Abstract
Health systems worldwide are at a critical juncture due to an increasing demand for health services and a diminishing pool of health human resources. While COVID-19 exacerbated nursing deficits, the need to strengthen and sustain the health workforce in Canada was evident decades prior and supported by numerous studies that warned of significant shortages. Post pandemic, building health system capacity has become paramount. This article examines innovative nursing employment initiatives in Canada. It provides a snapshot of federal, provincial and territorial approaches, with a particular focus on Internationally Educated Nurses (IENs) due to burgeoning interest in and competition for their skills and services. However, recognizing that health human resource planning is a persistent challenge, further initiatives are suggested. These include complementary policy development to improve retention and policy frameworks that support proactive long-term strategies to address the cyclical shortage of nurses.
Introduction
Health systems worldwide at are a critical juncture due to an increasing demand for health services and a diminishing pool of health human resources.1,2 Nurses are the largest cohort of health workers worldwide, but an estimated 13 million more nurses will be required during the next decade. 3 Unarguably, COVID-19 exacerbated health system vulnerabilities and accelerated the need for change. Yet the call to strengthen and sustain the health workforce in Canada was sounded many years prior.
During the 1990s, health system restructuring and a volatile funding climate prompted healthcare organizations to adopt cost-cutting measures that reduced staffing. 4 In 1997, the Canadian Nurses Association warned of a subsequent nursing shortage. 5 In 2000, the Nursing Strategy for Canada was announced to “achieve and maintain an adequate supply of nursing personnel.” 6 However, the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 highlighted ongoing health system deficits and the lack of surge capacity to manage crises.4,7
Subsequent studies predicted a national shortage of 60,000 nurses by 2022 due to retirements, the ageing population, and increased complexity of patient care.8–10 Data published in 2022 indicated that almost 25% of nurses planned to leave their jobs or seek new jobs within the next three years because of occupational stress and burnout related to COVID-19. 11 This will further contribute to the nursing shortage.
The nursing supply in Canada includes Domestically Educated Nurses (DENs) and Internationally Educated Nurses (IENs) who have migrated to Canada. The latter accounted for “64% of the net increase” in the overall supply of nurses licensed to practise in Canada in 2022. 12 Historically, the demand for nurses has been reflected in escalating vacancy rates. Researchers have suggested vacancy rate is a proxy for staffing shortage. 13 In Ontario, Canada’s most populous province, an examination of nursing vacancies between 2019 and 2021 revealed a 100% increase in the number of jobs posted. 1
Nationwide, the number of vacant positions among health occupations increased almost 10% (n = 90,000) between the second quarters of 2022 and 2023. 14 Vacancies rose 26% (n = 29,700) for Registered Nurses (RNs) and registered psychiatric nurses 1 and 25% (n = 13,600) for Registered Practical Nurses (RPNs)/Licensed Practical Nurses (LPNs). 15 In addition, the number of positions that remained open for longer than 90 days increased to 63% for RNs, registered psychiatric nurses and RPNs/LPNs. 14 There are concerns that current vacancies signal “continuing difficulties in nurse recruitment and retention.” 14
The federal government is responsible for “setting and administering national standards for the healthcare system through the Canada Health Act [and] providing funding support for provincial and territorial healthcare services” 16 However, each province and territory is responsible for providing healthcare. 16 Building health system capacity is paramount. This article examines innovative nursing employment initiatives to strengthen and sustain the health workforce in Canada. It provides a snapshot of federal, provincial, and territorial approaches, with a particular focus on IENs due to burgeoning interest in and competition for their skills and services.
Canadian federal initiatives
Federal investments include funding transfers for domestic nursing education and immigration support to increase the supply of work-ready IENs. In April 2023, the Canadian government announced plans to invest $200 billion CDN in the health workforce over the next decade. 17 The Canadian Association of Schools of Nursing (CASN) will receive $2.4 million CDN to administer a four-year National New Nurse Residency Program to facilitate transition to practice for newly graduated DENs.
The federal government has also expanded the criteria for entry to Canada, which will assist IENs. In May 2023, a new category-based immigration stream was announced through which 9% to 12% of invitations to apply for permanent residency will be issued to skilled candidates with work experience in high-demand healthcare occupations.18,19 As of October 2023, 6,600 invitations were sent to applicants in this category. 20 The Foreign Credential Recognition Program funds “programs that contribute to the integration of skilled newcomers in their field or related field of study.” 21 This includes nurses in healthcare settings. Complementary pre-arrival support is available to help newcomers prepare for employment in Canada while still in their home countries. 22
Provincial and territorial initiatives
The provinces and territories have been strategic in their efforts to build workforce capacity. Incentives for nursing education, bridging programs and upskilling, and recruitment and retention are on the rise.
