For many years, Canada has relied on international migration to compensate for cyclical shortages in its skilled labour force. This paper reports on recent changes in Canadian immigration policy, namely, the introduction of new immigration programs focused on skilled workers, along with the implementation of domestic mobility agreements. With specific reference to the case of nursing, the paper highlights the necessity for integrated policy across multiple government levels and stakeholder groups, as well as the need to promote the development of evidence-based policy in the fields of immigration and health human resources.

Historically, Canada's immigration policy has been premised on the view that building the stock of human capital strengthens the economy, regardless of economic cycles (Green and Green 1999; Hawthorne 2006). This model is informed by the assumption that generally competent individuals will adapt and find adequate employment in some sector. As a result, all degrees are considered equal and no additional screening for charter language proficiency is mandatory, irrespective of where education was obtained (Hawthorne 2008). This policy carries potentially detrimental consequences for labour market integration of immigrant populations, as credentials of migrants may be incongruent with those sought by industry. In the last two years, these problems have been compounded by a global recession and the rise in unemployment worldwide.

In 2008, Prime Minister Stephen Harper acknowledged the need for a more efficient selection process for economic migrants that maximizes both economic and human resources (Phythian et al. 2009). To attract more skilled workers and avoid labour market displacement, the Canadian government implemented the Canadian Experience Class (CEC) Program in 2008 and the Foreign Credential Recognition (FCR) Program in 2009 (CIC 2008; HRSDC 2009). These programs prioritize skilled migrant selection based on domestic labour market needs and attempt to tackle Canada's chronic "brain waste" problem. The FCR was created to accelerate the foreign qualifications assessment process and workforce integration of internationally trained immigrants in regulated occupations, such as health services (HRSDC 2009).

Competitor countries for global talent, such as Australia, have in recent years revised their immigration policies. In 1999, the Australian government expanded its recruitment of skilled migrants through a two-step migration process that expedited the transition of temporary migrants and international students to permanent resident status. This process is efficient and cost-effective for the host country because education of international students is self-financed and, with host-country degrees, these individuals are ready for labour market integration (Hawthorne 2008). Compelling Australian evidence indicates that this policy has improved not only the labour market integration system, but also the general long-term economic success of immigrants (Hawthorne 2006, 2008). Census data for 2001 show that Australia has low unemployment rates of degree-qualified migrants – 7.8% – in contrast with Canada's rate of 14.7% for the same period (Hawthorne 2006). According to Australian data, such programs may have a strong impact on human health resources (HHR): in 2009 around 70% of all international medical students moved directly into Australia's medical workforce, along with an estimated 35% of international nursing students qualifying as registered nurses. This two-step migration strategy was included in the Canadian government's CEC Program (CIC 2008).

Canadian Mobility Legislation and Policy

The recent legislative changes affecting HHR in Canada began in 1995 with the Canadian Agreement on Internal Trade (AIT), established to "reduce barriers to the movement of persons, goods, services and investments within Canada" (Industry Canada 2009). The Labour Mobility Act of AIT targets barriers specific to national workforce migration within regulated professions: residency requirements; occupation-specific certification, licensing and registration practices; and differences in occupational standards (HRSDC 2009). This Act ensures that qualifications earned in one jurisdiction are recognized in another, and establishes occupational competency as the ideal assessment criteria of professionals. With the 2010 consolidation of the AIT, mobility legislation has been enacted in each province to comply with the federal Act. Mobility provisions specifically related to healthcare workers are now legislated, with exemptions listed and justified. Thus registered nurses, physicians, dentists, pharmacists, physiotherapists and a number of other health professionals educated in any province in Canada can become registered in another province without undergoing additional testing or assessment. Under the AIT, foreign qualifications of health professionals that are recognized in one province are valid across all jurisdictions in Canada.

To assist in this process of mutual recognition of qualifications among Canadian jurisdictions, the Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualifications, a joint initiative of national, provincial and territorial governments in collaboration with regulatory bodies, was announced in December 2009. This framework aims to address three issues: "accelerating the assessment and recognition of foreign credentials; implementing Enhanced Language Training and Bridge to Work initiatives; and providing up-to-date and pertinent labour market information" (HRSDC 2009). The framework led to the development of a national program, the Foreign Credential Recognition (FCR) Program, whose main objective is to complete each applicant's credential assessment process within one year while remaining fair, transparent and rigorous. The healthcare professions currently included in the FCR Program are medical laboratory technologists, occupational therapists, pharmacists, physiotherapists, registered nurses, dentists, licensed practical nurses, medical radiation technologists and physicians.

