In their own time: Refugee healthcare professionals’ attempts at temporal re-appropriation

Abstract

Scholarship on refugee labour market participation regularly alludes to the temporal dimension of the process, yet explicit engagement with it remains limited. I argue that researching the temporalities of refugee employment re-entry is valuable as it discerns the recursive interrelation between social structure and individual agency that advances or curbs the labour market trajectories of refugees. Namely, refugees’ perceptions of time inform their integration pathways. In this article, I interrogate how highly educated refugees perceive the temporalities imposed upon them by the integration framework, their efforts of temporal re-appropriation and the ways in which institutional factors inform these re-appropriation efforts and, thus, individuals’ sense of integration. To this end, I discuss and compare 11 refugee healthcare professionals’ perceptions of licensure procedures in Oslo and Malmö based on material from semi-structured interviews. The refugee professionals reported that the licensure appropriated their time through, for instance, prolonged suspension from work and abundance of pointless waiting time. Seeing time as a precious commodity, they deemed the imposed temporalities as problematic, employing different attempts of temporal agency to speed up the licensure process. When comparing the attempts of temporal re-appropriation between the licensure procedures in Oslo and Malmö, I find that the perceived clarity of the licensure requirements and process, accessibility of support structures and existence of tailored qualification programmes lend licensure a quality of institutional plasticity. This fosters individuals’ attempts to accelerate their licensure endeavours, thereby promoting their re-entry into the labour market. However, rather than disrupting the underlying power relations determining the relative value of foreign healthcare qualifications, temporal re-appropriation maintained the established institutional rationale.

Introduction

Conventional integration scholarship and policy-making situate refugees in search of employment in time in a particular way. Refugees are understood to follow a linear and sequential process of transition from a clearly demarcated start (arrival to the destination country) towards an ideal future of full integration, marked by refugees’ employment performance mirroring that of the majority population. Refugees’ past and present are evaluated with reference to this ideal, foregrounding their deficiencies in terms of resources, motivation and efforts. Furthermore, integration policies are underpinned by the expectation of fast integration (Çağlar, 2018; Rytter, 2018; Schinkel, 2018; Spencer and Charsley, 2016).

Explicit scholarly focus on the temporal dimensions of refugee employment re-entry remains scarce. Most studies interrogate how the protracted periods of unemployment due to the asylum application process or employment bans affect refugee labour market trajectories. They show that these periods potentially negatively affect refugee employment since they can lead to skills atrophy, decreased mental health and discouragement mechanisms in the form of stress, apathy and low motivation (Hainmueller et al., 2016; Marbach et al., 2018). Indeed, through its prolongation of uncertainty and inactivity, the asylum system has been identified as a source of profound distress for refugees (Clayton and Vickers, 2019). However, it is not only the quantity of waiting time that affects refugee employment but also its quality. Whereas asylum seekers cannot escape waiting (Haas, 2017), they can mould it in ways that contribute to, rather than cripple, their integration pathway. Waiting does not have to represent an ‘empty interlude’ (Rotter, 2016) leading to disqualification and discouragement; it can qualify as a field potent with opportunities. While they wait, asylum seekers can gain cultural and institutional knowledge, start acquiring language proficiency and foster social contacts (Brekke, 2004; Hvidtfeldt et al., 2018).

The solicitation of time as the main unit of analysis foregrounds the idea that refugee labour market integration is enacted as a dialectic interplay between the individual’s efforts and the institutional and organisational structures encompassing them (Mulvey, 2015). A growing body of literature, particularly on asylum seekers and detainees, employs the temporal lens to probe how asylum seekers’ realities are (re)produced and governed. In particular, prolonged waiting, characterised by experiences of uncertainty and liminality, has been identified not merely as a by-product of the asylum regime but as a mechanism of power and control (Andersson, 2014; Brux et al., 2019; Drangsland, 2020; Griffiths, 2017; Hansen, 2020; Haas, 2017). Concurrently, studies suggest that forced migrants exercise agency over their time even in the most constrained of circumstances (Clayton and Vickers, 2019; Griffiths, 2014; Kallio et al., 2021; Rotter, 2016).

However, how is refugees’ time governed once they obtain their residence permits and set up to settle in the destination country? What temporalities are imposed upon them, and how do they attempt to regain control over their time? In this article, I employ the perceptions of highly educated refugees to ponder over these questions. Specifically, I delve into their efforts at temporal re-appropriation along their employment trajectories and their perception of how the institutional setting informs their sense of time and thus their integration endeavours. To this end, I discuss and compare highly educated refugees’ perceptions of licensure procedures for healthcare professionals in Oslo (Norway) and Malmö (Sweden) as conveyed in semi-structured interviews.