Nursing education
There are various initiatives to increase enrolment and interest in nursing education as well as the number of nursing program seats. Ontario is investing $80 million CDN over three years for 2,000 new seats in publicly assisted colleges and universities. 23 Manitoba is investing $19.5 million CDN for 400 new seats, which will include campuses in rural and northern regions. 24 Comparable investments have been made in other provinces. British Columbia announced plans for an additional 602 seats, while Nova Scotia will add 380 seats.25,26
Financial support for nursing education has been implemented, particularly in priority communities and sectors. In May 2023, the Northwest Territories announced bursaries from $2,500 CDN to $10,000 CDN per year of study for Northern and Indigenous students in post-secondary programs in health or social services. 27 Funds are contingent upon a return of service in the Northwest Territories Health and Social Services System. Since 2006, the government of Yukon has awarded six bursaries a year to baccalaureate nursing students. Recipients receive up to $5,000 CDN per year for four years of study, and they must live or have lived in Yukon and commit to an in-territory return of service.28,29
In Ontario, the Learn and Stay Grant covers tuition and other education costs for students in eligible programs, including nursing, in priority communities in the northern, southwestern, and eastern regions of the province. Graduates must work a minimum of six months for every year funded and be employed in the region in which they studied. 30 Launched in February 2022, the Preceptor Resource and Education Program for Long-Term Care (PREP LTC) is a three-year initiative that funds nursing student placements and preceptor training in eligible LTC homes in Ontario. 31
Bridging programs and upskilling
The provinces and territories provide funding to public institutions for bridging programs and upskilling to increase workforce capacity. Bridging programs focus on education and help “workers address the gap between the knowledge and experience they have and what they need to work in their preferred job or field.” 32 Upskilling focuses on professional development and helps employees perform better in their current positions, expand their skills, and adjust to changing requirements in the work environment. 33
In Ontario, the BEGIN initiative: Bridging Educational Grant in Nursing supports unregulated healthcare workers to become RPNs and RPNs to become RNs. For each year of study, unregulated workers receive up to $6,000 CDN and RPNs receive up to $10,000 CDN. 34 Up to $5,000 CDN is available annually to cover additional costs for eligible participants. For every year of funding paid out, participants must complete a year of service in a priority sector, up to a maximum of three years. 35 The Critical Care Nursing Upskilling Program provides funding for Ontario RNs to acquire the specialized education and skills to work in critical care. 36 In 2021/2022, the provincial vacancy rate for critical care nurses reached 12% and the turnover rate reached 19%. 37
The Nursing Program Transformation in Ontario’s Colleges initiative offers hybrid learning to improve IENs’ access to nursing education. It also provides IENs with up to $6,000 CDN per year to help them obtain the credentials for practice within the province. 34 Alberta is likewise increasing bridging program enrolment for IENs and offering financial support. Under a new bursary announced in February 2023, eligible IENs attending selected post-secondary institutions will receive up to $30,000 CDN. 38 For every $6,000 CDN disbursed, they must provide a year of nursing service in rural Alberta, up to a maximum of five years. 39
Recruitment and retention
To boost nurse recruitment and retention, the provinces and territories are focusing on training, orientation, mentorship, and funding. The Nursing Graduate Guarantee (NGG) is an early program that has been successful in facilitating entry to practice for new nurses in Ontario. Introduced in 2007, the NGG supports newly graduated nurses who are within 12 months of registering with the regulatory body. 40 The provincial government subsidizes orientation for new nurses, including 12 weeks for the nurse’s transition to practice and 8 weeks for employers to reinvest in existing frontline nurses to help them meet their career goals. To increase the supply of nurses, the program was expanded in 2014 to include newly graduated nurses from other provinces and territories and newly registered IENs. 41 The Clinical Scholar Program, also supported by the Ontario government, encourages transition to practice by pairing experienced frontline nurses acting in a mentorship capacity with new nurse graduates, IENs, and nurses interested in upskilling. 42
Furthermore, the provinces and territories are funding initiatives to bolster the nursing workforce in sectors and locations that have difficulty recruiting and retaining nurses. For example, the Ontario Community Commitment Program for Nurses (CCPN) offers up to $25,000 CDN for a two year commitment to healthcare employers that have recruitment challenges and high rates of turnover and vacancy. 43 These employers receive $1,500 CDN per each eligible nurse to encourage their professional development. The Ontario Recruitment and Retention Incentive Program, introduced in 2021, was a two year solution to build workforce capacity in retirement homes by providing nurses with $10,000 CDN for a one year employment commitment. 44
Under the Saskatchewan Rural and Remote Recruitment Incentive, introduced in October 2021 and extended in December 2023, healthcare workers in high-demand positions are eligible for up to $50,000 CDN for over three years, contingent on a three year return of service.45,46 In June 2023, the provincial health authority of Prince Edward Island announced nurses would be receiving “pay increases and new incentives for working weekends and nights, as well as a bonus for committing to full-time positions.” 47 In November 2023, the government of Nunavut agreed to higher wages, recruitment and retention bonuses, and tuition reimbursement for nurses committed to working in the territory. 48
Internationally educated nurses
