Introduction: People need to move to where the work is. This has always been a normal part of job-searching strategies for individuals. We witnessed this pattern throughout the 20th century, especially towards the end. However, when large numbers of an occupational group have had to move because of economic issues, this normal pattern changes. Interest in the movement of healthcare professionals became acute in the latter part of the previous century because of emerging shortages in many health professions. As a result, employers, regulators and governments have been working together to address the issues underlying these patterns.

The compilation of the research undertaken for this Special Issue of the Canadian Journal of Nursing Leadership on migration and mobility, both to the United States (see the papers by McGillis Hall, Peterson, Price, Lalonde et al. and Peterson et al.) and across Canada (see McGillis Hall, Peterson, Price, Andrews et al.), provides excellent new evidence and paints a picture of our current understanding of the multifaceted factors at play with respect to this important health human resources issue. This research provides the nursing community and policy and decision-makers with an opportunity to compare current findings with earlier migration and mobility trends and challenges since the early 1990s, and enables us to predict how these may continue to have an impact into the next decade.

Reference is given to the fact that policy and decision-makers need to appreciate some of the present trends and to consider some additional factors as we face new opportunities in the nursing workforce. These issues resulted in all levels of governments and the broader nursing community coming together to address health human resources challenges through a variety of recruitment and retention policy initiatives and innovations. The federal initiatives that complement many of the provincial, territorial and broader nursing community efforts are highlighted. Moving forward, this research also lays the groundwork for continued and further research by questioning what still needs to be done.

What We Know: Understanding the Trends

Traditionally, Canada has had a low rate of emigration (0.3–0.4% per year). However, Canadian emigrants have included a disproportionate number of skilled workers. In the 1990s, Canada was a net loser to the United States, although the numbers were still relatively small compared to the stock of workers in the Canadian labour force (Baumann et al. 2004).

In order to fully understand the mobility and migration picture of Canadian nurses, we must first appreciate some of the historical trends in the Canadian nursing workforce. For the purposes of this discussion, data presented are for the registered nursing (RN) community, as the data for both the licensed practical nurse (LPN) (called registered practical nurse in Ontario) and the registered psychiatric nurse are more limited.

Nursing workforce

In the mid-1990s, with the significant reductions to healthcare budgets across Canada, we saw decreased numbers of nurses and other healthcare professionals working in this country, as governments implemented hiring freezes and early retirement packages. Workforce data reported by the Canadian Institute for Health Information (CIHI 2010) indicate considerable fluctuation in the registered nursing workforce. Between 1980 and 1993, there was an average annual growth rate of 3.3%, yet between 1993 and 2002, the average growth rate decreased by 0.2%. From 2002 to 2010, after the implementation of several recruitment and retention efforts at all levels of government and within the nursing community, the average growth rate was 1.9%. In terms of numbers, in 1993 the RN workforce was 235,738; by 1998, Canada had 227,814 RNs; and then in 2003, the workforce surpassed the 1993 level, with 241,415 RNs in Canada. Most recently, CIHI data demonstrate that there are 268,512 RNs employed in nursing in Canada, a 0.8% increase from the previous year of 2009.

Inflow/outflow

It would be of great interest to be able to determine the inflow and outflow of nurses between Canada and the United States. However, data to perform this analysis are not available, as CIHI reporting includes RNs who have migrated to another country only if they maintain their registration with a Canadian province or territory. The lack of comprehensive data and reliable information on nursing migration between Canada and the US makes comparisons impossible. Ideally, with more precise data, healthcare leaders and policy makers could calculate net loss and inflow–outflow ratios, enabling them to watch changes within the US health reform efforts and as most of Canada (excluding Quebec) embarks on the writing of the American National Council Licensure Examination for Registered Nurses (NCLEX-RN) (NCSBN 2011).

The whole picture

As outlined in many of the research papers highlighted in this Special Issue, Canadian nurses move to the United States for a number of reasons, specifically, lack of job opportunities, cost of living, feeling undervalued, family or personal issues, educational opportunities, pay and benefits, travel, weather, workload and working conditions (American [California]-mandated nurse–patient ratios).