The empirical case serves the given research inquiry in several ways. Labour market participation of refugees is steered by institutional and organisational structures to a larger degree than that of other migrant groups (Valenta and Bunar, 2010). This holds especially true for highly educated refugees, whose employment re-entry is shaped through not only the asylum regime and civic integration programmes but also processes of foreign qualification recognition (FQR), such as the licensure. Even though FQR processes are usually explored in relation to the inclusion and exclusion of knowledge (Andersson, 2021), research dealing with refugee participation in FQR procedures hints at the embedded temporal challenges relating to their duration (Bucken-Knapp et al., 2018; Bygnes, 2021), the pervasiveness of waiting (Loss et al., 2020) and the mechanisms of discontinuation (Kum et al., 2010).

Furthermore, juxtaposing refugee healthcare professionals’ perceptions of licensure procedures in the two localities reveals how particular institutional factors inform refugees’ temporal sense and, thus, their integration pathways. Explorations of institutional and organisational efforts to support refugee labour market integration commonly examine the logic and design of the policies and programmes at hand (e.g. Valenta and Bunar, 2010). This article complements these efforts by including the perceptions of refugees themselves, aiming to offer a more nuanced understanding of the involved actors and the ways the institutional system inform refugee employment trajectories (Bucken-Knapp et al., 2018; Spehar, 2021). While perceptions might not always accurately portray the contextual settings, they still inform individuals’ integration pathways. For instance, Berry and Hou (2016) have shown that perceived discrimination among migrants is not only detrimental to their wellbeing but also associated with poor integration outcomes.

In the following, I outline the conceptual anchor of the article, in which I unite the idea of integration as a two-way process with temporal approaches to the structure-agency dualism. Thereafter, I present the licensure contexts for healthcare professionals in Norway and Sweden and elaborate on the methods of material generation and analysis. In the subsequent sections, the empirical findings elucidate what temporal structures highly educated refugees’ feel are imposed upon them and how they relate to these structures and attempt to re-appropriate them. In the final empirical section, I elaborate on how the diverging structures of healthcare licensure in Norway and Sweden facilitate or curb highly educated refugees’ attempts at temporal re-appropriation, and I show how these inform the refugees’ perceptions of their integration endeavours. I foreground the perceived institutional characteristics that lend healthcare licensure a quality of institutional plasticity, fostering individuals’ attempts to accelerate their licensure endeavours. I conclude by reflecting on the relevance of temporalities for refugee integration and the impactfulness of their temporal agency, pointing to its limitations.

Temporal aspects of refugee labour market participation

I understand refugee labour market participation as an interplay of social structure and agency, and I argue that it is essential to pay heed to both when trying to account for it. As agents, refugees possess a capacity ‘to reflect on their position, devise strategies and take action to achieve their desires’ (Bakewell, 2010: 1694). However, this agency is embedded in a set of organised and patterned social behaviours that mould their agentic action known as ‘social structure’. Despite its connotation of stability, social structure is not a rigid social reality that is beyond the reach of human agency. It can and does change over time, not least because agents can exert control and transform their surroundings, even if only to a certain degree (Bakewell, 2010: 1694–1695). Put differently, refugee labour market participation is actively shaped by refugees’ agentic action, which is simultaneously moulded by these very social structures.

This understanding is echoed in the conceptualisation of refugee integration as a two-way process. Accordingly, refugee labour market participation does not depend merely on the capabilities and efforts of refugees but also on the social structures within the receiving society (Ager and Strang, 2008). However, integration research has chiefly been interested in how the demographic characteristics of refugees shape their labour market participation. The role of the institutional and organisational aspects within the receiving society has received less attention (Lee et al., 2020; Phillimore, 2021).

To grasp the ways the receiving society informs refugee labour market participation, Phillimore (2021: 7) suggests that it is useful to look at integration opportunity structures, that is, ‘sets of resources, arrangements and pathways that can facilitate or block integration’. She identifies five main domains: Locality implies the influence that place, through its accessibility to, for instance, employment, has on fashioning integration. Further opportunity structures are created by public discourses surrounding refugees as they shape the emotional orientation of the receiving society towards the newcomers, thus informing the nature of social relations refugees engage in. Moreover, the structural and support factors are crucial elements forming refugee integration, in particular, the policies surrounding asylum, integration (including licensure) and citizenship, as well as services like civic integration programmes and migrant support organisations.

Research results on the role of licensure for migrant healthcare professionals’ employment are mixed and inconclusive. Whereas one line of research postulates that licensure deters migrants’ professional re-entry (Peterson et al., 2014), other studies point to its inclusive potential. Research in Norway has shown that job applicants with minority backgrounds in healthcare occupations are subject to less discrimination than in other fields (Midtbø en and Rogstad, 2012) and that non-Western physicians and dentists demonstrate only slightly lower employment probability and incomes when compared with majority professionals (Drange, 2016). However, the positive outcomes depend on both the occupational closure of the healthcare sector and high labour demand.

