Mobility and movement is an increasingly important part of work for many, however, Employment-Related Geographical Mobility (ERGM), defined as the extended movement of workers between places of permanent residence and employment, is relatively understudied among healthcare workers. It is critical to understand the policies that affect ERGM, and how they impact mobile healthcare workers. We outline four key intersecting policy contexts related to the ERGM of healthcare workers, focusing on the mobility of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Continuing Care Assistants (CCAs) in Nova Scotia: international labour mobility and migration; interprovincial labour mobility; provincial credential recognition; and, workplace and occupational health and safety.
Employment-related geographical mobility (ergm) is defined as the mobility and extended travel or movement of workers between places of permanent residence and employment (Cresswell et al. 2016; Roseman et al. 2015). This mobility may range from travel across international and interprovincial borders to secure work, to extended local and regional movement conducted as part of regular daily work schedules (e.g., home care workers). Scholars from across disciplines are paying increasing attention to ERGM and relevant theoretical perspectives in various sectors (Cresswell et al. 2016; Green 2004; Haan et al. 2014). The literature on the migration and mobility of healthcare workers both globally (for example, Kingma 2006; OECD and WHO 2010; OECD 2008) and locally (Fitzpatrick and Neis 2015) is also flourishing. These studies point to a variety of challenges and concerns arising from the ERGM of healthcare workers, ranging from brain-drain, labour shortages and surpluses, and de-skilling, to the isolation and exclusion faced by foreign workers, as well as the specific vulnerabilities associated with healthcare work in the domestic sphere, as faced by home care workers.
It has been noted that geographical mobility among healthcare professionals takes place at higher rates compared to the general workforce, however, this mobility is mostly intraprovincial, rather than interprovincial, or in other words, between communities within the same province or territory (CIHI 2007). Relatively little is known, however, about the full spectrum of ERGM from international to local among healthcare workers in the Canadian context and the policies that influence and shape their mobility.
We focus on the mobility of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Continuing Care Assistants (CCAs) into, within, and out of Nova Scotia, while acknowledging that healthcare workers with a range of professional and paraprofessional backgrounds engage in regular ERGM. These intersecting policy contexts are: international labour mobility and migration; interprovincial labour mobility; provincial credential recognition; and, workplace and occupational health and safety. There are important shortcomings in these policy contexts that render workers engaging in ERGM vulnerable to a range of challenges.
Setting the Stage: Nova Scotia and the ERGM of Healthcare Workers
Many of the demographic characteristics of Nova Scotia are similar to those facing other provinces but are sufficiently exacerbated to warrant the label "canary in the coal mine" (Tutton 2008). Specifically, the ERGM of healthcare workers in Nova Scotia is occurring in a context characterized by:
- a large rural population;
- a declining and aging population;
- a declining and aging workforce;
- high rates of chronic diseases;
- out-migration; and
- an ongoing restructuring of the healthcare system.
Arguing from differing policy and academic perspectives, commentators suggest that a combination of these features produces a variety of labour shortages in the healthcare workforce (Province of Nova Scotia 2013b; Valiani 2012). Concurrently, workers' movements and mobility patterns into, out of, and within the province are occuring and may be increasing. The literature indicates that healthcare labour issues such as downsizing, casualization, the replacement of steady and stable jobs with shift work and the lack of guaranteed work hours and standardized patient-to-nurse ratios all make healthcare an "unfriendly" and difficult place to retain staff. Such factors may contribute to mobility, with Canada witnessing high rates of out-migration of nurses to the US (MacMillan 2013; McGillis Hall et al. 2013; Grinspun 2003).
Policies and policy-related literature of relevance to the ERGM of healthcare workers was gathered between September 2012 and December 2015 yielding over 30 relevant English language documents and website content.1 There were no limits placed on the dates of publications. Two main strategies were used to gather information:
1) Keyword searches in Google Scholar, JSTOR, EBSCOhost, MEDLINE, and ScienceDirect amongst others.2 Keywords included (but were not limited to) healthcare, human resources, Nova Scotia, labour mobility, demographics, immigration, outmigration, healthcare jobs, temporary foreign workers, mobility, vehicles, road, driving, commuting, motor vehicle accidents, and occupational safety and various permutations thereof.
2) Review of the official websites of government agencies, research institutions and think tanks. These agencies/institutions/think tanks included Statistics Canada, Health Canada, Citizenship and Immigration Canada, the Labour Mobility Coordinating Group, the Government of Nova Scotia, and the Healthcare Human Resource Sector Council.
