Nursing in the Canadian Health System

A Complex Workforce Challenge in Need of Multi-Dimensional Response

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Nursing as the Foundation of Canadian Healthcare

The Canadian healthcare system, built on the principles of universal access and public funding, depends heavily on its nursing workforce. Nurses not only provide direct patient care but also contribute to hospital efficiency, public health, and long-term system sustainability.

However, the nursing workforce is under significant strain, facing a combination of demographic shifts, financial pressures, policy inconsistencies, and global mobility trends. While there is broad agreement that more nurses are needed, the question of how to achieve this goal is far more complex. Simply increasing staffing numbers is not enough—workforce solutions must balance financial sustainability, professional standards, equity, and the integration of new healthcare technologies.

This paper explores Canada’s nursing workforce through a systems lens, recognizing the inter-dependencies between policy decisions, workforce planning, and patient care. It argues that maintaining and growing the nursing workforce requires a mix of regionally specific strategies that consider both short-term staffing needs and long-term sustainability.

1. Understanding the Canadian Nursing Workforce: Numbers, Trends, and Pressures

The Current State of Nursing in Canada

• Total Nurses (2023): ~450,000

  • Registered Nurses (RNs): ~310,000

  • Licensed Practical Nurses (LPNs): ~130,000

  • Nurse Practitioners (NPs): ~9,000

• Nurse-to-Population Ratio: ~1 nurse per 75 people (compared to the OECD average of 1 per 65)

• Demographics:

  • 60,000+ nurses expected to retire between 2024-2030

  • Only 10,000-12,000 new graduates enter the workforce annually

  • Male nurses make up ~10-12% of the workforce, a slowly increasing figure

Regional Workforce Challenges

Different provinces face distinct nursing workforce challenges based on geography, population density, and healthcare funding:

• Urban Centers (Toronto, Vancouver, Montreal): High patient loads, burnout, and wage disputes

• Rural & Remote Areas (Prairies, Northern Canada): Severe shortages, over-reliance on travel nurses, difficulty attracting full-time staff

• Quebec: Push to eliminate agency nurses, but inconsistencies in full-time hiring

• British Columbia: Expanding nurse practitioner roles but facing workforce planning challenges

Each province requires context-specific strategies, highlighting the need for national coordination while preserving regional flexibility.

2. Addressing Nursing Shortages: A Multi-Layered Approach

Retention and Workforce Stability

Retaining experienced nurses is as important as recruiting new ones. High workloads, administrative burdens, and lack of career development opportunities contribute to attrition. Some strategies under discussion include:

• Retention bonuses (~$10,000 over 3-5 years for nurses in high-need areas)

• Pension improvements to encourage longer careers

• Work-life balance measures such as flexible scheduling, mentorship programs, and reducing mandatory overtime

Balancing Full-Time and Agency Nurses

Agency nurses provide flexibility but at a financial cost. Overuse of agency nurses:

• Increases costs (2-3x higher than full-time nurses)

• Destabilizes the full-time workforce, as many nurses leave permanent positions for higher-paying agency roles

• Creates inequities in hospital staffing structures

Potential strategies to manage agency nurse reliance include:

• Capping agency spending at 7-10% of hospital nursing budgets

• Developing in-house float pools to reduce emergency reliance on agency nurses

• Incentivizing full-time positions through improved pay structures and benefits

However, a one-size-fits-all approach is not viable. Some rural and remote hospitals remain dependent on agency nurses due to recruitment challenges.

3. Internationally Educated Nurses (IENs): A Critical but Underutilized Workforce

The Role of IENs in Canada’s Nursing System

Internationally educated nurses (IENs) form 8-10% of the Canadian nursing workforce. Many come from the Philippines, India, Nigeria, and the UK, bringing valuable skills and experience. However, the pathway to practicing in Canada remains slow and inconsistent, with barriers including:

• Licensing delays (2-4 years compared to 6-12 months in Germany)

• Expensive credentialing processes ($5,000-$10,000 per nurse)

• Provincial inconsistencies in licensing requirements

• Discriminatory workplace barriers (lower pay, fewer promotion opportunities, assumptions about skill competency)

IENs as People, Not Just Workers

Current discussions often frame IENs as a workforce solution rather than as professionals with their own needs and challenges. The focus should not only be on reducing licensing times but also on ensuring:

• Fair compensation and career growth (not relegating IENs to lower-tier roles)

• Cultural responsiveness in healthcare settings (addressing biases and ensuring inclusion)

• Support for professional integration (mentorship, workplace orientation, and mental health resources)

Lessons from Germany and the UK

Germany integrates IENs quickly through:

• A national standardized credentialing process

• Equal pay for IENs and domestically trained nurses

• Government-funded bridging programs to help IENs transition into the workforce

Canada could adopt similar approaches, including national certification and paid supervised practice programs to accelerate IEN entry into the workforce.