To capture the dialectic interaction between integration opportunity structures and individuals’ resources and agency that is encompassed within refugee integration, I argue that it is useful to pay heed to the temporal aspects of refugee labour market participation. As a social process, refugee integration shapes and is shaped by time (Cwerner, 2001). Structurally determined patterns and velocities of integration traverse refugees’ own rhythms of settlement (Clayton and Vickers, 2019). Individuals’ orientations towards their futures might collide with institutional and organisational structures that re-form these outlooks (Mozetič, 2021). Their present is decelerated and punctured by deadlines and threshold-like moments set by the asylum and integration system (Griffiths, 2014), while simultaneously being permeated by the remnants of their past lives and mental presence in far-away time zones (Harper and Zubida, 2020). The continuity of their life courses was disrupted by flight and is now once again re-attempted (Bygnes, 2021).

Lending attention to the temporal dynamics of integration can unearth mechanisms of inclusion and exclusion. Time shapes our interpersonal relationships, impacts our stance towards the world and may spur conflicts (Macduff, 2006). Temporal asynchrony can be used to augment social disparities, contributing to feelings of exclusion, dissonance and marginalisation. In his study on migrant farm workers in Canada, Perry (2020) shows how temporal controls dent individuals’ sense of belonging. Conversely, the efforts to generate belonging rest implicitly on temporal notions like those of mutual past, common heritage and shared future (Griffiths et al., 2013).

To grasp the temporal complexity of the integration processes, where hegemonic temporal structures are in recursive interaction with the individual temporal agency, I lean on Cwerner’s (2004) concept of time politics and Flaherty’s (2003, 2012) idea of time work.

Time politics and time work

According to Cwerner (2004), time constitutes a fundamental resource of regulation of migrant flows and integration. Prolonged encampments at the European Southern borders are used for the purposes of migration control and for the financial benefits of the bordering and detention systems (Andersson, 2014). Access to citizenship often rests upon conditions like minimum legal residence periods and generational links (Cwerner, 2004). In her study on the suspension of deportation for rejected asylum seekers in Germany who start vocational training, Drangsland (2020) shows how the training contract – through its ‘future giving’, suspension and deportability – recalibrates individuals’ relations to their present and future. To capture the ways asylum regime and integration structures regulate individuals’ time, Cwerner (2004) speaks of time politics, referring to the organisational appropriation of time by public institutions.

However, time does not simply happen to us. Individuals choose, commodify, structure, make, speed up, save and prioritise time. Whereas time politics can be understood as a form of temporal structure, the agency involved in individuals’ determination of temporal experiences is captured by Flaherty’s (2003, 2012) concept of time work. Time work allows us to instigate or suppress particular temporal experiences, enabling us to either resist or reinforce existent temporal structures.

Time politics and time work can be enacted along various temporal dimensions. They shape how individuals are positioned in relation to their past, present and future. They determine temporal sequence (i.e. the order of succession), along with what occurs simultaneously and what gets repeated. Allocation of time involves determining what our time is used for, and duration refers to the experience of the length of the time interval. Social structures attempt to determine the experience of the length of an event, engagement or interaction, and individuals try to shorten or prolong their perceived duration by making it pass faster or by decreasing its pace. Thus, the duration of events is closely connected to the tempo of processes and changes.

Whereas time work encapsulates individuals’ temporal agency, this does not imply it is independent from the social structure. As a purposeful effort, time work is animated by individuals’ goals, principals, wishes and aspirations, which reflect a certain set of values and are informed by one’s social positions. Moreover, individuals’ temporal agency is shaped by the very thing it tries to alter: the social structure (Flaherty, 2012).

Licensure procedures for migrant healthcare professionals in Oslo and Malmö

Non-EU/EEA-trained professionals, such as highly educated refugees in this study, who wish to practice within healthcare fields (e.g. medicine, dentistry and pharmacy), are legally obliged to obtain a license from a government agency. They have to participate in licensure procedures, which encompass the assessment of existent knowledge and skills and the fulfilment of additional requirements (Moss, 2014; Sumption, 2013).

In Norway and Sweden, non-EU/EEA-trained healthcare professionals kick off the licensure by applying for the authorisation at the designated government agency – the Directorate of Health (Helsedirektoratet) in Norway and the National Board of Health and Welfare (Socialstyrelsen) in Sweden. They provide the agency with their foreign educational credentials, transcripts and licenses (in the original language and translated into English or one of the Nordic languages). In both countries, refugee healthcare professionals can initiate the application process only after they have been granted asylum (Schuster et al., 2013). Once they obtain residency, refugees commonly enrol in civic integration programmes (the introduction programme (introduktionsprogrammet) in Norway and the establishment programme (etableringsprogrammet) in Sweden), which are 2-year state integration programmes encompassing language and orientation courses, as well as labour market integration support, which encompasses FQR guidance from their public employment services (PES) case officers.

