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Program evaluation of a model to integrate internationally educated health professionals into clinical… Greig, Alison; Dawes, Diana; Murphy, Susan; Parker, Gillian; Loveridge, Brenda Oct 11, 2013

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RESEARCH ARTICLE Open AccessProgram evaluation of a model to integrateinternationally educated health professionals intoclinical practiceAlison Greig*, Diana Dawes, Susan Murphy, Gillian Parker and Brenda LoveridgeAbstractBackground: The demand for health professionals continues to increase, partially due to the aging population andthe high proportion of practitioners nearing retirement. The University of British Columbia (UBC) has developed aprogram to address this demand, by providing support for internationally trained Physiotherapists in theirpreparation for taking the National Physiotherapy competency examinations.The aim was to create a program comprised of the educational tools and infrastructure to support internationallyeducated physiotherapists (IEPs) in their preparation for entry to practice in Canada and, to improve their pass rateon the national competency examination.Methods: The program was developed using a logic model and evaluated using program evaluation methodology.Program tools and resources included educational modules and curricular packages which were developed andrefined based on feedback from clinical experts, IEPs and clinical physical therapy mentors. An examination bankwas created and used to include test-enhanced education. Clinical mentors were recruited and trained to provideclinical and cultural support for participants.Results: The IEP program has recruited 124 IEPs, with 69 now integrated into the Canadian physiotherapyworkforce, and more IEPs continuing to apply to the program. International graduates who participated in theprogram had an improved pass rate on the national Physiotherapy Competency Examination (PCE); participation inthe program resulted in them having a 28% (95% CI, 2% to 59%) greater possibility of passing the written sectionthan their counterparts who did not take the program. In 2010, 81% of all IEP candidates who completed the UBCprogram passed the written component, and 82% passed the clinical component.Conclusion: The program has proven to be successful and sustainable. This program model could be replicated tosupport the successful integration of other international health professionals into the workforce.Keywords: International health graduates, Educational program development, Program evaluation, IntegrationBackgroundHealth-care education around the world varies in educa-tional standards, curriculum, and evaluation methods. Theincreasing demographic presence of ‘visible minorities’and internationally-trained professionals, demands equalaccess to employment opportunities that support practicein occupational roles according to their qualifications andwork experience. Support for this transition is essential tomaximize skilled contribution to the development of acountry [1]. Canada is known as a country with a broadimmigration policy which is reflected in its ethnic diver-sity, with over 71,559 people transitioning from temporaryto permanent Canadian resident status in 2010 [2]. Thedemand for health professionals continues to increase inCanada, partially due to the aging population and the highproportion of practitioners nearing retirement. Similartrends are predicted across all health professions [3-5],prompting the need for initiatives to increase the numberof health professionals entering clinical practice. There is aneed and desire to use readily available resources, the* Correspondence: alison.greig@ubc.caDepartment of Physical Therapy, Wesbrook Mall, The University of BritishColumbia, Vancouver, BC, Canada© 2013 Greig et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Greig et al. BMC Medical Education 2013, 13:140http://www.biomedcentral.com/1472-6920/13/140internationally-trained health professionals. To enter clin-ical practice, these health professionals need to demon-strate that they are safe and competent practitionerswithin the Canadian health care system. The knowledgeand skills required to obtain a license to practice a profes-sion vary by country and often by state or province, andmost practitioners will require at least some orientation tothe new health system and