Our study is limited to public documents and to key policies related to ERGM during the period of data collection. Four people from relevant stakeholder agencies were consulted during the final phases of this study as our research clarified the key agencies and their role. These agencies include the provincial College of Registered Nurses, the Nova Scotia Nurses' Union, the Nova Scotia Office of Immigration, and the Department of Health and Wellness. Our consultations augmented the policies extracted through our online searches and provided additional insight. Although the original project design included physicians, midwives and social workers, we limited ourselves to the study of nurses and CCAs, where information was more readily available. We acknowledge our study does not capture all policies that may affect the ERGM of healthcare workers, but it provides an overview of some general concerns and relevant policy contexts. We identified four key policy contexts following our review of the literature and websites, and discuss each of these contexts from the international to the local level, in turn below.
a) International Labour Mobility and Migration
One of the key policy contexts related to the international mobility of healthcare workers is the Temporary Foreign Worker Program (TFWP), which is administered federally, and aims to fill labour shortages in the Canadian work force. Employers wishing to hire foreign workers under the TFWP need to obtain a Labour Market Impact Assessment (LMIA), which documents that an employer has searched for and failed to find a Canadian recruit, and has obtained a work permit for the worker they intend to hire. The TFWP is utilized by employers across Canada, in a variety of industries.
Temporary Foreign Workers (TFWs) in Healthcare in Nova Scotia
Nurses utilize the TFWP to move into Nova Scotia from overseas and work in the province. During the 2008–2015 period, there were 1,022 TFW positions on approved LMIAs – that is, where the request of the employer to hire a TFW was approved by the federal government – in the health occupations in Nova Scotia (Government of Canada 2016). Information requested from Citizenship and Immigration Canada (CIC – renamed to Immigration, Refugees and Citizenship Canada in 2015) suggests a limited number of work permits have been issued in Nova Scotia. Between the years 2009–2014, the CIC issued 135 work permits for the following three categories: RNs and registered psychiatric nurses; general practitioners and family physicians; and LPNs. Of these three categories, LPNs were the most populous (95 permits). Further details about the employers of these workers were not available for analysis. However, statistics reported by the College of Licensed Practical Nurses, Nova Scotia, indicate that during the period 2012–2016, the profession registered an average of 302 new LPN registrants a year, thus it can be deduced that the figure provided by CIC represents a significant portion of newcomer LPNs (CLPNS, 2016).
Federal and Provincial Regulation of TFWs
CIC and Employment and Skills Development Canada regulate the entrance of workers into the country; however, once they are working in Nova Scotia, provincial labour legislation applies. The Worker Recruitment and Protection Act has portions that amend the Labour Standards Code to provide protections for foreign workers. These portions include provisions such as prohibiting the charging of recruitment fees to foreign workers coming to Nova Scotia, prohibiting employers from reducing wages or any other condition of employment that the employer agreed to provide at the time of recruitment, and prohibiting a recruiter or employer from retaining a worker's property, e.g., a passport or work permit.
b) Interprovincial Labour Mobility
The constitutional right to move for employment for Canadian citizens and permanent residents within Canada is supported at the national level through the Agreement on Internal Trade (AIT). The AIT has the explicit aim of eliminating unnecessary interprovincial barriers to the free movement of workers, goods, services and investments, including achieving full labour mobility for workers in regulated occupations in Canada. This applies to the labour mobility among healthcare workers. The implementation of the AIT remains problematic, with each province listing occupations where exceptions to full labour mobility are maintained. Nova Scotia maintains seven such exceptional occupations. LPNs are the only one of these seven exceptional occupations relevant to this study. Practitioners in these exceptional occupations must undergo additional procedures before they can practice in Nova Scotia (Province of Nova Scotia 2013b).
c) Credential Recognition, Provincial Licensure and Fairness Legislation
Credential recognition and provincial licensure as it relates to ERGM is particularly important for healthcare providers entering the country or crossing provincial boundaries. Health professions that are regulated (medicine, nursing, etc.) are regulated through provincial Colleges; each College has its own standards for assessing qualifications. Although competency exams for regulated health workers are delivered nationally (except in Quebec), practitioners are licensed and registered to practice by provincial/territorial professional regulatory bodies.