Apart from these commonalities, the Norwegian Directorate requires non-EU/EEA medical doctors (but not dentists and pharmacists) to send their credentials for verifications to the Educational Commission for Foreign Medical Graduates’ (ECFMG) Electronic Portfolio of International Credentials (EPIC) in the United States. The verification encompasses, among others, contacting the issuing institution, something that has proved to be particularly challenging in the case of refugees (Loo, 2016: 3). Moreover, the Norwegian and Swedish agencies advertise significantly different application processing times. At the time of this empirical study, the Swedish Board estimated the processing time at 2 months, the Norwegian Directorate at 7 months.

Since non-EU/EEA credentials are typically not deemed equivalent to those valid in the destination country, healthcare professionals have to fulfil additional requirements before obtaining a license (Andersson, 2021; Sumption, 2013). Indeed, Alecu and Drange (2019: 38) write, ‘(I)mmigrants have the educational qualifications that are necessary, but not sufficient, to receive a licence’. The requirements differ between professions and countries, yet they commonly encompass acquiring the destination-country language, passing a knowledge examination, attending courses on safe-handling and on national healthcare legislation and health services and undergoing a type of clinical training.

The initial application procedure and the acquisition of the additional requirements are a lengthy and onerous process, often taking several years to complete (Eriksson et al., 2018; Skjeggestad et al., 2015). The lengthy procedures are problematic because they put the candidates in financial difficulties and lead to deskilling; they also potentially lead to decreased motivation (Davda et al., 2018). To tackle this issue, many European countries, including Sweden, set up tailored qualification programmes that enable faster labour market re-entry for migrants (including refugees) with certain occupational backgrounds (Eriksson et al., 2018). One such programme is the Swedish ‘short route’ programme (korta vägen), which offers employment-related guidance, coaching and training, as well as work placements and an intensive occupation-related Swedish language course. ¹ The intensive language course and the fact that participants engage in these modules in parallel allows the participants to speed up their licensure. In their analysis of the effectiveness of international qualification programmes for labour market participation of migrant health professionals, Khan-Gökkaya et al. (2019) observe that participation in such programmes not only promotes self-confidence among its participants but also leads to increased language proficiency and results in higher chances of passing knowledge exams.

Moreover, the occupation-related guidance encompassed in short route programmes provides participants with a clear understanding of the licensure requirements and proceedings. Access to information about the application process and requirements facilitate foreign professionals’ access to FQR (Schuster et al., 2013). Further, research indicates that procedural transparency, accomplished through the accessibility of the responsible agency, is important. The inaccessibility of information concerning the state of one’s application and the related perception of arbitrary discretion can weigh heavily on the applicants, leading to feelings of exasperation, angst and desperation (Loss et al., 2020).

Considering these differences between licensures in Oslo and Malmö, we can expect that the licensure structures in Malmö create integration opportunity structures that facilitate employment participation since they allow refugee healthcare professionals to engage in shortening the duration of their licensure.

Methods

The empirical material this article is based on was gathered as a part of a qualitative study on the labour market participation of highly educated refugees in Oslo (Norway), Malmö (Sweden) and Munich (Germany). I conducted semi-structured interviews with 41 individuals who possessed a completed university degree from outside of EU/EEA, obtained asylum in the destination country and were originally from the Middle East or Afghanistan.

Whereas time represented a salient topic in the whole material, this article engages exclusively with interviews with 11 refugee healthcare professionals in Oslo and Malmö (five and six interviewees, respectively). I decided to delimit the sample to healthcare professionals, first, to allow for a comparison of how the interplay between the perceived temporal structures and agency unfolds in specific institutional settings and, second, because the temporal theme is particularly prominent in healthcare professionals’ narrations. I excluded the German sample because it includes only two refugee healthcare professionals who were still in the initial application stages of the licensure and thus had little thoughts on the topic.

Eight research participants were medical doctors (including three specialists), two were dentists and one was a pharmacist. Seven interviewees came from Syria, three from Afghanistan and one from Yemen. Nine were male and two female. Six interviewees were in their 40s and five in their 30s. At the time of the interview, six research participants had lived in the destination country for about 3 years, three had been there for 5 years and two for 2 years. ² None of the interviewees had re-entered their profession yet. Rather, they were still participating in civic integration programmes for refugees, learning the language and seeking to obtain their licenses. Although the majority had temporary 3-year residence permits, not one perceived their temporariness as a source of uncertainty and stress. The protracted duration of conflicts in their home countries made them assured that their residence permits would be extended.

Individuals were invited to participate in the study by means of active (through social media) and passive recruitment (through integration initiatives, migrants support organisations and personal contacts). Snowballing was employed to recruit further interviewees. The interviews were conducted between September 2016 and July 2017. As such, interviewees’ perceptions of licensure reflect the regulations and support structures existent at that time. The interviews were conducted when, where and how it was most suitable for the interviewees. We met at the interviewees’ homes, integration programme premises, the author’s office or cafés. They were conducted in Norwegian, Swedish or English, and all but one were audio-recorded. The interviews lasted between one and 3 hours (on average, about 2 hours).