societal expectations of healthcare delivery. Others will require retraining in the basicsciences and clinical skills [6].In order to obtain a license to practice Physiotherapy inCanada, in all provinces except Québec, Physiotherapistseducated outside Canada must complete the two-part na-tional Physiotherapy Competency Exam (PCE). In 2005there was a notable discrepancy in pass rates between inter-nationally trained Physiotherapists and Canadian graduates;less than 50% of internationally trained Physiotherapistsexam attempts translated into passes, compared to greaterthan 92% of Canadian educated candidate attempts [7].The challenges to internationally trained Physiotherapistssuccess are thought to be lack of familiarity with the Can-adian healthcare system, differences in Physiotherapy prac-tice between countries, issues with language fluency,specialisation in specific areas of practice that provide achallenge on a generalist examination, and lack of familiar-ity with the Canadian National examination format.There is some literature about internationally trainedhealth professionals; this literature mainly reflects theprocess of examining the credentials, competency, demo-graphic characteristics and distribution of internationalmedical graduates (IMGs) [8-11]. There is some literaturewhich considers IMG’s and nurse’s experiences whilerecertifying, or the training programs ability to aid inte-gration into the recipient country’s medical communityand the country’s needs [12-18]. The conclusions fromthis work are that medical training programs need: i)support for international graduates to facilitate programcompletion, including faculty and peer mentoring,psycho-social counselling, and educational and orienta-tion activities; ii) help to master the contextual areas ofpractice in addition to ensuring academic and technicalcompetence; iii) understanding from administrators andfaculty of cross-national medical training and practices(in terms of similarities and differences) [18]. It is rea-sonable to suggest that the experiences and challenges ex-perienced by IMGs and nurses as they recertify andintegrate would be similar across other health professions.To meet the demand for licensed Physiotherapists inCanada, and more specifically British Columbia (BC),and to provide support for internationally-trained phys-iotherapists who wish to continue to practice their skillsand gain licensure, the “Internationally Educated Physio-therapists (IEP) Program Project” was established at theUniversity of British Columbia.MethodsThe aim of this project was to create the educational tools,curriculum, and infrastructure needed to sustain a pro-gram supporting internationally trained Physiotherapistsapplying for licensure in BC. The primary objective of theprogram was to increase the pass rate of internationallytrained Physiotherapists taking the PCE. The UBC ethicsboard states that ethical approval is not needed for pro-gram evaluation.Program developmentThe project team used a conceptual framework to map theprogram components, clarify the nature of program goals,and guide the program development [19]. To this end theprogram was developed using a logic model (Figure 1),which provides a schematic representation of the logical re-lationships involved in the transformation of resources intodesired outcomes. The components of the logic modelare: Inputs (the human, financial and material re-sources, and their organization); Activities (the services,products, and/or transactions that transform the inputsinto outputs); Outputs (the transformation of resourcesinto something that is delivered to clients); Outcomes(short-, intermediated, and long-term); Relationships(the relationships between the components) [20]. Fi-nally, this project was evaluated using a “program evalu-ation” approach. Program evaluation has been definedas systematic investigation of the merit, worth, or sig-nificance of an object [21].Program implementationThe IEP project was developed in a partnership with keyBC Physiotherapy stakeholders (university, professionalorganization, regulatory body, health authorities) whichprovided oversight, guidance, communication services, ad-vertising and marketing support, identification and recruit-ment of mentors and content experts. A key role in themanagement of the program was the Program Coordinator,who was a trained and licensed Physiotherapist with over40 years of