4. Technology, AI, and the Future of Nursing: Complementing, Not Replacing, Human Care

Potential Benefits of AI in Nursing

Technology can alleviate workload pressures by:

• AI-powered workforce planning to predict shortages in advance

• Automated documentation to reduce administrative burden

• Telehealth expansion to support rural and remote care delivery

Challenges in AI Integration

While AI and automation offer solutions, concerns remain about:

• Equity in access (rural areas may lack digital infrastructure)

• Job displacement fears (AI should complement, not replace, nurses)

• Training gaps (ensuring all nurses, including older professionals, can use new technologies effectively)

Sweden has successfully implemented AI-driven scheduling and digital patient monitoring, reducing burnout and improving efficiency. A phased, regionally sensitive approach in Canada could yield similar benefits.

5. A Context-Specific, Balanced Policy Approach

Given the complexity of Canada’s nursing workforce challenges, a single nationwide policy will not work. Instead, the healthcare system must adopt a layered strategy that balances:

• National coordination to ensure licensing consistency and workforce mobility

• Regional flexibility to tailor solutions based on local workforce needs

• Short-term measures to address immediate shortages (retention bonuses, targeted recruitment)

• Long-term workforce planning (education expansion, IEN integration, technology adoption)

Tailored Strategies by Region:

Region Key Challenge Suggested Policy Urban Centers High burnout, staff shortages AI-driven scheduling, mental health support, workload reduction Rural & Remote Severe shortages Higher wages, housing incentives, telehealth expansion Quebec Reducing agency reliance Gradual transition plan, incentives for full-time hiring Prairies & North Retention issues Pension incentives, career progression pathways IEN Workforce Slow integration, discrimination Standardized national credentialing, workplace inclusion initiatives

6. A Multi-Dimensional Approach to Strengthening Canada’s Nursing Workforce

The sustainability of Canada’s healthcare system depends on a well-supported nursing workforce. While workforce shortages, regional disparities, financial constraints, and changing healthcare demands pose challenges, these issues must be addressed with a combination of short-term interventions and long-term systemic reforms. There is no single solution—policymakers must balance workforce expansion, cost management, professional development, and equity concerns to ensure the system remains functional and responsive to future healthcare needs.

This conclusion synthesizes the key strategies discussed in this paper, offering a structured, multi-layered approach to stabilizing and strengthening Canada’s nursing workforce.

A. Workforce Retention and Stability: Keeping Experienced Nurses in the System

Retaining existing nurses is one of the most cost-effective ways to address shortages. The following measures could improve workforce stability:

• Retention incentives: Providing targeted retention bonuses (~$10,000 over 3-5 years) for nurses in high-need areas.

• Improved pension benefits: Strengthening pension contributions to encourage nurses to remain in the workforce longer.

• Work-life balance initiatives: Expanding flexible scheduling, reducing mandatory overtime, and implementing mental health and burnout prevention programs.

• Career progression pathways: Offering mentorship programs and structured career advancement opportunities to keep mid-career nurses engaged.

By reducing attrition, these strategies minimize the financial and operational burden of constantly replacing nurses.

B. Managing the Role of Agency Nurses: Flexibility Without Over-Reliance

While agency nurses provide necessary flexibility, excessive dependence on them increases costs and destabilizes the workforce. A balanced approach includes:

• Capping agency nurse spending at 7-10% of hospital nursing budgets (with flexibility for rural and remote areas).

• Developing internal float pools to reduce emergency reliance on external agencies.

• Ensuring pay equity between agency and full-time nurses to prevent full-time staff from migrating to agency roles.

