Which Provinces Struggle the Most to Keep Young Nurses?
Economic Note examining the proportion of young nurses leaving the profession over the past decade across Canada
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This Economic Note was prepared by Emmanuelle B. Faubert, Economist at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.
Nurses are a vital part of Canada’s healthcare systems. According to the International Council of Nurses, these healthcare professionals provide almost 80% of hands-on care around the world.(1) If our healthcare systems are to deliver the care our population needs, it is crucial to ensure that nurses, once trained, remain in the profession. Unfortunately, these caregivers are in chronic shortage everywhere, with the result that a majority of Canadian nurses have witnessed a deterioration in the quality of the care delivered in their workplaces.(2) And deteriorations in quality come at the expense of patients, both in terms of waiting times and of health outcomes.
In 2023, the MEI published a Note showcasing the state of nursing in Quebec specifically.(3) The present document is wider in scope and looks at Canada in its entirety, examining the situation across all the provinces.
Worsening situation across Canada
The Canadian systems’ ability to retain nurses, especially young nurses, has been declining over the years. In 2013, for every 100 young nurses entering the profession, 32 left before the age of 35.(4) This number has fluctuated over the years, but the general trend has been upward. By 2022, the most recent year for which data is available, it had climbed to 40 departures per 100. In a single decade the proportion of young nurses abandoning the system increased by 25% (see Figure 1).(5)
This state of affairs is expected to continue deteriorating. A 2018 study estimated that by 2030, the country would be short 117,600 nurses.(6)
Some provinces do better than others
The severity of the issue, however, varies across Canada. While Manitoba and British Columbia lost less than a third of their new young nurses in 2022 (which is still significant), many provinces’ ratios were closer to one half. New Brunswick performed worst of all, losing eight young nurses for every ten that entered the profession (see Table 1).
When looking at the data from all provinces, we can also see that not every one has evolved in the same way; the situation has deteriorated in the great majority of provinces, while improving in only a few (see Appendix).
Ontario, for example, which ranked third in young nurse retention in 2022, is nonetheless in a much worse place than it was a decade earlier. In 2013, Ontario only lost 19 young nurses for every 100 that joined the profession. By 2022, this ratio had increased to 35 in 100, an increase of 83%. While Ontario’s current situation remains better than that of most other provinces, this may not be true for much longer if the trend is not reversed.
British Columbia, on the other hand, has improved more than any other province over the last decade. In 2013, the province lost 47 young nurses for every 100 new ones, but by 2022 had shrunk that ratio to 31 in 100, a decline of 32% over the decade.
With so many young nurses failing to make it even to the middle of their careers, let alone persevering until retirement, it becomes essential to enquire why they are leaving in droves.
Why are nurses leaving?
Nurses are leaving for multiple reasons that include insufficient remuneration, stressful work environments, overwork, and problems with work-life balance to mention just a few.(7) Most of these reasons are thus ultimately related to undesirable working conditions, a critical issue that, according to the available evidence, affects nurses all across the country.
The Canadian Federation of Nurses Unions polls nurses across Canada annually to assess the situation with respect to these issues. This year’s edition revealed that nine in ten nurses consider themselves burnt-out, and an alarming four in ten, or 40%, intend to leave the profession within the next year (not age specific).(8) This would suggest that the trend continues to deteriorate. The collected evidence also points specifically to the lack of schedule control, overtime, and other similar factors as the principal reasons why nurses leave.
In a single decade the proportion of young nurses abandoning the system increased by 25%.
Interestingly, this same poll shows that nurses who mentioned a desire to leave their current employment were also more likely to be interested in working for independent (private) agencies.(9) This indicates that agencies are an option of last resort for overworked and burned-out nurses in the public system, a way for them to obtain better flexibility and improve their working conditions without leaving the profession altogether.
Canadian nurses need better working conditions and more flexibility
Increased flexibility in all forms is essential to improving nurse retention in Canada. Better pay, while important, is not sufficient on its own, because it is mainly the working conditions that are affecting the nurses the most, and causing many to leave, or change careers, before reaching retirement. The reasoning is that while high salaries might be good for attracting new nurses, good working conditions are essential for retention. After all, burnt-out nurses cannot hang on very long before being unable to continue, no matter how much they are paid. And their departures increase stress on those who remain, hence the vicious cycle of the nursing shortage.
A 2022 study in Taiwan showed that professional autonomy, workload, interpersonal interaction, and working condition flexibility were significantly related to burnouts. They found that work flexibility led to greater satisfaction amongst nurses, an important factor of nurse retention.(10)
This is why a significant improvement in nurses’ working conditions could be achieved simply by allowing them more flexibility,(11) something that can take multiple forms. One example would be more flexible collective agreements that allow for more contractual freedom between nurses and their employer. This would permit them to take into account the different needs of each region, which is particularly important for remote regions. It would also allow consideration of nurses’ individual preferences regarding nights and weekend shifts, instead of systematically assigning the shifts to young nurses.
Most of these reasons are ultimately related to undesirable working conditions, a critical issue that affects nurses all across the country.
Another example would be to encourage nurses’ professional autonomy, including for nurses from independent private agencies.(12) Nurses need the complete freedom to practise their profession the way they want and wherever they want, whether that means work in a public hospital, self-employment in a nurse practitioner clinic, or contractual work through an independent agency. Trying to restrict them all to working for the same public system, as is currently being done in Quebec, leads only to burnout that increases the risk of losing nurses even more. By competing with the public system to attract nurses, independent nursing agencies provide these essential healthcare professionals with more employment options.