practice experience. The Program Coordinatorwas responsible for all activities of the program, includingrecruiting, scheduling, data collection, communication andfeedback sessions related to exam modules. All inputs andactivities are shown in Figure 1. Initial estimates projectedthat the program could admit four IEPs per cohort and sixcohorts per year, with some flexibility to include additionalstudents if there was excess demand.The program consists of two separate streams to assistIEPs in the preparation for the PCE: one in preparing forthe written component (QE), and the other to prepare forthe clinical component (PNE) of the national exam. IEPshad the option to participate in both streams of the pro-gram, or to receive support for the preparation of onlyone component of the PCE (the written (QE) componentGreig et al. BMC Medical Education 2013, 13:140 Page 2 of 8http://www.biomedcentral.com/1472-6920/13/140or the clinical (PNE) component). The QE consists of 200multiple-choice questions (MCQs) and the PNE is anobjective structured clinical examination (OSCE) to evalu-ate candidate’s interactions in controlled scenarios withstandardised clients. The primary objective of the programis to assist IEPs with their preparation for taking theseexams. To achieve this objective, modules including exam-ination writing skills, content area review, and practiceexam experiences (using tested-enhanced learning theory)were developed [22]. Many resources were available on-line; however, exams and workshops were initially deliveredface-to-face.Content experts developed initial versions of the curricu-lar modules covering the four primary areas of Physiother-apy practice using the DACUM (Developing a Curriculum)model [23]. All modules were assessed by an external ex-pert for accuracy, ease of use, and adherence to competen-cies as outlined by The Canadian Alliance of PhysiotherapyRegulators 2008 National Examination Blueprint [24]. Anupdated version of the Alliance National Examination Blue-print was introduced in 2009 [25], that included a fifth areaof practice (Multisystems); the IEP modules were revisedto include this new area of practice. Two examinationpreparation modules were purchased from the nationalPhysiotherapy Exam Skills Preparation Program andadapted to fit the IEP Program framework. Questions forthe exam bank were developed by the content experts andreviewed by both a clinical expert and an educational ex-pert to ensure the question format accurately reflected thequestions found in the PCE.Access to Physiotherapy mentors was initially identifiedas important to provide IEPs with the acquisition andreinforcement of practical skills in a Canadian context.Mentors were recruited from the clinical community basedon area of clinical expertise, and experience teaching andsupervising students. Three mentor-training workshopsthat focussed on facilitation techniques to support thelearning of entry-level physiotherapy skills were offered tointerested physiotherapists across the province. IEPs werematched with mentors who specialize in the primary areasof practice. The responsibilities of the mentors were tofacilitate the development of the knowledge, clinical skillsand clinical reasoning in each content area as expected inPhysiotherapy practice in Canada. Mentors were alsoresponsible for supporting the IEPs to achieve the compe-tencies, as outlined in each module.QE examination, PNE examinationEntering Physiotherapy PracticeIEPs recruited to program            Program examinationsTrained mentors Feedback from IEPs & mentorsProgram evaluationsMentoring:mobilesmall group Workshops:clinical skills labs,writing workshops.OSCE testsMCQ testsCurricular modules:musculoskeletal, neurology, cardiorespiratory, professional practice,multisystemsExam bankMCQOSCEMentor trainingSteering CommitteePhysiotherapy Association of BCCollege of Physical Therapists of BCVancouver Health AuthorityFraser Health AuthorityUniversity of British ColumbiaExperts:Content, Clinical, Educational LiteratureNational Exam BlueprintProgram Coordinator,MentorsInternationallyEducatedPhysiotherapists6 cohorts per yearInputsActivitiesOutputsShort-term OutcomesIntermediate OutcomesLong-term OutcomesRelationships:Figure 1 Logic model for Internationally Educated Physiotherapist (IEP) program.Greig et al. BMC Medical Education 2013, 13:140 Page 3 of 8http://www.biomedcentral.com/1472-6920/13/140Program