• Gradual transition plans for provinces, such as Quebec, seeking to reduce agency nurse dependence.

These policies promote financial sustainability while maintaining essential flexibility.

C. Fast-Tracking Internationally Educated Nurses (IENs) Without Compromising Standards

IENs are a critical but underutilized workforce resource. Current barriers slow their entry into the system, leading to prolonged shortages. Key reforms include:

• Creating a national, standardized credentialing system to replace inconsistent provincial licensing requirements.

• Reducing licensing times from 2-4 years to 6-12 months, similar to Germany’s model.

• Providing government-funded bridging programs so IENs can work in supervised roles while completing certification.

• Ensuring workplace equity by addressing discrimination, ensuring pay parity, and providing professional development opportunities for IENs.

These measures enhance workforce diversity while addressing shortages efficiently.

D. Expanding Nursing Education and Training: A Long-Term Investment

Canada must increase the number of new nursing graduates to meet future demand. This requires:

• Expanding nursing school enrollment through increased government funding and university partnerships.

• Developing fast-track programs for paramedics, licensed practical nurses, and other healthcare professionals transitioning into nursing roles.

• Providing student loan forgiveness for nursing graduates committing to work in under-served areas.

• Increasing rural training placements to encourage new nurses to work in remote communities.

By aligning education policies with workforce planning, Canada can increase its long-term supply of nurses.

E. Integrating AI and Technology to Reduce Workload and Improve Efficiency

AI and automation should complement, rather than replace, human-centered nursing care. Smart adoption strategies include:

• AI-powered workforce planning to predict and prevent staffing shortages.

• Automated documentation tools to reduce administrative burdens on nurses.

• Telehealth expansion to provide remote care and reduce strain on hospitals.

• Training nurses in AI and digital tools to ensure equitable access to new technologies.

While AI and automation offer cost-saving potential, equity in access and implementation must be considered to avoid deepening regional disparities.

F. Addressing Regional and Provincial Disparities: Context-Specific Solutions

Different regions require tailored solutions based on local healthcare realities. Some region-specific policies include:

• Urban centers (Toronto, Vancouver, Montreal): AI-driven scheduling, burnout prevention programs, and increased mental health support.

• Rural and remote areas (Prairies, Northern Canada): Higher wages, housing allowances, and expanded telehealth infrastructure.

• Quebec: Gradual transition away from agency nurses while increasing full-time hiring incentives.

• Atlantic Canada: Fast-tracking IEN integration and providing relocation incentives.

A nationally coordinated, regionally managed approach allows for flexible, context-specific solutions while maintaining overall workforce efficiency.

G. Strengthening Workplace Equity, Inclusion, and Cultural Responsiveness

Nurses are not just workers but professionals with diverse backgrounds, skills, and experiences. Workplace policies must reflect this by:

• Ensuring pay equity for all nurses, including IENs.

• Addressing workplace discrimination through targeted training and inclusive hiring policies.

• Expanding Indigenous-led nursing programs to increase representation and support culturally responsive care.

• Creating mentorship programs for underrepresented groups in nursing.

By fostering an inclusive and supportive work environment, nurse retention and job satisfaction improve, strengthening the system as a whole.

H. Strengthening National Coordination While Preserving Regional Flexibility

A unified, nationally coordinated approach to workforce planning can improve efficiency while respecting provincial healthcare autonomy. Potential policy actions include:

• Establishing a National Nursing Workforce Coordination Council to track trends and predict workforce needs.

• Standardizing inter-provincial nurse licensing to improve workforce mobility.

• Aligning education programs with labor market needs to prevent mismatches between supply and demand.

A hybrid governance model, where national policies support regional implementation, ensures both efficiency and adaptability.

The sustainability of Canada’s nursing workforce is a long-term investment that requires both immediate action and systemic reform. The nursing profession sits at the intersection of workforce planning, healthcare funding, technological advancements, and social equity—making it one of the most complex policy areas in the healthcare system.

Rather than seeing nursing shortages as a crisis to be solved with a single intervention, policymakers must adopt a multi-pronged strategy that balances:

• Short-term measures to address immediate shortages, including retention incentives and fast-tracked IEN integration.

• Mid-term workforce stabilization, such as managing agency nurse costs and expanding nurse-led care models.

