November 2004

Building the Future: An integrated strategy for human res o u r ces in

MOBILITY OF NURSES IN CANADA MOBILITY OF NURSES IN CANADA

Mobility of Nurses in Canada

This report is part of an overall project entitled Building the Future: An integrated strategy for nursing human resources in Canada.

Mobility of Nurses in Canada © 2004 The work in this publication was provided to The Nursing Sector Study Corporation courtesy of/or under license from the respective authors. First edition: May 2004 (PDF); Revised edition: November 2004 (PDF)

Publisher The Nursing Sector Study Corporation

Authors Andrea Baumann RN, PhD Jennifer Blythe PhD Camille Kolotylo RN, PhD Jane Underwood RN, MBA

Editor Maude Downey Translator Jodoin Designer Fuse Communications and Public Affairs

Project Management The Nursing Sector Study Corporation 99 Fifth Avenue, Suite 10 Ottawa, K1S 5K4

Phone (613) 233-1950 E-mail [email protected] Website www.buildingthefuture.ca

Mobility of Nurses in Canada (English, PDF) ISBN 0-9734932-2-4

Également disponible en français sous le titre: Mobilité des infirmières et infirmiers au Canada (document en français, PDF)

This project is funded in part by the Government of Canada. The opinions and interpretation in this publication are those of the author(s) and do not necessarily reflect those of the Government of Canada.

Building the Future: An integrated strategy for nursing human res o u r ces in Canada MOBILITY OF NURSES IN CANADA

Errata for Mobility of Nurses in Canada First edition: May 2004 (PDF); Revised edition: November 2004 (PDF)

The following changes have been made to the revised edition of Mobility of Nurses in Canada.

P. 5, line 11: “in Canada” added after “Also,” and the following text added at the end of the sentence, “(Exception: has not had an education program for RPNs since 2001.)”

P. 5, Section 2.1.3.: Second sentence has been changed from “RNs and LPNs are regulated in all provinces and territories whereas RPNs are unique to the four provinces of Western Canada.” to “In Canada, RNs and LPNs are regulated in all provinces and territories whereas RPNs are regulated only in the four provinces of Western Canada.”

P. 42, First paragraph: Third sentence has been deleted, “Such a database would in fact be a regional database, encompassing the four provinces of Western Canada where RPNs are educated and regulated.”

P. 42, Second paragraph has been replaced as follows:

Previous paragraph: A new psychiatric nursing education program was introduced in Saskatchewan in 1996; however, refused to license graduates of this program because of concern that it has insufficient psychiatric nursing content (Psychiatric Nursing Education, 2000). and have expressed similar concerns (Psychiatric Nursing Education, 2000).

Current paragraph: The first psychiatric nursing education program in Saskatchewan was established in 1930. This diploma program was integrated into the University of Saskatchewan’s College of Nursing in 1997. However, Manitoba refused to register graduates of this program because it had insufficient psychiatric nursing content. Alberta and British Columbia had similar concerns as did the Saskatchewan regulatory body. The program lost its approval status in 2001 and although the Saskatchewan government is actively involved in efforts to re-establish the program, there currently is no psychiatric nursing education program in Saskatchewan. (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, November 4, 2004.)

P. 47, last bullet in 6.3.2.: Second and third sentences replaced as follows.

Previous text: Manitoba does not license graduates from Saskatchewan’s current RPN program. Thus, any migrants from Saskatchewan who are registered in Manitoba have likely graduated from either the previous program in Saskatchewan, or from elsewhere (Psychiatric Nursing Education, 2000).

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Current text: There has been a mutual recognition/reciprocity agreement between the four regulatory bodies since 1979. When the Saskatchewan diploma program was integrated into the College of Nurses at the University of Saskatchewan, Manitoba stopped recognizing those new graduates. That program lost its approval status in 2001 and there is no current psychiatric nursing program in Saskatchewan. Therefore any Saskatchewan RPNs going to other provinces have graduated from a previous Saskatchewan program or from elsewhere. (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, November 4, 2004.)

P. 38 and P. 46: Bar charts have been replaced so they more accurately represent the data. Note there is no change in the data provided.

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Table of Contents

Errata for Mobility of Nurses in Canada ...... i Preface ...... vi Executive Summary ...... 1 1. Introduction ...... 4 2. Methods ...... 5 2.1. Search Strategies and Identification of Relevant Literature ...... 5 2.1.1. Published Literature and Bibliographic Databases ...... 5 2.1.2. Grey Literature ...... 5 2.1.3. Data from Regulatory Bodies ...... 5 2.1.4. Statistical Data ...... 6 2.1.4.a. Compilation of Nursing Statistical Data ...... 6 2.1.4.b. Description of Nursing Statistical Data ...... 7 2.2. Data Quality and Limitations ...... 8 3. Mobility Trends in the General Population ...... 10 3.1. Historical Trends (1961–1996) ...... 10 3.1.1. Trends and Factors by Province ...... 12 3.1.2. Gains and Losses ...... 14 3.2. Recent Trends (1996–2001) ...... 16 3.2.1. In-migration ...... 16 3.2.2. Out-migration ...... 16 3.2.3. Gains and Losses ...... 17 4. Mobility of Registered Nurses (RNs ) ...... 19 4.1. RN Mobility in Ontario (1984–1989) ...... 19 4.2. RN Mobility in the 1990s (1990–1997) ...... 20 4.2.1. Mobility Factors ...... 21 4.3. RN Settlement Patterns in BC (1999, 2000) ...... 22 4.4. Recent RN Mobility, RNDB Data (2001–2002) ...... 24 4.4.1. Composition of Provincial/Territorial RN Workforce ...... 25 4.4.2. Distribution of Canadian RN Graduates ...... 26 4.4.2.a. Gains and Losses ...... 29 4.5. Recent RN Mobility, Data from Regulatory Bodies (2001–2002) ...... 30 4.5.1. Requests for Registration Verification of Credentials (2001) ...... 30 4.5.2. Actual Inter-jurisdictional Movement of RNs (1999–2002) ...... 31 5. Mobility of Licensed Practical Nurses (LPNs) ...... 33 5.1. LPN Settlement Patterns Within BC (1999, 2000) ...... 33 5.2. Recent LPN Mobility, LPNDB Data (2000–2002) ...... 35 5.2.1. Composition of Provincial/Territorial LPN Workforce ...... 36 5.2.2. Distribution of Canadian LPN Graduates ...... 38 5.2.2.a. Gains and Losses (2001–2002) ...... 39 5.3. Recent LPN Mobility, Data from Regulatory Bodies (2001) ...... 41 5.3.1. Requests for Registration Verification of Credentials ...... 41 5.3.2. Actual Inter-jurisdictional Movement of LPNs ...... 41

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6. Mobility of Registered Psychiatric Nurses (RPNs) ...... 42 6.1. RPN Settlement Patterns Within BC (1999, 2000) ...... 42 6.2. Recent RPN Mobility, RPNDB Data (2001–2002) ...... 43 6.2.1. Composition of RPN Provincial Workforces (2002) ...... 44 6.2.2. Distribution of Canadian RPN Graduates in 2002 ...... 45 6.3. Recent RPN Mobility, Data from Regulatory Bodies (2001–2003) ...... 46 6.3.1. Requests for Registration Verification of Credentials (2001, 2002) ...... 46 6.3.2. Actual Inter-provincial Movement of RPNs (1998–2003) ...... 47 7. Context of Nurse Mobility ...... 48 7.1. Effects of Internal Trade Agreements ...... 48 7.1.1. RN Mutual Recognition Agreement ...... 48 7.1.2. LPN Mutual Recognition Agreement ...... 49 7.1.3. RPN Mutual Recognition Agreement ...... 49 7.2. Migration Barriers, Challenges, and Motivations ...... 50 7.2.1. Barriers and Challenges ...... 50 7.2.2. Motivations ...... 50 7.2.2.a. Motivations for Nurses Specifically ...... 50 7.2.2.b. Costs of Mobility to Employer ...... 52 7.3. RN Salary Scales and Mobility ...... 52 8. Recommendations ...... 53 REFERENCES ...... 54 Appendix A. Main Search Method ...... 59 Appendix B. Nursing Association Web sites ...... 62 Appendix C. Limitations of Data ...... 63 Appendix D. Source of RNs per Workforce, by Province/Territory of Registration, 2001 ...... 69 Appendix E. Retention and Mobility of RNs per Workforce, 2001 ...... 70 Appendix F. Estimated RN Migration Based on Requests for Verification of Credentials in 2001 71 Appendix G. Actual Inter-jurisdictional Mobility of New Registrant RNs, by Endorsement and by Examination, 1999 to 2002 ...... 72 Appendix H. Estimated LPN Migration Based on Requests for Verification of Credentials in 2001 ...... 73 Appendix I. Actual LPN Inter-jurisdictional Mobility, 2001 ...... 74 Appendix J. Estimated RPN Migration Based on Requests for Verification of Credentials in 2001...... 75 Appendix K. Actual RPN Inter-provincial Mobility, 1998–2003 ...... 76 Appendix L. Salaries for Nurses (RNs, LPNs and RPNs) ...... 77 Appendix M. Acronyms ...... 80 Appendix N. Glossary of Key Terms ...... 81 Appendix O. Key to Geographical Names and Acronyms ...... 83 The Research Team ...... 84

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List of Tables and Figures Table 1. Key Inter-provincial Flows of the General Workforce, in Percentages and Numbers, 1961–1996 ...... 11 Table 2. Key Inter-provincial Flows of the General Workforce, in Percentages, 1989 ...... 12 Table 3. Twelve Key Inter-provincial Flows of the General Workforce, in Numbers, 1996–2001 ...... 17 Table 4. Summary of Net Gains and Losses, 1976–2001 ...... 18 Table 5. RN Settlement Patterns in BC in 1999, 2000, by Supplying Province ...... 23 Table 6. Composition of RN Workforces, by Province/Territory of Registration, 2002 ...... 26 Figure 1. Retention of RN graduates, by province/territory of graduation, 2002 ...... 27 Table 7. Three Most Frequent Destinations for RNs, by Province of Graduation, 2002 ...... 28 Table 8. Comparison of Requests for RN Verification of Credentials and Actual Registration, 2001 ...... 31 Table 9. LPN Settlement Patterns in BC in 1999, 2000, by Supplying Province ...... 34 Table 10. Composition of LPN Workforces, by Province/Territory of Registration, 2002 ...... 37 Figure 2. Retention percentages of LPN graduates, by province of graduation, 2002 ...... 38 Table 11. RPN Settlement Patterns in BC in 1999, 2000, by Supplying Province ...... 43 Table 12. Composition of RPN Workforces, by Province of Registration, 2002 ...... 45 Figure 3. Retention percentages of RPN graduates, by province of graduation, 2002 ...... 46

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Preface

This report is part of an overall project, Building the Future: An integrated strategy for nursing human resources in Canada. The goal of the project is to create an informed, long-term strategy to ensure that there is an adequate supply of skilled and knowledgeable nurses to meet the evolving needs of all Canadians. Through surveys, interviews, literature reviews, and other research, Building the Future will provide the first comprehensive report on the state of nursing human resources in Canada. The project comprises the following two phases.

Phase I: Research about the nursing labour market in Canada is being conducted in stages. Reports will be released as the research work is completed to share interim findings and recommendations with the nursing sector. This is the first of these reports. A final report will be produced at the conclusion of this phase that will include all of the recommendations accepted by the Nursing Sector Study Corporation.

Phase II: A national strategy will be developed in consultation with government and non-government stakeholders that builds on the findings and recommendations presented at the completion of Phase I.

To oversee such a complex project, the Nursing Sector Study Corporation (NSSC) was created in 2001. The Management Committee of NSSC comprises representatives of the signatories to the contribution agreement with the Government of Canada and other government groups.

The multi-stakeholder Steering Committee for the project comprises approximately 30 representatives from the three regulated nursing occupations (, registered psychiatric nurse, and ), private and public employers, unions, educators, health researchers, and federal, provincial and territorial governments. The Steering Committee guides the study components and approves study deliverables including all reports and recommendations.

Members of the Management Committee and the Steering Committee represent the following organizations and sectors. Aboriginal Nurses Association of Canada National Union of Public and General Employees Association of Canadian Community Colleges Nurse educators from various institutions Canadian Alliance of Community Health Centre Ordre des infirmières et infirmiers auxiliaires du Associations Québec Canadian Association for Community Care Ordre des infirmières et infirmiers du Québec Canadian Association of Schools of Nursing Professional Institute of the Public Service of Canada Canadian Federation of Nurses Unions Registered Psychiatric Nurses of Canada Canadian Healthcare Association Representatives of provincial and territorial Canadian Home Care Association governments Canadian Institute for Health Information Service Employees International Union Canadian Nurses Association Task Force Two: A human resource strategy for Canadian Practical Nurses Association Canadian Union of Public Employees Victorian Order of Nurses Canada Health Canada Human Resources Development Canada

Together, we are committed to building a better future for all nurses in Canada and a better health system for all Canadians.

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Executive Summary

This report describes the inter-jurisdictional migration of members of the three regulated nursing professions throughout Canada in the past decade: Registered Nurses (RNs), Licensed Practical Nurses (LPNs, referred to as Registered Practical Nurses in Ontario), and Registered Psychiatric Nurses (RPNs). Methods The report is based on (a) published literature, (b) grey literature, (c) statistical data, and (d) data from regulatory bodies. Data were located through comprehensive searches of the Internet and databases of published literature, as well as through direct contact with representatives of regulatory bodies and other experts. The scope of the study is limited by the quality of the data. The Canadian Institute for Health Information (CIHI) aggregates statistics from Registered Nurses’ regulatory bodies annually and has recently released the first publication of aggregated national data from Licensed Practical Nurses and Registered Psychiatric Nurses. There is little literature on inter-jurisdictional mobility, and current statistical databases lack common definitions or shared categories. The absence of unique identifiers makes it difficult to track individual nurses between jurisdictions and prevents the compilation of accurate statistics. Findings The movement of nurses in Canada resembles that of the general population, with an east to west flow of migrants. Additionally, for RNs and LPNs, Atlantic Canada and Western Canada form regional markets within which there is mutual exchange of nursing personnel. RPNs migrate among the provinces of Western Canada, where they are regulated. Data collected in the 1990s indicate that inter-provincial mobility increased between 1990 and 1997, with Alberta, British Columbia, , and Ontario having the highest immigration rates. The researchers hypothesized that most migrants were new graduates, the majority less than 25 years of age, but some were in the 25 to 34 age group. Nurses in older age groups tended to remain in their province of graduation (Health Human Resources Unit [HHRU], 2000). In 2002, British Columbia (29.2%), Alberta (22.8%), and Ontario (21.5%) had the highest RN provincial immigration rates (CIHI, 2003a). Historical or trend data for LPN and RPN migration are not available at the national level. RPNs experienced increased inter-provincial mobility in 2000 to 2001, which has since decreased.

In 2001, the majority (86.7%) of RNs in the Canadian workforce (CIHI, 2002a) continued to be employed in their province of graduation. , British Columbia, and Ontario retain the highest proportion of their graduates. Saskatchewan, , Manitoba, and Newfoundland and Labrador have low retention rates.

Regional markets in Atlantic and Western Canada persisted and the east–west flow of nurses continued. Quebec (93.7%), British Columbia (91.4%), and Ontario (90.6%) retained the highest proportion of home-educated RNs (i.e., nurses educated in the province; CIHI, 2003a); Saskatchewan (66.1%), Prince Edward Island (69.7%), Newfoundland and Labrador (72.6%), and Manitoba (72.6%) had the lowest retention rates (CIHI, 2003a), indicating less migration out of the former provinces than

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the latter. Migration to the territories was high because there is only one regional school of nursing supplying graduates. More than one quarter of nurses in the territories came from Ontario (29.6%), with additional graduates from Alberta (15.2%), and British Columbia (11.1%; CIHI, 2003a).

There is limited information on the mobility of LPNs and RPNs. The east to west movement of LPNs is similar to that of RNs and the general population. In 2002, the majority of LPNs (92%) and RPNs (greater than 80%) were employed in the same jurisdiction as their jurisdiction of initial graduation from basic nursing education (CIHI, 2003b, 2003c). There is some indication, based on the number of requests for verification of credentials, that the highest numbers of LPN migrants go to British Columbia. They migrated primarily to British Columbia (31%), Alberta (20.3%), and Ontario (19.4%; CIHI, 2003b). RPNs migrated mainly to Alberta (29.7%) and British Columbia (16.1%; CIHI, 2003c), with some movement to Saskatchewan and Manitoba.

Of all the provinces, excluding Quebec (unavailability of data), Ontario (96.8%), British Columbia (95.1%), and (92.6%) retained the highest percentage of the graduates educated in these provinces; Saskatchewan (84.9%) and Manitoba (85.3%) retained the fewest graduates (CIHI, 2003b). Manitoba (94.6%) and Saskatchewan (91.6%) retained the most RPNs (CIHI, 2003c). Many LPNs migrated from other provinces to the Yukon Territory and Northwest Territories; the LPN education program in the territories is offered only on an occasional basis (every two to three years; CIHI, 2003b). RPNs move mostly within the four provinces of Western Canada, where their profession is regulated. There are some, however, who practise in the territories or in Ontario and do not use their professional designation of RPN, but they maintain their registration with their home province (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, September 15, 2003). There appears to be little interest in migration to Manitoba, but Manitoba graduates express interest in migration to British Columbia and Alberta.

Movement of nurses among jurisdictions can be attributed to several factors: the number of nursing programs that are available; the migration patterns of the general population; the availability of better employment or career opportunities; and the location of schools (i.e., students attend school in another jurisdiction and return home for employment) (CIHI, 2003a, 2003b). Other motivations for migration include the expectation of better working conditions, such as full-time employment, greater income and benefits, and opportunities for personal or professional growth. Retirement, the relocation of a spouse, and other family-related reasons are also implicated in inter-jurisdictional mobility (CIHI, 2003b). Studies did not report higher salaries as the major reason for migration; however, rates of migration are highest in those provinces where nurses receive the most pay. CIHI (2003a, 2003b) suggested that higher incomes might influence the decision for RNs and LPNs to move. Recommendations 1) Collecting accurate information on all three regulated professions requires coordination at a national level. A priority for policy makers in nursing, health care organizations, and governments must be to decide what data should be collected and who should collect it.

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2) CIHI (2002b) defines a unique identifier as a unique, non-reused, lifetime number assigned either on entry into an education program or on application for first licensure. Adopting a unique identifier for each nurse would achieve the following.

a) Facilitate accurate tracking of nurses throughout their careers by preventing double- or under-counting (CIHI, 2002a, 2003a, 2003b, 2003c; Kazanjian, 2000).

b) Allow individuals to be tracked inter-jurisdictionally, in and out of the profession and through changes in educational and practice status.

c) Provide accurate information for the construction of a database that would facilitate workforce projections and planning for educational places and health human resources.

3) Conduct further research regarding the following.

a) Factors that influence mobility and attract nurses to specific jurisdictions.

b) Factors that erode recruitment and retention efforts in times of severe global shortage.

4) Promote known motivating factors, such as full-time employment, benefits, and job security.

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1. Introduction

This report focuses on the inter-jurisdictional migration patterns throughout Canada over the past decade of members of the three regulated nursing professions: registered nurses, licensed/registered practical nurses, and registered psychiatric nurses. It does not include information on other types of mobility such as hospital/community or urban/rural mobility. This report is intended to complement the Canadian Nursing Labour Market Synthesis to be presented as part of the overall research for Building the Future.

It begins with a description of the methodology used to gather data for the report, including the sources used and a discussion of the quality of the data. An overview of the migration patterns of the general Canadian workforce is followed by a description of the movement of nurses throughout Canada. Finally, issues relevant to the migration of nurses, such as internal trade agreements, and barriers to and motivations for migration are discussed. The report concludes with recommendations for action.

The following acronyms are used in this report.

• RNs registered nurses • LPNs licensed/registered practical nurses • RPNs registered psychiatric nurses (Note that although the acronym RPN refers to registered practical nurses in Ontario, Canada, it is not so used in this report.)

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2. Methods

2.1. Search Strategies and Identification of Relevant Literature An exploratory approach was adopted because relatively little is known about the mobility of nurses. Both published literature and grey literature were investigated (see Appendix A). Emphasis was placed on literature produced since 1990; however, significant earlier publications were also considered. Major statistical resources were investigated. In addition, information was sought from all nursing regu- latory bodies. As stated in the introduction, the nursing workforce in Canada consists of three regulated professions: • RNs registered nurses • LPNs licensed/registered practical nurses • RPNs registered psychiatric nurses Note that although the acronym RPN refers to registered practical nurses in Ontario, Canada, it is not so used in this report. Also, in Canada, RPNs are educated and regulated as a separate profession only in Manitoba, Saskatchewan, Alberta, and British Columbia. (Exception: Saskatchewan has not had an education program for RPNs since 2001.)