In Nova Scotia, the College of Registered Nurses of Nova Scotia is the regulatory body for almost 10,000 RNs and nurse practitioners. LPNs are regulated by the College of Licensed Practical Nurses of Nova Scotia.3 CCAs are not regulated, but since 2006, the provincial Department of Health and Wellness has required certification. Because of the challenges of credential recognition, regulatory bodies themselves have come under increasing oversight. In Nova Scotia, the Fair Registration Practices Act (FRPA) "governs the process a regulatory body follows to register a person who applies to practice as a member of that occupation" (Province of Nova Scotia 2013). According to FRPA, "registration must follow a fair procedure and be transparent, objective, and impartial" (Province of Nova Scotia 2013).
d) Workplace and Occupational Health and Safety
Legislation and Collective Agreements
General workplace safety in Nova Scotia is governed by two complementary pieces of legislation: the Workers Compensation Act and the Occupational Health and Safety Act. The healthcare sector is also regulated through the Co-ordinated Home Care Act, that sets out the legal framework through which services may be offered to eligible Nova Scotians in their homes (NS Legislature 1990: 1–2). These pieces of legislation, however, do not contain any direct mention of geographic mobility of healthcare workers.
The Nova Scotia Government and General Employees Union maintains collective agreements with the Nova Scotia Health Authority and other healthcare workers such as schedulers, home support, and long-term care. The Nova Scotia Nurses' Union negotiates collective agreements for nurses in their union employed in acute care, long-term care and home care. In these agreements, the basic parameters that govern travel for work duties are set, including reimbursements, monthly allowances and mileage. There are also many private agencies offering home care services in Nova Scotia, not all of whom employ unionized workers. For these agencies, the private contract between the employer and worker governs the conditions of their mobility.
Workplace and Occupational Health and Safety of TFWs in Healthcare
Many TFWs are in-home caregivers, who are trained healthcare professionals or para-professionals, and they face a unique set of workplace safety issues. Several scholars considered TFWs to be "precarious migrants" (Goldring and Landolt 2013: 207; Sikka et al. 2011). Their international ERGM prevents them from having rights similar to local workers and thus potentially affecting their safety concerns. The intersection of precarious migration and low-status domestic work leads to a potentially vulnerable labour situation: "… given domestic workers' precarious economic and (often) immigration status, many workers would minimize the problems they encountered" (Hanely et al. 2010: 430–31).
Safety in Homes and on the Road: Local Mobility and Occupational and Health Safety
ERGM-related occupational health and safety concerns for healthcare workers arise particularly in home care. Fitzpatrick and Neis (2015) note that musculoskeletal disorders, the potential for facing violence and abuse (verbal, physical or sexual), and exposure to communicable diseases and allergens are common. They draw attention to how "[v]iolence in these workplaces is under-reported, and is often tolerated by workers when the clients have dementia" (Fitzpatrick and Neis 2015: 49).
In the Occupational Health and Safety Act, Section 82.15 exempts "employers with multiple temporary workplaces" from conducting violence risk assessments at each individual workplace if an assessment and prevention plan covering all "similar workplaces" is drawn up and "takes into account the circumstances and interactions that an employee is likely to encounter in the performance of their work" (NS Legislature 2015). Employers of home care providers would fall into this category.
Lippel and Walters (2014) have examined occupational health and safety policy challenges in different "facets" of mobile workers' lives, such as "getting to work" (p. 6). They note the health and safety challenges in getting to work by car, including "the quality and maintenance of vehicles, the road conditions, the abilities of the driver, and the challenges of the road for particular workers" (p. 6). They argue that there are regulatory gaps in each of these areas and there is a need for regulations. They suggest that there are "a broad range of mobile workers" who are "invisible to regulators and, to some extent, to unions," (p. 86) such that there is a lack of adequate regulation and health and safety concerns.
The four policy contexts noted above indicate a lack of congruence and critical blind spots, findings supported in the broader health workforce literature (Bourgeault et al. 2014). This may arise from the fact that policies are often developed in different policy communities (international, interprovincial, provincial and the workplace), and there may be little or no knowledge concerning the impact on mobile health workers.
In international migration, cross-border mobility has long-reaching impact on the worker's residence, labour protection rights, and occupational health and safety. Credential recognition affects both international and interprovincial mobile healthcare workers. Federal arrangements that are put in place to facilitate interprovincial mobility do not require mandatory compliance, leaving provinces to develop their own monitoring mechanisms. Consequently, no measures are in place to ensure these mechanisms operate consistently.