The “war” on independent nurses: Quebec’s bad example
The Quebec government has decided to ban the public system’s use of independent agency nurses. Such a ban will only worsen the situation even more by pushing a greater proportion to leave the profession altogether.(13) This measure, to be implemented in increments at first in the larger urban areas in the spring of 2025, will gradually be extended to all regions of the province in 2026. While the ban is not currently in effect, a first phase has already been put in place: there is now a cap on the remuneration that can be given to agency nurses.(14) Healthcare centers are also being forced to gradually reduce the number of agency nurses in their employ so as to reach the desired zero before the deadline comes into effect. It will take a few years for consequences of the ban to be fully reflected in the data, but we are already seeing some of the impact of this policy in Quebec.
Currently, the most rural regions of the province are already unable to function properly, as not enough nurses are interested in working in remote areas at the newly proposed lower salary. Most nurses working in remote regions come originally from the larger urban centers and do not intend to stay in the region permanently. They are not interested in working in remote areas if they can earn the same wage much closer to home. At this point, many rural ERs have had to reduce the number of beds in their facilities or reduce their opening hours due to the labour shortages induced by Quebec’s “war” on independent nurses.(15)
Once the ban on the use of independent nurses comes fully into effect, the shortages will likely be felt in larger urban centres as well as in remote regions.
Trying to restrict them all to working for the same public system, as is being done in Quebec, leads only to burnout that increases the risk of losing nurses.
This policy should be reversed and independent nurses allowed to be used by the province’s hospitals and healthcare centres. Other provinces should not follow Quebec’s example, and actually do the opposite, leaving more room for agency nurses and giving them the freedom to practise their profession wherever they please.(16) Surely the priority is to have patients treated, no matter who the nurses work for.
Conclusion
The latest available data show that the proportion of young nurses leaving the profession has been worsening over the last decade across Canada, with the situation varying to some degree at the provincial level.
The provincial public healthcare systems have not been able to solve this problem, nor to propose the better working conditions and flexibility that would have helped reduce these losses by providing nurses with work environments that better fits their individual needs. On the contrary, the situation seems to be getting worse, especially in Quebec where a “war” has been declared on nursing agencies and, therefore, on increased flexibility in working conditions.
The main objective of this Economic Note is to sound the alarm by presenting the data at the Canadian level as well as for the individual provinces. But it is only a starting point. It would be worthwhile to investigate further why some provinces, such as British Columbia, seem to have performed better.
Nurses are at the core of our healthcare systems. It is therefore essential to ensure that they have access to flexible contracts and ample professional autonomy, and that they are generally taken care of. As the chief executive of the International Council of Nurses remarked, “I would argue the health of the nursing workforce could be the greatest determinant of the health of the world’s population over the next decade.”(17)
References
- UHC2030, News and Events, News, International Council of Nurses: Why nurses are so important for UHC, consulted on August 13, 2024.
- Canadian Federation of Nurses Unions, CFNU Member Survey Report, March 2024, p. 22.
- Emmanuelle B. Faubert, “The Nurse Shortage in Quebec: Improving Flexibility and Working Conditions,” Economic Note, MEI, October 2023.
- The term “nurse” as used in this Economic Note comprises nurse practitioners, registered nurses, registered psychiatric nurses, and licensed practical nurses. This is in order to provide a more complete picture of the nursing supply as a whole. CIHI, Nursing in Canada 2023 – Data Tables, Table 4: Supply, 2024.
- Author’s calculations. CIHI, Nursing in Canada 2023 – Data Tables, Table 4: Supply, 2024.
- Tina Novotny, “How global nursing talent is driving healthcare system transformation,” Hospital News, March 22, 2024.
- Huan-Fang Lee and Ying-Ju Chang, “The Effects of Work Satisfaction and Work Flexibility on Burnout in Nurses,” The Journal of Nursing Research, Vol. 30, No. 6, December 2022, pp. 1-2.
- Canadian Federation of Nurses Unions, op. cit., endnote 2, pp. 6–7.
- Ibid. p. 14.
- Huan-Fang Lee and Ying-Ju Chang, op. cit., endnote 7, pp. 5-6.
- Isik U. Zeytinoglu et al., “Flexible employment and nurses’ intention to leave the profession: The role of support at work,” Health Policy, Vol. 99, No. 2, February 2011, pp. 155-156.
- Huan-Fang Lee, Ying-Ju Chang, op. cit., endnote 7, pp. 5-6.
- Emmanuelle B. Faubert, “Le Québec dépend des infirmières indépendantes,” Le Soleil, May 21, 2024.
- Government of Quebec, Pour le personnel – Vers la fin des agences privées en santé : Québec resserre les règles, October 4, 2023.
- Fanny Lévesque, “La Côte-Nord plongée dans « une crise sans précédent »,” La Presse, May 13, 2024.
- Kelly Grant, “Canadian nurses’ unions urge politicians to crack down on for-profit nursing agencies,” The Globe and Mail, October 11, 2023.
- Megan Ford, “Covid-19: New findings point to widespread trauma among nurses,” Nursing Times, January 13, 2021.