evaluationThe program evolved since inception as a result of feed-back from a variety of sources, including data collectedfrom the IEPs, mentors and the IEP Advisory committeethrough focus groups and interviews. Feedback indicatedthat sample exam questions and practice exams were notperceived to accurately reflect the final PCE exam, andthat there was a lack of detailed feedback after practiceexams. Furthermore, IEPs suggested that modules werenot specific enough and that IEPs were unfamiliar withterminology used within the Canadian Physiotherapy con-text. In response, study questions and a glossary of termswere added to each module, more complex vignette-basedquestions were developed, and based on the results oftheir exams IEPs are provided with guidance to further re-sources and study suggestions.Several new initiatives resulted from the interviews withIEPs, including: clinical skills lab reviews; written tutorialworkshops; mobile mentors; small group mentorship; deliv-ery of written exam modules to remote communities; andtransitioning the written program to an on-line platform. Inaddition, the written exam preparation was transitioned toa fully on-line program, so all aspects of the module was ac-cessible to IEPs throughout BC, across Canada and eveninternationally.Program effectivenessThe first step of the Program Evaluation was the forma-tion of a program logic model followed by analysis of theoutcomes defined in the model. Data for IEP candidates,all international Physiotherapy graduates, and Canadiangraduates is shown for the PCE across time (Table 1). Thedifferences between National exam results for IEPs whohad participated in the IEP Program compared with otherinternationally trained Physiotherapists who had notparticipated in the program were tested using Fisher’sexact test. The relative risk of passing the exams for IEPsand other internationally educated candidates was calcu-lated, with 95% confidence interval using Wald’s formula.The term “risk” is used throughout the text as risk ratioswere used rather than the term “chance” which impliesother statistical tests.ResultsEducational modular and curricular packagesSeven modules, based on the PCE blueprint and the corecompetencies of entry level physiotherapy in Canada,were developed and trialled.Exam bankMore than 500 MCQs and 22 OSCE questions were de-veloped, reviewed and, stored in the exam bank withmarking guides and patient model instructions whereappropriate. This supported the administration of in-ternal written tests and internal clinical tests.MentorshipInitially 35 mentors were trained and paid for a maximumof 10 hours per IEP to provide one-on-one support andexpertise during the exam preparation. The number ofmentors trained was sufficient for the number of IEPs res-iding in the Lower Mainland of British Columbia, how-ever, there were challenges pairing mentors with IEPs whoresided out of the Lower Mainland, particularly those IEPsin rural areas. To address this, mobile and small groupmentorship models were developed, which involved men-tors from the Lower Mainland travelling to meet with IEPsin remote areas. This model proved to be cost effectiveand time efficient. In addition, higher IEP to mentor ratios(small group learning), maximised the mentor time andTable 1 Canadian alliance of physiotherapy regulators examination results2008# 2009# 2010# 2011#§ Total*Written component (QE)All candidates 738 (78) 755 (76) 766 (77) 2259 (77)Canadian-educated 503 (93) 555 (94) 566 (94) 1624 (94)Internationally-educated+ 235 (58) 200 (49) 200 (51) 635 (53)IEP program 1 (33) 7 (54) 21 (81) 13 (56) 43 (67)Clinical component (PNE)All candidates 691 (85) 758 (85) 801 (88) 2250 (86)Canadian-educated 506 (95) 538 (96) 618 (96) 1662 (96)Internationally-educated+ 185 (66) 220 (67) 183 (70) 588 (68)IEP program 4 (100) 26 (100) 27 (82) 16 (80) 70 (92)Data represent people who passed the exam (% pass).#Year of taking exam.*Since beginning 2008 to end Dec 2010.+Includes IEP program candidates.