• Long-term investments in nursing education, AI, and technology adoption to build a resilient workforce for the future.

By integrating national coordination with regionally tailored solutions, Canada can maintain a high-quality, financially sustainable, and adaptable nursing workforce that meets both present and future healthcare demands. The challenge is complex, but through strategic, evidence-based solutions, a stronger, more resilient nursing system is achievable.

References

• Austin, Z., & Gregory, P. A. M. (2024). Enhancing integration of internationally educated health professionals in the healthcare workforce: Implications for regulators. Journal of Nursing Regulation. Retrieved from https://www.journalofnursingregulation.com/article/S2155-8256(24)00026-7/pdf

• Bourgeault, I. L., Neiterman, E., LeBrun, J., & Viers, K. (2010). CIHR/Health Canada Chair in Health Human Resource Policy. ResearchGate. Retrieved from https://www.researchgate.net/profile/Elena-Neiterman/publication/266090623_CIHRHEALTH_CANADA_CHAIR_IN_HEALTH_HUMAN_RESOURCE_POLICY/links/54aeb3bb0cf29661a3d3a770/CIHR-HEALTH-CANADA-CHAIR-IN-HEALTH-HUMAN-RESOURCE-POLICY.pdf

• Buchan, J., Catton, H., & Shaffer, F. (2022). Sustain and retain in 2022 and beyond: The global nursing workforce and the COVID-19 pandemic. International Nurse Migration. Retrieved from https://www.intlnursemigration.org/wp-content/uploads/2022/01/Sustain-and-Retain-in-2022-and-Beyond-The-global-nursing-workforce-and-the-COVID-19-pandemic.pdf

• Duenas, G. (2022). Registration challenges of Filipino nurses in Ontario. ResearchGate. Retrieved from https://www.researchgate.net/profile/Gerry-Duenas/publication/363731790_CHALLENGES_OF_FILIPINO_NURSES_1_Registration_Challenges_of_Filipino_Nurses_in_Ontario/links/632b95f0071ea12e364f87a5/CHALLENGES-OF-FILIPINO-NURSES-1-Registration-Challenges-of-Filipino-Nurses-in-Ontario.pdf

• Joensuu, R., Suleiman, K., Koskenranta, M., et al. (2024). Factors associated with the integration of culturally and linguistically diverse nurses into healthcare organizations: A systematic review. Wiley Online Library. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1155/2024/5887450

• Kurup, C., Betihavas, V., Burston, A., & Jacob, E. (2023). Strategies employed by developed countries to facilitate the transition of internationally qualified nurses into clinical practice: An integrative review. Wiley Online Library. Retrieved from https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/nop2.2023

• Llena‐Nozal, A., Rocard, E., et al. (2022). Providing long‐term care: Options for a better workforce. International Social Security Review. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1111/issr.12310

• McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., & Sloane, D. M. (2011). Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. NIH. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3201822/pdf/nihms285341.pd

• Newton, S., Pillay, J., & Salma, J. (2012). The migration and transitioning experiences of internationally educated nurses: A global perspective. Journal of Nursing Management. Retrieved from https://www.academia.edu/download/34389503/2012_The_migration_and_transitioning_experiences_of_internationally_educated_nurses_A_global_perspective.Journal_of_Nursing_Management.pdf

• Salma, J. (2009). Career advancement and education opportunities: Experiences and perceptions of internationally educated nurses. University of Alberta. Retrieved from https://era.library.ualberta.ca/items/7885cb30-69d2-433f-afb8-adcfcf564891/view/310e4f81-c17a-44a9-b0c5-3dc001ca356a/Salma_Jordana_Fall-202009.doc

• Walton-Roberts, M. (2023). The future of health care work and the place of migrant workers within it: Internationally educated nurses in Ontario, Canada during the COVID-19 pandemic. Journal of Immigrant & Refugee Studies. Retrieved from https://scholars.wlu.ca/cgi/viewcontent.cgi?article=1005&context=gnmp

• Wong, C. A. (2008). The role of authentic leadership in nursing and healthcare. University of Alberta. Retrieved from https://era.library.ualberta.ca/items/a0ec5ef9-b76f-4cc5-b376-9a878340df08/download/d5629eea-023b-4bc0-9bee-76267330c6df