I. Background

A United Nations report released in 2010 indicated that over 57 countries were reported to have a critical shortage of health workers, including nurses [1]. As countries across the world struggle to cope with a shortage of nurses, the recruitment of internationally educated nurses (IENs) to work in health care organizations has become a strategy commonly used to meet patient care and nurse staffing demands [2]. In the US nursing labor market, IENs have been credited with easing the effects of the shortage of US nurses [3]. Global competition for IENs is likely to grow as health care settings increasingly rely on IENs to fill vacancies.

In Canada, a shortfall of full-time registered nurses (RN) from 11,000 in 2007 to close to 60,000 in 2022 is predicted [4], making it likely that IENs would increasingly be used to fill RN vacancies. At the same time, the percentage of IENs employed in nursing in Canada has remained stable over the past five years [5]. Recent Canadian workforce data indicate that there were 24,474 IENs employed in Canada in 2013 [5], with most coming from the Philippines (49%), India (11%), United States (9%) and the United Kingdom (6%) [6], [7]. While these numbers may appear small – representing 9% of the 276,914 RNs employed in nursing in Canada [5] – the number of IENs is expected to grow as the shortage continues. Investments in systems to support the successful integration of IENs into Canadian work settings are therefore critical to ensure patient safety.

Much of the literature to date on international nurse migration has focused on health human resources discussions related to why nurses migrate [8], [9], [10], [11], ethical recruitment policies and the impact on the source country of losing nurses [9], [12] and demographic descriptions and migration patterns [13], [14]. While some literature has examined the integration of IENs into the workplace, much of this work has focused on describing initiatives developed by work settings [15], with less attention being paid to gaining information directly from IENs themselves who are employed in these settings. Canadian research is minimal, and has focused on demographic profiling of IEN cohorts by donor country [16]. This study surveyed a sample of IENs employed in Canada about their experiences entering Canada and seeking nursing work.

II. Methods

The push-pull theory of migration provided the framework for this study. The ability to recruit foreign-trained nurses is dependent on certain “push” and “pull” factors [9], [10], [17]. Push factors generally reflect conditions in the country of origin that drive nurses to seek employment in another country: lack of nursing job availability, poor wages and working conditions, economic instability and health and safety concerns [9], [11], [17], [18]. Pull factors reflect conditions that draw nurses to the country of immigration and may include higher wages, improved working conditions, greater opportunity for professional development, and a better lifestyle [9], [11], [17], [19].

A cross-sectional approach was used including surveys of a random sample of IENs who were employed in health care organizations across the province of Ontario, Canada and directly involved in patient care. The study was completed following approval from the Health Sciences Research Ethics Board of the University of Toronto. A stratified random sample of registered nurses (RNs) drawn from the College of Nurses of Ontario registration database formed the basis of the study.

The survey was an adaptation of one used in earlier research on nurse migration [10], [11] and included an open-ended question inviting study participants to provide comments about their immigration experiences. Survey data were entered and analyzed using SPSS version 21 (SPSS, Chicago, IL, USA), and descriptive statistics were used to analyze the survey responses. The number of responses and the percentages are reported. Data from the open-ended question were content analyzed and triangulated with the quantitative survey data to provide context regarding participating nurse’s experiences with the move to Canada to work as a nurse [20]. The results were then integrated to complement one another at the end of the study.

III. Results

A. Characteristics of Study Participants

Responses were received from 2,017 IENs (RR=47%). The majority of study respondents were female (95%) and married (80%). Over half of the respondents were mid-career nurses between the ages of 31 and 50 (51%), followed by those over the age of 50 (46%), while very few were under the age of 30 (3%). Almost half of the IENs in this study indicated that they were from the Philippines (49%), while far fewer were European (15%), from Asian countries (15%), the United Kingdom (8%), Africa (8%) or the Caribbean (5%). Close to a third of the participants reported that they spoke English (30%), Filipino (29%), Chinese (7%), while the remainder spoke a number of other languages.

Close to two-thirds of the participants (64%) had diploma preparation, while the remainder were prepared at the Baccalaureate nursing level. The majority of participants (63%) had between five and ten years or work experience as a nurse prior to coming to Canada to work, with close to half of these (48%) employed here for less than ten years. Almost three-quarters (72%) were employed full-time and worked in staff nurse roles (91%). The majority worked in teaching (32%) and community hospitals (27%), or long-term care settings (22%), while the remainder were employed in home care, public health or other ambulatory care settings (19%).

