Perspective from the Canadian Nurses Association
The research profiled in this issue of CJNL provides important insights into contemporary issues for nursing in Canada. The papers individually and collectively deepen our understanding of why nurses enter nursing, relocate within Canada and remain in or leave their positions and the profession. Informed by the work and experience of the Canadian Nurses Association (CNA), this commentary explores the implications of the work for nursing in Canada.
Recruitment into the Profession
In their paper on factors that influence career decisions in Canada's nurses, Price and colleagues identify the reasons that nurses enter the profession. The finding that the caring nature of the profession was a key factor in choosing nursing as a career attests to recognition of the association between nursing and caring that has long endured among the public. Indeed, the research found that when nurses felt the time they had to devote to hands-on patient care was inadequate, they became dissatisfied with their jobs and disillusioned with the profession. Further adding to their dissatisfaction with their profession or nursing workplace was the "lack of caring and work ethic" (p. 5) that some respondents perceived among nurses newly entering the profession. Sadly, these respondents stated that their level of dissatisfaction was such that they would not recommend nursing as a career. A profession that fails to attract and retain practitioners cannot be sustained.
Another perspective is presented in the work of Canadian authors Beth Perry (More Moments in Time: Images of Exemplary Nursing, 2009) and Laurie Gottlieb (Strengths-Based Nursing, 2012), who each suggest that caring can be conveyed in the briefest of nurse–patient interventions and has transformative effects for both patient and nurse. Reading their stories of nursing care reaffirms the need for nurses to cultivate and call on personal attributes such as resilience and hardiness. These attributes, along with skills such as recognizing and managing conflict, negotiation and advocacy should be essential core content for all nursing education programs.
Additionally, our profession must ask and answer questions, including: How do we socialize nursing as a knowledge profession in which the centrality of caring is demonstrated not only through touch and presence but also by advocacy, critical thinking and accountability for outcomes? How do we evolve recruitment methods and processes for nursing so that those considering entering the profession have a clearer picture of the promise and the challenges inherent in nursing and an understanding that the role of the nurse will be ever-changing as the healthcare system evolves?
Several of the papers shed light on the reasons nurses relocate within Canada and the challenges they encounter in doing so. From the lead paper by McGillis Hall and colleagues ("I Was Never Recruited: Challenges in Cross-Country Migration"), we learn that recommendations to simplify the nursing licensing process and consider a national licensure system have been made since 2006. Given the findings that the majority of nurses continue to live and work in the province where they were educated, and that nursing migration is decreasing, it is clear that those who do migrate have specific and compelling reasons for doing so – including finding initial or improved employment (e.g., a full-time job), moving to accompany a spouse, or in association with their military service (Price et al. 2013). The finding that 88% of respondents (more than 2,300 individuals!) who had moved within Canada identified licensing as their greatest challenge is a sad commentary on the licensing/registration processes in our country. Some reported that navigating the licensing process in their new jurisdiction took three to eight months – longer than it took to obtain registration in the United States. The result was frustration, and feeling disrespected and not valued. In 2006, CNA published Toward 2020: Visions for Nursing, which linked responsiveness, quality and patient safety to effective regulation of nurses. It is time to find a way to reduce barriers to nurse mobility across Canada by improving timeliness and efficiency in the registration processes of each province and territory. A "national unique identifier" for each nurse in Canada is another initiative that has the potential to enable a better understanding of nurse migration patterns. CNA has been advancing that idea in its discussions with the federal government, for example, in its 2012 pre-budget submission to the House of Commons Finance Committee (CNA 2012).
Understanding and monitoring how nurses migrate within Canada is important for reasons beyond nursing education and workforce data. The paper by Andrews and colleagues demonstrates the utility of a Geographical Information System in facilitating such monitoring. As governments and employers seek innovative ways of maximizing limited resources, they must consider where nurses are needed the most and where they can make the greatest difference to the health of Canadians. With proper coordination among education institutions, employers and governments, migration of nurses within Canada could be driven by the nurse's desired destination and the area of greatest need. One suggestion is to network provincial coordinating bodies, such as Workforce Ontario and WorkBC, and thereby create a central site where nurses can find information about employment opportunities across the country. However, inconsistencies in the knowledge and practice competencies required by regulators in each province and territory also hinder the migration of nurses, especially licensed/registered practical nurses (LPNs).