§Incomplete data (% is of known results), Alliance not published.Greig et al. BMC Medical Education 2013, 13:140 Page 4 of 8http://www.biomedcentral.com/1472-6920/13/140provided a more “dynamic” session for the IEPs. Feedbackfrom IEPs and mentors, indicated that few IEPs utilizedthe allocated time with mentors, and that IEPs found theother components of the program (e.g. practice exams,workshops, clinical lab days etc.) of more benefit. Thementorship model therefore moved to self-regulated ac-cess; that is, IEPs were given contact details for mentorsand were encouraged to make independent arrangementsto meet with mentors according to need.IEP candidatesThe first cohort of nine IEPs was admitted into the pro-gram in July 2008. Figure 2 shows the flow of IEPs throughthe program. As of 1st January 2012, 124 IEPs have partici-pated in the program. Data on IEP characteristics, Table 2,demonstrate that IEPs come from a variety of countries,with the majority coming from the UK (31%) and India(21%). Most IEPs have been employed as a Physiotherapistfor less than five years (62%), with 14% never having prac-ticed as a Physiotherapist prior to entering the program. Inthe first three years, more than 65% of the IEPs had Englishas their first language but this dropped to 50% in 2011.Written and clinical examsTable 1 shows the PCE exam results for IEP programparticipants relative to all PCE candidates, Canadian-educated candidates, and all Internationally-educated can-didates examination results. In the first year, 2008, therewere very few graduates from the IEP program due to tim-ing of the exams, three taking the written (QE) componentand four the clinical (PNE) component, with 33% and100% passing respectively. In 2010, 26 IEPs took the QEexam with 81% passing and, 33 took the PNE with 82%passing. The pass rate for IEPs taking the QE between2008 and 2012 is 0.67, and for those taking the PNE is0.92. These rates are significantly higher (p < 0.05 and p <0.001, respectively using Fisher’s exact test) than the passrate for all the internationally-educated physiotherapistswho took the QE and PNE where the pass rate is 0.53 and0.68 respectively. Taking the IEP program conveys a 28%increase in risk of passing the written exam, with a risk ra-tio (RR) in comparison to other international graduatestaking the QE of 1.28 (95% CI, 1.02 to 1.59). The resultsfrom the PNE are even more positive with RR = 1.39 (95%CI, 1.27 to 1.52); IEP candidates have a 39% increase inEntered Physiotherapy Practicen = 124In employment = 69 (34 in public sector)Failed PNE / QE = 24Pending/Deferred/In program = 20Unknown = 6Temporarily not working = 5Wrote QE examn = 65Pass = 42(65%) Fail = 23(35%)Completed PNEn = 83Pass = 73(88%) Fail = 8(10%)Not reported = 2(2%)PNE deferredn = 5QE deferredn = 6Wrote initial MCQ examn = 50Mean score = 57% ± 9%Completed initial OSCEn = 83Mean score = 63% ± 9%No initial MCQ examn = 21No initial OSCEn = 5Entered IEP Programn = 124PNE (clinical) programn = 88QE (written) programn = 71Wrote final MCQ examn = 63Mean score = 66% ± 8%Completed final OSCEn = 75Mean score = 72% ± 6%No final MCQ examn = 8No final OSCEn = 13Figure 2 Flow diagram of candidates through Internationally Educated Physiotherapist (IEP) Program (July 2008 to January 2012).Greig et al. BMC Medical Education 2013, 13:140 Page 5 of 8http://www.biomedcentral.com/1472-6920/13/140risk of passing the clinical exam when compared to inter-national candidates who do not take the IEP program.Of the 65 IEPs taking the QE exam 65% had Englishas their first language, of these 63% passed the exam. Ofthe 35% who did not have English as their first language,40% passed the QE. IEP candidates who have English astheir first language have a non-statistically significant58% increased risk of passing the QE, RR = 1.58 (95% CI0.93 to 2.67, p = 0.09). Of the 83 IEPs taking the PNEexam, 74% had English as their first language, of these93% passed the exam. Of the 26% who did not haveEnglish as their first language, 67% passed the PNE.For the PNE, IEP candidates who have English as theirfirst language have a statistically significant, 40% in-creased risk of passing with an RR = 1.4(95% CI, 1.03 to1.9, p = 0.03).Of the 124 people who entered the IEP program 69 areknown to have entered the Canadian physiotherapy work-force, with 34 of these known to be working in the publicsector, five people are temporarily not in the Canadianworkforce, due to child care or visa problems, and 20 areawaiting immigration approval for entry to Canada.DiscussionThe aim of the IEP Program was to create the educa-tional tools and infrastructure needed to sustain a pro-gram supporting internationally trained Physiotherapistsapplying for licensure in BC. Consideration was given todeveloping a program that included the necessary