The migration of nurses from Canada to the United States has occurred for decades, although substantial increases have been noted since the 1990s. A survey of 4,295 Canadian-educated nurses in the US identified that this trend in mobility is largely unchanged. Almost half the nurses in this study migrated to the US in search of full-time work, often after unsuccessfully seeking employment here in Canada prior to leaving. Incentives to migrate were provided, although the opportunity for full-time work was often perceived as an incentive to move. While some intent to return is apparent, this is unlikely to occur given the levels of satisfaction with work and the high value attributed to Canadian nurses by US employers. Policy makers and nurse leaders are urged to use these data to formulate strategies aimed at retaining Canada's nurses in this country.

Background

Canadian workforce data indicate that there were 354,910 regulated nurses employed in Canada in 2010, of which 268,512 are registered nurses (RNs) (CIHI 2010). The most recent report on the state of Canada's nursing workforce predicts a nursing shortage of RNs that will reach 60,000 by 2022 (CNA 2009). In contrast, projections in the US provide inconsistent estimates on the state of that country's nursing shortage.

Some authors suggest that the shortage has ended, primarily as a result of the surge of approximately 243,000 RN positions seen at the beginning of the recession in late 2007 (Staiger et al. 2012). However, US employment projections released as recently as February 2012 suggest that RNs are the occupation expected to have the largest employment growth in coming years (US Bureau of Labor Statistics 2012). Specifically, RN growth estimates are predicted to rise from 2.74 million in 2010 to 3.45 million in 2020, a 26% increase of 712,000 nurses (US Bureau of Labor Statistics 2012). Current workforce modelling indicates that RN shortages in the US will continue to grow between 2009 and 2030, with the largest needs expected in California, Florida and Texas (Juraschek et al. 2012).

At the same time, a considerable increase in Canadian nurse migration to the US was seen between 1990 and 1999 (McGillis Hall et al. 2009a). Research exploring mobility trends reported that newly graduated internationally educated nurses (IENs) employed in the US were most likely to come from Canada (Buchan et al. 2003). A report examining the characteristics of IENs in the US identified that most Canadian nurses reside in Texas, Florida, North Carolina, California, New York and Michigan (Commission on Graduates of Foreign Nursing Schools 2002).

Findings from the most recent 2008 National Sample Survey of Registered Nurses in the US indicate that the second largest group of IENs in the US were Canadian-educated nurses (HRSA 2010). Specifically, of the 165,539 IENs employed in the US in 2008, 11.9% or 19,699 came from Canada (HRSA 2010). In addition, the states employing the largest numbers of IENs at that time were California, New York, Texas and Florida, while smaller numbers were evident in New Jersey, Illinois, Maryland, Virginia and Nevada (HRSA 2010).

The urgency with which the US is recruiting IENs to cope with its nursing shortage is apparent. The most recent US licensing examination statistics suggest that there were 613 Canadian-educated RNs writing the certification exam between October 2010 and September 2011, demonstrating that the continued migration of Canadian nurses to the US can be expected (National Council of State Boards of Nursing 2011). These statistics affirm the need for policy makers and healthcare leaders to understand and act on the factors that may influence Canadian nurse migration. The objective of this study was to identify why nurses left Canada to work in the US, and to determine retention policies that might address these issues.

Theories of human capital are often used as the basis for framing studies of professional work migration, as they highlight that individuals migrate for employment and remuneration that is appropriate to their education (Iredale 2001). Human capital theory proposes that devoting resources to the education and career development of individuals constitutes an investment that will produce future returns for an organization (McGillis Hall 2003). In this study, the underlying principles of human capital are that Canadian nurses possess skills, experience and knowledge that have an economic value to US healthcare organizations and the US workforce (McGillis Hall 2003).

Method

This study was conducted in 2008 and 2009 using a mixed-methods approach. A cross-sectional survey research design was used to sample all RN registrants from Canada working in US states known to employ Canadian nurses (i.e., Texas, Florida, North Carolina, California, New York, Michigan). Following research ethics board approval, the selected US state boards of nursing were approached to provide mailing addresses to the researchers for all registrants who had identified that their basic nursing education was obtained in Canada, and were licensed and currently working in the US. Contact with the nursing state boards was facilitated by nursing workforce researchers who served as consultants to the study. In addition, the policy leader on the study liaised with her US counterparts in policy and government positions to assist in this process.

Attempts to access Canadian nurses in Michigan and Florida were unsuccessful, as those state boards of nursing indicated that they did not have information on the country of origin of their nurse registrants. The same was true for a number of other state boards of nursing that were approached to participate at the time. Despite these challenges, a total of 10,056 Canadian-educated nurse registrants working in the US were surveyed, and 4,481 nurses (45%) responded, of which 4,295 (43%) questionnaires were usable. Close to half of the study participants were employed in California (n=2,054; 48%), followed by over a quarter in Texas (n=1,196; 28%) and the remainder in North Carolina (n=733; 17%) and New York (n=312; 7%). Workforce estimates indicate there are close to 20,000 Canadian-educated nurses living and working in the US, over half of whom were sampled for this study. Responses were received from 4,295 of these, and thus the results can be considered representative of nurses from this country who migrate to the US. While the majority of respondents came primarily from California and Texas, these two states have been destination points for Canadian nurses for decades, and are the states most likely to experience nursing shortages in the future.

