Clinician’s Commentary on Kalu et al.

Since the start of the new millennium in 2000, there has been a growing focus among health care professions on understanding the complex situations that new Canadians face as they go through the process of immigration and into professional practice.^2–4 Immigration data have shown a marked increase in the number of individuals from developing countries who have arrived in Canada with professional qualifications, seeking to make it their new home. Previously unrecognized problems have emerged and added to the difficulties of relocating to a different country and culture.⁴ Government agencies and non-governmental organizations have established partnerships that have led to initiatives and many projects and publications aimed at understanding and ameliorating these major problems.⁴

One example is Berry,^5,6 who developed a framework of acculturation that has proven to be invaluable for research into the lived experiences of immigrants settling into Canadian life. Berry’s model provides a graphic representation of the interactions and transactions among individuals, life roles, environments, and expectations in a given context.⁶ This framework has enabled researchers to gain a clear appreciation of the unique experiences of immigrants and refugees, and it has highlighted the potential hot spots for attention and mediation. Berry offered a one-stop shop for all who sought to trace a specific journey from arrival in Canada (dealing with government rules and demands) through integration into social and everyday life, entry into particular contexts (professional, technical), and, finally, development of one’s own societal niche.⁶

Government contexts demand strict adherence to policies and protocols, and professional and academic bodies such as associations and universities have their own expectations.^7,8 These contexts become an intricate maze that requires all parties to collaborate to be successful in its navigation. Since 2000, health professionals have undertaken multiple research projects designed to inform educators, researchers, and clinicians of the intricacy involved in bringing internationally educated colleagues into Canadian work cultures^7,9

Kalu and colleagues undertook a seemingly simple yet actually complex study using qualitative data from the Canadian Physiotherapy Assessment of Clinical Performance (ACP) evaluations of internationally educated physical therapists (IEPTs), administered by their clinical instructors while the IEPTs were enrolled in a bridging programme.^1,10 The ACP is reliable, valid, and based on the assessment of competencies demonstrated by learners in their internships during the bridging programme.¹⁰ Kalu and colleagues analyzed clinical instructors’ comments that identified each IEPT participant’s strengths and areas needing improvement.¹¹ The first internship required the demonstration of basic hands-on clinical skills while integrating theory into practise. The second internship sharpened the focus and required higher standards for incorporating both clinical and professional behavioural skills. Kalu and colleagues then integrated and synthesized the data from each field of competency, with the goal of affirming the participants’ readiness to embrace autonomous practice.

Kalu and colleagues reviewed the clinical performance assessment records of 100 IEPTs, including the information gathered during the two internships for each participant included in three successive learner cohorts.¹ The participants’ demographic information reinforces the multicultural backgrounds of those enrolled in the bridging programme. Canadian health professions have a widespread commitment to developing accessible bridging options for new practitioners, including IEPTs. Each profession has developed an educational model that reflects its values and tenets of practice; these models aim to prepare newcomers for autonomous practice.

The article by Kalu and colleagues included two helpful illustrations. Figure 1 outlined the steps in the data coding process, from extracting the core concepts reflected in the comments sections to restating and regrouping these concepts into subcategories within each ACP role,¹¹ merging these findings across roles, and, finally, identifying the central themes of professional practice and professional conduct. This process culminated in a workable profile for everyone being evaluated, one that they could apply to their own practice. Figure 2 illustrated the relationships and expectations among the clinician, the complex patient, and the health care system, thus providing a way to ensure that skills and behaviours matched the needs of all players.

Both figures are highly informative and integrate well into Berry’s acculturation model, discussed earlier.⁵ They reflect the macro, meso, and micro details inherent to the immigration and acculturation processes. The evaluations ensured that IEPTs were measured against standards that applied to every learner entering clinical practice. The study by Kalu and colleagues has broad utility across professions.

Future directions for research are many. However, they should include exploring clinical instructor cohorts and working with participants using Berry’s model as a map by which all participants can plot their journeys.⁵