Both broad and narrow key words and phrases were used to search all sources. A broad term such as nurse(s) was used in an effort to capture information relating to all three regulated nursing professions. More focused words and phrases such as registered nurse(s), licensed practical nurse(s), and registered psychiatric nurse(s) were used in an effort to access data for each of the regulated nursing professions.

2.1.1. Published Literature and Bibliographic Databases Information on published literature was searched through bibliographic databases such as MEDLINE, CINAHL, Healthstar and Ovid. Popular publications and academic literature were also scanned.

2.1.2. Grey Literature Grey literature was searched on the Internet with Copernic Pro 2001 using key words and phrases such as inter-provincial migration, nurse mobility, migration of nurses in Canada, and labour mobility. The Internet provided access to grey literature such as reports, news releases, statistical data and databases, as well as documents from university-based academic research units, governmental publications, and nursing regulatory bodies. Documents and data were also obtained through direct correspondence with government officials, research units, nursing associations, and regulatory bodies.

2.1.3. Data from Regulatory Bodies Direct contact was made with regulatory bodies for the regulated nursing professions in all provinces and territories (see Appendix B). In Canada, RNs and LPNs are regulated in all provinces and territories whereas RPNs are regulated only in the four provinces of Western Canada.

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2.1.4. Statistical Data Migration and mobility data for the general population were accessed from Statistics Canada Census 2001. For migration and mobility data on nurses, a variety of sources were used. These data were published by the Ontario Human Resources Data Centre at the University of Waterloo (Hiscott, 1991); the Health Human Resources Unit (HHRU), Centre for Health Services and Policy Research at the University of British Columbia; the Canadian Nursing Association (CNA); and the Canadian Institute for Health Information (CIHI).

2.1.4.a. Compilation of Nursing Statistical Data RNs. National data on RNs were collected and managed through the collaboration of the following groups: the provincial/territorial regulating authorities; the Canadian Institute for Health Information (CIHI), an independent not-for-profit organization; Statistics Canada; and the Canadian Nurses Association (CNA). Sources used in this report include the following.

• Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 — the title of the new series, which is based on the most recent data from the Registered Nurses Database (RNDB; CIHI, 2003a). • Supply and Distribution of Registered Nurses in Canada — published annually from 1999 to 2001 by CIHI. • Revised Registered Nurses Database Series (from 1980 to 1988) and Registered Nurses Management Data (from 1989 to 1998) — earlier versions, published by Statistics Canada.

LPNs and RPNs. The first publication of nationally compiled LPN and RPN data was released in the fall of 2003. Outside of these national databases, only limited information about these professional groups is available from printed sources (Kazanjian, Wood, Yip, Rahim-Jamal, & MacDonald, 2000) or in the grey literature. Sources used in this report include the following.

• Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 is a recently released inaugural compilation based on data from the Licensed Practical Nurses Database (LPNDB; CIHI, 2003b). • Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2002 is a recently released inaugural compilation based on data from the Registered Psychiatric Nurses Database (RPNDB; CIHI, 2003c).

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Background on Compilation of LPN and RPN Data

Until recently, there was no national collection system or data set for LPNs and RPNs. However, CIHI has been collaborating with LPN and RPN provincial/territorial regulating bodies to prepare and publish national statistics for these professions (CIHI, 2003a). In 2000, CIHI completed the development of minimum data sets for LPNs and RPNs. In 2001, LPN representatives approved the minimum data set for LPNs for data collection in 2002 (CIHI, 2003c). In 2002, RPN representatives approved the establishment of a standardized minimum data set for collection of data about RPNs (CIHI, 2003c).

In 2002, the provincial/territorial regulating authorities submitted an approved subset of data electronically to CIHI for processing and verification. The data collected for the RPNDB are in accordance with an agreement between the authorities responsible for RPN licensure in the four Western Canadian provinces and CIHI (2003c). Note that although RPNs are regulated only in the four provinces of Western Canada, they can be and are employed in other jurisdictions in Canada.

2.1.4.b. Description of Nursing Statistical Data CIHI compiles statistics for the Registered Nurses Data Base (RNDB), the Licensed Practical Nurses Database (LPNDB), and the Registered Psychiatric Nurses Database (RPNDB) from data provided by the nursing regulatory bodies. Records are kept of all RNs, LPNs, and RPNs who submit their registration forms and are actively practising and employed in nursing (no secondary registrations, except in the territories). In order to allow for timely reporting, only data from the first six months of the registration period are reported on in the databases.

In contrast, the nursing regulatory bodies report on data from the full 12-month period, and include the following categories: active practising, typically; secondary registration; employed in nursing, other than nursing; not employed and not stated. Further, each jurisdiction has varying 12-month registration periods, which affects point-in-time comparisons (CIHI, 2003a, 2003b, 2003c). These factors must be considered when comparing CIHI data with data received directly from the regulatory bodies.

The yearly nurse registration forms include self-reported information, which is not cross- referenced by year or by jurisdiction and is not verified with the registrants. All records received by CIHI are reviewed for validity and logic, with errors reviewed jointly by CIHI and the regulatory board representatives (CIHI, 2003a, 2003b, 2003c). Other points to note regarding CIHI’s data are as follows.

• RNs, LPNs. Data that do not reflect the primary jurisdiction of employment, such as inter-provincial duplicates and those living abroad, are identified and removed, except for territorial data (CIHI, 2003a, 2003b). Also not included are those who have left the workforce, who are employed in a field other than nursing, who failed to state their employment status at the time of registration, or who maintain associate or non-practising status (CIHI, 2003a, 2003b).

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• RNs. “Nationally, the CIHI (reported) total represents 84.7% of the total number of active-practising registrations received by the jurisdictions during the registration year” (CIHI, 2003a, p. 43).

• LPNs. Similarly, the LPNDB (reported) total represents 85.8% of the total number of active-practising, employed registrations received by the jurisdictions during the registration year (CIHI, 2003b, p. 15). Data from Quebec and Nunavut were unavailable for the LPNDB (CIHI, 2003b). Also, only incomplete data were available for several other jurisdictions.

• RPNs. In order to accurately count the number of RPNs employed in the four provinces of Western Canada, data have been eliminated for those living outside this region (in Canada or abroad) but who maintain registration in one of the region’s provinces (CIHI, 2003c). CIHI’s figures represent only those psychiatric nurses employed in psychiatric nursing, not all active registrants, so CIHI will report lower numbers than year-end numbers from regulatory associations (CIHI, 2003c). The data for RPNs in BC in 2002 include both those employed and those not employed in psychiatric nursing, which leads to an over-counting of 0% to 8% of RPNs in that province (CIHI, 2003c).

• RNs, LPNs, RPNs. The composition of the nursing workforce in each jurisdiction is defined as where graduates are currently registered and employed. (CIHI, 2003a, 2003b, 2003c).

2.2. Data Quality and Limitations The following are some general comments on the limitations of the data. (See Appendix C for more detailed information.)

General Limitations. The search of the published literature led to the retrieval of only a few articles and most of these were descriptive in nature. Also, access to information on LPNs and RPNs is very limited. Data became available nationally for LPNs and RPNs only in 2003.

Limited Analysis Possible. The limitations of current databases and other statistical resources preclude statistical analysis of trends in nurse migration.

Non-standard Data Elements from Regulatory Bodies. The regulatory bodies do not collect standardized data. Nonetheless, CIHI has agreed with the respective regulatory bodies on certain data core elements they are to submit from registrants: 20 for RNs (CIHI, 2003a); 29 for LPNs (CIHI, 2003b); and 31 for RPNs (CIHI, 2003c). Not all data elements could be collected in the first year of the LPNDB and RPNDB (CIHI, 2003b, 2003c).

Barriers to Standardized Data Collection. In a meeting with representatives from the RN provincial regulatory bodies, barriers to a standardized data collection tool and expansion of this minimum data were identified, including local law/regulations, unique practice patterns, and political will.

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Absence of National Unique Identifiers. It is currently impossible to track nurse migration accurately (CIHI, 2002a, 2003a, 2003b, 2003c). When nurses receive their licenses, they do not receive unique identifiers at the national level that they keep throughout their working lifetime. This limits the quality and reliability of the data. CIHI attempts to remove duplicate registrations from its database, but some are inevitably missed.

Undercounting. Because data submitted after the first six months of each jurisdiction’s 12-month registration period are deleted, CIHI annually undercounts the actual number of active-practising RNs, LPNs, and RPNs (CIHI, 2003a, 2003b, 2003c). When data collection ceases, CIHI’s reported totals for the respective databases represent the following approximate percentages of data captured for active-practising nurse registrations received by the jurisdictions in the registration year.

RNs — receives 95% to 99% of total registrations, consequently undercounting by 1% to 5%. (CIHI, 2003a).

LPNs — receives 94.9% of total registrants, consequently undercounting by 5.1% (CIHI, 2003b).

RPNs — receives and captures more than 95% of total registrations, consequently undercounting by less than 5% of RPNs employed in the provinces of Western Canada (CIHI, 2003c).

LPNs: Active Registration Compared with Employment. When tabulating the total number of active registrations, the regulatory associations do not differentiate between those LPNs employed in practical nursing and those not employed in practical nursing, whereas CIHI does (CIHI, 2003b).

RPNs in BC: Employed and Unemployed Registrants. The data for RPNs in BC in 2002 include both those employed and those not employed in psychiatric nursing, which leads to an over-counting of 0% to 8% of RPNs in that province (CIHI, 2003c).

Errors with Third-party Data. The use of third-party data increases chances of error, with jurisdictional regulatory bodies collecting registration data for administrative purposes and submitting a subset of these data to CIHI for use in the respective databases (CIHI, 2003a, 2003b, 2003c).

Unreliable Gauge of Migration. Using the disparity between place of graduation and place of registration as a proxy for migration is unreliable in that the exact numbers of nurses who migrate is not known.

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3. Mobility Trends in the General Population

3.1. Historical Trends (1961–1996) In order to understand national nurse mobility, it is essential to examine mobility trends in the general population. Canada is divided into economically diverse and culturally distinct regions. Uneven economic performance across these regions generates continual adjustment in the labour market, with redistribution of workers from areas of low demand to areas of high demand (Lin, 1998). Historically, some migration patterns date back to at least the time of Confederation, with steady net population losses in the Prairie and Atlantic Provinces (Finnie, 2000). (Note that provinces and territories joined Confederation at various times, ranging from 1867 to 1949). Lin (1998) indicates that within Canada, people move for two main reasons:

• family-related reasons (i.e., because spouse/parents/friends moved, 25.3%); and • economic reasons (job transfer, new job, look for work etc., nearly 38%).

The overall movement of people in Canada is from east to west, with west often being relative only to the point of origin. Below, results from two sources reflect this, showing similar results. Lin (1998) found that inter-provincial mobility showed a strong regional concentration. But west (specifically Alberta and BC) and Ontario were the main destinations. Further below, in “Recent Trends,” data from the 2001 Census indicate that migration stopped at the Rocky Mountains, making Alberta a more important destination than BC.

Data for 1971, 1981, 1991, 1996 — See Table 1 Data for 1989 — See Table 2 (Lin, 1995; Vachon & Vaillancourt, 1999) (Lin, 1998) • Migrants from the Atlantic Provinces • Migrants from the Atlantic Provinces stayed in generally moved to Ontario, Alberta, and the Atlantic provinces or moved to Ontario or British Columbia. west (Lin, 1998).

• Quebec residents moved to Ontario, the • Quebec’s migrants moved mainly to Ontario, Atlantic Provinces, and British Columbia. Nova Scotia, and British Columbia.

• Ontario residents moved to Alberta, British • Ontario’s migrants moved to Quebec and Columbia, and the Atlantic Provinces. Nova Scotia.

• Those from the Prairie Provinces (Manitoba • Those from Western Canada moved within the and Saskatchewan) moved to Alberta, region or moved to Ontario, although the third Ontario, and British Columbia. destination for residents of BC was Nova Scotia (Lin, 1998). • Residents of British Columbia relocated to the Prairie Provinces, Alberta, and Ontario.

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The two tables below provide details for the above comparisons. In Table 1, the data given in percentages make it somewhat comparable to Table 2, which is based on adults only. The data given in actual numbers make it comparable to the table further below in “Recent Trends” (Table 3. Twelve key inter-provincial flows of the general workforce, in actual numbers, 1996–2001).

Table 1. Key Inter-provincial Flows of the General Workforce, in Percentages and Numbers, 1961–1996

WESTERN CANADA CENTRAL CANADA ATLANTIC PROVINCES BC AB SK MB ON QC NB PE NS NL % Actual # % Actual # % Actual #

In-migration AB to BC 47.7 121,112 QC to ON 66.1 137,939 within region SK/MB to AB 41.7 89,241 SK/MB to BC 28.2 60,455 BC to SK/MB 27.5 55,667 AB to SK/MB 20.5 52,030 BC to AB 16.8 34,006

In-migration ON to BC 24.3 95,930 Atlantic to ON 55.6 99,605 ON to Atlantic 22.6 89,064 from other ON to AB 22.6 89,032 BC to ON 4.8 9,752 QC to Atlantic 11.22 3,480 regions Atlantic to AB 15.4 27,546 Atlantic to BC 12.0 21,551

Out-migration BC to ON 4.8 9,752 ON to BC 24.3 95,930 Atlantic to ON 55.69 9,605 from regiona ON to Atlantic 22.6 89,064 Atlantic to AB 15.4 27,546 ON to AB 22.6 89,032 Atlantic to BC 12.0 21,551 QC to Atlantic 11.2 23,480 QC to BC 11.0 22,925

Source: Vachon & Vaillancourt (1999, pp. 113–117). Based on Canadian census years 1971, 1981, 1991, 1996 — those over 5 years of age. aThis row contains the same data as “In-migration from other regions” where applicable.

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Table 2. Key Inter-provincial Flows of the General Workforce, in Percentages, 1989

WESTERN CANADA CENTRAL CANADA ATLANTIC PROVINCES BC AB SK MB ON QC NB PE NS NL % % %

In-migration BC to AB 68.7 ON to QC 43.3 PE to NS 55.5 within region AB to BC 54.8 QC to ON 23.9 NB to NS 44.0 SK to AB 45.6 QC to BC 20.2 NS to PE 15.6 MB to AB 28.1 PE to NB 13.3 SK to BC 22.1 MB to BC 23.4

In-migration NL to BC 12.6 NL to ON 51.0 QC to NS 20.8 from other regions QC to BC 20.2 NS to ON 50.8 ON to NS 17.1 NL to AB 16.8 MB to ON 23.6 NB to QC 23.1 AB to ON 19.9 PE to ON 19.7 NB to ON 17.2 BC to ON 13.4

Out-migration MB to ON 23.6 QC to NS 20.8 NL to ON 51.0 from regiona AB to ON 19.9 ON to NS 17.1 NS to ON 50.8 BC to ON 13.4 QC to BC 20.2 NB to QC 23.1 PE to ON 19.7 NB to ON 17.2 NL to AB 16.8 NL to BC 12.6

Source: Lin (1998), adults (16 to 69 years of age) aThis row contains the same data as “In-migration from other regions,” where applicable.

3.1.1. Trends and Factors by Province British Columbia had very high inter-provincial and international migration. Between 1961 and 1996, it had a gain of 725,000, the highest population gain by a province during that period (19% of its 1996 population; Vachon & Vaillancourt, 1999). For 33 of those 36 years, British Columbia had a positive in-migration, and between 1988 and 1996, it gained more than 30,000 people every year (Vachon & Vaillancourt, 1999).

In-migration factors Lifestyle, weather, recreational opportunities. Out-migration factors Cost of living, weather, availability of jobs.

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Alberta gained population overall from migration, gaining 6% of its 1996 population from migration between 1961 and 1996. Alberta is unique in terms of its economy, with its migration strongly related to the price of oil (Vachon & Vaillancourt, 1999, p. 111).

In-migration factors After an increase in the price of oil, in-migration doubled from 61,000 in 1972–1973 to 124,000 in 1981–1982.

Out-migration factors Out-migration increased in the early 1980s because of the recession, reaching a high of 105,000 in 1984 (Vachon & Vaillancourt, 1999, p. 111).

Manitoba and Saskatchewan experienced a net loss of population of 21% of their populations between 1961 and 1996 in all years but four; during these four years, they experienced a net gain in population (Vachon & Vaillancourt, 1999).

In-migration/ “Manitoba appears to be more sensitive to oil prices than Saskatchewan Out-migration factors where the price of grain may matter more” (Vachon & Vaillancourt, 1999, p. 110).

In Ontario, migration in and out is related to both economic and political events. Ontario experienced an overall gain of migrants (less than 3% of its population) between 1961 and 1996 (Vachon & Vaillancourt, 1999).

In-migration factors Of the large out-migration from Quebec between 1961 and 1971, most settled in Ontario (Vachon & Vaillancourt, 1999).

In-migration / Economic and political events affect in- and out-migration for Ontario. Out-migration factors Between 1974 and 1988, in- and out-migration to Ontario was related to the economy of Alberta. In 1981, the recession in Alberta caused increased in-migration (linked with out-migration from Alberta) and decreased out-migration.

Out-migration factors An increase in petroleum prices in 1973 and 1979 caused large out-migration from Ontario (Vachon & Vaillancourt, 1999).

Quebec is identified as a “different (distinct, unique)” (Vachon & Vaillancourt, 1999, p. 108) province because of the predominance of the French language and the lack of knowledge of English by the majority of its population (Vachon & Vaillancourt, 1999). Other factors affecting the province are the increased awareness of nationalism between 1961 and 1996, the election of the Liberal party in 1960 initiating the révolution tranquille, and the visit of French President de Gaulle (Vachon & Vaillancourt, 1999). “Overall, Quebec suffered an out-migration of 563,000 individuals between 1962 and 1996. This represents nearly 8% of the 1996 population of Quebec” (Vachon & Vaillancourt, 1999, p. 109).

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In-migration factors Many immigrants come from countries where French is the first language.

Out-migration factors Between 1969 and 1971, increased out-migration from Quebec was due to the first language law (Bill 63) in 1969 and the October Crisis in 1970 (Vachon & Vaillancourt, 1999). In 1976, the election of the Parti Québécois again increased out-migration (Vachon & Vaillancourt, 1999). In 1985, the election of the Liberal Party reduced out-migration to its lowest level since 1962. In 1990, the failure of the Meech Lake Accord gave momentum to the nationalists, causing a further increase in out-migration.

In Newfoundland, between 1961 and 1996, there was a net out-migration for 31 of these 35 years, mostly related to fishing restrictions and lack of employment.

In-migration factors Positive net migration flows to Newfoundland were experienced when unemployment insurance was most generous, between 1971 and 1979 (Vachon & Vaillancourt, 1999).

Out-migration factors Between 1961 and 1996, out-migration from Newfoundland was probably due to fishing restrictions (Vachon & Vaillancourt, 1999).

In the Maritimes (New Brunswick, Prince Edward Island, Nova Scotia) the migration factors are affected by the overall employment situation as well as by incentives and industrial strategies to increase employment.

In-migration factors In-migration to the Maritimes increased after 1970, probably due to the “generosity of unemployment insurance in 1970” (Vachon & Vaillancourt, 1999, p. 107).

Out-migration factors From 1981 to 1982, recession reduced out-migration from the Maritimes (NS, PE, NB). Between 1992 and 1996, out-migration decreased from Prince Edward Island perhaps because of the economic activity generated by the building of the fixed link (Vachon & Vaillancourt, 1999).

3.1.2. Gains and Losses 1971–1996. Internal migration has a marked impact on the composition of the populations of provinces. Internal mobility in Canada between 1971 and 1996 has diminished by one third (Vachon & Vaillancourt, 1999).

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In 1989, Nova Scotia, Alberta, and British Columbia gained more inter-provincial migrants than they lost for a net gain in population from inter-provincial migration, while also experiencing relatively high levels of emigration compared to the size of their populations (Lin, 1995; Vachon & Vaillancourt, 1999). Meanwhile, Saskatchewan, Newfoundland and Labrador, Prince Edward Island, Manitoba, and New Brunswick experienced a net loss of people in 1989 (Lin, 1995). In Quebec, the adult population remained relatively unchanged. In Ontario, both in-migration and out-migration were substantially lower than in most provinces.

Between 1961 and 1996, Newfoundland, Quebec, Manitoba, and Saskatchewan were the main losers of population to Ontario, Alberta, and British Columbia (Vachon & Vaillancourt, 1999).

