[This article was originally published in Nursing Leadership, 26 (Special Issue)]

The purpose of this study was to explore how educational opportunities may affect nurses' decision to move within Canada. Thematic analysis of qualitative data obtained from 35 registered nurses and 35 licensed practical nurses highlighted educational opportunities available in Canada and how these influence nurses' decision to move across the country for work. The results indicate that Canadian nurses value continued learning but face several barriers while trying to further their education. Two main themes emerged: support for and access to continuing education. Canadian nurses perceive a lack of support, both financially and in the form of scheduling, for engaging in continuing education. Additionally, the lack of access to accredited continuing education programs was reported. The findings and implications of this study are examined within the context of nurse mobility.

Background

Increasing evidence points to the importance of continuing education to nurses' practice and professional development. Several studies have demonstrated that providing nurses with continuing education opportunities increases job satisfaction (Best and Thurston 2004; Penz et al. 2008) and decreases turnover (Bjørk et al. 2007). The literature suggests that nurses value continuing education for a number of reasons, including professional and personal growth, and improved patient care and career opportunities (Hughes 2005; Nalle et al. 2010). Some reports suggest that the main motivating factors for nurses to participate in continuing education were organizational support and recognition, financial rewards and availability of resources (Hegney et al. 2010; Nalle et al. 2010).

However, nurses face many challenges when trying to further their education. The barriers identified include work schedule and family obligations, time, lack of support and recognition for their efforts, program cost, time away from work and lack of funding (Hegney et al. 2010; Hughes 2005; Nalle et al. 2010). The sample of nurses in Hughes's study felt that their days off and the time they spent with their families was very important, and that shift work led to fatigue and lack of motivation to participate in further education. Additionally, rural nurses reported having to travel great distances to participate in continuing education; the farther they lived from a college or university, the less likely they were to attend (Beatty 2001; Hegney et al. 2010).

The Canadian Nurses Association released a position statement in 2004 stating that employers are responsible for providing nurses with support to access and engage in continuing education, such as providing them with study leaves and funding. However, Canadian literature suggests that nurses and other healthcare professionals continue to experience barriers to accessing continuing education and receiving support from their employers (Curran et al. 2006; Penz et al. 2007). These barriers could have implications for nurse migration across Canada, although the nature of this relationship is unclear at this time.

Kingma (2001) and Kline (2003) discuss the "push–pull" factors of nurse migration, where the push factors are in the nurses' country of education and the pull factors are in the country of emigration. Professional development is one of the three main categories that Kingma describes as a reason for nurses to migrate. Baumann and colleagues' (2004) Canadian report on the immigration and emigration of nurses identified that educational opportunities were a "pull" factor.

McGillis Hall's team (2009a) examined the reasons behind the emigration of Canadian nurses to the United States and explored whether these nurses (n=651) would be interested in returning to Canada. Although few respondents stated that they migrated to North Carolina because of educational opportunities, over 30% of the respondents cited the lack of continuing education opportunities as a disincentive to returning to work in Canada. Another study conducted by McGillis Hall and colleagues (2009b) found that in 2004 there was a higher number of Canadian-educated nurses that were furthering their education while working in the US compared to American nurses. This finding led the authors to conclude that continuing education may be an important factor in nurse migration. Although these studies were conducted with nurses working in the US, the authors' findings shed light on the importance of continuing education in the migration of nurses.

Exploring support and access to continuing education opportunities available for nurses may provide an understanding of factors that influence nurse mobility in Canada. The overall purpose of this study was to explore how educational opportunities may affect nurses' decision to migrate within Canada. The secondary purpose of this study was to gain a greater understanding of potential continuing education strategies that policy makers can implement to recruit and retain Canadian nurses.

Method

This paper examines qualitative data obtained from a large survey of Canadian registered nurses (RNs) and licensed practical nurses (LPNs) on Canadian nurse migration (see also the paper by McGillis Hall et al. in this Special Issue).

The data consisted of comments retrieved from the surveys of 35 RNs and 35 LPNs from across nine different provinces and territories (P/T). In this paper, continuing education is generally defined as any post-registration education in nursing, such as specialty certifications, post-RN baccalaureate degree, conferences and workshops. Participants' comments were analyzed using thematic analysis.

Thematic analysis can be defined as "a method for identifying, analysing and reporting patterns (themes) within data. It minimally organizes and describes your data set in (rich) detail. However, frequently it goes further than this, and interprets various aspects of the research topic" (Braun and Clarke 2006: 79). Braun and Clarke's (2006) notion of six phases of thematic analysis was used to analyze the data. The data were first read and reread; notes were taken regarding initial ideas of what was in the data. Next, the data were coded and "organized into meaningful groups" (Braun and Clarke 2006: 88). The codes were then examined and arranged into potential themes. Finally, the themes were reviewed, refined and then named.