B. Reasons for Migrating to Canada

IENs described different rationales for coming to work in Canada, which could be categorized as professional or personal reasons. The primary professional motivator was salary and benefits, followed by working conditions, opportunity for professional and/or career development, opportunity for educational advancement, having access to resources to care for patients, the reputation of a health care organization, and opportunities for gaining specialty certification (see Table 1). Some of these were further highlighted in comments made by the participants:

Table I. Internationally educated nurses’ reasons for migrating to canada
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“Canada is one of the best places for nurses. The money is good.”

“As RN in Canada, nurses have independent clinical skills and critical thinking. Canada gives nurses more autonomy to work.”

“Working as a nurse in Canada helped me expand my nursing knowledge and continues to allow me to advance in my career.”

Additionally, personal reasons for migrating were noted including quality of life decisions, the opportunity to become a full-time resident of Canada, moving with a family member who got a job in Canada, a safer living environment, living in a more politically stable country, the opportunity to bring their family to Canada, and finally the opportunity to provide financial support for family back in their country of origin.

“Working was a secondary reason – but immigration status was primary. I would have preferred not to have practiced nursing again, but needed the income.”

“I needed to support my family and nursing is the only profession I possess. And for my children’s benefit – I wanted the free education for elementary to high school.”

“We moved to Canada to bring our teenagers away from a violent country. I don’t ever want to leave here. Canada has been good to me/my family.”

C. Supports Provided for Migrating to Canada

Study participants also provided information on whether recruitment incentives and supports were offered to them to come to work in Canada. Table 2 demonstrates that over three-quarters of respondents received no recruitment assistance at all.

“No soul in Canada helped me when I came to this country.”

“We applied in the Canadian Embassy directly and followed the process on point basis for permanent residency in Canada. Nobody except community centres helped us to find jobs and school.”

“There was no recruitment. As a matter of fact the [regulatory college] was not very welcoming or helpful facilitating my entering nursing in Canada.”

When incentives were discussed, a small number identified that having a good salary and benefits was an incentive. Far fewer thought that incentives were being provided with tuition reimbursement or financial support for educational advancement, flexible scheduling, a full-time job that was not available in their country of origin, relocation assistance, signing bonuses or free and/or reduced housing.

“The hospital might not be the best, but they provide classes like ACLS. Where I was before, my employer did not even support/pay for CPR.”

In addition, the main information source available to IENs regarding moving to Canada to work was friends and family.

“No help [was] offered before I came. I was just told to do the best you can. Help came from word of mouth, referrals to friends of friends.”

“No one helps you. You have to be brave and face the new world yourself. It’s about survival and it’s a challenge.”

“The people I met at the TOEFL [English language] course helped me through the process of preparing for the RN exam, and to find the schools to take the necessary courses.”

Few indicated support from publications, newspapers or print media, job fairs or recruitment agencies, health care settings recruiting internationally, the individual regulatory bodies across Canada’s provinces, and internet recruitment agencies.

“I came through a private nanny recruitment agency. I paid ++ money to get them to process my papers.”

“We needed to pay 4500$ US to an agency to help us find an employer.”

“The processing ($) fee that the [regulatory college] requires to assess our qualifications is too expensive to us who are just starting to live in Canada.”

Table II. Supports provided to internationally educated nurses for migrating to canada
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D. Facilitators and Barriers on Migrating to Canada

Similarly, Table 3 demonstrates that the key facilitators to IENs moving to Canada came from family and friends, while the required licensing exam in Canada was perceived as the lead barrier.

“I came to Canada as a Registered Nurse with a university degree, but I didn’t have a chance to use my degree to be able to work as an RN in Canada. I was told to volunteer before [regulatory college] would look at my papers. I had to work as an aide, then an RPN, then do a 1-year refresher. It took me 3 years to be an RN again.”

“I worked as a live-in caregiver for 3 years, then challenged the Canadian nurse exam and successfully passed. I had to work as a nanny first – it was the easiest and cheapest way to come to Canada, despite the degree I had attained before coming here.”

“It was a terrible experience to apply for my license. I was very discouraged by the [regulatory college]. They were very unhelpful, despite me sending the information they required 6 months prior. The [regulatory college] gives a hard time to foreign trained BScNs to get through the exam.”

Table III. Facilitators and barriers for internationally educated nurses to migrating to canada
Full size table

“The [regulatory college] could do a much better job of explaining the regulations they have for nurses. They should look at “fast tracking” applications. And also have a “person” giving out advice on the process, not just a “recording” or “letter/manual!.”

In addition, IENs noted challenges with learning about different nursing and clinical practices, moving expenses, personal biases against them due to their coming from a different country, finding a place to live, the interview process, learning to speak a new language, taking the English language test, and perceptions that their qualifications were doubted by others.