cur-riculum, resources, mentorship and practice opportun-ities to assist IEPs in their preparation for the exams andentering the Canadian workforce. As many resources aspossible were made available on-line to serve the needs ofIEPs from clinical practice sites distant from Vancouver.Evaluation was built into the program to inform continuingprogram improvements and the development of additionalprogram initiatives. This has resulted in the Programattracting greater numbers of IEPs than projected, and pro-viding the flexibility to support and accommodate thesegreater numbers. Projections identified the capacity to sup-port and accommodate 8 IEPs per year in the practical and16 in the written, and over the first 4 years of the program(2008–2011), 124 IEPs have participated. The program nowrecovers its expenses through charging the IEPs, and al-though participation has declined relative to the fundedprogram, enrolment has been sufficient to cover costs.Using a framework to build the modules, gaining regularfeedback and, making the necessary changes to develop aninternationally educated health professional program hasproven highly successful. Only 24 health professionals(19%) who entered the program were unable to succeed innational examinations and join the Canadian physiotherapyworkforce. However, these professionals may retake theexamination and enter the workforce in the future. Thelong-term data regarding entry of IEPs into practice indi-cates that at least 69 IEPs, who completed the IEP Program,entered the Canadian Physiotherapy workforce, with 34 ofthese working in the public sector.The IEPs who participated appear to be representative ofthe population of Canadian immigrants; in the Canadiangeneral populace the ratio of European to Asian immi-grants is changing over time. In our population 58% of stu-dents came from the UK in 2009 and 12% in 2011, versus10% of students from India in 2009 and 40% in 2011. Thetop four countries for physiotherapist immigrants prac-ticing in Canada to have received their basic physiotherapyeducation, from 2007 to 2009, were UK (21%), India (15%),USA (10%) and Australia (8%) [26]. The IEP program hadfewer applicants from the U.S.A. and more from Australia;this could be explained by British Columbia having a lowerTable 2 Characteristics of international educatedphysiotherapists accepted into program2008* 2009* 2010* 2011* TotalNumber admitted 13 31 38 42 124Sex nMale (%Male) 10 (77) 15 (48) 18 (47) 16 (38) 59 (48)Years of practice as physiotherapistNever practiced 1 (8) 11 (35) 6 (16) 0 18 (14)<5 8 (61) 16 (52) 21 (55) 15 (36) 60 (48)5 to 10 3 (23) 4 (13) 7 (18) 22 (52) 36 (29)>10 1 (8) 0 1 (3) 5 (12) 7 (6)Not recorded 0 0 3 (8) 0 3 (2)Country of physiotherapy educationAustralia 1 (8) 6 (19) 7 (18) 1 (2) 15 (12)Austria 0 0 1 (3) 0 1 (1)Belgium 0 0 0 1(2) 1(1)Brazil 2 (15) 0 1 (3) 3 (7) 6 (5)Egypt 0 0 0 1 (2) 1 (1)Finland 1 (8) 0 0 0 1(1)India 0 3 (10) 6 (16) 17 (40) 26 (21)Iran 0 1 (3) 2 (5) 2 (5) 5 (4)Israel 0 0 1 (3) 3 (7) 4 (3)Netherlands 1 (8) 1 (3) 2 (5) 0 4 (3)New Zealand 1 (8) 1 (3) 1 (3) 0 3 (2)Pakistan 0 0 1 (3) 0 1 (1)Philippines 0 0 2 (5) 7 (17) 9 (7)South Africa 1 (8) 0 0 1 (3) 2 (2)United Kingdom 6 (46) 18 (58) 9 (24) 5 (12) 38 (31)United States 0 1 (3) 4 (10) 1 (2) 6 (5)Unknown 0 0 1 (3) 0 1 (1)English as 1st language 10 (77) 28 (90) 25 (66) 21 (50) 84 (68)All data are n (%). Percentages do not always add up to 100% dueto rounding.*Year of entering program.Greig et al. BMC Medical Education 2013, 13:140 Page 6 of 8http://www.biomedcentral.com/1472-6920/13/140U.S.A. and higher immigration rate from Asia and thePacific than other provinces (Canadian average = 9% fromUSA, 25% from Asia and the Pacific; B.C. 6% and 59%respectively). Training, examination methods, healthcarecontext, and physiotherapist roles in the UK and Australiaalign more closely with Canadian standards than thosefrom other countries (i.e. India and the Philippines); it ispossible that Physiotherapists from countries with differentacademic procedures seek more opportunities to receiveadditional support for the exam preparation.The primary objective of this program was to increasethe pass rate of internationally trained Physiotherapists tak-ing the PCE. The success of the program in increasing thepass rate of IEPs taking the PCE has been achieved withinternational graduates who took the program having a28% greater possibility of passing the written