I Was Never Recruited: Challenges in Cross-Canada Nurse Mobility
The internal migration of nurses within Canada has had limited study. This paper reports the results of a survey of registered nurses and licensed practical nurses who had migrated between the provinces and territories in Canada. Factors contributing to internal nurse mobility included seeking full-time work, opportunities for career advancement and flexible scheduling options. Few nurses received incentives to move between the provinces/territories to work. A number of challenges with internal migration are identified, including complexities related to licensing and limitations in available job information. Implications for nursing health human resources policy related to nurse retention in Canada are identified and discussed.
A great deal of the research being conducted in the area of nurse migration has been directed towards the movement of nurses from one country to another, a key consideration in health human resources planning globally. Little attention has been focused on internal migration or mobility within a country, such as that occurring between the provinces/territories (P/T) in Canada.
The first report to deal with the interjurisdictional movement of nurses in Canada described patterns of mobility based primarily on an analysis of data collected from secondary databases, and cited challenges with the lack of available information in this area (Baumann et al. 2004). The authors noted that the majority of nurses seek employment and remain in the province where they were educated, and that most who did migrate across jurisdictions were newly graduated nurses (Baumann et al. 2004). Rationale for nurse mobility across Canada in this secondary data analysis was thought to be linked to the availability of nursing programs, improved employment and career opportunities, and patterns of migration that match those of the general population. Following this work, an environmental scan of the literature aimed at exploring ways of facilitating cross-jurisdictional mobility of nurses in Canada identified the need to "streamline" the licensing process and consider a national licensure system (Torgerson et al. 2006).
Most recently, a report describing the geographic distribution and internal migration of Canada's healthcare providers was developed using census data (CIHI 2010). A 10% decrease in nurse mobility across the provinces was reported over 10 years, from 71,835 in 1991 to 46,535 in 2001 (CIHI 2010). In addition, over two-thirds of Canada's nurses remained in the community where they completed their educational program, with less than a quarter of the nursing population (18%) migrating in 2001. While British Columbia had been the destination of choice or "magnet" province for nurse migration over the years, by 2001 Alberta had replaced it (CIHI 2010). Few conclusions were drawn from this analysis, as the determinants of migration available were limited (CIHI 2010). These reports, while not an accurate measure of nurse mobility within the country, highlight the need to develop a more accurate understanding of migration across Canada. As well, a better understanding of the factors contributing to the internal migration of nurses across Canada is needed to develop realistic recruitment and retention policies. The migration of nurses from one jurisdiction in Canada to another may be considered a loss to the P/T that the nurse has left. However, efforts to support nurse mobility between jurisdictions offer the potential to retain nurses within Canada. If employment opportunities exist to migrate to a different P/T for work, this availability of work may prevent nurses from seeking employment in another country such as the United States.
The internal mobility of nurses in Canada is an important area to examine. The loss of nurses to other countries, as has been seen with Canadian nurse migration to the US (McGillis Hall et al. 2009a,b), has economic consequences on nursing health human resources in Canada, representing a loss of human capital that may be permanent. In contrast, the loss of nurses to other provinces can be considered a positive investment in labour capital, with nurses migrating to locations in the country where the jobs are, creating labour market equilibrium.
The objective of this study was to map the mobility patterns and identify the basic motivations for mobility of Canadian nurses across the P/T to work. The mobility patterns are described in a separate paper in this issue of the journal (Andrews et al. 2013). This paper focuses on presenting the results of the research questions conducted through a survey aimed at identifying the factors that influence nurses to leave their home P/T to work in another, and the facilitators that can be employed to retain nurses in Canada.
This descriptive cross-sectional study surveyed a purposive sample of RNs and LPNs who had migrated between Canadian P/T. The survey was adapted from one used by the principal investigator to study Canadian nurse migration to the US (McGillis Hall et al. 2009a, b 2013) and included questions about factors contributing to the decision to migrate, current and past work experience, work mobility, perceptions of work and work environments, and demographics. The sample was drawn from the registration databases of the regulatory licensing bodies for nurses (RNs and LPNs) from across Canada, facilitated by the Canadian Institute for Health Information (CIHI), one of the decision-makers on this study, through its annual meeting with regulatory bodies. Surveys were sent to 3,700 RNs and 1,750 LPNs for a total of 5,350 nurses sampled. Data collection took place in 2010 following research ethics board approval.
Quantitative data were analyzed using SPSS version 19; in this paper we present descriptive results. Respondents chose to write substantial additional comments at the end of the survey in an area designated "anything further to add." These qualitative comments were content-analyzed in an iterative manner by three members of the research team. During initial descriptive coding the comments were sorted into main topics, and overarching categories were created. Data within each category were explored further and, where applicable for this paper, simultaneously triangulated with the data obtained from the surveys (Morse 1991). This approach permitted the integration of both quantitative and qualitative study data and enables insight into the area of nurse mobility across Canada that may not have been evident through the use of the quantitative survey data only.