Recruitment and retention initiatives for IENs emphasize funding and the removal of employment barriers. Manitoba is covering assessment and bridge training fees for in-province IENs, while British Columbia is covering assessment and application fees for IENs interested in working in the province.49,50 Saskatchewan is providing settlement support, orientation, and the Transition to Registered Nursing in Canada (TRNC) 14-week pathway 51 for nurses in “good standing.” 52 The International Credential Recognition Grant provides IENs with up to $6,000 CDN and additional funding to assist with licensure in Saskatchewan. 53 Internationally educated nurses can apply for funding prior to their arrival in the province. New Brunswick offers free individualized support through its IEN Navigation Service and introduced a five year initiative in June 2023 to reduce financial barriers for IENs.54,55
Some provinces and territories have developed recruitment strategies in cooperation with regulatory bodies. In April 2023, the government of Alberta, in partnership with the College of Registered Nurses of Alberta (CRNA), introduced a new approach to streamline the application and employment processes for IENs in good standing. Changes included formal recognition of IENs’ expertise and experience and reducing the time to licensure. 56 The College of Registered Nurses of Newfoundland and Labrador (CRNNL) implemented a Designated Countries Pathway to accelerate registration for “IENs who were educated and who are currently licensed in good standing in United States of America, United Kingdom, Ireland, India, Philippines, Australia, New Zealand, Nigeria, or Hong Kong.” 57 In October 2023, following a request from the Yukon Registered Nurses Association (YRNA), the territorial government approved amendments to the Registered Nurses Profession Act. 58 Changes include “special regulation procedures that will permit student nurses to practise and registered nurses, nurse practitioners from other places, recent graduates and internationally educated nurses to apply directly for work in the Yukon.” 59
A common employment hurdle for IENs in Ontario is the evidence of practice requirement. Applicants to the regulatory body must have experience practising as a nurse within the last three years. The Supervised Practice Experience Partnership (SPEP) introduced in 2022 involves the College of Nurses of Ontario (CNO), Ontario Health and approved healthcare organizations. A minimum of 140 hours of supervised participation are required in the program, which provides IENs with “relevant current nursing practice experience” 60 to facilitate employment uptake.
Discussion and conclusion
Canada is facing a projected shortage of more than 117,000 nurses by 2030. 10 This article examined innovative nursing employment initiatives to strengthen and sustain the health workforce, with a particular focus on IENs. The initiatives have different timelines, funding amounts and eligibility requirements and do not flow from one overall policy. Yet they endeavour to address the concurrent increased demand for and diminished supply of nurses by supporting education, bridging programs and upskilling, and recruitment and retention. Similar initiatives are being implemented for internationally trained physicians. 61
Historically, Canada has been a top destination for IENs,62,63 but recruitment has intensified post COVID-19. Given the need for a health workforce that better reflects the increasingly diverse population it serves, this approach has merit but also caveats. Canada welcomed more than 1.3 million new permanent residents between 2016 and 2021 and almost 1.5 million are expected between 2024 and 2026.64,65 Internationally educated nurses can help reduce health inequities and health service disparities for newcomers.66–68 In 2021, IENs accounted for 9% of the national nursing supply, which was less than in other Organization for Economic Co-operation and Development countries such as Ireland (47%) and the United Kingdom (18%). 69 Nonetheless, Canada cannot rely solely on foreign-trained talent to solve a homegrown issue.
Health workforce planning must be ethical and “reflect the delicate balance between brain drain, brain gain, and the individual migrant’s right to live and work in their country of choice.” 3 Furthermore, it should prioritize increasing the domestic supply of nurses.70,71 Several of the initiatives focus on expanding nursing seats and enrolment. Workforce planning must also be equitable. Despite being a valuable resource, IENs have been undervalued, underutilized and underemployed.72–75 The literature demonstrates that career advancement, leadership opportunities, mentorship, and recognition enable commensurate employment of this highly skilled cadre.76–79 These facilitators are included in the NGG, the CCPN, and the SPEP, which jointly supported 8,700 nurses between 2020 and July 2023. 80 An evaluation of projects funded by the Foreign Credential Recognition Program reflected “low default rates and positive employment outcomes.” 81
Recognizing that health human resource planning is a persistent issue and that more data is needed to better understand the workforce uptake of IENs, further initiatives are suggested. These include complementary policy development. For example, policies that emphasize workforce integration, which is the “process by which nurses enter the workforce efficiently, effectively, and with productive employment,” 82 could help improve retention. Greater collaboration among the federal, provincial, and territorial governments is recommended to ensure sustained health workforce investments and a consistent workforce supply.
Health human resource planning to date has largely been political rather than theoretical or analytical. Policy frameworks that support proactive long-term strategies are vital to address the cyclical shortage of nurses. Standardization and sharing of recruitment and retention data could help provide a deeper understanding of the associated costs and the approaches that work. This might be difficult as health is a provincial responsibility and healthcare organizations vary in size and capacity to evaluate. However, mechanisms such as dashboards and other information monitoring tools could be implemented to track the progress of staffing initiatives, and successful initiatives could be disseminated nationwide.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Institutional Review Board approval was not required.
