How can we increase attraction and retention of nurses? A research with young nurses ()
1. Introduction
In the healthcare sector, the enduring challenge of attracting and retaining a diverse workforce, particularly nurses, has been relatively well-documented [1] [2] [3] [4] . Of particular concern is the mounting difficulty in attracting and retaining young nurses [5] , which has exacerbated labor shortages, driven by shifts in demographics and the retirement of seasoned nursing professionals [6] . The aging population has amplified the demand for healthcare services, intensifying the strain on the labor force. These challenges can be primarily attributed to two factors: the organization of work and the application of Lean Management principles [7] [8] , with a specific focus on issues related to work control and work-family balance [9] [10] .
In recent years, concerns related to work-family balance, work control, and autonomy have emerged as pivotal issues within the nursing profession in Canada, prompting early exits from the field, often occurring within just five years of graduation [3] . Early retirements also persist as a formidable challenge across various healthcare occupations, compelling organizations to seek strategies for retaining their workforce [11] [12] .
The existing literature predominantly highlights two primary dimensions: challenges pertaining to achieving a balance between work and personal life and intricacies associated with work organization, encompassing Lean management principles and job control [7] . Several countries have embraced Lean Management as a response to the perceived challenges within the healthcare sector, with certain organizations believing it can enhance operational efficiency in nursing [13] . However, its effectiveness remains a subject of scrutiny, given the numerous criticisms stemming from its origins in the automobile industry, and its subsequent abandonment in many organizations’ human resources management practices [13] .
Our previous research has also delved into the significance of support from educational institutions concerning internships and coursework [14] [15] . We sought to explore how this support framework could be adapted to the nursing profession. Our investigation enabled us to discern various factors linked to the organization of nursing courses. However, our respondents also emphatically underscored the pivotal role of the work environment in facilitating the delicate equilibrium between work, family, and educational commitments. This equilibrium is fostered through measures such as flexible work schedules and optimized work organization [16] .
Through this ongoing research initiative, our objective is to illuminate the pathways to confront these diverse challenges and to identify a range of measures that can effectively contribute to the attraction and retention of nursing students, as well as the enduring retention of nurses within the healthcare system [17] . Our findings are intended to serve as a beacon, guiding not only academic institutions, especially colleges and universities offering nursing programs, but also hospitals, clinics, and other healthcare entities that employ nurses. By collaboratively addressing these challenges and implementing the recommended measures, we aim to bolster the healthcare workforce, ensuring the continued delivery of high-quality patient care.
2. Problem Statement and Research Questions
In addition to grappling with a shortage of nursing professionals, the Canadian province of Québec is confronted with a rapidly aging population, a predicament shared by numerous countries. By 2031, it is projected that 15% of the population in Québec will be 65 years or older, with a twofold increase in the number of individuals aged 85 and above within the next two decades. Furthermore, the Health Department reports that 48% of the population aged 15 and over in Québec suffers from at least one chronic health condition. This demographic shift has exacerbated the gap between public income and the escalating costs of healthcare, demanding the exploration of sustainable solutions. In response, Lean Management has been introduced in certain healthcare organizations, although not always with resounding success [7] .
It is essential to note that a comprehensive quantitative survey was previously conducted in November-December 2020, involving nearly 800 nurses who generously participated by completing an online questionnaire. The survey primarily delved into various aspects related to work-family balance measures, such as childcare support and flexible working hours, work organization, and the degree of autonomy in decision-making. These facets have been recognized as pivotal factors during nurses’ collective bargaining endeavors in Québec over the years [8] . They have consistently surfaced in literature and media discussions as significant sources of dissatisfaction contributing to the ongoing challenge of attracting and retaining nurses, spanning even a decade [3] .
In the quest to address the specific challenges pertaining to the attraction and retention of young nurses, particularly in light of the current nursing shortage in Canada, our focus has shifted towards nursing students. This new research fills a gap in previous research as it addresses precisely the issue of attraction and retention, and centers on the challenges which make it difficult for nursing students, thus providing new insights on the issue. We aim to investigate the support mechanisms available to them to facilitate the harmonization of their academic pursuits with work and family responsibilities. This investigation has led us to formulate two key research questions:
Research Questions
1) What are the distinct challenges encountered by nursing students in reconciling their work, family, and academic commitments?