In regards to the workplace and occupational health and safety, regular ERGM conducted by healthcare workers raises a number of issues that various policies address in a haphazard or arbitrary manner. For unionized workers, some protections are afforded by their collective agreements, however, for non-unionized workers, the conditions of their mobility are governed by private contracts.
These concerns are situated within a burgeoning literature exploring the unique features, challenges and concerns regarding ERGM. Given that the demographic and policy trends affecting ERGM in Nova Scotia have not significantly changed since the original research was conducted, we suggest our findings have continued relevance. Our research highlights the need for a more comprehensive, consistent and inter-sectoral set of governance mechanisms for ERGM of healthcare workers, by identifying points at which current practice places responsibility on individuals that would be better placed on institutions. For example, mobile employees carry disproportionate responsibility for occupational safety when driving or at remote settings. Inconsistencies across employers and across jurisdictions serve to aggravate that imbalance by introducing greater uncertainty for employees. Consistent policies would help to sustain a mobile workforce while reducing undue strain on individual employees regarding their mobility along the spectrum of ERGM. We call for congruence between policies to encourage greater harmonization across jurisdictions. Comprehensive and consistent policies and processes are needed to address the many challenges confronting mobile health workers and to support them to meet both the health system demands and the health needs of the population.
Intersection des contextes politiques liés à la mobilité géographique des travailleurs de la santé : le cas de la Nouvelle-Écosse, Canada
La mobilité et les déplacements sont de plus en plus importants au travail, cependant la mobilité géographique pour le travail (MGT) – soit le déplacement des travailleurs entre le lieu de résidence permanente et le lieu de travail – est relativement peu étudiée chez les travailleurs de la santé. Il est primordial de comprendre les politiques qui affectent la MGT ainsi que leur impact sur les travailleurs de la santé. Nous dégageons quatre contextes d'intersection politique liés à la MGT des travailleurs de la santé, notamment pour la mobilité des infirmières autorisées, des infirmières auxiliaires autorisées et des préposés aux soins prolongés en Nouvelle-Écosse. Ces contextes sont : la mobilité et la migration de la main-d'œuvre internationale; la mobilité de la main-d'œuvre interprovinciale; la reconnaissance provinciale des titres de travail; et la santé et la sécurité au travail.
About the Author
Shiva Nourpanah, PhD, Department of Sociology and Social Anthropology, Dalhousie University, Halifax, NS
Ivy Bourgeault, PhD, Telfer School of Management, University of Ottawa, Ottawa, ON
Lois Jackson, PhD, School of Health and Human Performance, Dalhousie University, Halifax, NS
Sheri Price, PhD, School of Nursing, Dalhousie University, Halifax, NS
Pauline Gardiner Barber, PhD, Department of Sociology and Social Anthropology, Dalhousie University, Halifax, NS
Michael P. Leiter, PhD, School of Psychology, Deakin University, Melbourne, Australia
Correspondence may be directed to: Shiva Nourpanah, Department of Sociology and Social Anthropology, Dalhousie University, Halifax, NS; e-mail: firstname.lastname@example.org
The On the Move Partnership: Employment-Related Geographical Mobility in the Canadian Context is a project of the SafetyNet Centre for Occupational Health & Safety Research at Memorial University. On the Move is supported by the Social Sciences and Humanities Research Council through its Partnership Grants funding opportunity (appl. ID 895-2011-1019), the Research and Development Corporation of Newfoundland and Labrador, the Canada Foundation for Innovation, and numerous university and community partners in Canada and elsewhere. The authors would also like to acknowledge funding provided by Canadian Institutes of Health Research Institute of Gender and Health Research Chair in Gender, Work and Health Human Resources.
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1. This time frame reflects the first phase of the SSHRC-funded project "On The Move: ERGM in the Canadian Context." During this phase, the research team gathered information to provide some understanding and background of policies influencing ERGM among Nova Scotia healthcare workers. A version of this paper was presented at the Annual Canadian Sociology Association, Ottawa, June 6, 2015, and subsequently revised for the current ‘Discussion and Debate’ paper.
3. A draft Act for a new nursing regulator combining these two colleges was submitted to government on February 12, 2018 (https://crnns.ca/about-crnns/creation-of-one-nursing-regulator-in-ns/).
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