Smaller communities in Canada, particularly those located in rural areas, find it difficult to attract and especially retain health-care professionals, leading to poorer health outcomes.
For example, in March 2022, the physician shortage in Northern Ontario forced the emergency department in Red Lake to close for 24 hours, and those with medical emergencies had to drive over 200 kilometres to the nearest hospital. In the same region, staffing shortages of nurses and personal support workers are exacerbated by recruitment and retention challenges. Similar situations exist in many small communities across Canada.
It’s no surprise then that all five Northern Ontario cities participating in the Rural and Northern Immigration Pilot, designed to bring more immigrants to smaller communities, are prioritizing health-care professionals. But can they keep them?
Recruiting internationally educated health-care professionals (IEHPs) to work in underserved communities is not new. However, challenges in keeping them in these communities persist. As immigration researchers, we have documented the challenges of retaining newcomers in Canada’s small communities, with a recent focus on IEHPs.
Why popular approaches don’t work
Common approaches used to encourage IEHPs to work in smaller communities often include “return of service” contracts requiring that IEHPs work in underserved areas for several years as a pathway to licensure to practise within the province or territory. For example, the National Assessment Collaboration’s Practice-Ready Assessment programs for international physicians, offered in seven provinces, require a return-of-service commitment in a rural area of the province.
These somewhat coercive strategies tend to be ineffective in the long term because they focus primarily on attracting IEHPs to smaller communities and do not address the reasons why they tend to leave. These reasons include social and professional isolation.
The factors driving social isolation for IEHPs in smaller communities include distance from family members and social connections, limited access to settlement services that can facilitate connections to the community, the lack of a large immigrant population and access to cultural and religious supports, limited employment and educational opportunities for family members, and experiences of racism and discrimination.
The factors driving professional isolation in smaller communities include long work hours and limited time off for vacation due to the small size of the health-care team, and limited opportunities for professional development and advancement within a cohort of peers. IEHPs may also find that they lack the generalist skill sets required for practising in smaller communities, which can differ considerably from urban health care.
While several of these factors apply to all health-care professionals, whether Canadian-born or internationally trained, others tend to be unique to IEHPs, compounding their sense of isolation and their motivation to move to a large urban centre.
Reasons to stay
Several strategies can be used to support the retention of IEHPs, including training and experience in small community health care. As an example of the importance of training and experience, the Northern Ontario School of Medicine (NOSM) has increased the number of physicians and dietitians who practise in smaller communities in Northern Ontario.
NOSM graduates are familiar with the needs of these communities and, due to their specialized training, are prepared to serve them long-term. Once established in a community, professional networks and professional development opportunities can also help IEHPs to overcome professional isolation.
In addition, IEHPs will be more likely to stay in small communities if their families are happily settled in the community and they feel socially connected. Addressing racism and discrimination in the community is a first step. Also, the spouses of IEHPs may require special assistance to find employment related to their field of study. The children of IEHPs may benefit from connections to educational and extracurricular activities.
The right fit
Efforts should also be made to attract IEHPs with characteristics that make them more likely to stay. IEHPs who are from small or rural communities may find it easier to adapt to living and working in smaller Canadian communities, making them much more likely to stay.
Communities should also communicate what kind of lifestyle they can offer to IEHPs, and IEHPs should know what to expect, improving fit. IEHPs may be attracted to smaller communities because of the housing, educational and outdoor leisure opportunities on offer, or because of the sense of safety and community that some smaller centres can provide. Importantly, these location attributes may appeal more to IEHPs who are at a certain point in their lives. Those prioritizing homeownership or raising children may be more likely to have their needs met in a smaller community.
For the upcoming Municipal Nominee Program, in which communities will have more say in the selection of new immigrants, a key measure of success will be how the program addresses labour shortages and retention in key sectors such as health care. The ability of small communities to make the right matches and address professional and social isolation for IEHPs will be essential.
Natalya Brown, Associate Professor of Economics, Nipissing University; Melissa Kelly, Research fellow, Canada Excellence Research Chair (CERC) in Migration and Integration, Toronto Metropolitan University, and Victoria Esses, Professor, Department of Psychology, Western University