1961–1996. While they did attract migrants, the Atlantic Provinces, Quebec, Saskatchewan, and Manitoba did not experience a net gain in population through internal migration (Vachon & Vaillancourt, 1999) and most residents were born there. In contrast, most residents of British Columbia were born elsewhere (Vachon & Vaillancourt, 1999).

1989. Residents of Quebec and Ontario were relatively immobile. Quebec’s adult population remained relatively unchanged in 1989, with a slight population loss (Lin, 1989). Ontario’s gross in- and out-migration flows were considerably lower than in most other provinces, although a population loss through inter-provincial migration occurred that year (Lin, 1998).

1976–2001. The Yukon Territory and Northwest Territories reported net migration losses in 1981 and 1996 when the difference between the number of incoming and outgoing migrants was compared (Statistics Canada, 2002b). The Yukon Territory experienced a small net population gain from inter-jurisdictional migration in censuses of 1991 and 1996, while the Northwest Territory reported continuing net population losses through out-migration (Statistics Canada, 2002b).

Overall Family considerations (spouse moved) and economic reasons (job in-migration factors offers, looking for work, job transfers; Lin, 1998). Movement from the Atlantic provinces to Ontario may be because Ontario is the nearest English-speaking province (Vachon & Vaillancourt, 1999). The Quebec and Ontario exchange may reflect the exchanges between “field operation and head offices” in both provinces (Vachon & Vaillancourt, 1999, p. 113).

Overall Family considerations (spouse moved) and economic reasons (job out-migration factors offers, looking for work, job transfers; Lin, 1998).

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3.2. Recent Trends (1996–2001) The 2001 Census indicated that population growth [birth] rates have declined in every province except Alberta since the early 1990s, with inter-jurisdictional migration responsible for the most significant census-to-census changes (Statistics Canada, 2002a). Canada experienced one of the smallest census-to-census growth rates in its population, with four jurisdictions experiencing growth greater than the national average of 4.0%: Alberta, Nunavut, Ontario, and British Columbia (Statistics Canada, 2002a). Natural increase declined in all jurisdictions, while inter-jurisdictional migration remained relatively stable (Statistics Canada, 2002a). While Nunavut had a population growth rate of 8.1% since the 1996 Census — mainly due to the high birth rate among the Inuit population and the development of its capital, Iqaluit — this still represents a substantially decelerated natural growth rate (Statistics Canada, 2002a).

Between 1996 and 2001, inter-jurisdictional movement involved almost 3.2% (905,700) of the Canadian population — the lowest level of movement in Canada in more than two decades. Most people who moved were young, with 47% between the ages of 25 and 44 (Statistics Canada, 2002b). The historical trend of east to west movement continued, although Alberta replaced British Columbia as the destination of choice [population over age 5] (Statistics Canada, 2002b).

3.2.1. In-migration Between the 1996 and 2001 censuses, rates of in-migration shifted in some jurisdictions. The 1996 Census recorded a decreased in-migration in Newfoundland and Labrador, Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Alberta, the Yukon Territory and Northwest Territories, while Prince Edward Island, Saskatchewan, and British Columbia experienced increased in-migration (Statistics Canada, 1997). The 2001 Census recorded net gains in population through in-migration in Prince Edward Island, Ontario, and Alberta, but reported a continued net loss in population due to out-migration in Saskatchewan, Newfoundland and Labrador, British Columbia, Nova Scotia, New Brunswick, Quebec, Manitoba, and the Yukon Territory and Northwest Territories. Nunavut became a separate territory in April 1999; while the 1996 Census indicated a very slight population gain (0.4%) there, the 2001 Census indicated a small net out-migration and resultant population loss (Statistics Canada, 2002b).

3.2.2. Out-migration From 1996 to 2001, six provinces experienced small changes in population, less than 1.5%, up or down (Quebec, Manitoba, Prince Edward Island, Nova Scotia, New Brunswick, and Saskatchewan): Quebec, Manitoba, and Prince Edward Island populations increased; virtually no change occurred in Nova Scotia’s population; and a decline occurred in the populations of New Brunswick and Saskatchewan (Statistics Canada, 2002a). British Columbia experienced a small net loss in population for the first time in three decades (Statistics Canada, 2002b). Strong out-migration from the Yukon Territory (9.5%) and Northwest Territories (8.6%), and from Newfoundland and Labrador resulted in net losses relative to their populations (Statistics Canada, 2002a, 2002b). Migrants from Western Canada tended to remain in Western Canada (Lin, 1995). The population losses due to out-migration from the

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Yukon Territory and Northwest Territories are considered volatile changes given the already small sizes of the territorial populations (Statistics Canada, 2002b). Between 1996 and 2001, both of these territories had growth rates higher than the national average but suffered net population losses due to high net outflows of migration to the rest of Canada (Statistics Canada, 2002a). The net population loss in Nunavut is attributed to the decline in the natural growth rate and out-migration to other jurisdictions in Canada (Statistics Canada, 2002a).

3.2.3. Gains and Losses Net Population Gains. Between 1996 and 2001, Alberta — and to a much lesser extent, Ontario and Prince Edward Island — experienced a net gain in population due to migration. People moved to Alberta from Saskatchewan, Ontario and, in particular, British Columbia. Alberta’s attractiveness is attributed to its economic expansion and growth in the labour market (Statistics Canada, 2002b). Ontario had the second highest net migration gain in population of all jurisdictions, although this accounted for only 0.5% of the population over age 5, and Prince Edward Island reported a small net gain in in-migration (Statistics Canada, 2002b).

Table 3. Twelve Key Inter-provincial Flows of the General Workforce, in Numbers, 1996–2001

WESTERN CANADA CENTRAL CANADA ATLANTIC PROVINCES BC AB SK MB ON QC NB PE NS NL

In-migration BC to AB 89,685 QC to ON 80,505 within region AB to BC 46,955 ON to QC 36,690 SK to AB 37,645 MB to AB 20,775

In-migration ON to BC 52,825 BC to ON 48,330 ON to NS 18,220 from other regions ON to AB 44,045 AB to ON 32,275 NS to ON 22,140

Out-migration BC to ON 48,330 ON to BC 52,825 NS to ON 22,140 from regiona AB to ON 32,275 ON to AB 44,045 ON to NS 18,220

Source: Based on data from 2001 Census of Canada (Statistics Canada, 2002b). Note. Data are based on population age 5 and over. aThis row contains the same data as “In-migration from other regions,” where applicable.

Net Population Losses. Between 1996 and 2001, several jurisdictions suffered net population losses (Statistics Canada, 2002a). Newfoundland and Labrador, which had reported losses since 1981, recorded its largest net population loss in two decades and the highest net out-migration rate of all the provinces due to inter-provincial migration (and has shown a net loss in every census since 1981). The likely cause was a decline in the fishing industry and a high unemployment rate, particularly among the 15 to 24 age group.

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Saskatchewan reported the second highest net loss relative to its population.

All three territories suffered a net loss (Statistics Canada, 2002b). The Yukon Territory and Northwest Territories lost 9.5% and 8.6% of their populations, respectively, to out-migration (Statistics Canada, 2002b).

New Brunswick sustained its fifth straight census-to-census net population loss through inter-provincial migration from 1996 to 2001, four times the level during the previous census period (Statistics Canada, 2002b).

British Columbia reported a net loss in its migratory exchanges in the 2001 Census, a dramatic turnaround from the 1996 Census, which reported that British Columbia had attracted more inter-juris- dictional migrants to the province than it lost (Statistics Canada, 2002b).

Quebec reported the largest net loss of all the jurisdictions through migration, its biggest loss since the mid-1980s (Statistics Canada, 2002b). Although Quebec’s net loss was low in the 2001 Census, it has recorded strong net outflows in inter-provincial migration during the last 30 years.

Manitoba, Nova Scotia, and Nunavut experienced small net migration losses from 1996 to 2001 (e.g., NL 6.1%, QC 0.9%). For the fifth straight census, Manitoba reported a net loss in population, although it was down only slightly from the previous census (Statistics Canada, 2002b).

Table 4 below gives a summary of the net populations gains and losses between 1976 and 2001.

Table 4. Summary of Net Gains and Losses, 1976–2001

West Central Atlantic North

Net Migration BC AB SK MB ON QC NB NS PE NL YT NT NU

1976–1981 G G L L L L L L B L L L –

1981–1986 G L L L G L L G G L L L –

1986–1991 G L L L G L L L L L G L –

1991–1996 G G L L L L L L G L G L G

1996– 2001 L G L L G L L L G L L L L

Source: Statistics Canada (2002b) Note. Net migration refers to the difference between the number of in- and out-migrants. G = net gain; L = net loss; B = balanced (i.e., the difference between in- and out-migrants is 0.0).

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4. Mobility of Registered Nurses (RNs)

More data are available about RNs than the other regulated nursing professions. These data are considered relatively reliable. Regarding intra-provincial migration, only Ontario and British Columbia are discussed as data from other jurisdictions are not available. While the data from Ontario focus on employment, the data from British Columbia focus on geographical mobility of nurses. Kazanjian et al. (2000) addressed the inter-jurisdictional mobility of RNs in 1990 and 1997 in their reports. CIHI’s national database for registered nurses, using data from 2001 and 2002, provided the majority of the information for the discussion below (CIHI, 2002a, 2003a).

4.1. RN Mobility in Ontario (1984–1989) Hiscott (1991) provided an overview of mobility patterns for RNs in Ontario using employment and non-employment variables. He identified general mobility in the RN workforce by associating it with changes in the postal codes of RN registrants over a one- and five-year period (Hiscott, 1991), with the following results.

• 10.4% change from 1987 –1988 (1-year period) • 19.3% change from 1984 – 1989 (5-year period)

Hiscott also identified RNs who changed residence from one census metropolitan area to another in Ontario. The incidence of mobility “appears quite substantial over the five-year time frame” (Hiscott, 1991, p. 16).

• 5.2% change from 1987 –1988 (1-year period) • 10.2% change from1984 – 1989 (5-year period)

Limitations of Data. A limitation of using changes in postal codes to indicate mobility is that major and minor geographical moves are not distinguished. Hiscott (1991) cautions that these descriptive statistics are crude estimates and are an underestimation of the true magnitude of RN mobility. Comparing differences in postal codes at one point in a year does not account for multiple changes within the year.

RN Mobility Factors. Unmarried nurses were more likely to move their place of residence than were married or older nurses (Hiscott, 1991). Correlations between postal code and employment variables (employment place, employment status, employment responsibility, and type of position) from1987 to 1988 and 1984 to 1989 were very weak. The correlation between marital status and postal code was the strongest, which is not surprising since changes of residence frequently occur with marriage. Most of the associations found between pairs of variables were very small, indicating that change in one variable does not necessarily affect another.

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4.2. RN Mobility in the 1990s (1990–1997) Kazanjian and colleagues conducted research on RNs in Canada in the 1990s under the auspices of HHRU. To examine the extent of RN mobility in the Canadian nursing workforce, Kazanjian et al. (2000) used data collected by the jurisdictional regulatory bodies in their annual registration processes in 1990 and 1997, which at that time had been analyzed and submitted to Statistics Canada (until 1995) and CIHI (since 1996) (Kazanjian et al., 2000). Data were requested for 1990 and 1997, requiring Statistics Canada and CIHI to approach each jurisdiction for permission for access to these data for both time periods, which was granted.

Mobility indicator: Place of graduation compared with current registration (Kazanjian et al., 2000)

In the absence of a national unique registration number, it is not possible to track nurse movement within Canada. Instead, Kazanjian used a proxy measure to assess mobility: if the place of graduation from basic nursing education differs from the current province of nursing registration, it is assumed that the nurse has migrated.

Limitations of Data. Because data from 1990 were incomplete, the researchers were unable to calculate rates of inter-provincial mobility with precision; thus, the results and conclusions were tentative. With this proviso, it was estimated that 4% of RNs were employed elsewhere than in the jurisdiction of registration in 1997 (Kazanjian, 2000). RNs that were registered in a jurisdiction in 1990 but not in 1997 were considered to have retired, died, left the profession, or migrated to another province/territory or country (Kazanjian et al., 2000). The limitations of the use of the above indicator include the following.

• It does not account for nurses who are not registered or not working in nursing. • It does not link out-migration from one jurisdiction to in-migration in another. Double counting occurs when a nurse is registered in two jurisdictions simultaneously. • Nurses who spend time in other provinces and then return home are not tracked. • Nurses who leave Canada can be counted only if they maintain their registration and if they do return to work in another province are counted as new immigrants. • Nurses who attend school in other provinces with the intention of returning home to work are considered migrants. • The practice of renewing memberships at the beginning of the year means that nurses who migrate later in the year are not tracked. • It also does not account for intra-jurisdictional movement, which is particularly relevant for remote and rural populations.

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Workforce Composition and Mobility. In a study of the nursing workforce, Kazanjian et al. (2000, p. 37) suggested that inter-jurisdictional mobility is probably “a major contributor to inflow, relative to international migration or local production.” Overall in 1997, approximately 27% of the total number of practising RNs were not registered in the same province or territory as in 1990, indicating migration (Kazanjian et al., 2000). In 1997, Alberta and British Columbia had much lower proportions of retained RN graduates (62.57% and 52.66% respectively) than the other provinces, suggesting large out-migration. Nova Scotia and Ontario had a decrease in the proportion of retained RNs, suggesting higher in-migration rates to fill out their workforce (Kazanjian et al., 2000). Most other jurisdictions, except for Prince Edward Island and British Columbia, experienced a decrease in the proportion of RNs who attained their basic nursing education from other jurisdictions in Canada, suggesting a decrease in the numbers of in-migrants (Kazanjian et al., 2000).

“In general, the number and proportion of employed RNs resident in their province of basic education rose between 1990 and 1997” (Kazanjian et al., 2000, p. 25), suggesting a decrease in inter-jurisdictional mobility between these years. In 1997, the majority of RNs were employed in the province from which they received their basic nursing education (Kazanjian, 2000). “Given the high proportion of home-province-educated RNs in all jurisdictions except Alberta, BC. and the territories, it is possible that for the other provinces, the inflow represents those returning to the workforce and new graduates, as well as those who had trained in their home province, migrated for a time, and then returned [home] between 1990 and 1997” (Kazanjian et al., 2000, p. 30).

4.2.1. Mobility Factors To estimate inter-provincial/territorial mobility, Kazanjian et al. (2000) examined data for RNs who were registered outside their jurisdictions of graduation. In 1997, approximately 27% of the total number of practising RNs were not registered in the same jurisdiction as in 1990.

The in-flow group in 1997 comprised RNs who were registered in a jurisdiction other than the one in which they were registered in 1990. Compared with the total RN population, members of this group were less likely to be employed in nursing in Canada, and more likely to have an unknown employment status, to be employed outside of nursing, or not employed.

Compared with retained RNs, RNs who migrated were much less likely to be employed in nursing and much more likely to describe themselves as not employed (Kazanjian et al., 2000). The female out-flow group were also more likely to be older (aged 55 to 64) and much less likely to be aged 35 to 44. The concentration of the outflow group in the oldest age group suggests that many had retired (Kazanjian et al., 2000). Furthermore, the outflow group were much more likely to have been educated elsewhere in Canada (Kazanjian et al., 2000).

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Kazanjian et al. (2000) hypothesized that the majority of migrants had the following characteristics:

• were recent home-educated nursing graduates, less than 25 years of age; • were nurses 25 to 34 years of age who might also be new graduates, nurses returning to the workforce following maternity or some other leave of absence, or those who had moved; or • were nurses 35 and older who had most likely been out of the workforce in 1990 or had relocated recently.

Kazanjian et al. (2000) noted that compared to the total RN population, migrants who were still employed in nursing were less likely to be employed full-time or part-time, much more likely to be working casually and more likely to be younger (under 34 years of age). Between 1990 and 1997, nurses in older age groups tended to remain in their provinces; as in the general population, increasing age was negatively correlated with relocation.

4.3. RN Settlement Patterns in BC (1999, 2000) The HHRU (2000) examined the settlement pattern in 1999 of inter-jurisdictional nurse migrants within BC. Dividing the province into three regions, they found the following results.

Vancouver and District — had the highest proportion in the new registrants group (59.25%; HHRU, 2000, p. 77).

Capital — had the highest proportion of BC graduates in the total group (55.89%; HHRU, 2000, p. 75), with Ontario graduates more likely to have relocated to the Capital Region than other areas.

Other BC — Alberta graduates were more likely to have relocated to other parts of BC than to Vancouver and District and Capital regions (11.28%, HHRU, 2000, p. 75).

The HHRU (2000, 2001) also examined the settlement patterns of nurses from different provinces, aggregating nurses from provinces east of Ontario into a single category (Other Canada). The implications of these patterns are not discussed in the report and comparable data are not available for other provinces. See Table 5 below for details. To view regional maps of the various health boards, visit .

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Table 5. RN Settlement Patterns in BC in 1999, 2000, by Supplying Province

High (%) Health boards with highest and lowest % of settlement in 1999 (p. 81) %Total Low (%) BCa 53.79 67.95 Thompson Health Board 36.92 Peace Liard Community Health Services Society

AB 8.06 24.68 East Kootenay Community Health Services Societyb 4.71 Simon Fraser Health Board

ONc 10.40 15.86 Coast Garibaldi Community Health Services Society 7.57 Northern Interior Health Board

SK/MB 8.03 15.41 Peace Liard Community Health Services Society 5.26 Vancouver/Richmond Health Board

Other 5.22 10.81 North West Community Health Services Society Canadad 2.63 Cariboo Community Health Services Society

%Total High (%) Health boards with highest and lowest % of settlement in 2000 Low (%)

BCa 54.62 69.19 Thompson Regional Health Board (p. 17) 37.24 Peace Liard Community Health Services Society (p. 77)

AB 7.87 25.14 East Kootenay Community Health Services Society (p. 53)b 5.44 Vancouver/Richmond Regional Health Board (mainland) 4.83 North Shore Regional Health Board (pp. 41, 45)

SK/MB 7.77 15.02 Peace Liard Community Health Services Society (p. 77) 5.08 Vancouver/Richmond Regional Health Board (p. 41)

ONc 9.86 14.47 Coast Garibaldi Community Health Services Society (p. 61) 7.35 Simon Fraser Regional Health Board (p. 29)

Other 5.11 22.03 Vancouver/Richmond Regional Health Board (p. 41) Canadad 4.22 Thompson Regional Health Board (p. 17)

Source: 1999 data (HHRU, 2000); 2000 data (HHRU, 2001). Note. Data regarding intra-jurisdictional mobility of RNs were not available from other jurisdictions. aBC graduates were unevenly distributed throughout the province. bShares a long boarder with Alberta, which may account for the higher percentage of Alberta graduates in this region (HHRU, 2000; HHRU, 2001). cON graduates were more evenly distributed throughout the province than graduates from BC and Alberta. dOther Canada includes all provinces east of Ontario (QC, NB, NS, PE, NL).

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4.4. Recent RN Mobility, RNDB Data (2001–2002) For the purposes of this section of the report, data will be used from the Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 (CIHI, 2003a). This contains data on the nursing workforce for graduates of Canadian schools of nursing in other jurisdictions (inter- jurisdictional or internal migrants), graduates of nursing schools from within the jurisdiction (retained graduates) and graduates from foreign schools of nursing, and those for which the place of graduation is unknown. The first interpretation looks at the composition of provincial/territorial nursing workforces. The purpose is to examine the percentage of each category of graduate per workforce: retained, internal migrants, foreign, and unknown or not stated (CIHI, 2003a). The second is an analysis of the distribution of each jurisdiction’s graduates — those who are retained and those who migrate to another Canadian jurisdiction.

Mobility indicator: Place of graduation compared with current registration (CIHI 2003 a, b, c)

In the absence of a national unique registration number, it is not possible to track nurse movement within Canada. Instead, CIHI uses a proxy measure to assess mobility: if the place of graduation from basic nursing education differs from the current province of nursing registration, it is assumed that the nurse has migrated.

Note: This measure does not account for nurses in the following categories: not registered, not working in nursing, educated outside their home province/territory and returned, and migrated outside their home province and returned. It also does not account for intra- jurisdictional movement, which is particularly relevant for remote and rural populations.

CIHI uses the above indicator to differentiate among five categories of graduates. • Canadian — nurses who graduated from Canadian nursing programs (including international students). • Retained — nurses who remain registered and employed in the province/territory where they graduated. 1) In the context of the composition of a provincial/territorial workforce, retained refers to the percentage of retained graduates out of the entire workforce. 2) In the context of distribution of home-educated graduates, retained refers to the percentage of these graduates who remained in their home province. • Internal migrants — nurses who are registered and employed in a province/territory other than where they graduated. • Foreign — nurses who graduated from schools of nursing in other countries (may be Canadian citizens). • Unknown — nurses for whom the place of graduation is unknown.

