists who registered in Ireland through the TCQR process. Using a phenomenographic approach, we identified a number of categories that provided insight into the ways that participants experienced and conceptualised this phenomenon. In so doing we identified valuable information on the experiences of applicants, and on areas that warrant attention and development as further iterations of the process emerge.

Author contributions

JB conceived the research question, and all authors were involved in the design of the study. JB undertook the interviews, while JB and MF analysed and interpreted the data. All authors were involved in the writing and critical revision of the manuscript. All authors have read and approved the manuscript.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.