The interview questions revolved around individual’s educational and occupational background, flight, asylum procedure, the initial time in the destination country (participation in civic integration programme, FQR, possible employment, etc.) and future outlook. The interviews focused on mapping the participants’ occupational trajectories and aspirations and their perceptions thereof. The semi-structured nature of the interviews and the broad scope of topics enabled the interviewees to speak of subjects that were close to their heart and me to obtain rich contextual understanding of their employment trajectories.

My interest in the temporal aspects of highly educated refugees’ labour market participation surfaced inductively through initial dramaturgical coding (Saldaña, 2009) of the material, where the topic of time prominently emerged as an area of conflict. The codes referred to, for instance, wasting of time, waiting, (too) lengthy durations and (too) slow processes. Once attuned to this tension-laden topic, I embarked on a closer engagement through iterative cycles of focused coding (Charmaz, 2006) and consultations with the existent literature, allowing me to discern the more elusive temporal aspects of, for example, historical context, frequency, sequencing and attempts of acceleration. I found that the interaction between imposed temporal structures and individuals’ temporal agency appeared to represent a pervading concern within interviewees’ perceptions of their labour market trajectories.

Despite my best efforts to include as many quotes from the material as possible in the following empirical sections, only a few are presented. Even though temporal concerns were raised extensively, they were mainly referred to implicitly. Therefore, the empirical sections mainly paraphrase interviewees’ perceptions and include only a few succinct quotes.

Time politics of licensure procedures

Licensure procedures imposed upon the interviewed refugee healthcare professionals certain temporal experiences through their requirements, regulations and assistance provisions. The licensure time politics established temporal rhythms and ruptures and allocated participants’ time to specific activities, drawing a line from their pasts, over their presents, into their futures. This appropriation of interviewees’ time was mostly characterised by prolonged suspension from work, abundance of pointless (waiting) time, dismissal of the past, uncertainty about the future and neglect of historical circumstances.

Unanimously, the interviewees stated that the licensure took too long time. They saw the lengthy duration as problematic mainly because they thought that the licensure structure and assessment styles allocated their time to activities that were keeping them away from, rather than in touch with, their professions. Many spent extensive amounts of time informing themselves about the application process and gathering and translating the required credentials. Moreover, they perceived that the process involved a lot of waiting. They waited for decisions, answers, the overturning of decisions or empty spots in courses. Therefore, for many, the time spent on licensure was like a professional dead-time – a stasis. Hence, the sense of deceleration and suspension of time that has been documented during asylum seekers’ periods in transit camps, asylum procedures and detention (Griffiths et al., 2013; Turnbull, 2016) was also evoked by the interviewees, who were recognised refugees. They expressed it in relation to the perceived slow passage of the professional time and the associated lack of progress.

Moreover, many interviewees observed that the licensure requirements designated applicants’ time to learning that was not conducive to their professional futures. Rather than learning the language in standardised, often low-paced courses encompassed within civic integration programmes, the interviewees would have preferred to attend intensive, occupation-related language courses. Many claimed that a better way to recognise their skills would have been through on-the-job assessment and training rather than knowledge tests. Ergo, many interviewees perceived much of the time spent on the licensure as lost and wasted.

The interviewees expressed that the licensure not only squandered their present but also rendered their futures unknown and uncertain. The demanding requirements made many insecure about whether they will ever be able to re-enter their professions. The lengthy licensure kept the interviewees locked in the state of uncertainty, making it difficult for them to envision their professional prospects. The acquisition of the license acted ‘as the “key” to resuming their lives and “unlocking” their futures’ (Brux et al., 2019: 1447). Simultaneously, the interviewees perceived that the licensure casted ‘suspicion on their qualifications’ (Skjeggestad et al., 2015: 1130). By having their knowledge tested and by being required to repeat parts of their training, refugee healthcare professionals believed that their ‘professional integrity and experience were being questioned’ (Kum et al., 2010: 328). This feeling was most often reflected in the sentiment that, professionally, they were ‘staring from zero’, implying that there existed nothing prior to right now – as if their professional past, experiences, knowledge and identity never existed.

Lastly, the interviewees perceived that the documentation requirements did not take into consideration the tumultuousness of their flight and the historical context of their countries of origin (which were, in most cases, also the countries of their higher education). Several interviewees recounted having lost their documents during their flight and facing challenges when trying to get a hold of the required documents from countries embroiled in armed conflicts, political instabilities and dictatorial regimes.

Time counts

The interviewees related to the imposed licensure temporalities and forged their own attempts of temporal re-appropriation through their own ideas and expectations concerning the temporal flow of their integration trajectories. Individual’s relation to time is not made with utter autonomy; it is tied to priorities, values and expectations reflecting individual’s social positions (Flaherty, 2012). This section considers how the interviewees’ social positions as ‘refugees’ and ‘professionals’ informed their temporal values and notions.