Despite the economic downturn, the federal government announced that immigration would not be affected. In fact, the FCR Program was implemented partly in response to the recent global recession. Record numbers of permanent residents were admitted to the country – 247,243 in 2008 (CIC 2009a) – and target immigration levels remained between 240,000 and 265,000 for 2009 and 2010, with a focus on economic class migration to meet long-term labour workforce demands and to help the country recover (CIC 2009b).

The CEC Immigration Program, as in the Australian model, expressly targets international students and temporary workers who seek to obtain residency. This program enables immigration policy to be highly responsive to shifting labour market requirements and provides the quickest and most direct pathway for would-be immigrants, avoiding the lengthy process of the skilled worker migration path and the nominee process of the Provincial Nominee Program (PNP). Under the CEC program, a small number of these workers and international students are eligible to apply to remain.

Provinces also moved to harness immigrant labour as part of an economic stimulus plan. The PNP allows the provinces to develop immigration strategies tailored to local labour market needs. Initially developed as a limited program to attract doctors and nurses in 2001, its expanded version offers qualified immigrants an accelerated pathway to permanent residence (Ministry of Advanced Education and Labour Market Development 2009). PNP 2011 figures are set to eclipse previous records, with 40,000 immigrants to be accepted under this program (CIC 2011). In line with these burgeoning opportunities for labour force growth, provinces have developed economic strategies, such as Open Ontario, to create jobs and attract and retain foreign workers and students (Ontario Office of the Premier 2010).

Table 1 summarizes the relevant legislation and policy initiatives.

Policy Relevance for Healthcare Workers

Under changes in immigration policy in response to the recession, only those within the 38 qualifying occupations may be considered for permanent resident status under the skilled worker category. Workers in 10 healthcare occupations (managers in healthcare, specialist physicians, general practitioners and family physicians, audiologists and speech language pathologists, physiotherapists, occupational therapists, head nurses and supervisors, registered nurses, medical radiation technologists and licensed practical nurses) (CIC 2010) remain eligible. Furthermore, as with the Australian policy, in-country international students are now targeted as a source of future skilled workers. For instance, the Open Ontario Plan proposed by the McGuinty government aims to add 20,000 spaces in colleges and universities in Ontario. Part of this plan is to "increase international enrolment by 50 per cent" (Ontario Office of the Premier 2010), or over 12,000 spaces (CIC 2009a). With more foreign students in Ontario, the number of job-ready immigrants eligible for permanent residency through the CEC would increase. Because the premier did not specify the disciplines in which these new spaces will be created, the direct impact of the plan on the healthcare workforce is unknown. If, however, universities are to train more health professionals, immigration and workforce integration will be facilitated only for individuals who are pursuing post-secondary education and can afford to pay international tuition fees. Although this strategy would contribute to building a bigger foreign-born, domestically trained health workforce, it would not solve Canada's problem of "brain waste" of those who suffer the disconnect between migration policy and the active recruitment of skilled workers and domestic employment opportunities. Despite being in high demand, many healthcare professionals who migrate face serious accreditation barriers and are often unable to secure employment in their profession.

Nursing Human Resources and Migration

Currently, only 7% to 8% of Canada's nursing workforce was trained abroad, compared to an average of 11% among all OECD countries (MacDonald-Rencz 2009). Blythe and Baumann (2009) found that workforce uptake of internationally trained nurses is related to barriers faced during the migration process, regulatory procedures and licensing examinations in Canada. Most of Canada's foreign-educated nurses immigrated under the standard point system, live-in caregiver program or as dependents for reasons other than pursuit of career opportunities. Moreover, family priorities and social obligations may cause a delay in seeking employment, compounding the challenges associated with nursing certification and labour force integration (Papademetriou 2009). Furthermore, Canada's net migration of nurses is negative (Little 2007). The HHR personnel shortage in Canada is an effect not only of an aging workforce, but also of out-migration. The 1990s tax cuts and healthcare reform caused layoffs and cuts in both education and employment of nurses, creating a decline in available nursing positions (Aiken 2007). Then, under the North American Free Trade Agreement, the movement of goods and human capital across North American borders was facilitated. Pull factors such as exemption from taking the National Council Licensure Examination and active recruitment by US hospitals have motivated many Canadian nurses to seek employment in the United States (McGillis Hall et al. 2009). Since the 1990s, the ongoing depletion of the nursing workforce in Canada highlights a dire need for policy reform that improves recruitment, transition to practice and retention of trained nurses (CNA 2007). However, based on the immigration trends of the past decade, qualified nurses will continue to migrate to Canada as dependents rather than economic immigrants, as well as through the rapidly increasing temporary categories such as the live-in caregiver program, and thus require considerable support for successful transition to the workforce.