Almost a third of respondents came from Alberta, followed by close to a quarter from New Brunswick. The remainder came from Saskatchewan, Ontario, Yukon, Nova Scotia, Newfoundland and Labrador, Manitoba, British Columbia and Quebec. A breakdown of responses by P/T and provider group is shown in Figure 1.
While most P/T regulatory groups (n=10) participated in the study, some chose not to be involved or were unable to participate for individual reasons (i.e., Association of Registered Nurses of Prince Edward Island; College of Registered Nurses of British Columbia; College of Registered Nurses of Manitoba; Ordre des infirmières et infirmiers auxilliaires du Québec; Registered Nurses Association of Northwest Territories and Nunavut).
Despite these challenges, the overall sampling requirements for the study were exceeded, and completed surveys were received from 2,675 nurses from across the country for a 50% overall response rate. The response rate for RNs was 51.3% and for LPNs 44.5%. Thus, the study results describe the perceptions of some nurses who move across Canadian P/T for work, although it may not capture the full scope of nurse mobility for all P/T. For example, as Table 1 demonstrates, over half of the respondents came from two provinces (Alberta and New Brunswick).
|Table 1. Nurse mobility in Canada|
|Nursing education completed in past decade||1,242||46.4|
|Nursing education completed outside Canada||148||5.5|
|Currently enrolled in baccalaureate nursing program||235||8.8|
|Currently enrolled in master's nursing program||118||4.4|
|First employed in P/T of initial education||1,826||68.3|
|Moved to another P/T for nursing education||320||11.9|
|Migrated because unable to find work in P/T of initial nursing education||882||32.9|
|Work status is desired (full-time, part-time or casual)||2,264||84.6|
|Hold more than one nursing position||562||21.0|
|Less than two years of employment experience in current P/T||1,364||50.9|
|Employed in community hospital||933||34.9|
|Employed in academic teaching hospital||796||29.8|
|Employed in long-term care setting||563||21.0|
|Employed in other settings||383||14.3|
|Received no incentives to move between P/T to work||2,207||82.5|
|Incentive of full-time employment||757||28.2|
|Incentive of career advancement opportunities||346||12.9|
|Incentive of innovative scheduling options||238||8.9|
|Plan to move to another P/T to work||402||15.0|
|Have explored interprovincial moves for nursing work||850||31.7|
|Have nursing work experience in another country||418||15.6|
|Have nursing work experience in the US||265||9.9|
|Have nursing work experience from UK/Philippines/Australia||153||5.7|
|Currently licensed to practise in another country||153||5.7|
Close to two-thirds of study respondents were RNs and the remainder LPNs (see Table 1). The majority were married females. The average age of study participants was 40 years. Over half of the participants were diploma-prepared, while baccalaureate degrees were held by just under half; the remainder had certificate-level education. Close to half of the respondents had completed their nursing education over the past 10 years, and very few had received their initial nursing education outside Canada. In addition, few were currently enrolled in ongoing nursing educational programs at either the baccalaureate or master's level.
Factors influencing cross-Canada nurse mobility
Over two-thirds of the study participants were first employed in the P/T where they were initially educated to be a nurse. Few had moved between jurisdictions to complete their initial nursing education, and all of these indicated that they did so to attend a particular educational institution of their choice. Close to a third of participants migrated to find employment after not being able to find work in the province in which they were initially educated. Of these, all but three plan to return to their home province to work in the future. Qualitative comments from surveys provided details to support these findings:
There's not enough full-time jobs. I'm only in Alberta because this is where the full-time jobs are. In Ontario [where I went to school] part-time is anywhere from 2 shifts/month to 16 shifts/month based on 8 hr shifts.
I am looking to relocate back to BC and have been applying [there] for over 6 months. I'm willing to work on call casual and in a hospital or LTC [long-term care]. I really want to go back but there are no opportunities right now, even though I know they are short staffed.
The majority of study respondents had received no recruitment incentives when they moved to another P/T for work. Some participants considered the ability to obtain full-time work an incentive, while others described opportunities for career advancement and innovative scheduling models as incentives to move. Very few identified receiving any form of financial incentive to relocate across the country, as substantiated by qualitative comments on the surveys:
I was never recruited or received incentives. Incentives could potentially lead to competition for nurses among and between provinces. It would be an incentive if employers offered relocation allowance, flexible working hours or self-scheduling.
At my hospital … learning/education opportunities, flexible scheduling and opportunity for travel are good incentives.