In addition to these factors, licensing rules and regulations and pass/fail rates of each country's respective exam need to be taken into account to further our understanding of monitoring the migration patterns across our borders. Interestingly, the average pass rates of Canadian nurses writing the NCLEX-RN for the first time between 1997 and 2000 was 62% (n=200 new exam writers, all four years combined) (NCSBN Annual Reports 2013). More recent information from the National Council of State Boards of Nursing indicates that Canadian pass rates are hovering in the 60% range, as demonstrated in 2008 with a pass rate of 65.4% (n=638 new exam writers), increasing to 66.9 % in 2009 (n=586 new exam writers) and dropping to 60.9% in 2010 (n=529 new exam writers). However, the NCSBN Annual Report (October 2010 to September 2011) states that 88% of first-time US-educated registered nurses passed the exam, compared to 35% of internationally educated individuals writing the exam for the first time. This figure suggests that Canadian-educated nurses do better than the overall group of internationally educated nurses taking the NCLEX examination, but they are not yet achieving a pass rate at the level of their US-educated counterparts.

In 2006, 809 of the 6,003 individuals who wrote the Canadian Registered Nurse Exam (CRNE) for the first time were internationally educated. Of the 809, 9.8% were from the United States. While information specific to US nurses is not available, the pass rate for all internationally educated nurses was 63% compared to Canadians, with a pass rate of 96% (CRNE Bulletin 2006).

It is important to understand the picture of migration patterns between the two countries to ensure a stable nursing workforce now and in the future. To do so, we require comparable data and strong communication channels between the two countries to develop an open and collaborative approach to addressing present and future health workforce needs.

Mobility within Canada

Labour mobility was a characteristic of the 20th-century workforce, one that has continued into this century. According to Human Resources and Skills Development Canada, every year, approximately 200,000 Canadians relocate to a different province or territory and look for work (HRSDC 2011). That individuals need to relocate to get employment has not been a public policy concern until recently, when that relocation turned into higher-than-average emigration of Canadians. One reason cited for higher emigration versus interprovincial movement is a number of labour mobility barriers within Canada.

The Agreement on Internal Trade (AIT) is an intergovernmental trade agreement signed by Canadian first ministers that came into force in 1995. Its purpose is to reduce and eliminate, to the extent possible, barriers to the free movement of persons, goods, services and investment within Canada and to establish an open, efficient and stable domestic market. The ultimate goal of AIT is to permit ease of movement of Canada's health workforce across provincial and territorial jurisdictions. The research undertaken for this Special Issue on migration and mobility helps to highlight the extent of the movement within our Canadian borders and the reasons for that mobility, namely, employment opportunities, career advancement and work flexibility. For the most part, our nurses (both registered nurses and licensed practical nurses) stay in the province where they graduated. This fact in itself suggests that we need to find incentives to attract our nursing workforce to consider career opportunities in our rural and remote communities. Licensing challenges appear to be a significant issue among those who have moved to another jurisdiction and speak to a need to arrive at common processes and practices across the country. As outlined in this issue's paper by Andrews and colleagues, the concept of mapping the mobility of the nursing workforce using a Geographical Information System (GIS) approach should be considered as an important tool for decision- and policy makers to monitor the trends and patterns occurring across the country.

Throughout the research papers, a common theme that emerges is the need to value the role of nurses. Healthy workplaces equate to a healthy and stable workforce, and one of the ways to create a supportive work environment is through nursing continuing education opportunities. The paper by Lalonde and colleagues explores the motivating factors and barriers for nurses to participate in continuing education opportunities, including support, recognition, financial reward on the one hand and low pay, time and lack of support on the other. Clearly, one can see the link between continuing education opportunities and staff turnover, and thus food for thought for decision- and policy makers at all levels.

The nursing ideal and the impact of our perceptions and expectations of the field of nursing are adeptly described in the paper by Price and colleagues. This research can help us all consider how our future nurses are educated, trained and mentored to describe a more realistic picture of nursing in today's reality, as well as to provide opportunities for interesting and fluid career opportunities across our broad and expansive Canadian landscape.

The research presented on licensed practical nurses (LPNs) in the paper by Harris and colleagues paints a somewhat different picture than that of the registered nursing community and provides an opportunity for future investigation and consideration. In addition to salary and job availability, we learn that LPNs choose to move to another jurisdiction for three primary reasons: (a) to expand their scope of practice, (b) to advance their education and career and (c) for professional respect and recognition. To meet population health needs, policy and decision-makers will need to consider how to maximize the entire nursing workforce, including the role of LPNs.

Last but not least, the paper by Nelson reminds us of the impact of international policy, the role of the state and its relation to mobility and migration patterns globally.