Meanwhile, the regulated professions continue to move towards the adoption of common licensure standards across all Canadian provinces in accordance with the requirements of the AIT. The situation, however, is problematic. Some provinces rely heavily on international migration to replace domestic graduates lost to interprovincial migration (Silversides 2009). Under the PNP, a number of provinces have been quick to mount independent international recruitment programs for nurses, such as that launched by the Government of Saskatchewan (2008). These local initiatives risk creating a "back door" entry to the Canadian workforce and undermining the national moves to create a single Canadian standard for credential recognition in each of the health professions. Variation in entry requirements has raised concerns, most particularly in the case of medicine. As Dove (2009) contends, with easier interprovincial mobility of physicians under the AIT, the retention of doctors and other health workers in certain provinces and territories could prove to be a challenge. Although immigrants sponsored under the PNP gain priority for permanent residency over other applicants, new and stricter national standards for accreditation and licensure of health workers would create greater barriers to workforce integration.

Although relying on immigration to fill the gaps in the domestic labour force is not a long-term solution to Canada's HHR shortage, neither is reducing migration of health professionals realistic in a globalized world (Papademetriou 2009). HHR is particularly challenging in a labour market that is deeply dependent on skilled migrants, such as Canada's. The mobility of workers and the portability of credentials have set the stage for locally driven initiatives that attract skilled workers who are then free to move within the country. Meanwhile, as immigration policy focuses on attracting more skilled workers, the ability of Canadian professional associations and regulators to manage the challenges of skill recognition, mobility agreements and workplace integration remains to be seen. Policy discussions become even more complex in light of intense ethical debates over health worker migration in general.

These mobility and skill recognition challenges are uniquely Canadian, and Australia provides a marked contrast to Canada in this context. While the PNP is Canada's fastest-growing immigration pathway, Australia has largely maintained federal control of immigration policy, so the "back door" issue is less of a concern. Secondly, Australia recently eliminated cross-jurisdictional credential challenges by dissolving state-based regulatory boards and, in 2010, creating a national health professional regulation agency that regulates all health professionals in the country (AHPRA 2011).

Unlike their Australian counterparts, Canadian policy makers, regulators and employers meanwhile need to respond to these challenges in an increasingly devolved, as opposed to a centralized, system. There is therefore all the more need for all stakeholders to come together to create an integrated policy framework to ensure that recent initiatives to bring skilled workers more easily into Canada do not undermine the development of long-awaited national standards and mobility agreements. The further development of evidence-based policy in the fields of immigration, credential and competency recognition, and health human resources will be critical for Canada to meet this challenge. A national and provincial alignment of policy in immigration, internal mobility and HHR planning is now imperative.

Le paysage changeant des politiques d'immigration au Canada: répercussions sur les ressources humaines en santé

Résumé

Pendant plusieurs années, le Canada a compté sur la migration internationale pour compenser les pénuries cycliques de main-d'œuvre qualifiée. Cet article porte sur les récents changements dans les politiques d'immigration au Canada, en particulier l'introduction de nouveaux programmes d'immigration centrés sur les travailleurs qualifiés, de même que la mise en place d'accords de mobilité domestique. L'article, qui traite spécifiquement du cas des soins infirmiers, souligne le besoin de politiques intégrées entre les multiples niveaux de gouvernement et les groupes d'intervenants, ainsi que le besoin de promouvoir le développement de politiques fondées sur les données probantes dans le domaine de l'immigration et des ressources humaines en santé.

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