Most interviewees were eager to re-embark on their professional pathways as soon as possible. Due to the experience of displacement, the interviewees had not practiced their professions in years. The idea that the long-lasting licensure further prolongs this separation was unsettling as they were afraid of losing their know-how (see also Mozetič, 2018) and sensed their motivation and energy being drained. Furthermore, displacement rendered interviewees’ careers discontinuous. The unwilling and unanticipated career disruption further fuelled their eagerness to re-enter their professions and made them frustrated at the realisation of having to ‘start from zero’ rather than to ‘start from where they are’ (Andersson, 2021: 16). Whereas, for some, pressing the reset button constitutes the appeal of migration, even propels it (Kanzaki Sooudi, 2014), that was not the case here. The interviewees’ expressions of relief, happiness and gratitude for being able to lead lives in safety were mixed with a nostalgic longing for their good, in some cases even wealthy, and personally and professionally fulfilling lives that they were forced to leave behind. For them, starting from zero, professionally, did not mean opening up possibilities; it implied having had lost nearly everything they had built up. In contrast to temporary and more mobile migrants, the interviewed refugee healthcare professionals were not able to reinterpret the permanence of their migration as a ‘time of exception’ (Suter and Cangià, 2020), which allows individuals to re-imagine their transient stay abroad as a transformative and liminal space in which professional and personal identities can be called into question. Instead, they attempted to forge a continuum between their pre- and post-migration lives, where profession represents a crucial cohesive link (see also Mozetič, 2021).

Moreover, the interviewees’ desire to re-enter their professions as soon as possible was tied to their awareness of the predominant societal expectations of swift refugee employment (Rytter, 2018), and of being dedicated and proactive in their efforts. Whereas the question of deservingness of asylum protection is usually tied to the condition of forced migration (Yarris and Castañ eda, 2015), here, the interviewees demarcated themselves as deserving of being a part of the receiving societies and of their support through their attempts to embody a ‘good refugee’ (Hetz, 2021) who is willing to integrate and contribute. The way the interviewees encountered the perceived integration temporalities was also rooted in the ways they lived their professional pre-migration lives. The interviews were pervaded with narrations about the centrality of work and the extensive proportions of their lives dedicated to it. In their home countries, the interviewees led lives with long work hours, multiple employments and weekends devoted to work. ‘Sitting around’ and having holidays and pastime were not the goal.

Taken together, the interviewees’ temporal ideas and expectations yielded a permeating sense of value attached to the time at their disposal. For them, integration time was of utmost value, representing a precious commodity (Flaherty, 2003) that should not be wasted but instead employed efficiently.

Attempts of re-appropriation

In the eyes of the interviewees, licensure procedures were inhabited by asynchronous, even impeding temporalities. Their desire to use their time effectively to achieve fast professional re-establishment was often at odds with the perceived cumbersomeness of the licensure time politics. The temporal disaccord did not remain unchallenged. The interviewees engaged in different techniques of time work to align the perceived licensure time politics with their own expectations about the licensure flow, progress and duration. Thus, temporal sequencing and allocation represented essential techniques of temporal agency.

By paying attention to how they used their time and by setting the order of the licensure requirements, the interviewees hoped to speed up the licensure tempo and thus shorten its duration. The ways the interviewees engaged with their time were often not coincidental or done simply to kill time. Instead, it was done intentionally to hasten the licensure process. Case in point is Wahbi, a Syrian medical doctor living in Malmö. In his quest to ‘find the shortest way’ to the Swedish medical license, he decided to continue pursuing the language course encompassed in the Swedish establishment programme while he simultaneously applied for the short route programme. With time, depending on the outcome of his short route application and the results of his language training exams, he would decide which path hastened his progression the most. If he obtained excellent results on his Swedish exam in the establishment programme, he would be able to skip the subsequent level of the language course and proceed to a more advanced language course. Alternatively, he would enter the short route programme and thereby shorten his licensure process. His considerations are just one illustration of the ways the interviewees strategised to accomplish the licensure in the fastest possible way.

The interviewees spoke of the dedication and diligence with which they tried to accomplish licensure requirements in order to employ rather than waste their temporal currency. Furthermore, they filled the void periods of waiting by engaging in what Rotter (2016) calls ‘active’ waiting, that is, spending their time on activities that were conducive to their professional re-entry. When waiting to attend a language course, many used their time to prepare their licensure applications or to do work placements. Echoing previous research on asylum seekers’ agentive work to tamper the constraints of waiting (Brux et al., 2019; Rotter, 2016), the interviewees actively used their time while waiting to obtain asylum. Whereas the interviewees were not allowed to formally apply for licensure before they obtained their residence permits, they worked on it in other ways. They informed themselves about the licensure prerequisites, commenced obtaining the required documents and started to learn the language.