section thantheir counterparts who did not take the program. The re-sults for the clinical exam are even more impressive withthe IEP program students having a 39% increase in risk ofpassing. A greater percentage of Canadian-educated candi-dates for the PCE continue to pass both elements of thePCE but the gap is closing, particularly in the clinical com-ponent. The program was developed partially due to theobservation that in 2005 less than 50% of PCE attemptstranslated into passes in IEPs [7]; the students who partici-pate in the program now far surpass this with more than65% gaining a pass. Trends in IEP successes on the QEalso indicate higher pass rates over time, suggesting a posi-tive impact of the new initiatives including the writtenworkshops, additional resources (expanded exam bank,additional written exam practice, glossaries and self-studyquestions), mobile mentors, small group mentorship, andtransitioning the written program to an on-line platformto promote access throughout BC, across Canada andinternationally.It may be expected that those who do not have Englishas their first language would have more difficulty with par-ticipating in the course and passing the exams, in particu-lar, the written element. This appears to be false for theQE, the relative risk is 1.58 but the confidence interval isvery wide, crossing 1 (equality) and is not significant. How-ever, in the slightly larger number of people taking thePNE (n = 81), the relative risk demonstrates that those withEnglish as their first language have a significant, 40%greater risk of passing the clinical element. The IEP successrate on the PNE indicates a slight decrease over time, whenmore candidates who did not have English as their firstlanguage participated.Although the IEP program targets internationally trainedPhysiotherapists, this model could be transferred to otherhealth professions given the identified need to supportinternationally trained health professionals transitioninginto the Canadian workforce [14], and the similarity in pro-cesses related to the passing competency examinationsprior to registration in these professions [27]. Using pro-gram evaluation methodology, including the logic model,proved a successful approach for the development of a pro-gram that aimed to integrate internationally educatedhealth professionals into clinical practice.LimitationsAs this is a relatively new program, there are not sufficientnumbers of IEPs who have participated to enable sub-analyses of the data and examination of particular ele-ments of the program. Collecting more qualitative datawill allow for more in-depth analysis of the IEPs integra-tion into Canadian practice and the impacts on accultur-ation and socialization.ConclusionsPotentially this program model could be applied to sup-port integration of international health graduates fromany background into the workforce. While this programused as a primary outcome measure improved perform-ance on national competency examinations, many pro-gram elements also support international practitioner’sintegration into the Canadian health care system andpractice. Further examination of the role specific pro-gram elements may have on improving internationallyeducated health professional’s understanding of the cul-tural context of Canadian practice is needed.Competing interestsGP received reimbursement for her work coordinating the IEP program.Authors’ contributionsAG conceived of the study and participated in its design and coordinationand helped to draft the manuscript. DD carried out the analyses and draftedthe manuscript. SM participated in study design and coordination. GPparticipated study coordination. BL oversaw study concept, design andcoordination. All authors read and approved the final manuscript.AcknowledgementsPhysiotherapy Association of BC, College of Physical Therapists of BC,Vancouver Health Authority, Fraser Health Authority, and the University ofBritish Columbia helped to design this program.The pilot program was funded through a grant from the Ministry of JobsTourism and Innovation, Government of British Columbia.Received: 5 November 2012 Accepted: 8 October 2013Published: 11 October 2013References1. Racism in the Canadian job market; how widespread is discrimination againstvisible minorities in Canada’s labour market? Canadaimmigrants.com.2. Research and Statistics: http://www.cic.gc.ca.3. Federal/Provincial/Territorial