Accomplishments

Recruitment and retention efforts at the provincial and territorial levels have been significant and have helped to address many of the nursing workforce challenges in Canada. Information regarding these specific strategies is well documented on each jurisdiction's website. At the federal level, the government has attempted to complement provincial and territorial initiatives and span a number of themes, including healthy workplaces, health human resources strategies, an internationally educated health professionals' initiative, data development, loan forgiveness for nurses wishing to work in rural and remote areas, skills development, team-based care and nursing metrics. Table 1 provides links to more information on these federal initiatives. Nursing stakeholders at national, provincial and territorial levels are also to be commended for their active recruitment and retention efforts that span program development and implementation, research, tools and resource development or position papers. Clearly, a multi-pronged, multi-stakeholder approach has been required, and our collaborative efforts are beginning to pay off as we see our nursing workforce numbers rise.

Where to Now?

Canadians value their healthcare, and they respect the role nurses play in providing good-quality, safe care. Movement between Canada and the United States and between provinces and territories is a reality and a personal choice. Policy and decision-makers at all levels of government, and the nursing stakeholder community from both countries, should be encouraged to monitor the trends, stay attuned to inflow and outflow data and appreciate the factors at play. As Canada and the United States align to share the same RN exam in 2015, our need for this type of research, and for thoughtful health human resources planning and management, will be extremely important.

Comparable data between Canada and the United States will also aid in our ability to identify and track trends and patterns in order to be aware and alert to areas for concern. This research will serve many purposes, including the need for further research, policy development and implementation. It fosters communication between the entire nursing community to have a better understanding of the migration and mobility factors at play. Decision- and policy makers need to stay attuned to the flow factors both in and out of Canada and within our country, and understand the contributing factors. This includes appreciating the reasons that nurses move and also why they stay. If trends look to become worrisome, incentives to attract, attain and retain our nurses will need to be put in place. Throughout all these research papers, a simple message comes across loud and clear: Nurses stay if they are valued.

About the Author

Barbara Foster, BScN, RN, Nurse Manager, Nursing Policy Unit, Health Canada, Ottawa, ON

Sandra MacDonald-Rencz, RN, MEd, Nursing Executive Advisor, Strategic Policy Branch, Health Canada, Ottawa, ON

Linda McGillis Hall, RN, PhD, Kathleen Russell Distinguished Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON

Correspondence may be directed to: Barbara Foster, BScN RN, nurse manager, Nursing Policy Unit, Health Canada, 200 Eglantine Driveway, Jeanne Mance Building, Tunney's Pasture, Address Locator: 1918A, Ottawa, Ontario K1A 0K9; tel.: 613-946-3889; fax.: 613-957-8487; email: barbara.foster@hc-sc.gc.ca.

References

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): 41–50.

Baumann, A., J. Blythe, C. Kolotyloe and J. Underwood. 2004. Building the Future: An Integrated Strategy for Nursing Human Resources in Canada – Mobility of Nurses in Canada. Ottawa: Nursing Sector Study Corporation.

Canadian Registered Nurses Exam (CRNE) Bulletin. 2006 (November). "Statistics on CRNE Writers." CRNE Bulletin No. 9. Retrieved January 2, 2013. <http://www2.cna-aiic.ca/CNA/documents/pdf/publications/CRNE-Bulletin-November-2006-e.pdf>.

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.

Human Resources and Skills Development Canada (HRSDC). 2011 (August 17). Labour Mobility. Retrieved January 2, 2013. <http://www.hrsdc.gc.ca/eng/workplaceskills/labour_mobility/index.shtml>.

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.

McGillis Hall, L., J. Peterson, S. Price, M. Lalonde and S. MacDonald-Rencz. 2013. "Stemming the Flow of Canadian Nurse Migration to the US." Canadian Journal of Nursing Leadership 26(Special): 8–19.

National Council of State Boards of Nursing (NCSBN). 2011 (December 8). "NCSBN and Pearson VUE to bring NCLEX-RN Examination to Canada." News release. Retrieved January 2, 2013. <https://www.ncsbn.org/3048.htm>.

National Council of State Boards of Nursing (NCSBN). 2013. Annual Reports, 1997–2000. Retrieved January 2, 2013. <https://www.ncsbn.org/525.htm>.

Nelson, S. 2013. "Global Trends, Local Impact: The New Era of Skilled Worker Migration and the Implications for Nursing." Canadian Journal of Nursing Leadership 26(Special): 82–86.

Peterson, J., L. McGillis Hall and S.Price. 2013. "The Experiences of Canadian-Educated Early Career Nurses Who Practise in the US." Canadian Journal of Nursing Leadership 26(Special): 20–28.

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.