2) What solutions do nursing students envision on two fronts: their educational institution (university, predominantly, as the value of a university degree in nursing is on the rise) and their employers (since they engage in internships and are already integrated into the healthcare system)?
The structure of our paper is as follows: First, a comprehensive literature review will be conducted, shedding light on the current situation of nurses in Québec, Canada. Second, we will delve into the support mechanisms extended to nursing students. This focus is of particular significance as this demographic is rarely the subject of research, yet they represent the future of the nursing profession and are already making substantial contributions through their work during internships. We aspire to ascertain the support they receive from both their university and their employers during their nursing studies and internships, as this support plays a critical role in shaping their inclination to remain in the profession. Third, we will present the findings of our research involving nursing students enrolled in universities offering nursing specializations. Finally, we will engage in a thorough discussion, dissecting the challenges and proposing potential solutions for attracting and retaining nursing students, based on the outcomes of our research. Our ultimate aim is to reverse, or at least mitigate, the trend of nurses leaving the profession within five years of entering it, thereby bolstering the healthcare workforce.
3. Literature Review
Our literature review is divided in two parts. First, we explore the multifaceted landscape of work-family reconciliation in Québec in general, as this has an impact on nurses as all other groups, and then we focus on nursing professionals within the context of Québec, a predominantly francophone province of Canada. Our search strategy incorporated keywords in both English and French to ensure a comprehensive exploration of the available literature. We paid particular attention to nursing training options, which encompass two primary avenues in Québec: college and university programs. Our research, however, hones in on university nursing students, as they often contend with unique work-life challenges, particularly those associated with raising children. But we first present some issues on work-life balance in Québec in general, before we identify specific issues related to nursing, from our literature review.
3.1. Work-Family Reconciliation in Québec
The organization of families upon the arrival of a child has undergone significant social and cultural changes over several decades, moving towards equality in task-sharing [18] . Before delving into the specific challenges faced by nurses, let’s first review the highlights common to the workforce in Québec on this issue. While Québec is often as having a progressive work and family policy [19] [20] , there remain challenges, as we will see here for nurses.
The difficulties in balancing work, family, and studies affect everyone in this situation, but the challenges intensify with the level of education, being most pronounced among university students, closely followed by college students. This is primarily explained by the fact that individuals with higher education often hold more demanding jobs in terms of responsibilities and working hours, and they are also more likely to have children. Additionally, other factors can come into play, such as many programs requiring internships, as is the case for nurses [14] .
It’s worth noting that “a survey by the Canadian Consortium for Research on University Students (2015), conducted with more than 18,000 participants in their final year of an undergraduate program, reveals that over half of them had a ‘workplace learning experience,’ across all disciplines” (cited in [21] , p. 13). These workplace internships are, of course, beneficial for learning and training, but many individuals in this situation also hold other jobs, sometimes even full-time, which many consider demanding, especially in situations where the internship is unpaid. Student nurses are paid, but the internship still presents challenges.
The literature is equally concerned with the specifics of employment and the school structure, both of which greatly influence the success of work, family, and study reconciliation. An interesting distinction is made between job quality, which refers to its characteristics such as schedule, compensation, and stability, and work quality, which focuses on its conditions such as health and safety, autonomy, relationships with colleagues and employers, and benefits [22] . As concerns nurses, schedules can be quite challenging since hospitals are open 24 hours a day and 7 days a week.
The employer often plays a significant role in facilitating reconciliation. The more flexible and stress-free the employer is in terms of schedules, the easier the reconciliation [23] [24] . In the nursing sector, flexibility is limited as concerns schedules.
Regarding education, it is worth noting that the Statistics Canada Census reported that 64.8% of women aged 25 to 64 hold post-secondary degrees, whereas for men, this number is 63.4%. In 2011, it was the first time that women have surpassed men in this regard [25] and this trend has continued. The trend towards a significant change was observed in the 2016 census, where, for the first time, the number of women with doctorates specifically exceeded that of men.
The presence of a partner is also an important factor in the reality of work-family-study reconciliation. The number and age of children matter as well [4] [26] . We are experiencing a cultural shift, and new families share tasks and responsibilities differently than their predecessors. While women still bear the primary responsibility, men are increasingly involved [27] [28] .