Results

Respondents' comments reflected the importance to them of participating in continuing education and the barriers they experienced in accessing further education. As the sample came from nurses that had already moved within Canada, the nurses' discussion about the barriers they experienced in accessing continuing education occurs within the context of their decision to move in the first place or to remain where they migrated. Analysis of the qualitative data revealed two main themes: support for continuing education and access to continuing education.

Support for continuing education

Study participants revealed that an important reason for migrating to a new province or remaining in their current province was a perceived lack of support, either in the form of time off or pay from their employer, for providing them with on-the-job training and continuing education. Participants described considerable effort that they were required to put in to obtain the additional education they felt was necessary to provide optimal patient care in their work settings, something they considered a requirement for their work:

Some jobs require special education. Where I received my education [in Saskatchewan], if I required special education it was paid for. Other places, I discovered, require me to take the time off and educate myself, then hope for [a] job – not easy or smart!! I want to specialize as a "lactation consultant." I will do it on my own as there is no support from my hospital etc. … I am doing it for me and for the future mothers!

The need to use their own personal time to attend workshops and courses outside of work hours was highlighted. There was a perception that participating in continuing education was not only a requirement for their job, but also important for professional advancement opportunities and to meet their learning needs as professionals. As such, the majority of the nurses felt that there should be support for them through time off work or flexible working hours:

To attract and retain a nurse, the employer must offer a flexible and positive work environment that offers opportunities for advancement and training. The nursing profession requires ongoing training, and the employer should accommodate this training through monetary subsidy or accommodation of time off.

It would be nice to be able to continue my education without losing pay from my FT job. RN program is too difficult to enrol in when I am not going to be able to pay my bills if I enrol.

Several nurses discussed the need for flexible work scheduling to accommodate their interests in furthering their education. When flexible work scheduling was not available, nurses would change their employment status to part-time to accommodate their school schedule:

The reason I chose to work part-time was so I could work and complete my MN.

Not only were the participants concerned about balancing their work commitments and their interest in continuing their education, they were also trying to balance their personal lives. Without the support in the form of time off or flexible work schedules, the nurses would have to give up time with their families to participate in continuing education. It appeared essential to these nurses that the importance of their time with their families be recognized, valued and respected, and that this could come in the form of providing them with the time needed to continue their education without jeopardizing their personal time:

It would so assure motivation if structures would be in place to allow nurses to continue to work and at the same time be able to pursue career advancement, e.g., be able to work maybe evening or days and go to school when free. For example, for nurses who would like to pursue degree programs … This will make it easier for such nurses to raise their families conveniently and also pursue their career ambitions versus going to school full-time and relinquishing your position at work.

Access to continuing education

Several nurses in this study discussed the challenges in accessing education when they lived in remote areas or in cities that were not in the vicinity of an academic institution. Participating in continuing education required significant efforts, such as travelling long distances to a location that provides courses. This was done without financial support, as the cost of travelling, attending and overnight stays were paid out of pocket. These could be a significant barrier to nurses who would like to further their education:

I am having difficulty finding courses/programs available for advancing in education. I work [in] long-term care and in order to keep my scope [of practice] up to date I need more access to learning/upgrading opportunities without having to drive two hours to a city.

I believe that retention would improve if nursing education [in rural/remote areas] was available closer to home. I also personally know several people who would have chosen a career in nursing but didn't because they would have had to leave the territory to go to school – so I also think the nursing shortage might not be felt so strongly if nursing education was more accessible [in rural/remote areas].

As the geographic access to universities and colleges was such a challenge, alternative ways of meeting educational needs were sought through online learning. However, study participants expressed frustration over the limited options for accredited online learning. Lack of access to continuing education opportunities led to nurses' moving to cities or provinces with more available education-related resources:

I would also like to add that as an adult (older) learner – I have noted the difficulty in finding online accredited distance educational opportunities in Canada. This may impact whether a person continues to work in a certain province.

Discussion

It was evident that the nurses perceived that they did not receive organizational support in the form of time off or funding to engage in further education. As well, access to continuing education was a challenge for some. Kingma's (2001) and Kline's (2003) "push–pull" factors of nurse migration help deepen our understanding of how these reported barriers might affect nurses' decision to migrate within Canada.

Support for continuing education

The results of this study highlight that Canadian nurses were very keen to get involved in continuing education, but it was not easy to do so. Participants discussed the efforts that were required to obtain ongoing education across the country. These findings are similar to reports in the literature in which Canadian nurses who had migrated to the US to work identified the lack of continuing education opportunities in Canada as a disincentive to returning to work there (McGillis Hall et al. 2009a).