Advisory Committee on Health Delivery andHuman Resources: How many are enough? Redefining self-sufficiency for thehealth workforce a discussion paper. Ottawa: Health Canada; 2009.4. Canadian Nurses Association: Planning for the future: nursing human resourceprojections. Ottawa: CNA; 2002:87.5. Health Employers Association of BC, Ministry of Health Services: Healthhuman resource planning projections for physiotherapists in British Columbia.Victoria: Ministry of Health Services; 2010.6. Kidd MR, Zulman A: Educational support for overseas-trained doctors.Med J Aust 1994, 160(2):73–75.Greig et al. BMC Medical Education 2013, 13:140 Page 7 of 8http://www.biomedcentral.com/1472-6920/13/1407. Johnson K: Integrating internationally educated physiotherapists. Toronto:Canadian Alliance of Physiotherapy Regulators and Canadian Physiotherapyassociation; 2007.8. Boulet JR, Norcini JJ, Whelan GP, Hallock JA, Seeling SS: The internationalmedical graduate pipeline: recent trends in certification and residencytraining. Health Aff Millwood 2006, 25(2):469–477.9. Crutcher RA, Banner SR, Szafran O, Watanabe M: Characteristics ofinternational medical graduates who applied to the CaRMS 2002 match.CMAJ 2003, 168(9):1119–1123.10. Fink KS, Phillips RL Jr, Fryer GE, Koehn N: International medical graduatesand the primary care workforce for rural underserved areas. Health AffMillwood 2003, 22(2):255–262.11. Ko DT, Austin PC, Chan BT, Tu JV: Quality of care of international andCanadian medical graduates in acute myocardial infarction. Arch InternMed 2005, 165(4):458–463.12. Bates J, Andrew R: Untangling the roots of some IMG’s poor academicperformance. Acad Med 2001, 76(1):43–46.13. Hall P, Keely E, Dojeiji S, Byszewski A, Marks M: Communication skills,cultural challenges and individual support: challenges of internationalmedical graduates in a Canadian healthcare environment. Med Teach2004, 26(2):120–125.14. Rukholm EE, Stamler LL, Talbot LR, Bednash G, Raines F, Potempa K, NugentP, Clark DJ, Bernhauser S, Parfitt B: Scaling up the global nursing healthworkforce: contributions of an international organization. Collegian 2009,16(1):41–45.15. Searight HR, Gafford J: Behavioral science education and the internationalmedical graduate. Acad Med 2006, 81(2):164–170.16. Sochan A, Singh MD: Acculturation and socialization: voices ofinternationally educated nurses in Ontario. Int Nurs Rev 2007, 54(2):130–136.17. Whelan GP: Commentary: coming to America: the integration ofinternational medical graduates into the American medical culture.Acad Med 2006, 81(2):176–178.18. Wong A, Lohfeld L: Recertifying as a doctor in Canada: internationalmedical graduates and the journey from entry to adaptation. Med Educ2008, 42(1):53–60.19. Bordage G: Conceptual frameworks to illuminate and magnify. Med Educ2009, 43(4):312–319.20. Centers for Disease Control and Prevention: Framework for programevaluation in public health. MMWR Recomm Rep 1999, 48(RR-11):1–40.21. Hatry H, van Houten T, Plantz M, Greenway M: Measuring programoutcomes: a practical approach. Virginia: United Way of America; 1996.22. Larsen DP, Butler AC, Roediger HL 3rd: Test-enhanced learning in medicaleducation. Med Educ 2008, 42(10):959–966.23. Delta Pi Epsilon Society, L. R: Delta Pi Epsilon National Research ConferenceProceedings (Columbus, Ohio, November 15-17, 1990). [S.l.]. Distributed byERIC Clearinghouse; 1990.24. Canadian Alliance of Physiotherapy Regulators: Physiotherapy competencyexamination. Candidate handbook. Toronto: Canadian Alliance ofPhysiotherapy Regulators; 2008.25. Canadian Alliance of Physiotherapy Regulators: Physiotherapy competencyexamination. Candidate handbook. Toronto: Canadian Alliance ofPhysiotherapy Regulators; 2009.26. Canadian Institute for Health Information: Physiotherapists in Canada, 2009.Ottawa: Canadian Institute for Health Information; 2010.27. Sweatman L, Barry J, Liitle L, Davies J: International nurse applicants:initiatives, including LeaRN. Can Nurse 2003, 99(8):34–36.doi:10.1186/1472-6920-13-140Cite this article as: Greig et al.: Program evaluation of a model tointegrate internationally educated health professionals into clinicalpractice. BMC Medical Education 2013 13:140.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGreig et al. BMC Medical Education 2013, 13:140 Page 8 of 8http://www.biomedcentral.com/1472-6920/13/140


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