In their paper detailing the perspectives of LPNs on nurse mobility, Harris and colleagues point out that titles for LPNs are not consistent across the country – for example, Ontario calls LPNs registered practical nurses (RPNs). Moreover, there is considerable variation in LPN scope of practice throughout Canada. Not only are these inconsistencies a source of frustration for LPNs, they may also be linked to the study's finding that LPNs do not feel respected. The authors advise that policy makers, administrators and researchers look to fill this knowledge gap, explore the mobility of LPNs and "strengthen Canada's nursing workforce" (p. 2). Given that maximizing the use of their skills and education was cited by nurses as a primary motivator for their migration, further consistency and cross-Canada collaboration regarding health human resources planning is urgently needed.
Continuing education has long been identified by nurses as a factor that contributes to increased job satisfaction. Lalonde and colleagues discuss the role that continuing education plays in migration of nurses within Canada and report that a lack of support for continuing education was one of the reasons nurses identified for migrating to a new province. Nurses wanted to access continuing education to help them provide the best care possible to patients. Furthermore, they believed their professional advancement would be limited without further education or training.
In order to meet the evolving healthcare needs of the population, healthcare providers must keep their nursing knowledge current. Online learning and distance education are increasingly being accessed as strategies to balance education with scheduled shifts and long working hours and to expand education options for nurses working in remote and rural areas. However, how does a nurse choose a program? Should it be a program offered by a Canadian institution or one from the United States, Australia or the United Kingdom? How does one evaluate the quality of the various programs? How might the choice of the specific education provider affect one's future career or educational opportunities? One way to address this gap might be the creation of a national repository of information that compares and contrasts education programs using a consistent set of criteria, lists career options and opportunities associated with those programs and enables graduates to share their experiences.
As identified in the research, nurses expect employers to provide multifaceted support for education. However, such support is increasingly difficult given today's reality of tight budgets and staff shortages, and transparency and fairness in the allocation of resources are imperatives. In light of the evidence presented in this issue regarding the relationship between continuing education and job satisfaction, nurse retention and the delivery of high-quality care, reserving a specific percentage of healthcare organizations' budgets for staff education and development is indicated. Moreover, that percentage needs to be included in service agreements with ministries of health benchmarked across the country and reported in balanced score cards.
CNA's mission and vision are well aligned with the research presented in this issue of CJNL. The results create a compelling case for evolution and change in nursing recruitment, migration and education. This important new evidence will enable CNA and all stakeholders to advance that change to evolve, strengthen and sustain our profession.
About the Author(s)
Barbara Mildon, RN, PhD, CHE, CCHN(C), VP Professional Practice & Research & CNE,, Ontario Shores Centre for Mental Health Sciences, President, Canadian Nurses Association
Andrews, G., L. McGillis Hall, J. Peterson, S. Price, M. Lalonde, A. Harris and S. MacDonald-Rencz. 2013. "Mapping Nurse Mobility in Canada with GIS: Career Movements from Two Canadian Provinces." Canadian Journal of Nursing Leadership 26 (Special): 41–49.
Canadian Nurses Association (CNA). 2006. Toward 2020: Visions for Nursing. M. Villeneuve and J. MacDonald, PIs. Ottawa: Author.
Canadian Nurses Association (CNA). 2012. The Health of Our Nation: The Strength of Our Economy. Pre-Budget Submission to House of Commons Finance Committee. Ottawa: Author.
Gottlieb, L. 2012. Strengths-Based Nursing Care: Health and Healing for Person and Family. New York: Springer.
Harris, A., L. McGillis Hall, J. Peterson, S. Price, M. Lalonde, G. Andrews and S. MacDonald-Rencz. 2013. "LPN Perspectives of Factors that Affect Nurse Mobility in Canada." Canadian Journal of Nursing Leadership 26 (Special): 70–78.
Lalonde, M., L. McGillis Hall, J. Peterson, S. Price, G. Andrews, A. Harris and S. MacDonald-Rencz. 2013. "Support and Access for Nursing Continuing Education in Canadian Work Environments." Canadian Journal of Nursing Leadership 26 (Special): 51–60.
McGillis Hall, L., J. Peterson, S. Price, G. Andrews, M. Lalonde, A. Harris and S. MacDonald-Rencz. 2013. "I Was Never Recruited: Challenges in Cross-Canada Nurse Mobility." Canadian Journal of Nursing Leadership 26 (Special): 29–40.
Perry, B. 2009. More Moments in Time: Images of Exemplary Nursing. Athabasca, AB: Athabasca University Press.
Price, S., L. McGillis Hall, J. Peterson, M. Lalonde, G. Andrews, A. Harris and S. MacDonald-Rencz. 2013. "Factors That Influence Career Decisions in Canada's Nurses." Canadian Journal of Nursing Leadership 26 (Special): 61–69.
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