Some nurses plan to move to another P/T to work in the future, and close to a third of study respondents have explored interprovincial moves over the past few months. Some had experience working as a nurse in other countries, with the majority of these having worked in the US; much smaller numbers worked in the United Kingdom, Philippines or Australia. A few respondents were still licensed to practise in another country.
Over half of study participants were employed full-time, while just over a quarter worked in part-time positions; the remainder were employed casually. The majority of respondents identified that they were working the number of hours that they desired to work. Participants who worked part-time or casually did so for a sense of control or freedom, while some sought flexible work hours and others wanted varied work experience:
I will however look for [a] casual position when I return to Ontario as I have enjoyed the flexibility and freedom that casual work provides.
Close to a quarter of study participants held more than one nursing position. Participants were employed primarily in community or academic teaching hospitals and in long-term care settings. Over half of study participants had been employed for less than two years in the jurisdiction in which they were currently working.
Challenges to cross-Canada nurse mobility
Study participants identified that by far the greatest challenges to mobility in Canada that they encountered were related to licensing (n=2,341; 88%) and what they described as reciprocity across the country. Challenges with licensure were also identified by two-thirds of the study respondents as a reason for not moving again across P/T for work (n=1,721; 66%). Respondents provided further detail in survey comments:
Not easy to get licensing in any province – process takes about 3–8 months depending. There should be standard license fees across the P/T. It is difficult to transfer licence, too much red tape & takes a long time.
I think registration should be national not province-to-province. It takes longer to obtain a registration from province to province than obtain registration for the USA.
When we moved to Alberta the biggest hassle was having to send proof of education, association membership of PEI to Nursing Association of Alberta and having to pay both fees in full. Solution might be that there be one database that each association could access to obtain all this information & at renewal time the info is updated each year. Then there were fees for faxing & mailing and waiting times for obtaining info by other association.
In some cases, the challenges with licensure across the P/T were linked to turnover in the profession, as articulated in the comments of one study participant:
One major disincentive for moving within Canada as a nurse is the lack of parallel portability. I went from being a nursing educator in BC back to the bedside in Alberta. My lack of willingness to start back at "the bottom" of the career ladder is directly related to why I will be leaving nursing.
The majority of respondents identified that another factor limiting nurse mobility across Canada was the lack of information on nursing employment opportunities across the country (n=2,212; 84%):
It would be nice if there was a "one-stop" website or information package about nursing in different provinces. There is so much involved in cross-country moves. So many people to call, so many different things to look into. It would be very helpful if there was something we could use that broke down all of the information and what needs to be done – maybe kind of a checklist, of things we need to consider.
Finally, over half of study participants identified that they did not feel valued by their employer (n=1,519; 58%) and described inequities in the incentives provided to internationally educated and Canadian-educated nurses across the P/T:
Need to equalize incentives given to Canadian trained nurses moving to a province same as those given to internationally trained nurses. Nurses from the Philippines in our health region only had to sign a 1 year contract and received the same incentives that a Canadian trained nurse [who] had to sign a 2 year contract with the region received. And they wonder why the Canadian nurses feel undervalued and not welcome.
Factors influencing cross-Canada nurse mobility
On average, participants in this study were approximately five years younger than the average RN in Canada, reported to be 45 years (CIHI 2010), while most were recent graduates with limited experience. This finding suggests that mobility across the P/T may be more appealing to those newer in their nursing careers. A qualitative analysis of descriptive comments provided on the surveys identified that the varied work opportunities made available through a nursing career form part of what interests individuals in the nursing profession (Price et al. 2013). Similar findings were reported in recent Canadian research conducted with nursing students who saw nursing as providing travel options along with employment opportunities (Price et al. under review).
The availability of nursing employment – in particular, full-time work – remains a challenge for Canada's nurses. Not unlike any other career, nurses enter school with the aim of obtaining full-time work on graduation. Earlier research has identified that Canadian nurses migrated to the US throughout the 1990s in search of full-time work (McGillis Hall et al. 2009a,b, 2013). This current study highlights that nurses also move between the P/T in Canada to obtain full-time work when unable to find employment locally on graduation.
A substantial number of study respondents were married and currently employed in Alberta. At the time of this study, Alberta was hiring full-time nurses while other provinces had no job opportunities available, perhaps contributing to mobility to Alberta. This finding is consistent with those reported from census data and corresponds with the mobility patterns of the general population in Canada (CIHI 2010). The Alberta economy was strong, with the highest labour force participation and employment rate in the country, and qualitative comments from the survey reinforced that nurses often relocated with their spouse's work (see the paper by Price et al. in this Special Issue). While this factor serves to draw nurses to a province at a time of need, the effect may be temporary, and further attention to broader recruitment and retention strategies should be considered.