The 33-item survey used in this study was pilot tested and utilized with a sample of Canadian nurses employed in the US (McGillis Hall et al. 2009b). The survey included questions related to the decision to migrate to work in the US, current work characteristics, plans for returning to work in Canada and demographic information. Dillman's (2007) protocol for survey administration was employed with participants, who were provided with pre-paid envelopes for return of completed questionnaires. Focus groups were held with a random sample of 134 survey participants to augment the survey data and develop an in-depth understanding of the factors influencing the migration of Canadian nurses to the US. Nurses who indicated willingness to take part in focus groups when mailing back the survey were randomly selected and invited to participate. Between two and three focus groups were held for each of the states involved in the study, and an additional two focus groups were held with newly graduated nurses, the findings of which are presented in the next paper in this Special Issue of the journal (Peterson et al. 2013). SPSS version 19 software was used both to enter and to complete analysis of the quantitative survey data and to characterize the sample of Canadian-educated RNs in different US states.

Results

Demographic and work information for the Canadian nurse sample responding to the survey appears in Table 1. All study respondents were RNs, and the average age of participants was 46. Two-thirds of the nurse participants in this study were married, and the majority female. Close to half of the sample held diploma certification; similar numbers were baccalaureate-prepared, and fewer had master's-level education. Very few were enrolled in educational programs at the time of the survey, although three-quarters of the respondents indicated that their US employers provided incentives for them to further their education.

Close to three-quarters of the sample were employed full-time, with the remainder employed part-time or in casual positions. Almost all of the study participants indicated that their work, whether full-time, part-time or casual, was the work status that they desired. Some of the respondents held more than one nursing position. Over two-thirds of the participants were employed in direct patient care roles, while another 20% held nursing management positions and the remainder were in advanced nursing practice roles. Close to half had less than five years of nursing experience, while another 31% had between five and 10 years of experience. The remainder had more than 10 years of work experience.

Migration of Canadian nurses to the US

Almost half of the respondents indicated that they had migrated to California to work, while more than a quarter went to Texas. The pattern of migration of Canadian-educated nurses to different US states differed over the years, as outlined in Table 2. For example, half of the study participants who migrated in the early 1990s went to Texas, while this proportion declined to less than a third later that decade. Since 2001 almost two-thirds of respondents who migrated to the US have moved to California, followed by 29% to North Carolina and New York, and fewer than 10% moving to Texas. Almost half tried to find nursing employment in Canada prior to migrating to the US to work.

The movement of participants in this study indicates that nurse migration from Canada to the US accelerated in the early 1990s and remained at a high level throughout much of the next decade. Figure 1 demonstrates that a quarter of study respondents migrated to the US between 1991 and 1995, followed by 21% between 1996 and 2000, and 20% between 2001 and 2008.

The five key motivators for moving to the US were identified by study participants (see Table 2). Almost half of respondents identified that they left Canada to obtain full-time nursing employment, while 42% indicated that they moved for personal or family reasons. One-third reported migrating to the US because of a desire to travel, while fewer identified educational opportunities and improved salary and benefits as reasons for leaving Canada.

Over half of the nurse participants in this study had received relocation assistance as part of their move to work in the US, while half indicated that the salary and benefits offered to them were incentive to migrate. Almost half of the respondents considered full-time nursing employment to be an incentive to move to the US, while over a third identified career or ongoing educational opportunities and innovative scheduling options as recruitment incentives.

Close to a quarter of nurse participants in this study identified plans for returning to Canada to work, although few planned to do so over the next two years. In addition, the majority of respondents reported high satisfaction levels with their jobs and work in the US, and identified feeling highly valued by their US employers.

Discussion

Results from this research highlight that nurses continue to migrate from Canada to the US in search of full-time work providing direct patient care. This finding is consistent with those reported in an earlier study comparing Canadian-educated nurses to their US counterparts in three waves of data collected over an eight-year period from 1996 to 2004, in which full-time work opportunities were identified as an important motivator for migration to the US (McGillis Hall et al. 2009a). Consistent with human capital theory, nurses in the current study were predominately working full-time hours, and half of them explicitly identified that their primary reason for migrating to the US was to obtain full-time employment.

Migration for personal and travel reasons was also found, reinforcing results reported in a recent study of Canadian nursing students that suggests nursing is seen as a mobile profession, with work opportunities tied to travel (Price et al. under review). In addition, given the high number of married, mid-career nurses in this study, it is likely that moving with a spouse or partner was also a key factor in the decision to migrate. This finding is not unexpected considering the labour market mobility that emerged during the economic downturn in the US occurred close to the time of data collection in this study.

