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The Experiences of Canadian-Educated Early Career Nurses Who Practise in the US
[This article was originally published in Nursing Leadership, 26 (Special Issue)]
Nurses who are early in their careers make important decisions that begin them on unique career trajectories. One of these decisions may be migration. Little is known about the experiences and career decisions made by early career nurses who were educated in Canada and are working in the United States. Focus groups were conducted with nine nurses to explore and describe their experiences. Utilizing the Learning Theory of Career Counselling as a framework, the analysis highlighted the environmental conditions and learning experiences described by the participants. Two themes were identified: early decisions and ongoing decisions. The career trajectories of these nurses were characterized by decision-making. They made decisions about becoming a nurse, where to work and in what clinical specialty. The learning experiences and environments to which they were exposed influenced their early decisions and continued to influence their ongoing decisions about returning to Canada.
Each person's career trajectory is unique, with multiple factors contributing to career selection and ongoing decisions (Krumboltz 1996). Nurses early in their career have already made several major career decisions and invested a great deal of time, money and effort to obtain their educational and licensing requirements. However, it is not unusual for career decisions to change after the nurse enters the workforce. Recent research has shown that early career nurses have changed jobs (Kovner and Djukic 2009), career plans and even job values (Rognstad and Aasland 2007).
Mobility is often seen as a benefit to choosing a career in nursing. A study by Gillis and colleagues (2004) found that nursing graduates from Atlantic Canada took advantage of geographic mobility both within the country and to the United States. In fact, 18 of the 51 participants had worked in the US after graduating, although only six ultimately remained there. Little is known about Canadian-educated nurses early in their careers who have made the decision to migrate to the US. The purpose of this analysis was to explore and describe the career decisions and experiences of early career nurses who were educated in Canada and are working in the United States.
A qualitative exploratory design was utilized for this research. Data were collected through two focus groups held with nine early career nurses who were educated in Canada and were working in the US. Participants were part of a larger study examining Canadian nurse migration to the US, and had identified interest in participating in a follow-up focus group (McGillis Hall et al. 2012). The participants had between two and four years' experience at the time of the interview. A description of the sample appears in Table 1. The focus groups were conducted by telephone utilizing conferencing functions, permitting participant access from a variety of locations and time zones and increasing the feasibility of gathering data. A semi-structured focus group guide was utilized, containing six open-ended questions with prompts. The questions asked about their experiences transitioning to the work setting, their decisions about choosing nursing as a profession and the factors that would contribute to a decision to return to Canada.
|Table 1. Description of the sample|
|Location of nursing school||Alberta||1|
|Year of graduation||2005||1|
|Current state of employment||California||6|
The proceedings of the focus groups were transcribed, and data were analyzed using the thematic analysis strategy outlined by Braun and Clark (2006) and summarized below. First, the data were read and reread with the purpose of becoming familiar with the content. Next, the entire data set was coded, with codes developed inductively paraphrasing the participants' words. All coded data segments were collated, and the codes gathered together in larger thematic categories and subcategories.
The coded data extracts were reviewed to ensure consistency within each category, and revisions were made as necessary. Original transcripts were reread and themes reconsidered to ensure their validity and to capture any previously uncoded data. Revisions and rechecking with the original data continued until a narrative was developed. Throughout data analysis, discussions were held between team members and initial impressions and further analysis shared. Additionally, theories and previous findings in the literature were reviewed to provide further insights. Finally, the themes were defined, named and recorded.
The Learning Theory of Career Counselling (LTCC) (Krumboltz 1996; Krumboltz et al. 1976; Krumboltz and Worthington 1999) was used to guide the data analysis and interpret the findings. The theory helps to describe and explain individuals' career trajectories. Although much career counselling literature focuses on career selection, the LTCC clearly recognizes that people make many career decisions over the course of their working life. Job descriptions, work environments and people's preferences and values change (Krumboltz and Worthington 1999). Even in the relatively short time that the participants in this study had been working as nurses, there was evidence of the many decisions that they had made: they chose to pursue nursing as a career, chose a clinical specialty, chose to migrate to the US and, in some cases, chose to change jobs.
In the precursor to the LTCC, the Social Learning Theory of Career Decision-Making, four categories of influences on people's career decision-making were identified: genetics and natural abilities; environmental conditions and events; learning experiences; and task approach skills, or the interaction between genetic and environmental influences (Krumboltz et al. 1976). Learning was further differentiated into instrumental learning (e.g., learning through doing) and associative learning (e.g., learning through observing). The categories provide a useful framework to explore the decisions made by early career nurses. The focus for this paper will be on understanding the influence of environmental and learning experiences on career development, as these are factors over which individuals can have some control (Krumboltz 2009).