Challenges to cross-Canada nurse mobility
The absence of incentives to recruit nurses across the P/T provides evidence of the limited attention that has been paid to internal nurse recruitment in this country. To date, the drivers for P/T nurse mobility have been individual, as nurses move for personal reasons such as to obtain employment or to remain close to a family member. In contrast, research has demonstrated that substantial and varied incentives are offered by US settings to recruit Canada's nurses to that country to work (McGillis Hall et al. 2009a,b, 2013). Some respondents in this study highlighted disparities in the incentives provided for international recruits in comparison to Canadian nurses who migrate across the P/T, considering this a signal that they were not highly valued. This finding represents a concern as well as a considerable gap in current Canadian health human resources retention policy for nursing.
Perhaps the greatest challenge affecting nurse mobility in this country is the licensing process, which is considered lengthy and inconsistent among the P/T, and was independently described by several participants as a "hassle." It represents the key factor impeding their interest in moving across Canada to work. Respondents in this study articulated the need for a streamlined registration process across the country, echoing the findings of previous work in this area (Torgerson et al. 2006). This study also demonstrated that a number of nurses had explored interprovincial moves for nursing work, while some come from abroad and still hold licences to practise in other countries. This finding suggests an interest in mobility, and poses a potential risk to Canadian nurse retention if efforts to expand mobility opportunities are not enhanced.
The need for information on nursing work opportunities available across Canada was also highlighted in this study. Participants describe wanting greater detail about the positions available, as well as the environment surrounding the place of work, including the community. While information sources may currently exist that contain employment information, it is clear that enhancements to the materials available could serve to increase nurse mobility across Canada.
Little attention has been directed towards the potential recruitment opportunities that lie within the nursing workforce across the country. While the numbers of nurses who migrate across Canada are not large, it is apparent that some movement occurs between the P/T, primarily by more recent graduates who may want to combine travel and work options. Mobility opportunities for specific groups, such as nurses affiliated with the military, have not been explored to date. At the same time, there appear to be gaps in information available for nurses regarding positions available in Canada. In addition, the perceived bureaucratic challenges of licensure may be limiting nurse mobility across the country.
These findings suggest that there may be a role for better advertising of opportunities for jobs within the country, to capture the interest of those who are interested in travel. Efforts to address the job-related information needs of nurses, and more harmonized approaches to interprovincial licensing, offer the opportunity to enhance nurse retention in Canada. In addition, it is evident that the incentives provided within Canada to recruit nurses from across the P/T are limited in contrast to those offered to Canadian nurses to migrate to the US.
Findings from this study highlight some positive directions that can be taken by policy and nursing leaders that would enhance nurse mobility in Canada, including (a) streamlining the nursing registration process, (b) centralizing information on available nursing work opportunities across Canada and (c) reducing inequities in the incentives provided to all types of nurses who migrate across Canada in an effort to utilize these incentives more effectively.
This research provides evidence of the opportunities available for a more proactive approach to internal migration in Canada. It is evident that both RNs and LPNs are willing to move for work, and policy changes that enhance and promote internal mobility opportunities for nurses within the country could be beneficial for Canadian recruitment and retention. These should be developed in concert with decision-makers, including policy and system leaders, as the implications of interprovincial/territorial recruitment need to be considered and balanced with the internal health human resources demands and needs of the P/T. While nurses can be expected to continue to migrate to the US in the future, changes to existing policies and practices within Canada have the potential to decrease the rate of out-migration from the country and contribute to retention.
About the Author(s)
Linda McGillis Hall, RN, PhD, Kathleen Russell Distinguished Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
Jessica Peterson, RN, PhD, Assistant Professor, Loyola University, School of Nursing, New Orleans, LA, (Click here for Dr. Peterson’s current faculty page)
Sheri Price, RN, PhD, Assistant Professor, Dalhousie University, School of Nursing, Halifax, NS
Gavin Andrews, PhD, Professor, Department of Health, Aging & Society, McMaster University, Hamilton, ON
Michelle Lalonde, RN, MN, Lecturer, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
Alexandra Harris, RN, MN, MBA, Graduate Student, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
Sandra MacDonald-Rencz, RN, MEd, Nursing Executive Advisor, Strategic Policy Branch, Health Canada, Ottawa, ON
Correspondence may be directed to: Linda McGillis Hall, RN, PhD, professor & associate dean, research and external relations, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St., Suite 130, Toronto, ON M5T 1P8;
tel.: 416-978-2869; fax: 416-978-8222; email: firstname.lastname@example.org.
This study was funded by the Canadian Foundation for Healthcare Improvement and Health Canada's Office of Nursing Policy.
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