With increasing workloads, patient acuity, overtime, long hours and shift work, nurses are reluctant to spend their precious time off engaging in continuing education activities without being compensated for their time and expenses. There are also many challenges when trying to enrol in courses while doing shift work without the support of time off. For example, taking a course offered on the same day each week while doing shift work would be challenging without having employer support with time off, as the nurse's work schedule differs on a weekly basis. Spending time with family is important, and should be recognized and supported. However, with staff shortages and healthcare budget cuts, organizations may not have the resources to give nurses time off to take courses or to reimburse course costs.

A feasible and cost-effective option could be to provide nurses with the choice of a more flexible scheduling system that would allow them to continue to work their required hours, but with the flexibility of scheduling shifts around their courses. As well, flexible work scheduling would allow nurses to protect their time off with their families. Thus, providing nurses who are interested in continuing their education with flexible work schedules could be a strategy for keeping them in the workforce. Providing staff with the support of paid time off and travel expenses, as well as shift coverage, has been reported as a best-practice strategy to support continuing education (Curran et al. 2006).

An innovative funding strategy for cost-conscious employers could be doing a yearly lottery in which one nurse is randomly chosen to attend a continuing education session of his or her choice. Alternatively, participation in a continuing education event – for example, attending a national conference – could be a yearly award for outstanding service, where colleagues and management nominate a nurse and then one or two are randomly chosen from the pool of nominees. These novel strategies could go a long way towards encouraging nurses to remain in their province.

The results of this study highlight respondents' perceptions of the lack of support for engagement in continuing education. Thus, an important strategy at an organizational level would be to ensure greater communication and increased awareness of the available organizational supports for staff interested in pursuing continuing education activities.

Access to continuing education

The issue of access to continuing education proved to be a concern to study respondents.

The main obstacles revolved around living in rural or remote areas, distance travelled to a college or university, costs associated with overnight travel and limited distance education options. These findings are supported by previous studies (Curran et al. 2006; Penz et al. 2007). The lack of access to continuing education programs can be considered a "push" factor in nurse migration.

In this study, nurses who were interested in continuing education sought novel ways to meet their needs, particularly, seeking out online or distance education opportunities, such as post-RN programs and specialty-related courses. Nurses may choose to study via distance education programs for a variety of reasons, such as living in a remote area where there is no university and for the convenience of studying from home. At first glance, distance education programs appear to be the solution for this sample. However, participants discussed the limited number of Canadian universities that offered post-RN programs via distance education.

The Canadian Nurses Association's joint position statement from 2004 asserts that nurses should have access to flexible continuing education programs, as well as programs delivered using a variety of technologies. Access to continuing education through distance learning has the benefit of allowing nurses the ability to study around their work, as scheduling was a large concern. Providing distance education options using various technologies and self-directed learning programs has been identified as a key best practice for increasing access to continuing education (Curran et al. 2006). Additionally, an accessible repository describing the available online options would likely also increase access to continuing education.

Implications

These findings have implications at the organizational, provincial and federal levels. Strategies need to be put in place that would improve nurses' ability to participate in continuing education. Increasing support in the form of time off or flexible work scheduling would be an effective strategy. As well, investing in funding nurses, even partially, to engage in continuing education would be an effective way of supporting them.

Nurses who live in communities located at some distance from colleges and universities pose a different kind of challenge. The technology to support distance education is available. It might be advantageous to invest in this technology to increase nurses' access to post-RN programs and specialty certification courses. Additionally, using this technology at conferences could also improve access to continuing education. Perhaps implementing strategies to decrease nurses' effort at engaging in continuing education could encourage them to remain in their home province.

There is a need to increase our understanding of the supports, at the federal and provincial levels, that are available to nurses seeking to engage in continuing education activities. What supports are available across P/T? How can P/T learn from the successes of others across the country? Further research is needed on the various supports available and how successful these strategies have been at balancing engagement in continuing education and retention.

Conclusion

This study highlighted Canadian nurses' interests in pursuing continuing education, as well as the barriers that they face while trying to do so. The results further our understanding of how continuing education affects Canadian nurses' decision to migrate, and point towards strategies that might encourage their return home. The two main barriers identified were related to support, in terms of both financial remuneration and time off, and access to continuing education. The results have implications for policy makers at the organizational, provincial and federal levels. Organizations need to invest in their nurses' continuing education needs. Providing nurses with funding for continuing education, even in the form of a lottery, could go a long way towards encouraging them to remain in their province. As well, allowing nurses to schedule shifts around their courses would be beneficial without increasing staffing costs. The results also highlight the need for further research in the use of online and distance education as options for continuing education, particularly in the provision of post-RN programs and specialty courses. As the entry to practice continues to shift in Canada to baccalaureate-prepared nurses, one strategy to promote nurses' progression through undergraduate education is to increase the number of accredited distance post-RN programs across the country.

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