The latest issue of Nursing Leadership included a commentary (Kolawole 2010) referring to a recent report that we prepared for the Canadian Nurses Association (Tomblin Murphy et al. 2009). The writer of the commentary seems to criticize this report on two points, suggesting first that we underestimate the number of internationally educated nurses (IENs) in Canada and, second, that we undervalue the contributions of IENs to the RN workforce. I respectfully disagree with both these points.

The writer suggests that we underestimate the number of IENs because we do not count those who are not currently licensed to practise in our estimate of the national supply of RNs. The implication of this suggestion is that this licence should not be required as part of entry-to-practice regulations for RNs in Canada. This raises the question of what, then, should be required to enter practice as an RN? This is an important issue, but one that is outside the scope of our report. Changing entry-to-practice or licensing requirements would be an example of another policy scenario that could be estimated using the simulation model. However, as demonstrated in the report, such a policy does not appear necessary to alleviate the national shortage of RNs. Further, since we already include the number of IENs who have been awarded a licence to practise in Canada in our estimate of the national supply, this does not affect our estimate of the overall shortage – the difference between the number of RNs required and the number actually practising.

In addition, the writer implies that we diminish the contributions of IENs to the workforce. In our report we simply note that the number of foreign-trained RNs makes up a relatively small portion of the number of RNs already licensed in Canada, and hence even substantial changes in the former would have only a very modest impact on the balance between requirements and supply at the national level. At no point do we diminish the achievements or contributions of IENs working in Canada. The writer also claims that our report "does not consider the facts that nurses have a right to migrate and that they migrate for many possible reasons"; if this were the case, we would have simulated the elimination of in-migration rather than simply reducing it.

The writer's main theme seems to be that IENs face too many barriers to practising as RNs in Canada. This important matter was outside the scope of our report. However, the simulation model described in the report has the capacity to explore the effects of changing entry-to-practice regulation, as well as many other policy interventions in addition to those included in our report.

Finally, there seems to have been some misinterpretation of the purpose of the report, which was to estimate the shortage of RNs in Canada and test some potential solutions to it. As noted in the report, the various scenarios we tested represent examples of how the RN shortage might be addressed; these were selected by key stakeholders in the national nursing community as being of particular interest to them. They were not a prescription of the only possible solutions, and the mere absence of a particular scenario from the report does not imply that we think it invalid or irrelevant in any way.

Adrian MacKenzie
Senior Analyst, WHO Collaborating Centre on Health Workforce Planning and Research
Dalhousie University
Halifax, NS, Canada

Gail Tomblin Murphy
Professor, School of Nursing /Faculty of Health Professions and
Director, WHO/PAHO Collaborating Centre on Health Workforce Planning and Research
Dalhousie University
Halifax, NS, Canada

Stephen Birch
Professor, Centre for Health Economics and Policy Analysis
McMaster University
Hamilton, ON, Canada

Rob Alder
Associate Professor of Epidemiology, Faculty of Medicine and Dentistry
University of Western Ontario
London, ON, Canada

Lynn Lethbridge
Research Associate, Department of Community Health & Epidemiology
Faculty of Medicine, Dalhousie University
Halifax, NS, Canada

Lisa Little
Director, Public Policy
Canadian Nurses Association
Ottawa, ON, Canada

[Reply to the Rebuttal on "International Nurse Migration to Canada: Are we Missing the Bigger Picture"]

In the commentary "International Nurse Migration to Canada: Are We Missing the Bigger Picture," I suggested that the report "Tested Solutions to Eliminating Canada's Nursing Shortage" by Tomblin Murphy and colleagues (2009) underestimated the number of internationally educated nurses (IENs) in Canada. Furthermore, I suggested a broader view on the ethics of international nurse migration that not only takes into consideration the "brain drain" (especially from countries with a severe shortage of nurses) but also considers the "brain waste" of nurses who migrate to Canada and are unable to practise. Finally, I posed the question of how exactly a reduction in the in-migration of nurses will be achieved considering the policy and ethical implications for nurses as well as the diversity in immigration streams and recruitment conditions.

Contrary to Tomblin Murphy's rebuttal, the lack of inclusion of IENs in Canada in the calculation of solutions to eliminate the nursing shortage has severe implications for how we perceive IENs in Canada. In other words, I am not suggesting that registration with a regulatory body should not be required to practise as a nurse in Canada. I am suggesting that we rethink the way we see IENs. The question is: Are internationally educated nurses, currently residing in Canada, a potential pool of registered nurses in Canada? Do we see these nurses in the same way we see Canadian nursing students or graduates who are in the process of becoming nurses in Canada? If these two groups of nurses are seen in the same light, then if we consider reducing the attrition in the process of registration for Canadian nursing students and graduates, we should also suggest the same for the other (i.e., IENs). Note that my main argument is not to encourage the active recruitment of nurses from other countries, but to ensure the maximum utilization of IENs who are already residing in Canada.

In her rebuttal, the author notes that she and her colleagues considered the right of nurses to migrate by suggesting "simply reducing" the in-migration of nurses by 50% rather than an elimination of nurse migration to Canada. Of course, an elimination of nurse migration to Canada would have been a radical policy suggestion. Reducing in-migration of nurses to Canada by 50% also lies on the blurry line of radical policy changes, as it would be impossible to reduce by 50% without affecting IENs who are neither actively nor passively recruited, but who migrate to Canada independently.

Over the last 10 years in Canada, progress has been made in the integration of IENs, including the creation of several bridging programs across the country. However, we need to recognize that further improvements can still be made in the integration of IENs into the workforce. Suggesting that we reduce the in-migration of nurses (without consideration for the modes of migration, including passive, active or voluntary immigration) points us in the opposite direction of past successes. This approach would have severe consequences for the ethics of international nurse migration and the health needs of the diverse Canadian population.

Bukola Kolawole, RN, BScN, MN
PhD student, Lawrence S. Bloomberg School of Nursing
University of Toronto

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