“I was told many times, I need Canadian experience just to get an interview. I pierced ears to get my Canadian experience. I was not allowed to be employed as an RN because I was not a permanent resident though I’m already licensed.”

“In general, nurses in Canada think that if you are educated outside of Canada you do not know anything. In many cases there is a lack of respect for you as a professional. They don’t appreciate the fact that you are trying to learn a new culture and bring an asset and expertise from another culture.”

“The [regulatory college] is not treating people fairly regarding the assessment of education. They just count the number of years, not the subject matter that you have taken.”

IV. Discussion

A. Push and Pull Factors

IENs in this study provided an understanding of the key factors that have contributed to them coming to work in Canada. While salary and benefits were identified as key facets in their decision to migrate from a professional perspective, personal reasons such as having an improved quality of life and the potential to live in Canada permanently were also highly important ‘pull’ factors. Despite this, the experiences of migrating to Canada and obtaining employment as a skilled nurse by the IENs in this study were somewhat disheartening, and could be interpreted as ‘push’ factors that may keep them from entering the country.

While efforts have been made to establish programs for IENs to take once they have arrived in Canada, to bridge the gaps in credentials identified by Canadian regulatory licensing bodies, study participants questioned the assessment standards and practices they were subjected to. Several identified that they had Baccalaureate university degrees, yet were not considered fit for practice in Canada without obtaining Canadian practice experience and re-writing the nurse licensure examination. While the assessment practices employed by Canadian nurse regulators are designed to maintain practice standards and protect the public, the key issues for immigrant nurses appear to be the lack of transparency in the licensure process and the length of time it takes to obtain the Canadian nursing license.

The inadequate availability of information about licensing and regulation for nurse employment in Canada may also have served as a ‘push’ factor contributing to the limited growth noted in IEN mobility to Canada in the past five years. While Canada has not targeted recruitment of IENs to date, the Canadian Nurses Association recognizes that there may be benefits to the healthcare system in Canada with the employment of IENs, including ‘…filling of nursing vacancies by educated, experienced and often specialized nurses’ [21]. At the same time, internet websites for nurse regulators in Canada outline a multi-staged process and indicate that the time for assessment of an application is variable depending on the individual [22]. Participants in this study clearly articulated their experiences with this variability, with some identifying it taking years to complete the licensing process. From a broader, health human resources planning perspective, further consideration to recent experiences noted in other countries is warranted. For example, Buchan & Seccombe [23] describe a ‘collapse’ in recent international nurse recruitment activity from the EU to the UK resulting from challenging and costly entry requirements.

Close to half of the IENs in this study had less than ten years of experience working in Canada, although they brought considerable work experience with them from outside the country. A substantial number of the IEN respondents had between five and ten years of additional nursing work experience prior to coming to Canada. This finding suggests that while the numbers of IENs coming to Canada are not large, those who do migrate are highly qualified, mid-career nurses whose experience should be of great benefit to the Canadian health care system. These findings are similar to those reported by recent research on migration from other countries which highlight that the more highly educated and experienced nurses are the ones who leave [12].

V. Conclusion

The findings from this study provide important information about IENs’ perceptions and experiences of coming to Canada to obtain work in nursing. Study participants identified challenges with licensure as the key barrier to coming to Canada to work. It is evident that improvements in the information and materials related to nurse licensure in Canada are needed, through on-line documents that are clear and accessible to nurses from outside the country. A single location for licensing information, rather than different materials on each provincial regulatory college’s website would be beneficial. This should be made more possible as Canadian regulators move towards standardization through a national assessment process.

IENs also identified that their key resource for jobs and positions here in Canada was friends and families. This highlights a need for focussed attention and investment in the recruitment of IENs in the future in an effort to move forward. Health care managers and policy leaders should ensure that efforts are directed at determining ways to ensure that IENs are offered opportunities to develop in their careers and roles in the future in an effort to promote their retention.

The aging nursing workforce has led to concerns regarding the nursing shortage. One method of reducing this shortage is to recruit IENs. While considerable literature exists on nurse migration, limited focus has been directed towards the experiences of internationally educated nurses on coming to a new country to work. The findings from this research highlight the important gaps we have for IENs who wish to come to Canada to work as a nurse.

Acknowledgment

We would like to acknowledge Lorraine Dales, RN, MN, Research Assistant; Alexandra Harris, RN, MN/MHSc, PhD student; and Cassandra Vanderbrink, BScN student; all of the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto. We gratefully acknowledge the Ministry of Health and Long-term Care (Ontario, Canada), for their support and funding of this research. The findings reported herein are those of the authors. No endorsement by the MOHLTC is intended or should be inferred. We would also like to thank the nurses who gave their time to participate in this study.