Apart from paying attention to how they allocated their time, the interviewees were also careful about the order of their activities. Many tried to engage in parallel in as many relevant activities as possible. In order to obtain the license in a foreseeable future, Yasser, a medical doctor from Syria, did a work placement and attended a course in Norwegian health services and legislation while working within homecare service:

I work on three, four things at the same time. You see, now, I do a work placement at the hospital. I work [in homecare] during the weekends. And then I attend a course in Oslo. I do all of this at the same time so that after three months, I am done with three things. […] Work placement during the day and school in the evening. It requires a lot of effort. I get tired, but I must do it. Otherwise, I will never finish [with licensure].

That said, the interviewees’ capacity to exercise their time work was affected by the structure of the licensure procedure in which it was exerted. In the following section, I elaborate on how the perceived diverging institutional structures of the procedures in Norway and Sweden facilitated or hindered the interviewees’ attempts to re-appropriate the imposed temporalities according to their own needs, and I show how these affected the interviewees’ perceptions of their integration endeavours.

Institutional plasticity of licensure procedures

When comparing the perceptions of licensure between the interviewees in Oslo and Malmö, I found it striking just how differently the refugee healthcare professionals related their attempts at doing time work in the two contexts. The interviewees in Malmö thought that their attempts to accelerate the procedures were not only possible but also even fostered by the institutional setting. In contrast, the interviewees in Oslo often perceived that the setting held them back in their efforts to obtain the license. This made them unsure about the efficacy of their licensure efforts, let alone their attempts to speed up the process. Their narrations evoked the imagery of Sisyphean labour. This point was aptly illustrated by Kamal, a Syrian medical doctor, who tried to expedite the licensure by translating his medical records at his own costs in Syria only to realise that no matter how much he tried to ‘run’, the licensure system slowed him down:

I said to myself, to not take so long for translating, I translate all [documents] in Latakia with a sworn translator and I stamp them from the foreign ministry. […] I translate from Arabic to English in Latakia and I pay all costs. Why do I do this? To minimise the time, minimise the time. You know, we spent money to minimise the time and here a case worker [at the Norwegian Health Board] says, ‘For one question [concerning the licensure], I need four months’. So, how about translating 300 pages of my documents? To bring here my Arabic documents and if you give them to the municipality to translate, how much time will it take? If one question takes four months. But it doesn’t help. How much I run, how much they will say: ‘You must wait’.

The interviews revealed three distinct yet interrelated characteristics of the licensure procedures that informed these diverging perceptions of time work: clarity of the licensure framework, accessibility of support structures and existence of targeted qualification programmes. The interviewees in Malmö voiced a clear understanding of the requirements and progression of the licensure procedures, whereas the interviewees in Oslo mentioned that they were often unsure of what exactly was required of them. The interviewees in Oslo perceived that the licensure represented an opaque path and that their efforts to understand the requirements and process required a considerable investment of time. Many spent a lot of time gathering information about the requirements, particularly those connected to the initial application process. Nonetheless, even once their application was processed and the required supplementary training was determined, many were not sure whether the fulfilment of these requirements would provide them with a license. The unclear outcome of the laborious, long-lasting path often casts a shadow of doubt on the meaningfulness of their efforts, leaving them feeling the pointlessness of their actions.

This appeared to be closely connected to the support structures the interviewees thought were available to them. The interviewees in Malmö obtained their licensure-related information from the licensure agency itself or, in the case of uncertainties, were able to discuss the licensure with their PES case officers or the staff at the short route programme. None of the interviewees claimed to have experienced any difficulties in obtaining the information about how to apply for the validation of their certificates or about what was required of them to obtain the license. In contrast, the interviewees in Oslo found little support from their PES case officers and experienced the licensure agency as virtually unapproachable, receiving standardised and severely delayed answers to their questions. Because of that, the interviewees tried to navigate this (as perceived by many) opaque procedure on their own. They spent a lot of time gathering information about the licensure requirements, particularly those connected to the initial application process. In that sense, many experienced the mere embarking onto the licensure procedure as very time-consuming. Particularly challenging was the submission of the validation application to the American ECFMG, as applicants had to navigate a complex landscape of deadlines and requirements.

Consequently, the interviewees expressed that the opaqueness of the licensure and the lack of a support structure hindered them in allocating their time to the actual fulfilment of licensure requirements. Moreover, it instilled in them an uncertainty about the efficacy of their efforts to progress along the licensure pathway. With each new step they took towards the fulfilment of the requirements, instead of recognising progression, the interviewees thought that they discovered new requirements they were previously unaware of and that the path was only getting longer and longer. Many believed their efforts to be unavailing.

Last but not least, the interviewees in Malmö said that the short route programme enabled them to shorten their licensure process. Not only did it provide them with tailored occupation-related assistance, but it also offered an intensive language course that allowed them to reach the required language proficiency faster. Contrarily, the interviewees in Oslo did not have the possibility to access such a programme.

