If there’s truth to the saying “Doctors diagnose, nurses heal, then a recent report of the first drop in Canada’s regulated nursing supply in almost two decades could be cause for alarm.

According to the Ottawa-based Canadian Institute for Health Information (CIHI)’s Regulated Nurses, 2014, released June 23, last year saw a small 0.3 per cent fall nationally over 2013 in those holding active nursing licences (the “regulated supply”) and one per cent fall in the supply of registered nurses, the backbone of the public-sector nursing workforce.

Nationally 27,757 nurses let their one-year licences lapse at the end of 2013, while just 25, 397 registered in new jurisdictions. Almost 45 per cent of the national drop, says Andrea Porter-Chapman, CIHI’s manager of health workforce information, was due to a new regulation in Ontario, the province with the largest nursing pool and the second worst ratio of RNs to population. It stipulated that nurses could renew licenses only if they had actively practised in the past three years. That change may be driving what amounts to just a one-year aberration, says Porter-Chapman, but “it’s something to keep an eye on since it’s the first shift we’ve seen in 20 years.”

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Fortunately, the current active nursing workforce remains stable and robust but that could quickly change. With reports of more licensed nurses leaving than entering in 2014, 25 per cent of nurses nearing the traditional 58-ish retirement age and the average age of nurses holding steady at about 45, on-the-ground resources could soon be threatened. With potential attrition on the horizon, warn experts, Canada needs to keep a steady hand on the nursing supply tiller.

“Human resources planning is forever planning. It’s not just a response to a blip on your radar,” says Linda Silas, RN, president of the Canadian Federation of Nurses Unions (CFNU) in Ottawa. She adds that owing to health-care reform cutbacks in the 1990s, Canada is “missing a whole generation of experienced nurses” who would now be at the top of their game.

Another red flag in CIHI’s report was the slowing growth rate of new nursing graduates, which dropped from a range of six to 12 per cent over the past five years to below one per cent.

The still-iffy economy, ushered in by the 2008 recession, has a lot to do with that. “Admissions to nursing schools are surprisingly sensitive to employment opportunities,” says Cynthia Baker, PhD, executive director of the Canadian Association of Schools of Nursing. “Our graduates are not flying into jobs, and many of them juggle part-time employment for several years before finding permanent positions.”

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For the past two decades, nursing resources in Canada have been on cyclical roller coaster of under- and over-supply as health ministries cut back or beefed up funding for nursing education and employment.

“There’s simply no planning, says Silas, who was not surprised by the CIHI figures. “How is it that a quarter of our nurses could retire tomorrow and yet when you talk to new grads, they can’t get full-time jobs?”

Some, she adds, turn to stop-gap employment in other sectors from real estate to pharmaceutical companies while awaiting positions, “but that’s dangerous because if you don’t keep your clinical skills up, how can you be an efficient nurse?”

Other opt to go stateside where a shortage of nurses means more opportunity for full-time and specialized work. In a brain-drain coup at a July 2015 job fair in Windsor, Ont., 54 Canadian-taxpaer-trained nurses were snapped up by Detroit’s Henry Ford Hospital, which currently employs about 220 Canadian RNs.

One Canadian cross-border RN is Samrinder Sahota, 22, a 2104 graduate of the University of Windsor who enters the U.S. every day to work at Beaumont Health’s Oakwood Hospital in Dearborn, Mich. “I chose to go a U.S. hospital because I was could get full-time work in specialized care—plus they would train me better,” says Sahota, who underwent 12 weeks of specialized instruction before joining Oakwood’s’ intermediate intensive-care unit. The best he could hope for in Ontario was part-time general nursing.

Would he prefer to work in Canada if full-time work came up? “No, I would stay where I am,” says Sahota, even though the rate of pay is slightly lower. For him, a major factor is the culture of respectfulness at Oakwood, something he found lacking when he did his practical training in Ontario hospitals. “Here on the unit they value the opinions of a new staff member. They treat you respectfully like a colleague, not a new arrival, and that makes a big difference to the retention of nurses.”

Increasing numbers of new grads may be thinking along similar lines. In research at the University of Windsor led by nursing professor Michelle Freeman, PhD, the proportion of graduating nurses considering leaving Canada to work rose from 66per centin 2011 to 71per centin 2013.

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Silas thinks the pace of the US-bound trend may quicken as Obamacare extends American medical coverage and ramps up nursing needs. And potentially easing the cross-border flow is that as of January 2015 Canadian and American nursing students write a very similar national exam, the NCLEX-RN, administered by the same U.S. testing organization.

Even in the setting of permanent, full-time employment, the Canadian healthcare workplace can be anything but healthy for nurses. According to Silas, nurses face more violence, erosion of professional respect and autonomy, inflexible schedules, heavy workloads and increasing burnout. A 2015 CFNU report revealed that in 2014 nurses worked more than 19 million hours of overtime, 22per centof it—almost $200 million—pro bono. “Overtime contributes to excessive workloads and high levels of absenteeism, which erode patient care,” says Silas.

According to the CFNU survey, 30–40 per cent of nurses reported experiencing post-traumatic stress disorder symptoms, and 2014’s absenteeism rates rose a few basis points over 2012’s to 7.9 per cent, for a systemic cost of about $846 million a year.

Similarly, in a 2103 CBC online poll of Canadian nurses, 40 per cent reported burnout, and many said belt-tightening measures such as not calling in substitutes for sick nurses were threatening patient care. And almost two-thirds said inadequate staffing was preventing them from doing a proper job of delivering quality care.

According to the Canadian Nurses Association, serious shortfalls are looming and existing shortfalls are being masked by overtime and delayed retirements.

The human resources management of nurses—who make up a third of healthcare workers—will become more urgent as our growing population ages and demands for care increase and diversify. “Looking ahead it’s a very complex portrait, with increasingly diverse nursing needs,” says Baker. “In addition to acute-care hospital-based nurses, society will need more community- and home-based nursing services.”

What’s needed is a longitudinal strategy, a prospective plan. “If you don’t plan ahead, you’ll get periods where you have to pay enormous sums of money either to retain the existing experienced workforce or recruit from elsewhere,” says Silas. “If you plan, you won’t have to do that.”