Two overarching themes were identified from the data: early decisions and ongoing decisions. These highlight the complex career journeys of the participants. Findings are framed within the LTCC.
Participants discussed three early career decisions: the decision to become a nurse, the decision to work in the US and the decision of what area of nursing to pursue. These decisions were often interrelated, such that the decision to move to the US could coincide with the decision of clinical specialty. Participants revealed the environmental factors and learning experiences, often associative learning, that influenced these decisions. The LTCC posits that early career decisions are influenced by the exposures and learning that occur within the family setting and environment in which one is raised (Krumboltz 1996). This assumption was confirmed in the focus groups, as some participants recognized their decision to become a nurse was influenced by observing family members who were nurses. A few recounted that the decision to become a nurse was confirmed during nursing school. This finding highlights the importance of the influence of the school environment and the instrumental learning that occurred there on the decision to stay in nursing:
I think once I made the decision or just because I was young, the trial and error … you're still a little unsure. "Do I like this? Do I want it?" And the education program that I went through at the university, it was so supportive and so tight knit. … I think that my first-year experience alone really gave me the positive reinforcement, the know-how that you can make a difference … but not before I even started nursing, it wasn't a for-sure thing.
Many participants discussed the environmental influences that contributed to their decision to move to the US to work. For some, family and support systems were in the US, while the opportunity to earn high wages or to further education were motivators for others. Some wanted the opportunity to travel or to live in a warmer climate. Family influences that contributed to choosing nursing as a career also contributed to the decision to move to the US:
My [family member] was a nurse as well. And she had moved to [state] for five years and so that was kind of a goal of mine. And seeing her – her career was just so diverse. … I had other family members as well that were in the nursing community and they just didn't seem to have … a ladder that they could move up as quickly.
Other learning opportunities occurred in the form of career fairs. Participants attended these fairs to learn more about working in the US, and a few discussed the role of recruiters in their decision to migrate. Through the influence of recruitment strategies, the participants learned their value as a nurse as well as the environmental conditions in the US that would facilitate their finding full-time employment:
They plucked me out of school – fresh out of school. … they flew me down here for the interview, they put me up for a weekend just so that I could actually see what the place was like. … I think to some degree they actually put out a lot, and to me [it] kind of felt like they were just showing interest.
They were so gung-ho about getting you and giving you, or at least trying to give you, the things that you wanted and make your life a little bit better, when at the same time, I was having trouble getting a full-time job [in Canada]. So I mean, there was [a] sort of disparity, which ultimately probably led me to come here.
The choice of clinical specialty was also a significant early career decision. Several participants had specific career goals and had identified an area of nursing or patient population with whom they wanted to work. Some had achieved these goals while others had not. The focus groups revealed that environmental conditions played a major role in these nurses' ability to meet their goals and work in their desired area. For example, many of those who wanted to work in intensive care units or emergency rooms commented that they were unqualified as new graduates, needing to gain experience with patients who were less critically ill before being considered for these positions. For those who were unable to gain employment in their desired area, some were continuing to work towards their career goals, but others began a whole new career trajectory:
I think for me going into nursing school, I was thinking that I wanted to work internationally in an NGO or relief organization, and I have basically done that, actually, with my nursing career, so it's worked out quite well.
My original goal was just to immediately [go] into critical care, and I did sort of feel disillusioned after about year two, when I realized that I hadn't really realized my goals and I was kind of stuck in a job in a clinical area which I was sort of not really happy with.
As highlighted in the LTCC, career decisions continue after career selection has occurred. Early experiences and the instrumental learning that occurs through these experiences influence career decision-making (Krumboltz et al. 1976). Several participants had worked in both the US and Canada, and they compared their experiences in the two countries with regard to orientation and preceptorships, opportunities at work and for continued education, and work environments. The comparisons often influenced their thoughts about returning to Canada.
In both countries, many participants reported having good relationships with preceptors. There were varied experiences with orientation and preceptorships; however, these seemed to reflect institutional differences rather than differences between the US and Canada. While some participants reported that the preceptorship or orientation was longer in the US, others found no substantial differences, and one had a longer preceptorship in Canada. Although not all participants directly attributed these experiences to their career decisions, one nurse described the importance of the supportive environment on her decision to stay in the US:
One of the key factors that made me stay was the support that I received. If it was negative or a bad, or it was not necessarily too challenging but just wasn't fit for me, I probably would have left and went back home. But because it was quite well developed and supported [me], the preceptorship was probably one of the biggest influences on my stay here.