Because of the differences in the current methodology used by CIHI, territorial and provincial data are not comparable at this time (CIHI, 2003a). To present more accurate data, CIHI (2003a) included nursing registration duplicates in the data from the territories. However, this meant that

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Nunavut, the Yukon Territory, and the Northwest Territories all reported numbers of RNs per 10,000 population as much higher than the national average. There were approximately 460 full-time equivalent positions in the Northwest Territories and Nunavut in 2002, with almost 850 RNs filling these positions (CIHI, 2003a). This reflects the reliance on short-term and part-time staffing in the territories rather than the numbers present at any one time.

4.4.1. Composition of Provincial/Territorial RN Workforce Of the 230,957 RNs employed in Canada in 2002, it is interesting to note the composition of the labour market for each province and territory, as illustrated in detail in Table 6 below (CIHI, 2003a). The overall results for Canada were as follows.

• 92.2% (212,924) Canadian graduates • 6.9% (15,847) Foreign • 0.9% (2,186) Not stated

In three provinces, more than one-quarter of the RN workforce graduated from other jurisdictions in Canada — British Columbia (29.5%), Alberta (27.6%), and Prince Edward Island (27.9%) — indicating higher percentages of out-of-province RNs than the other provinces (CIHI, 2003a, p. 79). Two provinces also employ high percentages of internationally educated RNs: Ontario (10.5%) and British Columbia (15%) (CIHI, 2003a). As well, the percentages of internal migrants and foreign graduates are very high in the territories because there is only one there, in the Northwest Territories.

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Table 6. Composition of RN Workforces, by Province/Territory of Registration, 2002

Canadian

A. B. A + B Retained Internal Canadian Foreign Graduates Migrants Graduates Graduates Unknown %

BC 55.4 29.5 85.0 15.0 0.0 AB 61.6 27.6 89.2 3.5 7.3 SK 81.7 14.2 95.9 2.7 1.4 MB 84.0 10.7 94.7 5.3 0.0 ON 81.4 7.7 89.1 10.5 0.4 QC 95.9 1.9 97.8 2.2 0.0 NB 85.7 13.1 98.8 1.2 0.0 NS 77.9 19.7 97.6 2.4 0.0 PE 69.8 27.9 97.8 1.7 0.5 NL 92.9 4.9 97.9 1.9 0.3 YTa 0.0 92.6 92.6 5.5 1.8 NTa 9.2 80.3 89.5 10.1 0.4 NUa 0.0 85.7 85.7 13.6 0.7 Canada 80.0 12.2 92.2 6.9 0.9

Source: Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 (CIHI, 2003a). Note. Numbers may not add up because of rounding. aThe territories include inter-jurisdictional duplicates employed in nursing (CIHI, 2003a).

4.4.2. Distribution of Canadian RN Graduates Retention 2001. Appendix E shows the percentages of RNs who remained in their province of graduation in 2001 and the destinations (with percentages) of those who left. Similar numbers and percentages are not available in the most recent CIHI (2003a) publication, using 2002 data.

Mobility 2001. CIHI (2002a; Appendix D) identified the province of graduation for Canadian RNs in each of the provincial/territorial workforces and noted the following.

• Nurses from Atlantic Canada migrated predominantly to Ontario. • British Columbia and Alberta drew nurses from Ontario and from other provinces of Western Canada.

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• Most RNs in the Atlantic Provinces graduated from nursing schools in the Atlantic Provinces, with a minority graduating from Ontario. • There was limited migration to and from Quebec. • Ontario-educated RNs tended to migrate to Western Canada, the territories, and Nova Scotia. • RNs who graduated in Western Canada tended to stay in Western Canada. • Most of the RN workforce in the territories graduated in Ontario or Western Canada.

Retention 2002. In 2002, the majority of RNs (86.7%) in the Canadian workforce were employed in the jurisdiction where they initially graduated; the remaining 13.3% of RNs had either not re-registered or were registered outside the province/territory. This migration percentage of 13.3% for 2002 is lower than the estimated 27% rate reported for 1997 by Kazanjian et al. (2000). As seen in Figure 1, Saskatchewan (66.1%), Prince Edward Island (69.7%), Newfoundland and Labrador (72.6%) and Manitoba (72.6%) had a low percentage of RNs retained by those provinces (CIHI, 2003a), suggesting a high number of RNs lost to other jurisdictions. The proportion of employed RNs resident in their province of graduation rose between 2000 and 2001, suggesting a decrease in inter-provincial mobility, and remained approximately the same, with slight variations, in 2002 (CIHI, 2003a).

Figure 1. Retention of RN graduates, by province/territory of graduation, 2002

Source: Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 (CIHI, 2003a).

Mobility 2002. CIHI (2003a) presented the 2002 RNDB data in a different manner than previously, listing the three most frequent destinations for RN graduates by province, rather than percentages for all destinations. The overall inter-provincial migration pattern for RNs is similar to that of the general population, with British Columbia (29.2%), Alberta (22.8%), and Ontario (21.5%) attracting the most graduates from across Canada (CIHI, 2003a). There continued to be a general east to west movement of nurses in 2002 (see Table 7).

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Table 7. Three Most Frequent Destinations for RNs, by Province of Graduation, 2002

Province of Graduation

WESTERN CANADA CENTRAL CANADA ATLANTIC PROVINCES Destinations BC AB SK MB ON QC NB NS PE NL

First AB BC AB BC BC ON ON ON NS ON Second ON SK BC AB AB BC NS BC ON AB Third NS ON ON ON QC AB QC AB AB BC

Source: Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 (CIHI, 2003a).

General patterns of migration were as follows.

• Western Canada — RNs educated in the four provinces of Western Canada usually stayed in Western Canada or migrated to Ontario (CIHI, 2003a). • Ontario — Nurses from Ontario made up more than a quarter of the nurses migrating to the territories and also relocated to British Columbia, Alberta, and Quebec (CIHI, 2003a). Ontario attracted some RNs from across Canada, mainly from Newfoundland and Labrador, Nova Scotia, New Brunswick, and Prince Edward Island, with a small percentage from Quebec (CIHI, 2003a). • Quebec — RNs educated in Quebec tended to remain there. As well, more recent data indicated that there are more Quebec graduates in BC and Alberta than in New Brunswick (CIHI, 2003a). • Atlantic Provinces —RNs educated there tended to remain, although a number moved to Ontario, Alberta, and British Columbia. For Newfoundland and Labrador and Nova Scotia, the second and third main destinations were Alberta and British Columbia (CIHI, 2003a).

Potential Factors for Mobility. There were many factors mentioned, as follows.

• This may reflect a “preferred lifestyle, better job availability or more lucrative career opportunities in these provinces” (CIHI, 2003a, p. 83). • People from these provinces are more likely to attend an out-of-province school before returning to their home province for employment (CIHI, 2003a). • This also reflects province size. Exception — only 4% of graduates from Quebec relocated in spite of being the second largest province in general population and RN workforce size (CIHI, 2003a). • Language may be a factor in the lower migration rates for Quebec. • Atlantic Canada and Western Canada form regional markets within which there is mutual exchange, although less so in 2002 than in 2001.

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Some Unexpected Results. The 2002 data showed some surprising occurrences.

• There are more Quebec graduates in both British Columbia and Alberta than in New Brunswick — its neighbour and an officially bilingual province (French/English). • Nova Scotia is the third most frequent destination for BC graduates. • There are more graduates from New Brunswick in Ontario than in its neighbour provinces of Quebec and Nova Scotia (CIHI, 2003a, p. 83).

4.4.2.a. Gains and Losses Data from 2001 and 2002 show similar rates of RN retention. Quebec had the highest RN retention rate and Saskatchewan had the lowest, with more than one third of its graduates employed elsewhere (CIHI, 2002b, 2003a). Almost a third of Prince Edward Island RN graduates and approximately a quarter of graduates from Newfoundland and Labrador, Manitoba, Nova Scotia, and New Brunswick were employed elsewhere, indicating high emigration from these provinces (CIHI, 2002b, 2003a).

Provinces with low immigration rates have RN populations that are largely home-educated, (retained graduates), even when they have high rates of emigration. The following two examples illustrate this.

In 2001, Newfoundland and Labrador had a high proportion of retained graduates (92.8%) in the RN workforce, in spite of the fact that the province retained only 72.3 % of its graduates and large numbers (27.4%) were working elsewhere in Canada. The top three destinations were Ontario (8.4%), Nova Scotia (6.4%), and Alberta (5.7%; CIHI, 2002a; see Appendix E). In 2002, the top three destinations were Ontario, Alberta, and British Columbia (CIHI, 2003a; see Table 7), indicating a shift in migration destination. Exact percentages in 2002 were unavailable for comparison.

In 2001, Saskatchewan also had a high proportion of retained graduates (81.5%, see Appendix D) in its RN workforce, but had the lowest rate (66.0%, see Appendix E) of graduates being retained by the province, with the remaining 34% of their graduates being employed elsewhere, especially Alberta (16.8%) and British Columbia (10.0%) (CIHI, 2002a). In 2002, Saskatchewan continued to have a high proportion of retained graduates (81.7%) in its RN workforce, and still had the lowest rate (66.1%) of graduates being retained by the province, with the remaining 33.9% of their graduates being employed elsewhere. The top three destinations were Alberta, BC, and Ontario (CIHI, 2003a; see Table 7).

In contrast, provinces with high immigration rates have a lower proportion of home-educated graduates in their workforce, even when they also have high retention rates. Although only slightly more than half (55.4%) of the British Columbia nursing workforce is composed of home-educated graduates, 91.4% of their graduates remain in the province (CIHI, 2003a). Given that almost half of the workforce

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has migrated from elsewhere, it may be difficult to increase migration as a way of augmenting the nursing workforce. Instead, “increasing the number of seats available in nursing schools may have a greater effect on the future nursing supply for jurisdictions that retain a substantial proportion of their graduates than for jurisdictions that retain fewer of their own RN graduates” (CIHI, 2003a, p. 80).

The territories differ from the provinces because they depend on the provinces for their workforce. The one RN nursing school in the Northwest Territories contributes only 5.1% to that RN workforce (CIHI, 2003a). Substantial portions of the RN workforce in the territories are short-term relief staff who subsequently relocate to their home provinces (CIHI, 2003a). Most of the Canadian-educated nurses in the territories come from Ontario (29.6%), Alberta (15.2%), and British Columbia (11.1%) (CIHI, 2003a). There is a higher proportion of internationally educated RNs in the territorial workforce (8.2% in 2001, and 9.8% in 2002) than in the provincial nursing workforce (6.8% in 2001 and 2002; CIHI, 2002a, 2003a). Nunavut (10.4%) had the highest percentage of foreign graduates in the territories in 2001, although the Northwest Territories (8.5% in 2001; 10.1% in 2002) and the Yukon Territory (5.5% in both 2001 and 2002) also had relatively high percentages (CIHI, 2002a, 2003a).

4.5. Recent RN Mobility, Data from Regulatory Bodies (2001–2002) 4.5.1. Requests for Registration Verification of Credentials (2001)

Mobility indicator: Requests for registration verification of credentials

In the absence of a national unique registration number, provincial/territorial nursing regulatory bodies in Canada estimate mobility by tabulating the number of requests for registration verification of credentials. Note that these data reflect only the intent to move, and not actual movement.

A limitation to using data about registration verification is that regulatory bodies vary in the extent to which they collect and manage these data. Some do not track verification data at all, some collect information on members that leave their province/territory, while others keep records of those intending to migrate to their province/territory. A few other regulatory bodies track their own members extensively.

Verification of credentials from nursing regulatory bodies for 2001 was received from all jurisdictions except Quebec (see Appendix F). Manitoba does not retain data on registration verification (G. Hildebrand, College of Registered Nurses of Manitoba, personal communication, July 31, 2002).

Five provinces/territories (SK, NB, NS, PE, and YT) provided information about the sources of the requests for verification. Except for Ontario, there were more requests from other provinces/ territories than from other countries. Three provinces tracked actual in-migration from other Canadian jurisdictions for 2001: AB (786), PE (61), and SK (68). Ontario reported 1,176 registrants from out-of-province; however, this figure may also include migrants from abroad (College of Nurses of

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Ontario, 2002). The Ontario number from the 2001 annual report is inconsistent with other reports (CNA, 2002). The registrar for the RNABC noted that BC’s membership was most interested in migrating to Ontario, Manitoba, and Alberta. As well, requests for relocation to and departure from British Columbia increased between 2000 and 2001.

Numbers of recorded verification requests across all provinces were very small considering the potential numbers. The range was from 1,794 in BC to 47 in the Yukon Territory. Therefore, they are not a useful indicator of movement or intention to move.

4.5.2. Actual Inter-jurisdictional Movement of RNs (1999–2002) The Canadian Nurses Association tracks by year inter-jurisdictional sources of RNs who are new registrants in a jurisdiction either through endorsement of previous registration or through examination (see Appendix G). Table 8 below is a comparison of results from the tables in Appendices F and G and demonstrates why using verification of requests is unreliable.

Mobility indicator: Actual registration

Another mobility indicator is actual registration. The data on this indicator track new registrants in a province/territory, through either endorsement of previous registration or through examination (no information is available on the province/territory of origin of RNs writing the licensing examination).

These data differ from those generated using the frequently used indicator “requests for registration verification of credentials” confirming its inaccuracy and unreliability for estimating migration.

The Canadian Nurses Association tracks by year inter-jurisdictional sources of RNs who are new registrants in a jurisdiction either through endorsement of previous registration or through examination (see Appendix G). Table 8 below is a comparison of results from the tables in Appendices F and G and demonstrates why using verification of requests is unreliable.

Table 8. Comparison of Requests for RN Verification of Credentials and Actual Registration, 2001

Province/territory of potential/actual in-migration

BC AB SK MB ON QC NB NS PE NL YT NT Total

Verification requests (data from Appendix F) 1,794 786 68 n/r 715 n/s 235 344 61 200 47 147 4,397

Endorsement / examination (data from Appendix G) 362 526 68 0 415 55 53 134 52 33 33 0 1,731

Source: RN regulatory bodies (See Appendix B). Note. n/r = data not retained; n/s = data not submitted.

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The actual RN registration data indicate that most RNs qualify to practise in other Canadian jurisdictions through endorsement of their previous registration, rather than through examination. Ontario is the main province that qualifies RNs through examination whereas few RNs, if any, write an examination for licensure in other jurisdictions. No information is available on the original jurisdictions of RNs writing the examination.

The jurisdictions that most often grant licensure through endorsement of previous registration vary in each year. From 1999 to 2002, Alberta, Ontario, and British Columbia were the three main provinces. During this time, they also had the most new registrations of RNs through endorsement and examination. As well, a considerable number of RNs migrated to Nova Scotia (150 to 143 respectively). In 1999 and 2000, many nurses migrated to Manitoba and Saskatchewan, although this number has since decreased. In 2002, there was a large increase in nurses migrating to Quebec (244, mainly from Ontario). This could be a result of recruitment incentives by the province to bring graduates back home.

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5. Mobility of Licensed Practical Nurses (LPNs)

While data from RN regulating bodies are considered relatively reliable, those on LPNs have been considered limited and in need of attention (Kazanjian et al., 2000). Historically, there has not been a national database for LPNs. Kazanjian et al. (2000) did not address the inter-jurisdictional mobility of LPNs in their reports because of lack of data. CIHI has recently released the first national database for Licensed Practical Nurses entitled Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 (CIHI, 2003b). 5.1. LPN Settlement Patterns Within BC (1999, 2000) Some information on LPN migration is available from British Columbia; however, the high number of LPNs with an unknown place of graduation decreases the validity of the data. Most LPNs working in British Columbia in 2000 were educated in British Columbia, with any in-migration coming mainly from the Prairie Provinces, Ontario, a few from other provinces in Canada, and small numbers from foreign sources (HHRU, 2001). As with RNs, the LPNs generally migrated from east to west. Equivalent data from other jurisdictions are unavailable.

The HHRU (2000) examined the settlement patterns within British Columbia in 1999 of LPNs from other jurisdictions. They divided the province into the following three regions.

Vancouver and District — had the highest proportion of new Canadian registrants (86.96%; HHRU, 2000, p. 65). This may be attributed to new registrants relocating to large urban centres to gain experience in tertiary care centres.

Capital — Ontario graduates were more likely to have relocated to the Capital Region than to other areas.

Other BC — had the highest proportion of BC graduates (69.36%; HHRU, 2000, p. 63), although Vancouver and District (64.84%) and the Capital (65.73%) also had high percentages of BC graduates. Alberta graduates were more likely to have relocated to other parts of BC (8.50%) than to Vancouver and District or the Capital region (HHRU, 2000, p. 63).

The HHRU (2000, 2001) also examined the settlement patterns of LPNs from different provinces, aggregating LPNs from provinces east of Ontario into a single category (Other Canada). The implications of these patterns are not discussed in the report and comparable data are not available for other provinces. See Table 9 below for details. To view regional maps of the various health boards, visit .

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Table 9. LPN Settlement Patterns in BC in 1999, 2000, by Supplying Province

%Total High (%) Health boards with highest and lowest % of settlement in 1999 (2000, p. 66) Low (%) BC 67.35 83.25 Central Vancouver Island Health Board (Vancouver Island) 81.37 Coast Garibaldi Community Health Services Society 49.40 Peace Liard Community Health Services Society

AB 6.89 22.89 Peace Liard Community Health Services Societya 2.94 Coast Garibaldi Community Health Services Society

SK/MB 6.35 10.31 Thompson Health Board 3.29 North Shore Health Board

ON 7.75 11.34 North West Community Health Services Society 2.93 Kootenay Boundary Community Health Services Society

Other 3.82 9.64 Peace Liard Community Health Services Society Canadab 1.44 Central Vancouver Island Health Board (Vancouver Island) 1.46 Kootenay Boundary Community Health Services Society

%Total High (%) Health boards with highest and lowest % of settlement in 2000 Low (%) BC 68.07 83.41 Central Vancouver Island Regional Health Board (Vancouver Island; p. 33) 78.89 Kootenay Boundary Community Health Services Society (p. 57) 52.50 Peace Liard Community Health Services Society (p. 77)

AB 6.93 22.50 Peace Liard Community Health Services Societya (p. 77) 2.75 Simon Fraser Regional Health Board (p. 29)

SK/MB 6.20 10.87 Cariboo Community Health Services Society (p. 69). 3.02 Kootenay Boundary Community Health Services Society (p. 57)

ON 7.88 15.05 North West Community Health Services Society (p. 73) 3.02 Kootenay Boundary Community Health Services Society (p. 57)

Other 3.90 9.68 North West Community Health Services Society (p. 73) Canadab 1.09 Cariboo Community Health Services Society (p. 69)

Source: 1999 data (HHRU, 2000); 2000 data (HHRU, 2001). Note. Data regarding intra-jurisdictional mobility of LPNs are not available from other jurisdictions. aAs was similar with RNs, the number of Alberta graduates was highest in the region sharing a long boarder with BC. bOther Canada refers to aggregate of nurses from provinces east of Ontario.

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5.2. Recent LPN Mobility, LPNDB Data (2000–2002) CIHI Data and Analysis 2002. For the purposes of this report, data will be used from the Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 (CIHI, 2003b). This contains data on the nursing workforce for LPN graduates of Canadian schools of practical nursing, graduates from foreign schools of nursing, and those for which the place of graduation is unknown. The first interpretation looks at the composition of provincial/territorial LPN workforces. The purpose is to examine the percentage of each category of graduate per workforce: retained, internal migrants, foreign, and unknown or not stated (CIHI, 2003a). The second is an analysis of the distribution of each jurisdiction’s graduates — those who are retained and those who migrate to another Canadian jurisdiction.

Mobility indicator: Place of graduation compared with current registration (CIHI 2003 a, b, c)

In the absence of a national unique registration number, it is not possible to track nurse movement within Canada. Instead, CIHI uses a proxy measure to assess mobility: if the place of graduation from basic nursing education differs from the current province of nursing registration, it is assumed that the nurse has migrated.

Note: This measure does not account for nurses in the following categories: not registered, not working in nursing, educated outside their home province/territory and returned, and migrated outside their home province and returned. It also does not account for intra-jurisdictional movement, which is particularly relevant for remote and rural populations.

CIHI uses the above indicator to differentiate among five categories of graduates. • Canadian — nurses who graduated from Canadian nursing programs (including international students). • Retained — nurses who remain registered and employed in the province/territory where they graduated. 1) In the context of the composition of a provincial/territorial workforce, retained refers to the percentage of retained graduates out of the entire workforce. 2) In the context of distribution of home-educated graduates, retained refers to the percentage of these graduates who remained in their home province. • Internal migrants — nurses who are registered and employed in a province/territory other than where they graduated. • Foreign — nurses who graduated from schools of nursing in other countries (may be Canadian citizens). • Unknown — nurses for whom the place of graduation is unknown.