Work volition was highly apparent, with almost all respondents stating that they were working the hours they desired, indicating that nurses in this study had the capacity to make choices about their employment status. At the same time, despite receiving incentives from their employers for continuing education, nurse participants were not taking the opportunity to pursue further education. Given that almost half of the respondents had less than five years of experience, continuing education may be something that they will choose to explore in the future.

Canadian nurses in this study migrated primarily to California and Texas, two of the US states that are projected to have the highest nursing labour force needs in the future (Juraschek et al. 2012). However, the migration pattern to these two states has changed markedly over the years, with recent data indicating that the majority of nurses in this sample moved to California. A number of factors may have contributed to this shift in mobility. First, California was the first US state to legislate a standardized patient-to-nurse ratio for care provision, a policy that is highly regarded by many nurses (McGillis Hall et al. 2006). In addition, California has a number of magnet-designated hospitals, known as sites that exhibit a set of essential characteristics for the effective recruitment and retention of nurses. California is also widely recognized as a destination travel state because of climate and geography, and US nursing salary levels are highest on the Pacific coast (HRSA 2010).

Migration to the US was facilitated by financial incentives for more than half the nurses who took part in this study, with recruitment options that emphasized components of human capital, including enhanced salary, benefits and relocation assistance. Of interest, obtaining full-time employment was considered a recruitment incentive by close to half of the participants, further demonstrating the desire or need for full-time work that permeates these study findings.

Perhaps of greatest concern, from a management and policy perspective, is the report that close to half of the respondents – over 2,000 Canadian-educated nurses – sought employment here in Canada prior to migrating to the US.

This finding suggests that these nurses were interested in remaining in Canada and could potentially have been retained in this country had jobs been available to them. A recent study of 115 newly graduated nurses from a Canadian border community reported that 86% would prefer to work in Canada, although two-thirds also indicated that they were considering migrating outside the country for work (Freeman et al. 2012).

While some study participants identified intent to return to Canada to work, these plans were not projected for the immediate future. In addition, these nurses reported high levels of work and job satisfaction, key factors in shaping a positive work environment that facilitates nurse retention. As well, respondents highlighted the high value placed on Canadian nurses by US employers. When considered in the context of the earlier findings reported here, these nurses may not feel valued by Canada as they had to leave the country to find employment. In contrast, they were welcomed to the US, often received financial incentives to relocate, and at minimum obtained full-time jobs that they are very satisfied with. As a result, they feel highly valued by their employers. Return migration to Canada may not be an option that they decide to pursue.

The study attempted to survey nurses from all US states known to employ the highest numbers of Canadian-educated nurses. However, we were unable to reach nurses from two of those states – Michigan and Florida – to include in the study. Thus, while the overall sample size for the study was achieved, the study may not be generalizable to all Canadian-educated nurses who migrate to the US.

Implications

Data from this study indicate that although Canadian nurse migration to the US was at its highest in the early 1990s, only a slight decline has occurred since then, resulting in what appears to be a persistent mobility trend. For the most part, the reasons for migration remain unchanged over the years, as nurses tend to move to obtain full-time work. While financial incentives may enhance the decision to migrate, the key motivation for Canada's nurses appears to be one of employment.

Given this finding, nursing and healthcare leaders should be paying particular attention to how they employ nurses in the future. Specifically, efforts should be made to decrease the amount of temporary and part-time employment being offered to nurses, as it is apparent that the opportunity for full-time work is a key factor contributing to migration to the US. In addition, nurse and policy leaders should examine the positive initiatives that are offered by US states such as California, such as standardized nurse-to-patient ratios and magnet designations to hospitals, to determine whether any shifts in this area are needed in Canada. It is possible that similar practices exist in Canadian healthcare settings that are not well publicized or noted on organizational websites, and which could be highlighted.

Policy makers and nurse leaders should consider implementing enhanced advertising or media strategies that highlight available nursing positions, as well as reinforce that they value and want to employ the Canadian nurses who are being educated in this country. Such acknowledgement is particularly important when considered in context with the recent decision by Canadian nurse regulators to select the US-based National Council Licensing Examination (NCLEX) as the licensing exam for entry-to-practice as an RN in Canada beginning in 2015 (CNO 2012). The US National Council of State Boards of Nursing (NCSBN) website indicates that "the selection of NCLEX by Canadian nursing regulators marks the first time that the exam will be used for the purpose of licensure in another country" (NCSBN 2012). It is possible that adopting the NCLEX exam will contribute to an increase in Canadian nurse migration to the US, as Canadian nursing graduates will have the credential required to practise in the US.

Conclusion

There has been little or no substantive examination of the factors influencing the ongoing exodus of Canadian nurses to the US. Data from this study provide key information that can be applied directly to create nursing retention and recruitment policy in Canada. Specific retention strategies for stemming the flow of Canadian nurses to the US are necessary to reverse the factors that induce nurses to leave. As well, proactive efforts that demonstrate Canada's interest and commitment to retaining our nursing human capital are key for nursing health human resources planning in the future.

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