Other comparisons of the differences between working as a nurse in Canada and in the US were less varied. Participants mentioned higher salaries, more disposable income and, for those working in California, mandated nurse-to-patient ratios as benefits of their current work settings in the US. However, the main advantage they perceived was the opportunity for further career development and education, both in terms of availability and in terms of funding and the support to take advantage of these opportunities:
The pay is nice, the nurse-to-patient ratio was more important, but I think that the opportunities to advance your practice, advance yourself, is a benefit.
The major difference was probably more that you had a lot more opportunities for continuing education in the US, which was really nice. And they really were interested in you going, for example, and getting your ACLS or doing extra courses, things like that. And they simply had more money for that, I think.
Basically, it's the money and education and just, like, the opportunities. … There is a lot more resources here. Where[as] I found in Canada it was really difficult to work and then go to school and also pay for it. … I mean, opportunities are endless, I found here.
This favourable assessment contrasted with the negative perceptions these nurses had of the nursing work environments in Canada. Several participants had either worked in Canada or were in contact with friends or family members who worked in Canada. The perception of negative work environments, whether gathered through instrumental learning and their own experiences, or through associative learning by hearing stories from friends, was a contributing factor to the participants' decisions of whether or not to return to Canada and under what work situations:
We've never worked understaffed and just the context in which I can provide care, I feel very safe. I have one friend on a med-surg [unit] that has – like with being short-staffed, has had up to like eight or even nine patients. My other friend in the OR says they don't replace sick calls anymore. And I just, I don't want to work in that type of environment. My licence is too important to me.
For me, there's not a question of if I'll move back to Canada, because I will. My family's there, and that's really important to me. But … I've leaned towards the fact that I will probably still work in the States when I go home. Just because of – not that the ratios are that much better … there's just there's quite a few factors, and when I did precept in the hospital from the town I'm in, in Canada the morale was just – it was just palpable how negative it was, and I just don't really want to go back to that.
The LTCC provided a framework for understanding new nurses' career trajectories and decisions. The theory highlights that environmental conditions and learning, whether instrumental or associative, can contribute to career decisions. For these early career nurses, early decisions such as that to become a nurse, the decision to move the US and the decision of clinical specialty area were influenced by their learning experiences from family members and nursing recruiters and by the environment in which they were raised and went to school. Although the decision to become a nurse has been explored (Price 2009), this study revealed that the associative learning experiences from family members and recruiters might influence the decision of new nurses who were educated in Canada to move to the US. Early decisions started them on a career trajectory in which they were able to realize career goals, were continuing to work towards them, or had changed them completely. The participants' ongoing decisions were influenced by the comparisons they made between working as a nurse in the US and in Canada. These comparisons stemmed from the instrumental learning they gained by working in both environments, and associative learning gleaned from the stories of family members and friends who live in Canada. Of interest to administrators is the finding that early career nurses valued learning experiences such as career development opportunities. This finding confirms an earlier one that early career nurses place high importance on the opportunities for specialty certifications, continuing education and funding for education (Halfer 2011).
The negative perception that these nurses had of Canadian work environments was concerning. Oulton has noted that nurses "will go where they are respected, rewarded for their competencies and problem-solving skills, challenged appropriately, and given opportunities for personal and professional development" (2006: 37S). To entice these early career nurses to return to Canada, attention to career development opportunities and changing their perceptions of Canadian work environments are essential.
There were limitations associated with collecting the data through phone-based focus groups. Specifically, communication was limited to verbal exchanges. Any non-verbal communication or cues were not captured, a loss that may have decreased the richness of the data collected. Additionally, because exploring the experiences of early career nurses was not the main goal of the larger study, the sample was limited to those early career nurses who participated in the larger focus group and were willing to participate in additional ones. A more purposive sampling strategy might have uncovered different results.
The purpose of this analysis was to explore and describe the early career experiences and decisions made by nurses who had been educated in Canada and are working in the US. According to the LTCC, many factors influence career decisions, and through telling their stories and relating their experiences, the participants in this study provided insight into some of the factors influencing their career trajectories.
About the Author(s)
Jessica Peterson, RN, PhD, Assistant Professor, Loyola University New Orleans, School of Nursing, New Orleans, LA
Linda McGillis Hall, RN, PhD, Kathleen Russell Distinguished Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
Sheri Price, RN, PhD, Assistant Professor, Dalhousie University, School of Nursing, Halifax, NS
Correspondence may be directed to: Jessica Peterson, RN, PhD, assistant professor, Loyola University New Orleans, School of Nursing, 6363 St. Charles Ave., Campus Box 45, New Orleans, LA 70118; tel.: 504-865-2091; 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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