Because of differences in the current methodology used by CIHI, territorial and provincial data are not comparable at this time (CIHI, 2003b). To present more accurate data, CIHI (2003b) included nursing registration duplicates in the data from the territories. Providing data about the ratio of LPNs for every 10,000 people indicates the number of LPNs providing practical nursing care and how readily nursing services are available from LPNs. In contrast to the RN data, the ratio of LPNs per 10,000

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people is higher in Newfoundland and Labrador and Prince Edward Island than in the Yukon Territory and Northwest Territories (CIHI, 2003b, p. 38). The ratio is actually lowest in the Northwest Territories, at the national average of 19.1 (CIHI, 2003b). CIHI cautions that “The interpretation of the licensed practical nurse to population ratios requires an understanding of the role of an LPN, the multidiscipli- nary team and staff mix components, the service requirements and environment before a comprehensive measure can be presented” (2003b, p. 39). These percentages do not account for varying nursing service requirements, which differ by jurisdiction and geographical areas (e.g., rural and remote areas).

LPNs make up the second largest health care provider group in Canada, second to RNs (CIHI, 2003b). Of the 60,123 LPNs employed in practical nursing in Canada in 2002, 63.8% were employed in Ontario and Quebec (CIHI, 2003b). In terms of setting, nearly one half (47.5%) have worked in hospital settings and over a third (36.4%) in nursing home settings (CIHI, 2003b). Data from Quebec and Nunavut were unavailable for the LPNDB (CIHI, 2003b). Also only incomplete data were available for several other jurisdictions.

5.2.1. Composition of Provincial/Territorial LPN Workforce Of the 60,123 LPNs employed in Canada in 2002, 72.4% (43,530) graduated from a nursing program in Canada, 1.6% (986) graduated from an international nursing program, and 26% (15,607) did not state their place of graduation (CIHI, 2003b). This does not include data from Quebec or Nunavut, which were unavailable. Table 10 indicates the composition of LPNs in the labour market for each province and territory.

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Table 10. Composition of LPN Workforces, by Province/Territory of Registration, 2002

Canadian

A. B. A + B Retained Internal Canadian Foreign Graduates Migrants Graduates Graduates Unknown %

BC 71.7 23.3 95.0 0.0 5.0 AB 82.7 14.8 97.5 2.3 0.2 SK 85.3 13.0 98.3 1.7 0.0 MB 92.0 5.5 97.5 2.5 0.0 ON 93.2 3.4 96.6 3.2 0.1 QC ** ** n/s n/s 100.0 NB 91.6 7.9 99.5 0.5 0.0 NS 91.2 8.6 99.7 0.3 0.0 PE 91.7 7.9 * + 0.0 NL ** ** 71.4 0.0 28.6 YT 62.5 34.4 96.9 0.0 3.1 NT 15.2 82.3 * + * NU ** ** ** ** **

Canada – – 72.4 1.6 26.0

Source: Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 (CIHI, 2003b). Note. Numbers may not add up because of rounding. ** = Data for Newfoundland and Labrador, Quebec, and Nunavut not available (CIHI, 2003b). n/s = Data not submitted (CIHI, 2003b). * = Value suppressed to ensure confidentiality (CIHI, 2003b). + = Value suppressed in accordance with CIHI privacy policy (CIHI, 2003b).

In 2002, LPN workforces were made up primarily of retained LPNs (72.4%). This does not include Quebec, Newfoundland and Labrador, or Nunavut because of the unavailability of data (CIHI, 2003b). Five provinces, Prince Edward Island, Nova Scotia, New Brunswick, Ontario, and Manitoba, reported greater than 90% of their LPN workforces were retained graduates. Three of the provinces in Western Canada, British Columbia (23.3%), Alberta (14.8%), and Saskatchewan (13%), reported the largest in-migration of Canadian LPNs, while Ontario (3.4%) and Manitoba (5.5%) reported the smallest (CIHI, 2003b). The majority of the LPN workforce in the territories comes from migration, either inter-jurisdictional or international, given that the LPN education program in the Yukon Territory and Northwest Territories is offered only on an occasional basis of every two to three years (CIHI, 2003b).

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5.2.2. Distribution of Canadian LPN Graduates As well as examining the composition of the provincial/territorial workforces, CIHI (2003b) examined where graduates are currently registered and employed to determine graduate retention. Among Canadian LPN graduates employed in 2002, those graduating from Ontario (96.8%), British Columbia (95.1%), and New Brunswick (92.6%) were the most likely to remain and be employed in their province of graduation (see Figure 2). Saskatchewan, Manitoba, and Newfoundland and Labrador had the lowest retention rates. Similar to the RN data, Saskatchewan had the lowest rate (84.9%) of retained graduates (CIHI, 2003b). Among LPN graduates from Nova Scotia, Alberta, Manitoba, Newfoundland and Labrador, and Saskatchewan, 12% or more were employed elsewhere, indicating moderate emigration from these provinces (CIHI, 2003b). Generally, LPNs remained in the jurisdictions where they graduated.

Figure 2. Retention percentages of LPN graduates, by province of graduation, 2002

Source: Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 (CIHI, 2003b). Note. Yukon Territory and Northwest Territories data are not included as nursing programs there are offered on an occasional basis only (CIHI, 2003b). Nunavut data are not available for the year 2002 (CIHI, 2003b). Quebec data are not included because “Province of Graduation” was not available.

The overall inter-provincial migration pattern for LPNs is similar to the patterns for RNs and the general population, with British Columbia (31%), Alberta (20.3%), and Ontario (19.4%) attracting the most LPN graduates of Canadian practical nursing programs (CIHI, 2003b).

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LPNs may choose to relocate for many reasons, including the following (CIHI, 2003b, p. 57).

• greater availability of employment • higher income • availability of full-time employment • family reasons • personal development reasons

A high rate of out-of-province graduates may reflect the following factors (CIHI, 2003b, p. 56).

• the number of nursing programs within a jurisdiction • the migration patterns of the general population • better job availability and/or career opportunities in a neighbouring jurisdiction • the location of schools (i.e., people in a particular jurisdiction are more likely to attend school in another province before returning home to work)

Specific source and destination jurisdictions for migrants from each jurisdiction were not presented in the CIHI data for LPNs in 2002, therefore a more complete depiction of migration patterns is not possible.

5.2.2.a. Gains and Losses (2001–2002) To understand the impact of inter-jurisdictional migration on provincial/territorial LPN workforces, in- and out-migration of Canadian graduates must be considered together.

Limitations of Data. Conclusions are unable to be made regarding Quebec, Newfoundland and Labrador, and the territories because data were unavailable Also, more than one quarter of LPNs (26%) did not state their place of education, which makes it impossible to determine if these LPNs have relo- cated from their jurisdiction of graduation. In addition, specific jurisdictions of in-migration and out- migration — source and destination jurisdictions — were not provided in the LPNDB.

CIHI (2003b) reports that there is little movement of LPNs to provinces other than British Columbia, Alberta, and Ontario. Further examination reveals the following.

• Out- and in-migration were relatively balanced in Prince Edward Island, Nova Scotia, New Brunswick, Ontario, Saskatchewan, and Alberta (CIHI, 2003b). • In other provinces, there are gains or losses of workforce personnel. • British Columbia experienced considerably more in-migration than out-migration (CIHI, 2003b).

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• Manitoba experienced a larger percentage of out-migration of LPNs than in-migration (CIHI, 2003b). • The Yukon Territory and Northwest Territories have high rates of in-migration (CIHI, 2003b). The out-migration of graduates of the territories is unknown.

High Retention Rates. LPN data differ somewhat from RN data regarding immigration and emi- gration rates when compared to retention rates, in that the percentage of inter-jurisdictional migrants are lower overall. All provinces for which data are available had graduate retention rates of 84.9% or better, and five provinces had retention rates over 90%.

Provinces with low in-migration rates had LPN populations that were largely home-educated (retained graduates), even when they had high rates of out-migration, such as Newfoundland and Labrador and Manitoba. For example, in 2002, Manitoba had a high proportion of retained graduates (92.0%) in their LPN workforce, in spite of the fact that the province retained only 85.3% of their graduates and 14.7% were lost to other jurisdictions in Canada. It is unknown to which jurisdiction the LPN graduates from Manitoba relocated.

Other provinces with low in-migration rates also had LPN populations that were largely home-educated (retained graduates), but had low rates of out-migration: Prince Edward Island and New Brunswick.

Other provinces with high in-migration rates had high retention rates as well as high out-migration rates: Alberta, Saskatchewan and Nova Scotia.

In contrast, provinces with high in-migration rates had a lower proportion of home-educated graduates, even when they also had high retention rates. For example, even though the proportion of retained graduates was only 71.7% in the British Columbia nursing workforce, 95.1% of their graduates remained employed in the province, and there were high levels of in-migration (31.0%) and low levels of graduates lost to other jurisdictions (<5%; CIHI, 2003b).

This information is invaluable in understanding the mobility of graduates. “For example, increasing the … number of seats available in practical nursing schools may have a greater effect on future practical nursing supply for jurisdictions that retain a substantial proportion of their graduates than for jurisdictions that retain fewer of their own LPN graduates” (CIHI, 2003b, p. 56).

The Yukon Territory and Northwest Territories differ from the provinces because they depend on the provinces and internationally educated LPNs for their workforce. Nunavut data are unavailable for 2002. The LPN education program in the Yukon Territory and Northwest Territories is offered only on an occasional basis of every two to three years (CIHI, 2003b). It is unknown what percentage the territories contribute to the total LPN workforce.

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5.3. Recent LPN Mobility, Data from Regulatory Bodies (2001) 5.3.1. Requests for Registration Verification of Credentials

Mobility indicator: Requests for registration verification of credentials

In the absence of a national unique registration number, provincial/territorial nursing regulatory bodies in Canada estimate mobility by tabulating the number of requests for registration verification of credentials. Note that these data reflect only the intent to move, and not actual movement.

A limitation to using data about registration verification is that regulatory bodies vary in the extent to which they collect and manage these data. Some do not track verification data at all, some collect information on members who leave their province/territory, while others keep records of those intending to migrate to their province/territory. A few other regulatory bodies track their own members extensively.

Responses were received from most of the LPN regulatory bodies, with the exceptions of Quebec and Nunavut. Seven provinces provided detailed data (see Appendix H). Ontario received the highest numbers of LPN registration verification requests, followed by, in descending order, British Columbia, Alberta, Nova Scotia, Saskatchewan, New Brunswick, Newfoundland and Labrador, Manitoba, and Prince Edward Island. Seven provinces (Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Newfoundland and Labrador, and Prince Edward Island) provided information about the source of requests. Nova Scotia, New Brunswick, and Newfoundland and Labrador had slightly more requests for verification from Ontario and Western Canada than from Atlantic Canada. Verification requests for Alberta, Saskatchewan, and Manitoba came mainly from Western Canada and to a lesser extent from Ontario.

5.3.2. Actual Inter-jurisdictional Movement of LPNs

Mobility indicator: Actual registration

Another mobility indicator is actual registration. Data on this indicator track new registrants in a province/territory, through either endorsement of previous registration or through examination (no information is available on the province/territory of origin of RNs writing the licensing examination).

These data differ from those generated using the frequently used indicator “requests for reg- istration verification of credentials,” confirming its inaccuracy and unreliability for estimating migration.

Only five provinces tracked actual migration of LPNs from other provinces in 2001. (See Appendix I for details.)

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6. Mobility of Registered Psychiatric Nurses (RPNs)

Little information is available about the inter-provincial migration of RPNs. Historically, there has not been a national database for RPNs. Recently, CIHI released the first national database for Registered Psychiatric Nurses entitled Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2002 (CIHI, 2003c).

The first psychiatric nursing education program in Saskatchewan was established in 1930. This diploma program was integrated into the University of Saskatchewan’s College of Nursing in 1997. However, Manitoba refused to register graduates of this program because it had insufficient psychiatric nursing content. Alberta and British Columbia had similar concerns as did the Saskatchewan regulatory body. The program lost its approval status in 2001 and although the Saskatchewan government is actively involved in efforts to re-establish the program, there currently is no psychiatric nursing education program in Saskatchewan. (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, November 4, 2004.) 6.1. RPN Settlement Patterns Within BC (1999, 2000) Some historical information on RPN migration is available from British Columbia and covers RPN migration in that province in 1999 and 2000. However, the high number of RPNs with an unknown place of graduation decreases the validity of the data.

1999 Data. The HHRU (2000) examined the settlement pattern within British Columbia in 1999 of RPN migrants from other provinces. The researchers divided the province into the following three regions and noted the following.

Vancouver and District — had the highest proportion of BC graduates in the total group (68.09%; HHRU, 2000, p. 89) and the highest proportion of BC graduates in the new registrants group (90.91%; HHRU, 2000, p. 90) compared to Capital and Other BC.

Capital — Manitoba (12.84%) and Saskatchewan (13.51%) graduates were more likely to have relocated to the Capital Region than to other areas.

Other BC — Alberta graduates were more likely to have relocated to other parts of BC than to Vancouver and District or Capital Region (8.85%; HHRU, 2000, p. 89).

2000 Data. Most RPN s (64.68%) working in British Columbia in 2000 were educated in that province, with migration mainly from the Prairie Provinces, Ontario, a few from other provinces in Canada, and small numbers from international sources (HHRU, 2001). As with RNs, the gradient for RPN migration moves from east to west.

The HHRU (2000, 2001) also examined the settlement patterns of nurses from different provinces, based on place of graduation from basic nursing program, aggregating nurses from Manitoba and Saskatchewan into a single category, and listing Alberta separately. The implications of these patterns are not discussed in this report and comparable data are not available for other provinces.

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(Table 11 below provides details.) To view regional maps of the various health boards, visit .

Table 11. RPN Settlement Patterns in BC in 1999, 2000, by Supplying Province

%Total High (%) Health boards with highest and lowest % of settlement in 1999 (p. 93) Low (%)

BC 64.25 83.25 Central Vancouver Island Regional Health Board 81.37 Coast Garibaldi Community Health Services Society 49.40 Peace Liard Community Health Services Society

AB 4.09 22.89 Peace Liard Community Health Services Societya 2.94 Coast Garibaldi Community Health Services Society

SK/MB 11.42 10.31 Thompson Regional Health Board 3.29 North Shore Regional Health Board

%Total High (%) Health boards with highest and lowest % of settlement in 2000 Low (%)

BC 64.68 93.10 Coast Garibaldi Community Health Services Society (p. 61) 18.52 Peace Liard Community Health Services Society (p.77)

AB 4.03 22.22 Peace Liard Community Health Services Society (p. 77)a 0 Coast Garibaldi Community Health Services Society (p. 61)

SK/MB 11.69 42.86 East Kootenay Community Health Services Society (p. 53) 0 Coast Garibaldi Community Health Services Society (p. 61)

Source: 1999 data (HHRU, 2000); 2000 data (HHRU, 2001). aAs was similar with RNs and LPNs, the number of Alberta graduates was highest in the region sharing a long boarder with BC.

6.2. Recent RPN Mobility, RPNDB Data (2001–2002) For the purposes of this report, data were taken from the Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2002 (CIHI, 2003c). The first interpretation looks at the composition of provincial nursing workforces. The purpose is to examine the percentage of each category of graduate per workforce: retained, internal migrants, foreign, and unknown or not stated (CIHI, 2003c). The second is an analysis of the distribution throughout Western Canada of each province’s graduates — those who are retained and those who migrate to another province.

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Mobility indicator: Place of graduation compared with current registration (CIHI 2003 a, b, c)

In the absence of a national unique registration number, it is not possible to track nurse movement within Canada. Instead, CIHI uses a proxy measure to assess mobility: if the place of graduation from basic nursing education differs from the current province of nursing registration, it is assumed that the nurse has migrated.

This measure does not account for nurses in the following categories: not registered, not working in nursing, educated outside their home province/territory and returned, and migrated outside their home province and returned. It also does not account for intra-jurisdictional movement, which is particularly relevant for remote and rural populations.

Note: In order to accurately count the number of RPNs registered and employed in the four provinces of Western Canada, those living abroad, in eastern Canada, or in the territories are eliminated (CIHI, 2003c).

CIHI uses the above indicator to differentiate among five categories of graduates. • Canadian — nurses who graduated from Canadian nursing programs (including international students). • Retained — nurses who remain registered and employed in the province/territory where they graduated. 1) In the context of the composition of a provincial/territorial workforce, retained refers to the percentage of retained graduates out of the entire workforce. 2) In the context of distribution of home-educated graduates, retained refers to the percentage of these graduates who remained in their home province. • Internal migrants — nurses who are registered and employed in a province/territory other than where they graduated. • Foreign — nurses who graduated from schools of nursing in other countries (may be Canadian citizens). • Unknown — nurses for whom the place of graduation is unknown.

6.2.1. Composition of RPN Provincial Workforces (2002)

Registered Psychiatric Nurses (RPNs) make up “the largest single group of mental health professionals in Western Canada” (CIHI, 2003c, p. 29). In 2002, of the 5,132 RPNs employed in nursing in Western Canada, 89.2% were educated in Canada, 7.5% were internationally educated, and 3.3% had not stated their place of graduation (CIHI, 2003c). The individual provincial RPN workforces were largely made up of Canadian graduates, greater than 90% in each of the provinces of Western Canada except BC (80.4%; CIHI, 2003c). Table 12 indicates the composition of RPNs in the labour market for these provinces.

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Among Western Canadian RPN workforces in 2002, two provinces, Manitoba (94.6%) and Saskatchewan (91.6%), were made up primarily of retained RPNs. The two other western provinces, BC and Alberta, had fewer retained graduates (64.3% and 61% respectively) and large percentages of inter- provincial migrants, with Alberta (29.7%) attracting more RPNs from out-of-province than BC (16.1%; CIHI, 2003c). This differs from the RN and LPN data, which revealed that Saskatchewan had the lowest graduate retention rates (CIHI, 2003a, 2003b). BC (12.6%) also had the most foreign RPNs, with few migrating to the other provinces (CIHI, 2003c). Employment settings of RPNs varied from province to province (CIHI, 2003c). Out-migration rates per province are not presented in the CIHI data.

Table 12. Composition of RPN Workforces, by Province of Registration, 2002

Canadian Gradutes

A. B. A + B Retained Internal Canadian Foreign Graduates Migrants Graduates Graduates Unknown %

BC 64.3 16.1 80.4 12.6 7.0 AB 61.0 29.7 90.7 ** * SK 91.6 6.6 98.2 * ** MB 94.6 3.7 98.3 1.7 0.0

Canada – – 89.2 7.5 3.3

Source: Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2002 (CIHI, 2003c). Note. ** = Value suppressed to ensure confidentiality (CIHI, 2003c). * = Value suppressed in accordance with CIHI privacy policy (CIHI, 2003c).

6.2.2. Distribution of Canadian RPN Graduates in 2002 The overall inter-provincial migration pattern for RPNs differs somewhat from that for LPNs and RNs. Alberta and BC attract the most RPN graduates of Canadian psychiatric nursing programs (CIHI, 2003c). RPNs have more movement to other provinces than LPNs, but less than RNs. It is unknown why RPNs relocate. Specific source and destination provinces for migrants from each province were not presented in the CIHI data for RPNs in 2002, therefore a more complete depiction of migration patterns is not possible. Figure 3 below indicates the percentages of RPNs retained or lost by each of the four provinces of Western Canada.

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Figure 3. Retention percentages of RPN graduates, by province of graduation, 2002

Source: CIHI (Electronic communication from P. Sajan, March 17, 2004).

6.3. Recent RPN Mobility, Data from Regulatory Bodies (2001–2003) 6.3.1. Requests for Registration Verification of Credentials (2001, 2002)

Mobility indicator: Requests for registration verification of credentials

In the absence of a national unique registration number, provincial/territorial nursing regulatory bodies in Canada estimate mobility by tabulating the number of requests for registration verification of credentials. Note that these data reflect only the intent to move, and not actual movement.

A limitation to using data about registration verification is that regulatory bodies vary in the extent to which they collect and manage these data. Some do not track verification data at all, some collect information on members who leave their province/territory, while others keep records of those intending to migrate to their province/territory. A few other regulatory bodies track their own members extensively.

