The report "Tested Solutions for Eliminating Canada's Registered Nursing Shortage" (Tomblin Murphy et al. 2009) projects a nursing shortage in Canada and offers strategies for eliminating that shortage. Using a population needs–based approach, the report estimates that in the year 2007, the shortage of nurses was 11,000 full-time equivalent (FTE) registered nurses. By 2022, the shortage will grow to almost 60,000 FTE RNs. Strategies proposed by the authors to address the RN shortage include increasing nurses' productivity, reducing annual absenteeism, increasing enrolment and reducing attrition in entry-to-practice education programs, improving the retention of practising RNs and reducing international in-migration of nurses.

The global shortage of healthcare professionals is an important policy issue both nationally and globally. According to the World Health Organization (2006), there is a global shortage of 4.3 million healthcare workers. Several policy solutions have been suggested to solve the workforce shortage worldwide. However, recent policy solutions for the nursing shortage in Canada fail to consider "brain waste" resulting from the inability of internationally educated nurses (IENs) to integrate into the Canadian healthcare system.

IENs migrate to Canada for diverse reasons and under different immigration categories. Too often, proposed policy solutions fail to consider IENs who choose to migrate to Canada and are subsequently unable to practise here. One such recent policy document (Tomblin Murphy et al. 2009) is the subject of this commentary. This report, published by the Canadian Nurses Association, suggests reducing the in-migration of nurses by 50%. According to the authors, such a reduction would have an insignificant long-term effect because internationally educated registered nurses represent only a small fraction of the supply of Canadian RNs.

The authors' analysis is based solely on the number of IENs who write the Canadian Registered Nurse Exam (CRNE). Hence, it fails to consider IENs who migrate to Canada and are not able to write the national nursing registration exam. For instance, in Ontario, in 2007, 26.3% (n = 1,221) of RN applicants to the College of Nurses of Ontario were IENs (CNO 2008). In contrast, only 14.7% (n = 541) of those who wrote the RN exam were IENs.

Once IENs are granted permission to write the licensing examination, many are not able to pass it. While the pass rate of Canadian-educated nurses writing the CRNE is 96%, the pass rate of IENs writing it is 63% (CNA 2006). Moreover, the second-time examination success rate is even worse for IENs. In Manitoba, the first-time exam pass rate for IENs was 57% in 2008, while the second-time examination pass rate was 38% the same year (College of Registered Nurses of Manitoba 2009).

The authors' findings might have been different had the study considered all the IENs who begin the process of registration in Canada, including those who do not complete the registration process. This represents a large pool of potential nurses. Leaving out this human resources pool limits possible approaches to solving the country's nursing shortage.

The complex issue of international nurse migration requires that different positions be taken into account, including the right of nurses to migrate, as well as the unethical active and passive recruitment of IENs, especially by recruitment agencies (ICN 2007). The premise of this commentary is not to argue for the active or passive recruitment of nurses; it is to argue that there needs to be broader ethical consideration of in-migration of nurses to Canada. As a country with strong ethical and moral values, Canada should not only focus attention on the unethical active recruitment of nurses from predominant donor countries (especially in Asia and Africa). There is a need to consider the double ethical challenges of a brain drain, coupled with brain waste. Brain drain represents the out-migration of nurses with high human capital (including education and experience) into Canada, while brain waste represents the waste in human capital when IENs are unable to utilize their knowledge and skills in destination countries (such as Canada) because of difficulties in workforce integration. While the report of Tomblin Murphy and colleagues (2009) pays attention to the active recruitment of nurses and the resulting brain drain, it does not consider the facts that nurses have a right to migrate and that they migrate for many possible reasons.

Canada is a diverse country, with immigrants representing 19.2% of the population, the second highest immigration rate in the world (Hawthorne 2008). The diversity of its population should be represented in the country's professional healthcare workforce. The report of Tomblin Murphy and colleagues (2009) devalues the potential contribution of internationally educated nurses to the workforce, especially in maximizing diversity in the nursing workforce.

Take the cases of Ontario and Saskatchewan: 40% of IENs who begin the registration process in Ontario do not complete it to become RNs or RPNs (CNO 2005). In Saskatchewan, there is a disparity between the number of IENs who apply to become members of the Saskatchewan Registered Nurses Association and the number who become registered to practise. In 2007, although over 200 IENs applied to become RNs in Saskatchewan, fewer than 20 IENs succeeded (Saskatchewan Registered Nurses Association 2008).

The statistics in Ontario and Saskatchewan provide just a glimpse of the problem of integrating IENs into the healthcare systems of destination countries. Unfortunately, data are not available on the total pool of IENs in Canada who are unable to become registered to practise here. It is also very difficult to know the precise number of IENs currently in Canada. Why? Because IENs migrate under several possible immigration categories, including economic, family class, live-in caregiver or temporary immigration categories. Furthermore, when internationally educated nurses migrate to Canada under the economic class, they often do not do so as principal applicants, because many of them are women.

Challenges or barriers to registration include lack of information and communication, the assessment process itself, language difficulties, the cost of the CRNE and that of immigrating (Jeans et al. 2005). For instance, many IENs are not aware of the steps to registration pre-migration. Unlike in some countries, such as Australia, the lack of a foreign credential recognition pre-migration creates a further challenge for IENs post-migration to Canada, because many nurses are often not prepared with the appropriate documents required for registration here. The foreign credential recognition policy in Australia includes a mandatory pre-migration English test and credential assessment. In addition, Bauman and colleagues (2006) point out other barriers to licensure, including lack of support systems post-migration, difficulty in obtaining documents from country of origin, difficulty in passing the licensing examination and insufficient practical information on the migration process.

Increasingly, international organizations are taking action to diminish the global nursing workforce brain waste. Attention to the ethical recruitment of IENs is echoed in the World Health Organization's World Health Report (2006), which emphasizes the need for fair treatment of migrant health workers, including the provision of cultural orientation to ensure integration into the health systems of destination countries. Furthermore, the International Council of Nurses' position statement on nurse retention and migration (ICN 2008) suggests several recommendations for national nursing organizations, including the provision of cultural orientation programs to migrant nurses and ensuring that there are no distinctions in labour market outcomes among nurses from different countries.

Eliminating distinctions between IENs and Canadian-educated nurses is a challenge in Canada. Even after IENs have gained entrance into the Canadian nursing workforce, many are unable to reach leadership positions at the same rate as Canadian-educated nurses. Thus, much still needs to be done to address the disparity in the ability of IENs to achieve leadership positions compared to their Canadian-educated counterparts. In Ontario, while 7.59% of Ontario-educated nurses occupy administrative positions and 3.16% hold educator positions, 4.41% of IENs (except those from the United States) hold administration positions and 1.53% of IENs (except those from the United States) occupy educator positions (Baumann et al. 2006). Hence, strategies must be implemented to ensure the full integration of IENs into the healthcare system at all stages, including post-registration.

Another question raised by this report is how, specifically, we would decrease the in-migration of IENs. Should we decrease the active and passive recruitment of IENs? Should we close our borders to IENs (for instance, by lobbying to have nursing removed from Citizenship and Immigration Canada's preferred Skilled Worker list)? Or should we decrease the access of IENs to the profession? Each of these strategies has different policy and ethical implications that must be thoroughly considered.

Considering both the unethical brain drain and brain waste, recommended policy solutions in Canada should include advocating for reduced active and passive recruitment of nurses from other countries, while implementing policies to ensure the integration of IENs into the Canadian healthcare system. Strategies must be implemented at all stages, from pre-migration to post-nursing registration, to ensure the full integration of internationally educated nurses into the Canadian system.

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