The perceived clarity of the licensure procedure, the availability of support structures and the accessibility of targeted qualification programmes appeared to have lent the Swedish licensure a form of institutional plasticity (Strambach, 2010) that allowed the interviewees to mould the process according to their own temporal needs and expectations. The concept of institutional plasticity captures the ways actors deliberately mould existing institutional structures to their purpose without departing from the taken development trajectory (Notteboom et al., 2013). It refers to the possibility of creating a variety of trajectories that are all within the dominant institutional structure (Strambach, 2010). Thus, the interviewees in Malmö saw licensure as an integration opportunity structure that facilitated their efforts to expedite their professional re-entry. Their time work to hasten the licensure process was not experienced as taxing; instead, it lent the interviewees energy and motivation to walk along this demanding path. Despite the laborious licensure procedure he was engaged in, Baqir, an Afghani medical doctor living in Malmö, was ‘satisfied’ with his situation because ‘I know what I have to do. […] I know what is the next step’.

In contrast, the interviewees in Oslo told that their attempts to comprehend, move along and shorten the licensure time took a high toll on their motivation and wellbeing. Many said that the perceived onerous and unintelligible procedure was just an indirect way of denying non-EU/EEA healthcare professionals to practice. Many spoke of feelings of demotivation, frustration and exhaustion. Kamal, a Syrian medical doctor residing in Norway, used an analogy to depict how the curbing licensure made him start hating his profession:

If every day you think, ‘You must do this and do this and do this to pick apples’, you come to the degree when you hate apples. Because every day you think about apples, and every day they make something to prevent you from taking the apples. And, at last, you hate both of them. The apples and the persons.

For him, hope for a professional re-entry was the only thing that kept him going:

I look like somebody who is sinking but he is keeping hope. It looks like this. A little bit. And he knows that nobody will save him. But he is catching the hope, for the last minute. You know, we believe in God. I believe in God. It helps me continue my life. Because in these circumstances which I go through, this is very difficult for me.

Many others mentioned contemplating emigration as a possible exit strategy if the obtaining of the license should prove too (time-) demanding. For them, the importance of swiftly re-entering their profession outweighed the years-long efforts of trying to settle in the destination country by learning the language, making social connections and getting to know the system.

Conclusion

Encountered by what they perceived as a long process that is wasteful of their time, the interviewed healthcare professionals sought to engage in activities and to arrange their order in ways that would shorten the duration of the licensure. Nonetheless, as highlighted by the comparative aspect of the study, their attempts at temporal re-appropriation were facilitated or hindered by specific characteristics of the licensure as perceived by the individuals themselves. The refugee healthcare professionals in Oslo thought that the opaqueness of the licensure hindered their progression, let alone their attempts at its acceleration. The licensure acted as an integration opportunity structure that hindered highly educated refugees’ employment participation, fostering feelings of demotivation and desperation. In contrast, the perceived clarity of the licensure requirements and process, accessibility of support structures and existence of tailored qualification programmes lent the Swedish licensure the quality of institutional plasticity. By enabling the refugee professionals to hasten their employment re-entry, the institutional plasticity of the Swedish licensure represents an integration opportunity structure that potentially forges feelings of motivation, thus furthering their labour market participation.

However, whereas the refugee professionals in Malmö perceived that they were able to challenge the duration of the licensure and its imposed time allocation, the elements of licensure time politics that neglect applicants’ professional past and historical circumstances remained asserted. Licensure’s power over the recognition of foreign knowledge, skills and qualifications remained intact. The perceived institutional plasticity of the licensure in Malmö allowed the refugee professionals to accelerate the procedure without challenging its bottom-line rationale. In other words, the temporal agency of refugee healthcare professionals was not insurgent in the sense that it did not transmute the underlying assumptions about the relative value of foreign healthcare qualifications and therein embedded power relations. Therefore, their participation in the licensure procedure validated and reproduced its underlying principles.

Moreover, paying attention to the temporal dimensions of refugee employment participation complicates our understanding of the forces that animate refugee settlement processes. Through their time work, refugee healthcare professionals rebut and concurrently reinforce the notions encompassed in the conventional understanding of refugee labour market participation. With their desire for and efforts to achieve fast professional re-entry, they reproduce the expectation of speedy refugee integration and the idea of a ‘good refugee’ who is eager to integrate and contribute to the receiving society. At the same time, their perceptions that the licensure structure either restraints or supports them in their (accelerated) integration efforts underscore the essentiality of institutional factors in advancing or curbing refugee employment re-entry.

Indeed, zooming in on the temporal aspects of refugee labour market integration as perceived by the individuals themselves demonstrates that time is a critical factor affecting refugee employment endeavours. Integration structures that are perceived to unwaveringly protract refugees’ professional inactivity and programmes and procedures that are perceived to frivol away individuals’ time have the potential to dent highly educated refugees’ ambitions to participate in the labour market. By comparison, labour market participation institutions and organisations that are perceived to allow for temporal bending can possibly lend highly educated refugees the energy to walk down the challenging path of gaining employment commensurate with their ambitions.