Information was received from the College of Registered Psychiatric Nurses of Manitoba and the Registered Psychiatric Nurses Association of Saskatchewan, but not from the other RPN regulatory bodies (see Appendix J). Note that the following interpretations are based on a total of 36 requests. Manitoba’s verification data (2001 data) suggest RPNs had little interest in relocating to Manitoba, but RPNs from Manitoba (2002 data) were interested in relocating to Saskatchewan, Alberta, and British Columbia. Similarly, Saskatchewan’s data reflect that RPNs are leaving the province to relocate to Alberta and Manitoba.

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6.3.2. Actual Inter-provincial Movement of RPNs (1998–2003)

Mobility indicator: Actual registration

Another mobility indicator is actual registration. Data on this indicator track new registrants in a province/territory, through either endorsement of previous registration or through examination (no information is available on the province/territory of origin of RNs writing the licensing examination.)

These data differ from those generated using the frequently used indicator “requests for registration verification of credentials,” confirming its inaccuracy and unreliability for estimating migration.

Registered Psychiatric Nurses are regulated in the four provinces of Western Canada and are recognized in some other jurisdictions, such as Nunavut (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, September 15, 2003). Mobility of RPNs among these provinces is tracked by registrars in all four provinces. Results showed an increase in immigration from 1998 to 2002, with a decrease in 2003 (see Appendix K). Most RPNs migrate, in descending order, to Alberta (70), BC (61), Saskatchewan (36), and Manitoba (17). Mobility patterns for individual provinces are as follows. • BC — RPNs migrate to BC mainly from Alberta (24), Saskatchewan (20) and Manitoba (17). • AB — RPNs migrate to Alberta mainly from Saskatchewan (39), BC (17) and Manitoba (14). • SK — Saskatchewan accepts immigrant RPNs mainly from Alberta (23), Manitoba (11) and BC (2). • MB — RPNs migrate to Manitoba mainly from Saskatchewan (10), BC (4) and Alberta (3). There has been a mutual recognition/reciprocity agreement between the four regulatory bodies since 1979. When the Saskatchewan diploma program was integrated into the College of Nurses at the University of Saskatchewan, Manitoba stopped recognizing those new graduates. That program lost its approval status in 2001 and there is no current psychiatric nursing program in Saskatchewan. Therefore any Saskatchewan RPNs going to other provinces have graduated from a previous Saskatchewan program or from elsewhere. (A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, November 4, 2004.)

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7. Context of Nurse Mobility

7.1. Effects of Internal Trade Agreements The Forum of Labour Market Ministers (Human Resources Development Canada [HRDC], 2001) recognized that regulated workers expect freedom of movement throughout Canada and recognition of their qualifications without reassessment costs and processes. The Agreement on Internal Trade (AIT), which came into effect on July 1, 2001 (HRDC, 2001), was intended to enhance labour mobility by facilitating the relocation of regulated workers to other jurisdictions in Canada through mutual recognition of occupational certification (Centre for Industrial Relations, 2001). The AIT was intended to prevent duplicate assessment, training, and expense when licenced workers in regulated professions relocated for employment, while protecting the public and improving worker mobility (HRDC, 2001). The goal was greater productivity for employers, fewer delays in filling vacancies, and improved competitiveness. Ideally, qualified, regulated workers would be able to practise their occupation wherever opportunities for employment existed in Canada.

All jurisdictional governments in Canada except Quebec have agreed to allow individuals from regulated occupations or professions to have access to employment opportunities in their profession or occupation in any jurisdiction in Canada, without barriers or restrictions (HRDC, 2001). Most self-regulating occupations are taking steps to recognize the qualifications of workers from other jurisdictions by comparing standards and occupational requirements (HRDC, 2001). As a result, when workers are becoming licensed in a new jurisdiction, they should no longer face either delays in beginning employment or extra fees (HRDC, 2001). However, although 51 regulated occupations (including nursing) were asked to take steps to facilitate labour mobility among jurisdictions by recognizing qualifications and reconciling differences in occupational standards, a number of difficulties remained unresolved (HRDC, 2002a).

7.1.1. RN Mutual Recognition Agreement Mutual recognition of the qualifications of RNs in jurisdictions across Canada varies but is reported as being well underway (HRDC, 2002a), with almost all jurisdictional regulatory bodies having signed the RN Mutual Recognition Agreement (L. Little, CNA, personal communication, September 17, 2003). Except for Nunavut, which is included with the Northwest Territories, each province/territory has its own board or regulatory body that determines the requirements for nursing licensure.

RNs in Canada must pass the Canadian Registered Nurses Exam (CRNE) in order to register in all Canadian jurisdictions, except Quebec (HRDC, 2002a). RNs graduating in Quebec must pass the Quebec Professional Examination. RNs who graduated from elsewhere in Canada after 2000 are required to pass this exam before practising in Quebec. In order for Quebec graduates to register in other Canadian jurisdictions, they must pass English language skills testing and pass the national nursing examination. An exception to the above may exist, as anecdotal reports indicate that there is reciprocity between Ontario and Quebec, allowing RNs to work without writing an additional nursing examination (Steering Committee Member, personal communication, June 20, 2003). This reciprocal agreement will be reassessed in 2004 (Steering Committee Member, personal communication, June 20, 2003).

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7.1.2. LPN Mutual Recognition Agreement Licensed Practical Nurses are regulated in all jurisdictions across Canada. All provincial and territorial regulatory bodies signed a Mutual Recognition Agreement in 2001–2002 (“Licensed Practical Nurses,” 2001a). The Mutual Recognition Agreement recognizes that despite a high degree of commonality among jurisdictions, there are local differences in the education, scope of practice, and roles of LPNs. Applicants for registration in a jurisdiction requiring additional competencies may be required to obtain them through assessment, education, and/or clinical practice. The following are some examples.

• British Columbia requires further preparation in community nursing. • Alberta and Manitoba require additional competencies in physical assessment, infusion therapy, and . • Nova Scotia also requires additional competencies in infusion therapy and pharmacology. • Prince Edward Island requires further preparation in mental health nursing (“Licensed Practical Nurses,” 2001a).

Licensed Practical Nurses in all provinces, except Quebec, write the Canadian Practical Nurses Registration Examination. Quebec maintains its own examination, although examinations from other Canadian jurisdictions may be accepted (“Licensed Practical Nurses,” 2001a, 2001b). The LPN Mutual Recognition Agreement (“Licensed Practical Nurses,” 2001a) states that LPNs must meet the “language requirement in place in a jurisdiction in which they apply for registration/licensure” (p. 5). The document Standards: A framework for practical nurse registration standard: Labour mobility (“Licensed Practical Nurses,” 2001b) indicates that applicants whose first language is not the official language(s) of the jurisdiction must demonstrate competency in this language(s) through accepted language testing in the official language(s) of the jurisdiction (French or English). In these standards, reports on specific language requirements vary from not being specifically stated (“Licensed Practical Nurses,” 2001a, 2001b) in most jurisdictions to no requirements in the Northwest Territories (“Licensed Practical Nurses,” 2001b), English language testing required in BC and Alberta, and English or French acceptable in Manitoba.

7.1.3. RPN Mutual Recognition Agreement Registered Psychiatric Nurses are educated and regulated in the four provinces of Western Canada (BC, AB, MB, SK) (CIHI, 2003c). These provinces have an agreement allowing for mobility of RPNs within the region. A recent exception is that Manitoba does not recognize new graduates from Saskatchewan (HRDC, 2002a). Theses graduates must complete several courses prior to becoming registered in Manitoba.

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7.2. Migration Barriers, Challenges, and Motivations 7.2.1. Barriers and Challenges For the general population, including nurses, Lin (1998) notes that the following factors can act as barriers and challenges for those seeking employment.

• large family size • job tenure • union membership • increased age • being a francophone

Migration to and from Quebec occurs at a lower rate than migration among other Canadian jurisdictions because of language barriers (Lin, 1998). The lower migration rate of francophones from Quebec is typical of Canadian migration patterns in the general population (Lin, 1995).

7.2.2. Motivations Lin notes the following major motivations for migration in Canada and reports the key attributes of people in the higher migration categories as compared to those in the lower migration categories.

Major motivations (Lin, 1995) Key attributes (Lin, 1998)

• economic • better educated • family responsibilities • non-francophone • educational pursuits • younger • retirement • have smaller families • do not have job tenure

Socio-economic conditions resulted in a considerable number of people seeking employment in other provinces; these include the high unemployment in the Atlantic Provinces and a political climate that led to anglophone migration from Quebec (Statistics Canada, 2002b).

7.2.2.a. Motivations for Nurses Specifically Researchers (CIHI, 2002a) suggested that motivators for nurses to move between jurisdictions included the following.

• availability of jobs • greater income and benefits

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• full-time employment • family reasons • personal growth and development

Few studies have examined nurses’ motivation to migrate; nonetheless, migration may be related to the shift of nursing practice from institutional to community-based settings and the increase in casualization of the RN workforce (CIHI, 2001).

For RPNs, this may not be a motive as most are employed in full-time positions (66.9%); a further 27.6% are employed on a part-time basis and the remaining 5.5% on a casual basis (CIHI, 2003c). Still, a global shortage of RPNs has been reported, as has a shift from hospital to community- based psychiatric care (CIHI, 2003c; Psychiatric Nursing Education, 2000). A search of the literature did not reveal any relationships between deinstitutionalization and downsizing or restructuring.

For RNs in Ontario, the Registered Nurses Association of Ontario ([RNAO], 2001) noted that in the 1960s, many RNs (50.0%) left Ontario for travel or in search of improved weather conditions. In contrast, from 1991 to 2000, most RNs (69.51%) left to pursue job opportunities. This change corresponded to a downturn in the Ontario nursing labour market. RNs left Ontario in the 1990s because of limited opportunities for full-time employment, downsizing, or workplace issues.

A qualitative study (Ministry of Health Planning, 2000) reported that 18 RNs leaving, or intending to leave, British Columbia were motivated by the following.

• employment opportunities elsewhere • work issues • dissatisfaction with the workplace • lack of educational support • lack of opportunities for career development • lack of support and respect • the physical and psychological demands of the job • retirement • the relocation of a spouse • having a family with young children • financial reasons

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7.2.2.b. Costs of Mobility to Employer Relatively little of turnover is due to inter-jurisdictional migration; nevertheless, excessive mobility adds to employers’ costs. The cost of turnover per nurse is estimated at about US$25,000. These costs include interviewing, recruiting, orienting, and educating new nurses, as well as indirect costs associated with gaps in continuity of care (Jones, 1990; Tai, Bame, & Robinson, 1998).

Although not specifically applicable to Canada, the results of a US study are worthy of note. The study found a 29% reduction in the overall number of LPNs [across the US] from 1991 to 2000, which may be responsible in part for LPNs seeking employment in other US jurisdictions (Unruh, 2003). This large reduction in LPNs was linked to a considerable increase in RN workload and to a decrease in the overall skill mix of licensed nursing personnel (Unruh, 2003).

7.3. RN Salary Scales and Mobility In the 1990s, better salaries were not cited as the major reason for migration. Nurses considered that being respected, having job security, a stable work environment, full-time work, and a good salary and benefits were prerequisites of a good job (O’Brien-Pallas, Baumann, & Lochhass-Gerlach, 1998). Nurses in Ontario receive high rates of pay (CBC News, 2002; Canadian Federation of Nurses Unions, 2002), but according to the RNAO (2001) many nurses left the province because they did not want to work part-time or in an unstable work environment. However, there is an established relationship between economic factors such as wages, allowances, and benefits on the one hand and nurses’ job satisfaction and retention on the other (Blegan & Mueller, 1987; Hay Group, 2001; Shields & Ward, 2001).

The above notwithstanding, salary remains an important motive for migration. Rates of migration are highest to those provinces where nurses receive higher salaries (see Appendix L). For example, in the Atlantic region, Nova Scotia has the highest salaries for nurses and draws nurses from neighbouring provinces. In Canada, British Columbia, Alberta, and Ontario offer nurses the highest rates of pay and have the highest rates of immigration. In contrast, nurses in Newfoundland and Labrador and Saskatchewan have low salaries and low immigration. Quebec is the exception in that migration and salaries do not appear to be linked. Although Quebec nurses have salaries higher than those in Ontario, they have a low rate of migration, most likely related to language and registration requirements.

While aggressive recruitment occurs internationally, there is relatively little evidence of aggressive inter-jurisdictional recruitment within Canada. Nevertheless, nurses are tempted by relocation grants and inducements such as recruitment bonuses, higher salaries, and free education offered by more affluent provinces and health care institutions (Baumann et al., 2003).

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8. Recommendations

1) Collecting accurate information on all three regulated professions requires coordination at a national level. A priority for policy makers in nursing, health care organizations, and governments must be to decide what data should be collected and who should collect it.

2) CIHI (2002b) defines a unique identifier as a unique, non-reused, lifetime number assigned either on entry into an education program or on application for first licensure. Adopting a unique identifier for each nurse would achieve the following.

a) Facilitate accurate tracking of nurses throughout their careers by preventing double- or under-counting (CIHI, 2002a, 2003a, 2003b, 2003c; Kazanjian, 2000).

b) Allow individuals to be tracked inter-jurisdictionally, in and out of the profession and through changes in educational and practice status.

c) Provide accurate information for the construction of a database that would facilitate workforce projections and planning for educational places and health human resources.

3) Conduct further research regarding the following.

a) Factors that influence mobility and attract nurses to specific jurisdictions.

b) Factors that erode recruitment and retention efforts in times of severe global shortage.

4) Promote known motivating factors, such as full-time employment, benefits, and job security.

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REFERENCES

Baumann, A., Blythe, J., Denton, M., Zeytinoglu, I. U., Higgins, A., & Davies, S. et al. (2003). The new worker. Unpublished manuscript, Hamilton, Canada: Nursing Effectiveness, Utilization & Outcomes Research Unit, McMaster University.

Blegen, M., & Mueller, C. (1987). Nurses’ job satisfaction: a longitudinal analysis. Research in Nursing and Health 10, 227–37.

Building the Future. (2003a). About nursing in Canada: Registered nurses [Electronic version]. Building the future: An integrated strategy for nursing human resources in Canada. Retrieved November 11, 2003, from

Building the Future. (2003b). About nursing in Canada: Licensed practical nurses [Electronic version]. Building the future: An integrated strategy for nursing human resources in Canada. Retrieved November 11, 2003, from

Building the Future. (2003c). About nursing in Canada: Registered psychiatric nurses [Electronic version]. Building the future: An integrated strategy for nursing human resources in Canada. Retrieved November 11, 2003, from

Canadian Federation of Nurses Unions. (2002). CFNU national nurses’ salaries database: General duty registered nurse (salary is for the year 2002). Retrieved May 7, 2002, from

Canadian Institute for Health Information. (2001). Future development of information to support the management of nursing resources: Recommendation [Electronic version]. ISBN 1-894766-19-9 [PDF]. Ottawa, Canada: Canadian Institute for Health Information. Retrieved July 17, 2003, from

Canadian Institute for Health Information. (2002a). Registered Nurses Database: Supply and distribution of registered nurses in Canada, 2001 (Rep. No. ISBN 1-55392-025-2). Ottawa, Canada: Canadian Institute for Health Information.

Canadian Institute for Health Information. (2002b). What Is a Unique Identifier? Ottawa, Canada: Canadian Institute for Health Information. Retrieved July 8, 2002, from

Canadian Institute for Health Information. (2003a). Workforce trends of registered nurses in Canada, 2002. RNDB: Registered Nurse Database. (ISBN 1-55392-276-X [PDF]). Ottawa, Canada: Canadian Institute for Health Information.

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Canadian Institute for Health Information. (2003b). Workforce trends of licensed practical nurses in Canada, 2002. LPNDB: Licensed Practical Nurses Database. (ISBN 1-55392-276-1). Ottawa, Canada: Canadian Institute for Health Information.

Canadian Institute for Health Information. (2003c). Workforce trends of registered psychiatric nurses in Canada, 2002. RPNDB: Registered Psychiatric Nurses Database. (ISBN 1-55392-294-8 [PDF]). Ottawa, Canada: Canadian Institute for Health Information.

Canadian Nurses Association. (2002). Highlights of 2001 nursing statistics. Ottawa, Canada: Canadian Nurses Association. Retrieved August 8, 2002, from

CBC News. (2002, August 20). needs quick action: Report. CBC News Online. Retrieved August 8, 2002, from

Centre for Industrial Relations. (2001, July 17). Inter-provincial mobility. Weekly Work Report. Centre for Industrial Relations, University of Toronto. Retrieved May 25, 2002, from

College of Nurses of Ontario. (2002). CNO Membership Statistics 2001 [Electronic version]. Toronto, Canada: College of Nurses of Ontario. Retrieved July 15, 2002, from

Finnie R. (2000) Who moves? A panel logit model analysis of inter-provincial migration in Canada. Analytical Branch Research Paper Series. (Cat. No. 11F0019MIE, No.142). (ISBN 0-660- 27929-9). Ottawa, Canada: Statistics Canada. Retrieved July 23, 2002, from

Hay Group. (2001). The retention dilemma: Why productive workers leave – Seven suggestions for keeping them. Toronto, Canada.

Health Human Resources Unit. (2000). Place of Graduation 99: A status report on place of graduation for selected health personnel in the province of British Columbia [Electronic version]. Health Human Resources Unit, Centre for Health Services and Policy Research. The University of British Columbia. (Rep. No. HHRU 00:10). Vancouver, BC: The University of British Columbia. Retrieved April 6, 2002, from

Health Human Resources Unit. (2001). Inventory update 00: A regional analysis of health personnel in the province of British Columbia [Electronic version]. Health Human Resources Unit, Centre for Health Services and Policy Research. The University of British Columbia. (Rep. No. HHRU 01:6). Vancouver, BC: The University of British Columbia. Retrieved April 6, 2002, from

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Hiscott, R. D. (1991). Employment mobility of Ontario nursing professionals: Data analysis report 1984–1989. Part 1 – Registered nurses. The Ontario Nursing Human Resources Data Centre. The College of Nurses of Ontario and the Centre for Applied Health Research, University of Waterloo. Waterloo, Ontario: University of Waterloo.

Human Resources Development Canada. (2001, December 7). Mobility now easier for workers across Canada: Qualifications becoming more readily recognized across jurisdictions [Electronic version]. News Release. Forum of Labour Market Ministers (Federal-Provincial-Territorial). Ottawa, Canada: Human Resources Development Canada. Retrieved April 4, 2002, from

Human Resources Development Canada. (2002a). Report on implementation of the labour mobility chapter of the Agreement on Internal Trade [Electronic version]. (Rep. No. SP-428- 10-01E). Forum of Labour Market Ministers, Canada. Retrieved July 8, 2002, from

Human Resources Development Canada. (2002b). Labour mobility: What is labour mobility? Retrieved July 8, 2002, from

Jones, C. (1990). Staff nurse turnover costs: Part 1, A conceptual model. Journal of Nursing Administration, 20(4), 18–23.

Kazanjian, A. (2000). Nursing Workforce Study: Changes in the Nursing Workforce and Policy Implications, 5 [Electronic version]. Health Human Resources Unit, Centre for Health Services and Policy Research. The University of British Columbia. (Rep. No. HHRU 00:7). Vancouver, BC: The University of British Columbia. Retrieved April 6, 2002, from

Kazanjian, A., Wood, L., Yip, H., Rahim-Jamal, S., & MacDonald, A. (2000). Nursing workforce study: The supply of nursing personnel in Canada, II [Electronic version]. Health Human Resources Unit, Centre for Health Services and Policy Research. The University of British Columbia. Vancouver, BC: The University of British Columbia. Retrieved April 6, 2002, from

Licensed Practical Nurses Labour Mobility Consortium. (2001a, October). Licensed practical nurses mutual recognition agreement: Labour mobility. Unpublished Standards.

Licensed Practical Nurses Labour Mobility Consortium. (2001b, October). Standards: A framework for practical nurse registration standard: Labour mobility. Unpublished Standards.

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Lin, Z. (1995). Interprovincial labour mobility in Canada: The role of unemployment insurance, social assistance [Electronic version]. (Rep. No. IN-AH-220E-08-95). Ottawa, Canada: Human Resources Development Canada. Retrieved August 7, 2002, from

Lin, Z. (1998). Foreign-born vs. native-born Canadians: A comparison of their inter-provincial labour mobility [Electronic version]. Analytical Branch Research Paper Series. (Cat. No. 11F0019ME, No.114). (ISBN 0660-17529-0). Ottawa, Canada: Statistics Canada. Retrieved August 7, 2002, from

Ministry of Health Planning, Government of British Columbia (March, 2000). Assess and intervene: Report to the Minister of Health on the recruitment and retention of registered nurses and registered psychiatric nurses in British Columbia. Appendix 5 — Qualitative study of RNs leaving/intending to leave nursing jobs in BC [Electronic version]. Report to the Minister of Health, Ministry of Health Planning, Government of British Columbia. Victoria, BC: Government of British Columbia. Retrieved September 9, 2002, from

O’Brien-Pallas, L., Baumann, A., & Lochhass-Gerlach, J. (1998). Health human resources: A preliminary analysis of nursing personnel in Ontario. Toronto, Canada: Nursing Effectiveness, Utilization & Outcomes Research Unit, University of Toronto and McMaster University.

Psychiatric Nursing Education. (2000). Psychiatric nursing education: A program for Saskatchewan [Electronic version]. Registered Psychiatric Nurses of Saskatchewan. Regina, Saskatchewan: Registered Psychiatric Nurses of Saskatchewan. Retrieved September 19, 2003, from

Registered Nurses Association of Ontario. (2001). Earning their return: When & why Ontario RNs left Canada and what will bring them back [Electronic version]. Toronto, Canada: Registered Nurses Association of Ontario. Retrieved May 2002, from

Shields, M., & Ward, M. (2001). Improving nurse retention in the National Health Service in England. The impact of job satisfaction on intention to quit. Journal of Health Economics, 20, 677–701.

Statistics Canada. (1997). 1996 Census — Population: Mobility and migration. Ottawa, Canada: Statistics Canada. Retrieved September 9, 2002, from

Statistics Canada. (2002a). A profile of the Canadian population: Where we live. Highlights from the 2001 Census of Population [Electronic version]. 2001 Census Analysis Series. (Cat. No. 96F0030XIE010012001). Ottawa, Canada: Statistics Canada. Retrieved September 13, 2002, from

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Statistics Canada. (2002b). Profile of the Canadian population by mobility status: Canada, a nation on the move [Electronic version]. 2001 Census Analysis Series. (Cat. No. 96F0030XIE2001006). Ottawa, Canada: Statistics Canada. Retrieved December 10, 2002, from

Tai, T. W., Bame, S. I., & Robinson, C. D. (1998). Review of nursing turnover research. 1977–1996. Social Science and Medicine, 47(12), 1905–24.

Unruh, L. (2003). The effect of LPN reductions on RN patient load. JONA, 33(4), 201–208.

Vachon, M., & Vaillancourt, F. (1999). Interprovincial mobility in Canada, 1961–1996: Importance and destination. In H. Lazar & T. McIntosh (Eds.), Canada: The state of the federation 1998/99: How Canadians connect (pp. 101–122). : McGill-Queen’s University Press.

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Appendix A. Main Search Method

KEY WORDS AND PHRASES Note: All key words and phrases were used to search for data for each of the three regulated nursing professions: Registered Nurses, Licensed/Registered Practical Nurses, and Registered Psychiatric Nurses. As differing titles were found in the general search, they were then also used as search words. This list below is not a comprehensive list.

Immigration Nurse emigration Inter-provincial migration of nurses Nurse migration Labour mobility in Canada Nurse mobility Licensed Practical Nurse(s) Registered Nurse(s) Migration of nurses Registered Psychiatric Nurse(s) Migration patterns of nurses in Canada

SOURCES Databases CIHI Registered Nurses Database 2001 Electronic Databases at McMaster University: Health Sciences Library, Mills Library

Published CINAHL Literature HealthSTAR/Ovid Journals at Ovid MEDLINE

Grey Copernic Pro 2001 software (Search Tool) Literature Canadian Census Canadian Federation of Nurses Unions Canadian Institute for Health Information Canadian Nurses Association Canadian Nurses Association: Highlights of 2001 Nursing Statistics Canadian RN Directory CBC News Backgrounder CIHI Unique Identifier definition Definition for Registered Nurses Definition for Registered Psychiatric Nurses Health Canada Highlights from the Canadian Census 2001 Human Resource Development Canada

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International Council of Nurses a) b) Licensed Practical Nurses: Nursing Index for Links to Education, Employment, Hospitals, Literature, Organizations Ontario Nurses Act for definition of nurse: no longer accessible Provincial and Territorial Ministries of Health, Statistics Canada Registered Nurses and Registered Psychiatric Nurses a) Statistics Canada for Standard Occupational Classifications Statistics Canada: Census 1996 < http://www.statcan.ca/english/census96/nation.htm> Statistics Canada: Definitions of Mobility Statistics Canada: Job Tenure, Worker Mobility Statistics Canada: Profile of the Canadian population by mobility status: Canada, a nation on the move

Research Canadian Health Services Research Foundation Centres Canadian Policy Research Network Centre for Health Services and Policy Research (CHSPR) Institute of Intergovernmental Relations The Canadian Centre for Policy Alternatives The Canadian Council on Social Development The Centre for Health Economics and Policy Analysis The Institute for Social Research The Manitoba Centre for Health Policy

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The University of Toronto Ethnic Immigration and Pluralism Studies

Nursing See Appendix B for list of websites accessed for information. Associations

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Appendix B. Nursing Association Web sites

These Web sites were accessed for out-of-jurisdiction information.

Association Web site Accessed

BC Registered Nurses Association of British Columbia http://www.rnabc.bc.ca Aug. 7, 2002 College of Licensed Practical Nurses of British Columbia http://www.clpn.bc.ca/ Nov. 19, 2002 College of Registered Psychiatric Nurses of British http://www.crpnbc.bc.ca/ Nov. 19, 2002 Columbia

AB Alberta Association of Registered Nurses http://www.nurses.ab.ca/ July 5, 2002 College of Licensed Practical Nurses of Alberta http://www.clpna.com/ Nov. 19, 2002 Registered Psychiatric Nurses Association of Alberta http://ux.rpnaa.ab.ca/registration/ Nov. 19, 2002

SK Saskatchewan Registered Nurses’ Association http://www.srna.org/ July 5, 2002 Saskatchewan Association of Licensed Practical Nurses http://www.salpn.com/ Nov. 19, 2002 Registered Psychiatric Nurses Association of http://www.rpnas.com/ Nov. 19, 2002 Saskatchewan

MB College of Registered Nurses of Manitoba http://www.crnm.mb.ca/reg.htm July 5, 2002 College of Licensed Practical Nurses of Manitoba http://www.clpnm.ca/ Nov. 19, 2002 College of Registered Psychiatric Nurses of Manitoba http://www.crpnm.mb.ca/ Nov. 19, 2002

ON College of Nurses of Ontario http://www.cno.org/ July 5, 2002 College of Licensed Practical Nurses of Ontario http://www.rpnao.org/home.asp Nov. 19, 2002

QCa Ordre des infirmières et infirmiers du Québec http://www.oiiq.org/ July 5, 2002 Ordre des infirmières et infirmiers auxiliaires du Québec http://www.oiiaq.org/ Nov. 19, 2002

NB Nurses Association of New Brunswick http://www.nanb.nb.ca/ July 5, 2002 The Association of Licensed Practical Nurses of New http://www.anblpn.com/ Nov. 19, 2002 Brunswick

NS College of Registered Nurses of Nova Scotia http://www.crnns.ca/ July 5, 2002 The College of Licensed Practical Nurses of Nova Scotia http://www.clpnns.ns.ca Nov. 19, 2002

PE The Association of Nurses of Prince Edward Island http://www.iwPE.com/nurses/ July 5, 2002 general.html Prince Edward Island Licensed Nursing Assistants http://www.peilpn.com/ Aug. 22, 2002

NL Association of Registered Nurses of Newfoundland and http://www.arnn.nf.ca/links/ July 5, 2002 Labrador criteria_for_arnn_licensure.htm Licensed Nursing Assistants of Newfoundland and http://www.nlhba.nf.ca Nov. 19, 2002 Labrador

NT Northwest Territories Registered Nurses Association http://www.nwtrna.com July 5, 2002 NU (includes NU) Licensed Practical Nurses of the Northwest Territories No Web site available Nov. 19, 2002 Nunavut, Health and Social Services, Government of NWT http://www.hlthss.gov.nt.ca/ Feb. 13, 2003

YT Yukon Registered Nurses Association Email only [email protected] July 5, 2002 Licensed Practical Nurses of the Yukon Territory No Web site available Aug. 7, 2002 aQuebec nursing associations’ Web sites are not accessible in English.

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Appendix C. Limitations of Data

Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated)

Source: Canadian Institute for Health Information (CIHI) (Data through annual nursing registration renewals) • Registered Nurses Database: Workforce Trends of Registered Nurses in Canada, 2002 (CIHI, 2003a) • Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002 (CIHI, 2003b) • Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2002 (CIHI, 2003c)

1. The target population for each database is all nurses submitting active-practising registrations in a Canadian jurisdiction, one of the four provinces in Western Canada for RPNS, in the first six months of the jurisdiction’s registration/licensure year (CIHI 2003a, 2003b, 2003c). It excludes those nurses with associate or non-practising registration, those not employed in nursing, those failing to state their employment status, the potential nurse supply, Canadian-born nurses working outside of Canada, those who have left the workforce, or who do not voluntarily terminate their memberships. CIHI did institute a new validation procedure in 2001 to improve data quality (CIHI, 2003a, 2003b, 2003c).

2. The RNDB, LPNDB, and RPNDB systematically undercount the numbers of nurses, and the CIHI figures differ from the year-end statistics released by the jurisdictional authorities (CIHI, 2003a, 2003b, 2003c). Although, in the first six months CIHI receives approximately 95% to 99% of all RN records and 94.9% of LPN records, and 95% of RPN records because most nurses renew their registration one to two months prior to the registration period (CIHI, 2003a, 2003b, 2003c).

3. Registration forms per jurisdiction are non-uniform, although there are 20 agreed upon data elements for RNs, 29 for LPNs, and 31 for RPNs. Data collecting is the responsibility of the regulatory authority in each jurisdiction and these data are considered to be reliable by CIHI (2003a, 2003b, 2003c).

4. Data are an estimate and represent only 84.7% of the total number of active-practising RN registrations received by the jurisdictions during the registration year (CIHI, 2003a). Approximately 85.8% of all LPN registrations are identified as non-duplicates, employed in practical nursing, and included in the database (CIHI, 2003b). Approximately 95% of the total number of active-practising RPN registrations received by the jurisdictions during the registration year are reported in the CIHI RPNDB (CIHI, 2003c).

5. Annual registration data are not linked from year to year for individual nurses and data are not comparable year to year due to recent changes in collection and methodology.

6. Due to changes in methodology, data from the provinces cannot be compared with data from the territories. Provincial data can be compared with provincial data only and territorial data with territorial data (CIHI, 2003a, 2003b).

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Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated) 7. Data collected by a third party are subject to increased chances for error, as the information may not be entered accurately or classified or coded properly. The information submitted from the jurisdictions is not verified as correct and is manually entered into a system and submitted to CIHI in a standardized format for each database. The data entry accuracy is unknown, as an audit of data entry accuracy had not been completed as of publication date (CIHI, 2003a, 2003b, 2003c).

8. It is possible to be registered in two jurisdictions concurrently, leading to over-counting. CIHI (2003a, 2003b, 2003c) identifies records that do not reflect the primary jurisdiction of employment and removes inter-provincial duplicates.

9. Data from the territories included duplicate registration data from RNs and LPNs registered in other Canadian jurisdictions, leading to over-counting of RNs and LPNs in territorial data, although this is necessary to present more accurate territorial data (CIHI, 2003a, 2003b). The change in methodology for the territories does not impact the provincial data; it is only the territorial data that include both duplicate and non-duplicate RNs and LPNs employed in nursing (CIHI, 2003a, 2003b).

10. Elimination of nurses living abroad and inter-provincial duplicates introduces errors, for example, nurses living in the US and working in Canada would be erroneously removed as living abroad and nurses working temporarily in a northern territory and registered in a province would be removed as duplicates (although this leads to more accurate representation of territorial data; CIHI, 2003a, 2003b).

11. Data are not collected about nurses who emigrate to other countries (CIHI, 2003a, 2003b, 2003c). If a nurse does not retain registration in Canada, he/she cannot be tracked when he/she leaves Canada for another country.

12. RNs can be registered but actually unavailable for employment in nursing (O’Brien-Pallas, Baumann, & Lochhass-Gerlach, 1998).

13. CIHI (2003a, 2003b, 2003c) identifies many limitations for nurses. a. There is incomplete data on nurses living and working outside of Canada (unless they retain Canadian licensure). b. There is a lack of a comprehensive data source (either in the US or Canada) for Canadian RNs and LPNs going to the US. c. Data are sent from jurisdictional regulating authorities and are self-reported, which presents inherent reliability issues (although specific validity and logic tests have been conducted with the 2002 data). d. The data entry accuracy is unknown, and information on annual registration forms is not verified for accuracy. e. Data are collected using pre-printed forms, which remain unchanged unless changed by the registrant.

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Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated) f. A nurse who moves will not be counted as employed in his/her new jurisdiction until the beginning of the annual registration, if she/he moves after the six-month data collection time. g. Data collected after the six-month mark were deleted, leading to undercounting of nurses. h. A nurse living in one jurisdiction at the beginning of the year who moves and registers in another jurisdiction one to six months later would be deleted as a duplicate. i. A nurse who registers in one jurisdiction and then moves to another jurisdiction after having been counted in the original jurisdiction would be counted twice (over counting) if the nurse moves within the tracking period (usually the first six months). j. A nurse not working in nursing who registers in a region other than the province of residence will be deleted as a duplicate. k. Intra-provincial mobility is not tracked because a secondary registration would not be required for the same jurisdiction.

14. CIHI (2003a, 2003b, 2003c) identifies the difficulty that arises because of varying definitions used by various agencies: the data may vary according to the definition and therefore reported numbers and percentages differ, which may be confusing.

15. There are several comparability limitations in the 2002 data, in both provincial and territorial data, identified by CIHI (2003a, 2003b, 2003c).

16. RPNs may be registered in one of the four Western Canadian provinces and be employed in nursing outside of these provinces. These RPNs are included in the RPNDB even though they are employed outside of these four provinces (CIHI, 2003c).

17. CIHI (2003a, 2003b, 2003c) also identifies limitations of comparability of data with other sources, for example, differences in definitions, in data cleaning, editing, and processing, and in collection periods for data.

18. Nurses who are graduates of international nursing schools may be Canadians who migrated for education and were simply returning to Canada to practise (CIHI, 2003a, 2003b, 2003c); similarly, nurses from Canadian schools of nursing may include some students from foreign countries who came to Canada for nursing education (CIHI, 2003a, 2003b, 2003c).

19. The place of graduation is compared against the place of registration and is only an indicator of migration, not an accurate measure (CIHI, 2003a, 2003b, 2003c). CIHI is able to track only those nurses who remain in the country and are employed in nursing.

20. Data cannot be linked to other data sets; there is no national unique identifier (CIHI, 2001b). New identification numbers for nurses are assigned in each jurisdiction and are not linked when nurses migrate nationally or internationally, which leads to miscounted totals and inaccurate numbers regarding mobility (CIHI, 2003a, 2003b, 2003c).

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Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated) 21. Historical data are not available for LPNs and RPNs as 2002 was the first year of data collection (2003b, 2003c). Data from 2002 databases cannot be compared with data from previous years or databases (for example, Statistics Canada’s Labour Force Survey; CIHI, 2003b).

22. Over-counting can occur in LPN and RPN data if the file submission to CIHI includes non- practising members; some jurisdictions may include non-practising registration in reported totals (CIHI, 2003b, 2003c).

Source: Centre for Health Services and Policy Research: Health Human Resources Unit (HHRU), The University of British Columbia • Nursing Workforce Study (Kazanjian, 2000) (data through annual registration forms, survey, request from nursing regulatory bodies)

23. Information about nurses is based on data collected through annual registration forms (same limitations as above).

24. Incomplete data are used because certain jurisdictions did not provide data for research.

25. Due to incomplete data, there is minimal comparison possible between the two points in time compared (1990 and 1997).

26. There was no nationally collected data on LPNs and RPNs, and no standardized format for data collection and storage (Kazanjian et al., 2000).

27. There is no national unique identifier (Kazanjian et al., 2000).

28. It was “impossible to track inter-jurisdictional movement of nursing personnel in a precise manner” (Kazanjian et al., 2000, p. 2).

29. Estimates of movement of nursing personnel do not link out-migration from one jurisdiction to in-migration in another jurisdiction (Kazanjian et al., 2000).

30. Canadian nurses who leave Canada for a time, and then return to a different jurisdiction than the one previously left and registered in will be counted as an international in-migrant (and not someone previously registered in Canada) (Kazanjian et al., 2000).

31. Nurses who leave Canada will be counted only if they choose to retain registration in a Canadian jurisdiction (Kazanjian et al., 2000).

32. Other limitations of annual nurse registration are the following: a. Nurses relocating to one place and back to their original jurisdiction before annual registration is due will not be counted as having relocated.

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Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated) b. A nurse can relocate before the end of a registration year and will be counted as a member and not having relocated unless the nurse specifically terminates his/her membership (which is unusual). c. Members can register as non-practising if not employed in nursing and still retain membership. d. “None of the registration databases can be considered to be comprehensive of all individuals who have been employed in nursing in any one jurisdiction during any calendar year” (Kazanjian et al., 2000, p. 2). e. The registration reflects the member’s current status and is not updated until the next registration, if the nurse changes the inaccurate or changed portions of the pre-printed registration form. If the nurse does not make the necessary changes, the pre-printed data will be submitted regardless of accuracy (Kazanjian et al., 2000). f. “Surveys may not be the most effective or efficient method of collecting crucial information about employment practices and employer needs.” (Kazanjian, 2000, p. 11).

Source: Statistics Canada • Statistics Canada Census (Questionnaire to household addresses in Canada)

33. The census is conducted at a single point in time and some people are not counted or are counted twice due to various reasons, such as not counting a boarder in a home or people without a permanent residence, some households not receiving a questionnaire.

Source: Nursing associations or regulatory bodies in all applicable jurisdictions in Canada • Requests for registration verification of credentials

34. Some registrars did not provide requested data; others did not respond at all to the request for information.

35. Some jurisdictions track migration as a total number.

36. Few jurisdictions track where verification requests originate.

37. Few track actual in-migration to the jurisdiction.

38. Very few track out-migration from the jurisdiction.

39. There is confusion with some data as to whether registration verifications were for those nurses wanting to leave the jurisdiction or those wanting to consider relocation to the jurisdiction.

40. The number of nurses who actually migrate is not the same as the number who request registration verification; therefore, this is only a very rough estimate of nurses considering their options for relocation.

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Limitations of Data (Below nurse refers to RNs, LPNs, and RPNs, unless otherwise stated) 41. Other limitations when requesting data from the jurisdictional regulating bodies are that they can and do refuse to participate in research, refuse to share data, and some do not respond to requests for data at all (Kazanjian et al., 2000).

Source: Internet using Copernic Pro 2001 — a software search tool that searches other search engines, for example Google • Literature review

42. Internet information is not verifiable.

43. Several links are no longer available as Web sites are altered and updated.

44. Internet addresses are at times difficult to find (i.e., the link does not work or does not go directly to the document).

45. Web sites are frequently difficult to navigate, confusing, lack important information, or direct the user to contact the organization either by e-mail or by the postal system.

Source: Databases • Overall research

46. Databases are not cross-referenced or linked, which hampers in-depth analysis, monitoring and human resource planning (Ministry of Health Planning, 2000, p. 68).

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Appendix D. Source of RNs per Workforce, by Province/Territory of Registration, 2001

Graduation Provincial/territorial workforce for 2001 prov./terr. % BC AB SK MB ON QC NB NS PE NL YTa NTa NUa BC 55.4 3.0 0.9 0.8 0.5 – 0.3 0.6 * 0.1 16.1 7.9 10.1 AB 7.8 65.5 5.5 1.2 0.5 – 0.3 0.7 0.7 0.5 18.7 17.4 8.7 SK 3.7 7.4 81.5 2.6 0.4 – 0.1 ** 0.5 * 7.7 8.3 6.9 MB 3.9 3.9 4.1 83.6 0.8 ** 0.2 0.7 0.6 * 7.7 6.8 10.8 ON 9.5 7.6 2.8 4.6 81.4 1.1 2.5 4.7 3.8 1.7 31.5 20.8 25.7 QC 2.0 1.2 0.2 0.5 3.1 95.8 3.8 1.3 0.7 0.3 3.3 ** ** NB 0.7 0.5 ** 0.5 0.7 0.6 85.4 5.0 6.9 0.5 * 3.0 5.2 NS 1.2 1.3 0.2 0.5 1.0 – 4.2 77.8 10.9 1.5 5.5 5.3 6.6 PE ** ** 0.1 – ** * 0.6 1.4 71.9 0.1 * * 0.0 NL 0.8 1.7 0.2 ** .0.7 – 1.2 5.2 1.8 92.8 * 9.3 9.4 NT * * * * * 0.0 0.0 * 0.0 0.0 0.0 8.3 * Otherb 14.6 10.4 4.3 5.0 10.8 2.2 1.3 2.4 1.8 2.4 6.2 10.0 13.2

Source: Table adapted with permission from Supply and Distribution of Registered Nurses in Canada, 2001. Published by the Canadian Institute for Health Information, Ottawa, Canada. Note. * = Value suppressed in accordance with CIHI privacy policy. ** = Value suppressed to ensure confidentiality. aTerritories data include inter-provincial duplicates employed in nursing. There are no RN education programs in the Yukon Territory or Nunavut. bOther = foreign and not stated.

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Appendix E. Retention and Mobility of RNs per Workforce, 2001

Prov./terr. of Province/territory of graduation registration % BC AB SK MB ON QC NB NS PE NL NT BC 91.4 12.1 10.0 9.2 3.6 0.9 2.5 3.9 ** 3.3 * AB 4.2 80.6 16.8 7.7 2.4 0.5 1.4 3.3 ** 5.7 * SK 0.4 2.5 66.0 2.9 0.3 – 0.1 0.2 ** 0.3 * MB 0.5 0.7 2.6 73.3 0.7 0.1 0.6 0.6 ** 0.8 * ON 2.2 2.5 3.2 5.2 90.7 4.2 6.7 8.9 7.7 8.4 * QC ** 0.1 0.3 0.3 0.9 93.6 4.5 0.3 * 0.3 0.0 NB 0.1 0.1 0.1 0.2 0.3 0.5 77.1 3.6 3.3 1.3 0.0 NS 0.3 0.3 ** 0.5 0.6 0.2 5.2 76.0 8.9 6.4 * PE * – 0.1 ** 0.1 – 1.1 1.6 69.5 ** 0.0 NL – 0.2 * * 0.1 – 0.3 1.0 0.6 72.3 0.0 YTa 0.3 0.3 0.2 0.2 0.1 – * 0.2 * * 0.0 NTa 0.2 0.5 0.4 0.3 0.1 – ** 0.3 * 0.6 73.6 NUa 0.2 0.1 0.2 0.3 0.1 – ** 0.2 0.0 0.4 *

Source: Table adapted with permission from Supply and Distribution of Registered Nurses in Canada, 2001. Published by the Canadian Institute for Health Information, Ottawa, Canada. Note. * = Value suppressed in accordance with CIHI privacy policy. ** = Value suppressed to ensure confidentiality. aTerritories data include inter-provincial duplicates employed in nursing. There are no RN education programs in the Yukon Territory or Nunavut.

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Appendix F. Estimated RN Migration Based on Requests for Verification of Credentials in 2001

Intended destination Province/territory of origin of request Total requests BC AB SK MB ON QC NB NS PE NL YT NT BC 1,794 – – – – – – – – – – – AB 786 – – – – – – – – – – – SKa 68 5 28 16 14 2 1 0 0 2 0 0 MB n/r – – – – – – – – – – – ONb 715 – – – – – – – – – – – QC n/s – – – – – – – – – – – NB 235 27 37 2 7 58 12 54 19 8 1 10 NS 344 39 97 2 18 53 3 37 32 37 2 24 PE 61 2 16 1 2 6 1 8 16 7 – 2 NLc 200 – – – – – – – – – – – YT 47 17 16 1 1 – – 3 2 – – 7 NTd 147 – – – – – – – – – – –

Source: RN regulatory bodies (See Appendix B). Note. n/r = not retained; n/s = not submitted. aSaskatchewan numbers represent the number of registrations that were endorsed from other provinces without further requests. bOntario number from 2001 annual report numbers is inconsistent with other reports (CNA, 2002). cNL RN Supply Report 2000/2001, Health and Community Services Resource Sector Study. dNorthwest Territories data include Nunavut.

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Appendix G. Actual Inter-jurisdictional Mobility of New Registrant RNs, by Endorsement and by Examination, 1999 to 2002

1999 2000 2001 2002

BC 326 1 327 333 0 333 361 1 362 298 1 299 AB 388 0 388 350 0 350 526 0 526 498 0 498 SK 135 0 135 97 0 97 68 0 68 93 0 93 MB 136 0 136 116 0 116 0 0 0 66 0 66 ON 315 107 422 615 0 615 415 0 415 399 231 630 QC 64 0 64 52 0 52 53 2 55 242 2 244 NB 67 0 67 76 2 78 53 0 53 65 20 85 NS 150 0 150 103 0 103 133 1 134 143 0 143 PE 21 0 21 31 0 31 52 0 52 56 0 56 NL 36 0 36 39 0 39 33 0 33 27 0 27 YT 74 – 74 44 – 44 33 0 33 37 – 37 NT 74 0 74 162 0 162 0 0 0 72 0 72

Source: Canadian Nurses Association (2002) (used with permission from the CNA, July 21, 2003). Note. With endorsement, the licence from another jurisdiction is accepted and a licence is issued for new jurisdiction. With examination, the RN needs to write the licensing exam that is written on graduation from a nursing program.

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Appendix H. Estimated LPN Migration Based on Requests for Verification of Credentials in 2001

Intended destination Province/territory of origin of request Total requests BC AB SK MB ON QC NB NS PE NL YT NT BC 136 – – – – – – – – – – – – ABa 106 69 10 4 13 0 1 2 1 2 0 4 SK 45 11 30 2 1 – – – – – – 1 MBb 15 1 3 2 8 – – 1 – – – – ON 210 – – – – – – – – – – – QC n/s – – – – – – – – – – – NB 38 6 8 0 2 10 – 7 3 2 – – NS 74 10 12 – 5 25 – 11 1 4 – 6 PEc 4 – 1 – – 1 – 1 1 – – – NL 36 3 14 – – 8 – 4 5 – – 2 YT n/r – – – – – – – – – – – NT 11 4 4 1 2 – – – – – – –

Source: LPN regulatory bodies (See Appendix B). Note. n/r = not retained. n/s = not submitted. Data for Nunavut not submitted. aAlberta reported 210 total — actual numbers add up to 106. bManitoba actual numbers of LPN in-migration. cPrince Edward Island applied for and received licensure.

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Appendix I. Actual LPN Inter-jurisdictional Mobility, 2001

Destination Source jurisdiction jurisdiction BC AB SK MB ON QC NB NS PE NL YT NT Totals AB 9 11 10 18 4 4 10 – 4 1 – 71 SK 1 12 3 4 1 – – – 1 – – 22 MB 1 3 2 8 – – 1 – – – – 15 ONa – – – – – – – – – – – 121 NBa – – – – – – – – – – – 16 NS 2 2 1 – 10 1 8 2 3 – – 29

Source: Provincial regulatory bodies (See Appendix B). aSpecific source jurisdictions not given.

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Appendix J. Estimated RPN Migration Based on Requests for Verification of Credentials in 2001

Province requesting verification Province receiving request BC AB SK MB

MB (2001) For immigration 3 – 3 For emigration 5 8 4 SK (2002) For immigration – 2 1 For emigration – 5 5

Sources: College of Registered Psychiatric Nurses of Manitoba; Registered Psychiatric Nurses Association of Saskatchewan.

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Appendix K. Actual RPN Inter-provincial Mobility, 1998–2003

To BC To SK To MB To AB AB SK MB BC AB SK BC AB MB BC SK MB 1998 4 3 2 0 0 3 0 2 1 0 0 0 1999 4 3 4 0 0 1 1 4 3 0 0 0 2000 3 7 2 2 1 2 0 3 2 6 10 5 2001 6 5 6 0 0 3 0 2 5 4 23 5 2002 7 0 1 1 2 1 0 11 0 6 4 2 2003 0 2 2 1 0 0 1 1 0 1 2 1 Totals 24 20 17 4 3 10 2 23 11 17 39 13 61 17 36 69

Source: A. Osted, College of Registered Psychiatric Nurses of Manitoba, personal communication, September 2, 2003.

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Appendix L. Salaries for Nurses (RNs, LPNs and RPNs)

Appendix L-1: Samples of Salaries for RNs

Pay Dollars / hour Annual incomea Hours/ Agreement / specific facility Year scale week level Min. Max. Min. Max. BC Lifestyle Retirement Communities 2003 6 $24.43 $27.10 $47,638 $52,845 37.50 Ltd. – B.C. Government and Service Employees’ Union

British Columbia Nurses’ Union 2002 9 $24.70 $32.42 $46,416 $60,923 36.00 East Central Regional Health Authority 2000 7 $20.05 $24.06 $36,491 $43,789 35.00 7 – Alberta Union of Provincial Employees

AB Alberta Mental Health Board – Alberta 2000 8 $20.28 $24.86 $38,227 $46,861 36.25 Union of Provincial Employees

United Nurses of Alberta 2002 9 $24.70 $32.42 $47,449 $62,279 37.00 SK The Saskatchewan Cancer Agency – 2000 5 $19.89 $24.17 $37,493 $45,560 36.25 Saskatchewan Government and General Employees’ Union

Saskatchewan Union of Nurses 2002 5 $21.34 $25.92 $41,587 $50,512 37.50 MB Golden Door Geriatric Centre – 2003 6 $20.22 $24.54 $42,057 $51,043 40.00 Manitoba Government Employees’ Union

Manitoba Nurses’ Union 2002 6 $21.48 $25.33 $43,286 $51,030 38.80 ON Registered Nurses’Association of 2002 9 $21.75 $32.71 $42,412 $63,784 37.50 Ontario

QCb 1. FIIQ 2003 18 $18.64 $34.32 $35,143 $64,707 36.25 2. FIIQ 2003 12 $17.89 $26.65 $33,723 $50,235 36.25 NB New Brunswick Nurses Union 2002 6 $20.16 $24.53 $39,463 $48,017 37.60 Nova Scotia Nurses Union 2002 6 $22.35 $26.22 $43,572 $51,123 37.50 NS Capital District Health Authority – Nova 2002 6 $23.46 $27.53 $45,751 $53,679 37.50 Scotia Government and General Employees Union

PE PEI Nurses’ Union 2002 6 $19.35 $23.58 $37,733 $45,981 37.50 NL Newfoundland/ Labrador Nurses’ 2002 7 $20.05 $25.62 $39,104 $49,965 37.50 Union aAnnual Income = Hours per Week x 52 x Dollars per Hour. bSource: Collective conventions (Fédération des infirmières et infirmiers du Québec (FIIQ) and Quebec Union of Nurses and Nurses Aids (UQIIA): 1. for Infirmière Bachelière (Baccalaureate Nurse); 2. for Infirmière (Nurse). Data compiled by the Association of Nurses and Nurses’Aides of Quebec. (Gaétan Lévesque, personal communication, September 12, 2003).

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Appendix L-2: Samples of Salaries for LPNs

Agreement / specific facility Year Pay Dollars / hour Annual incomea Hours/ scale week level Min. Max. Min. Max.

BC H & H Total Care Services – B.C. 2003 4 $17.75 $18.75 $32,305 $34,125 35.00 Government and Service Employees’ Union

Lifestyle Retirement Communities Ltd 2003 4 $17.80 $19.70 $34,710 $38,415 37.50 – B.C. Government and Service Employees’ Union

AB Westview Regional Health Authority – 2000 6 $12.96 $15.57 $23,587 $31,049 35.00 Alberta Union of Provincial Employees

East Central Regional Health Authority 2000 7 $13.17 $17.06 $23,969 $31,049 35.00 – Alberta Union of Provincial Employees

Keeweetinok Lakes Regional Health 1999 6 $12.21 $14.68 $22,222 $26,717 35.00 Authority #15 – Alberta Union of Provincial Employees

Capital Health Authority/Caritas Health 1999 6 $12.45 $15.07 $25,086 $30,366 38.75 Group – Alberta Union of Provincial Employees SK Saskatchewan Association of Health Organizations – Saskatchewan Government and General Employees’ Union

1. Melfort Hospital 2001 6 $15.35 $16.25 $29,796 $31,543 37.60 2. Parkland Care Centre 1999 5 $13.72 $14.73 $26,868 $28,846 37.60 3. Chateau Providence 1999 3 $14.00 $14.92 $27,416 $29,218 37.60 4. North Central Health District 2000 4 $15.35 $16.25 $29,796 $31,543 37.30 MB Golden Door Geriatric Centre – 2003 6 $15.48 $18.92 $23,198 $39,353 40.00 Manitoba Government Employees’ Union

QCb UQIIA 2003 10 $15.10 $19.82 $24,464 $37,361 36.25 NS Capital District Health Authority – Nova 2002 6 $15.47 $17.38 $28,155 $31,631 35.00 Scotia Government and General Employees’ Union

PE PEI Nurses’ Union 2002 – $16.16 $17.58 $31,512 $34,281 – NL Newfoundland/Labrador Nurses’ Union 2002 – $16.37 $18.16 $31,930 $35,406 – aAnnual Income = Hours per Week x 52 x Dollars per Hour. bSource: Collective conventions Fédération des infirmières et infirmiers du Québec (FIIQ) and Quebec Union of Nurses and Nurses’Aides (UQIIA) for Infirmière Auxilliare (Nurses Aid). Data compiled by the Association of Nurses and Nurses’Aides of Quebec. (Gaétan Lévesque, personal communication, September 12, 2003).

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Appendix L-3: Samples of Salaries for RPNs

Agreement / specific facility Year Pay Dollars / hour Annual incomea Hours/ scale week level Min. Max. Min. Max. BC Health Employers Association of British 2003 4 $25.07 $39.70 $46,931 $74,318 36.00 Columbia – Nurses’ Bargaining Association Union of Psychiatric Nurses 2003 6 $24.39 $38.50 $45,658 $72,072 36.00 AB Alberta Mental Health Board – Alberta 2000 8 $20.28 $24.86 $38,227 $46,861 36.25 Union of Provincial Employees The East Central Regional Health 2000 7 $20.05 $24.06 $36,491 $43,789 35.00 Authority 7 – Alberta Union of Provincial Employees MB Golden Door Geriatric Centre – 2003 6 $20.22 $24.54 $42,057 $51,043 40.00 Manitoba Government Employees’ Union aAnnual Income = Hours per Week x 52 x Dollars per Hour.

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Appendix M. Acronyms

See Appendix O for acronyms used for provinces.

CIHI ...... Canadian Institute for Health Information CNA ...... Canadian Nurses Association CNO ...... College of Nurses of Ontario HHRU ...... Health Human Resources Unit, University of British Columbia HRDC ...... Human Resources Development Canada ICN ...... International Council of Nurses RN...... registered nurse RNDB ...... Registered Nurses Database LPN...... licensed practical nurse LPNDB ...... Licensed Practical Nurses Database RPN...... registered psychiatric nurse RPNDB ...... Registered Psychiatric Nurses Database

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Appendix N. Glossary of Key Terms

Note: This glossary is meant to indicate only how the following terms are used in this report. It is not meant to provide comprehensive definitions. emigration/out-migration/out-flow. Movement out of a jurisdiction/province/territory. home-educated graduate. Educated in the jurisdiction where currently registered and actively practicing nursing. immigration/in-migration/in-flow. Movement into a jurisdiction/province/territory. inter-jurisdictional/ inter-provincial/ inter-territorial. Between jurisdictions/provinces/territories. intra-jurisdictional/ intra-provincial/intra-territorial. Within a jurisdiction/province/territory. jurisdiction. A province or territory. labour mobility. Situations where workers qualified for work in a particular occupation in one province/territory have access to similar employment opportunities in another Canadian province/territory, which allows the qualified worker to work wherever opportunities exist (Human Resources Development Canada [HRDC], 2002b, p. 1). licensed practical nurse (LPN). LPNs are “regulated health care professionals who work in partnership with other members of the health care team to provide nursing services to individuals, families and groups of all ages. LPNs combine nursing knowledge, skill and judgement when treating health conditions, promoting health, preventing illness and assisting clients to achieve an optimal state of health. They assess, plan, implement and evaluate care for clients throughout the lifecycle as disease progresses and through palliative stages” (“Building the Future”, 2003b). mobility/migration. Movement of people from one place to another. net out-migration. When comparing in-migration and out-migration, more people have migrated from a jurisdiction than migrated into a jurisdiction. nurse. For the purposes of the report, a nurse is a graduate of an accredited nursing program who has passed the requisite licensing examinations and is registered with an appropriate regulatory body. A member of any of the three regulated nursing professional groups in Canada: registered nurses (RNs); licensed practical nurses (LPNs), with the title of registered practical nurses in Ontario; and registered psychiatric nurses (RPNs).

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registered nurse (RN). “Through their legislated scope, RNs are authorized to practice autonomously regardless of the complexity of the client’s/clients’condition(s) or the predictability of the outcomes of care. RNs are diversified health care workers, able to provide care to individuals, families, groups, communities and populations of all ages and levels of health. RNs provide client care across the continuum of health promotion, disease prevention, treatment, support and rehabilitation and palliative care” (“Building the Future”, 2003a). registered psychiatric nurse (RPN). RPNs “participate as members of interdisciplinary health care teams in providing holistic care to client groups in the context of mental and developmental health services. Psychiatric Nursing promotes the restoration of client health and wellness through health promotion initiatives that are evidence based. RPNs practice at all levels of prevention, including primary, secondary, and tertiary health care services across the life span” (“Building the Future”, 2003c)

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Appendix O. Key to Geographical Names and Acronyms

THE NORTH (the territories) NURSING education programs (Referred to in this document as the territories to in the territories avoid confusion with the Northwest Territories.) RNs – One in NT YT Yukon Territory LPNs – One in YK and NT, offered NT Northwest Territories on an occasional basis every NU Nunavut — formerly part of NT, until 1999 two to three years (CIHI, 2003b). It is unknown what percentage the territories contribute to the total LPN workforce. RPNs – None

YT

NT NU

BC

AB NL MB SK

QC PE ON NB NS

WESTERN CANADA CENTRAL CANADA ATLANTIC PROVINCES West Coast Prairie Provinces ON Ontario Maritimes (includes Labrador) BC British Columbia AB Alberta QC Quebec NB New Brunswick SK Saskatchewan PE Prince Edward Island MB Manitoba NS Nova Scotia –––––––––––––––––––––––––––– NL Newfoundland and Labrador — NF until October 2002

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The Research Team

The Nursing Effectiveness, Utilization and Outcomes Research Unit (NRU) has been engaged by The Nursing Sector Study Corporation to conduct research and prepare ensuing reports for Building the Future. The NRU is a network of researchers located in several provinces. The co-directors are as follows.

Linda O’Brien-Pallas, RN, PhD Andrea Baumann, RN, PhD Co-Principal Investigator, NRU Co-Principal Investigator, NRU University of Toronto McMaster University

Collectively NRU investigators have established reputations for conducting high quality research on a variety of issues related to nursing and health human resources. Nationally and internationally, the team has established extensive contacts in education, management, research, practice and policy development. AUTHORS’ BIOGRAPHIES Andrea Baumann, RN, PhD Co-Principal Investigator, NRU, McMaster University Dr. Baumann has authored or edited several books and chapters and has writen many peer-reviewed publications focusing on decision making and nursing. Her most recent work is on investment in human capital. She is the editor for the Journal of Advanced Nursing for the Americas. Dr. Baumann is known internationally for capacity building in educational health services. She is a member of several provincial and national research review committees and was a member of the interim governing council of the Canadian Institutes of Health Research.

Jennifer Blythe, MLS, PhD Senior Scientist, NRU, McMaster University Associate Professor, School of Nursing, McMaster University Dr. Blythe’s academic background includes degrees in anthropology, library and information science, and English language and literature. Dr. Blythe has authored book chapters, periodical articles and reports on human resources, women and work, nursing informatics and social change in Northern and Pacific communities. Her current research interests include innovation and change in health human resources and nurse migration. Recent committee work includes membership of the Hamilton Wentworth Training Board.

Camille Kolotylo, RN, PhD Senior Research Associate, NRU, McMaster University Dr. Kolotylo's previous research includes the study of chronic pain in women with migraine headache. Current interests include nursing human resources research. Camille has co-authored a book chapter and several peer-reviewed publications in the areas of pain and nursing care.

Jane Underwood, RN, MBA Clinical Professor, School of Nursing, McMaster University Professor Underwood’s research foci include the quality of workplace for nurses, roles and skills of professionals in community health, and the use of evidence by public health and community practitioners. She has taken an active role on numerous committees such as the Provincial Public Health Research Education and Development (PHRED) Committee and the Mandatory Programs Measurement Group of the Ontario Ministry of Health and Long-Term Care (MOHLTC), and has been involved in provincial initiatives such as the development of the Healthy Babies, Healthy Children Program. Professor Underwood had published in the area of and health promotion and currently is a reviewer for the Canadian Journal of Public Health.

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