When we discuss work-family-study reconciliation, we typically think of parents with young children [9] [10] [27] . However, we need to broaden this perspective. Adolescents also have specific and ongoing needs and should still be considered dependents for working parents. The aging population also brings a new reality: the duty for many to become caregivers for their family members (elderly, ill or handicaped) [29] , which adds a burden to families and can be a significant challenge for a student who also needs to work. This situation is more common for nurses, as they are seen as having more skills to care for the elderly.
Studies suggest that the ability to reconcile work and caregiving greatly depends on the ability to negotiate leave or flexible arrangements with the employer. Often, this requires presenting oneself as a reliable employee deserving of this “favor” [30] . Additionally, with the aging population and the challenges in the healthcare system, more and more people will be called upon to become informal caregivers during certain periods of their lives, often unexpectedly and urgently [4] [31] .
It should be added that work-family-study reconciliation problems vary by region. In Québec, in the Côte Nord and Saguenay regions, particularities have been identified concerning Indigenous students. While this population has access to various education allowances from the Ministry of Education, they have very low post-secondary education compared to the rest of Canadians. Multiple explanations are proposed, such as the consequences of cultural shock, inadequate communication, teaching methods insensitive to the specific challenges of First Nations, a history of assimilation through the education system [32] . It can also involve family reconciliation since Indigenous women often have children while they themselves are very young, and community support may be lacking if they have to move away to study [33] .
It should be noted that during the pandemic, many Québécois experienced significant difficulties, both related to their employment and private life. Several parents reported finding it challenging to oversee their children’s school activities, particularly those who had to combine home schooling when schools were closed or when children were ill (and interviewed nurses also reported this). This placed significant stress on families, including when parents of young children had to telecommute; in some cases, there was a decrease in productivity when young children were at home [33] , and the difficulties were heightened when work and studies had to be combined. Fathers have apparently contributed more, but mothers remained the primary caregivers of the family [34] [35] .
Paradoxically, the pandemic seems to have facilitated work-family reconciliation for a significant proportion of Québécois, especially those working in offices, for both men and women. One of the reasons cited is the frequency of telecommuting and reduced commuting to the office, saving time; telecommuting has significantly changed time management, especially at the beginning and end of the day [36] . However, this does not apply to nurses, who instead experienced greater difficulties during the pandemic, amid a labor shortage and parenthood. Employers demonstrated adaptability, as reported by numerous employees, which facilitated work-family balance within that specific context [3] [34] [35] . However, it’s important to acknowledge that the situation might have varied within the healthcare sector, which experienced significant strain during the pandemic.
3.2. Specifics of the Nursing Profession in Québec
The latest statistical report on the nursing workforce for 2020-2021 indicates that there are currently 80,491 nurses in Québec, of which 74,467 are employed, with 64.4% working full-time [37] . Out of this number, 89.2% are women, and 10.8% are men [38] [39] .
Of the active nurses in 2021, 3.7% are employed through placement agencies, which is 2761 nurses, to work in public healthcare facilities. This figure represents a 19% increase compared to 2019-2020 [37] .
One of the peculiarities of this profession is related to education. There are two major pathways available. Firstly, there is the college-level training, known as the Diploma of Collegial Studies (DEC) in nursing, which is a three-year program leading to a license and the title of licensed practical nurse [38] . Professionals with this qualification can access positions primarily in the hospital sector but also in clinics, CLSCs (Local Community Service Centers), CHSLDs (Long-term Care Homes), or other healthcare settings.
The second pathway is undergraduate university education, which is increasingly valued and sought after. Students complete initial studies in a science-related field at the college level, typically lasting two years, and then pursue a Bachelor of Nursing Science degree, which grants them the title of clinical nurse. Once employed in the public service, they can access positions in hospitals, CLSCs, schools, or administration [38] .
In parallel, other possibilities exist. For example, the option to obtain a Bachelor of Science degree through the accumulation of three certifications is recognized by most employers and allows a licensed practical nurse to attain the title of clinical nurse. If a nurse completes college-level technical studies and wishes to become a clinical nurse, the combined college-university program (DEC-BAC) offers an accelerated two-year version and allows them to work as a licensed practical nurse during their studies [39] .
It’s worth noting that in recent years, several organizations have been advocating to eliminate college-level training and promote university education. The OIIQ (Ordre des infirmières et infirmiers du Québec-Professional Order of Nurses) submitted a memorandum in May 2022 encouraging the enhancement of qualifications for the nursing workforce through bachelor’s degree programs [39] .
Therefore, multiple options exist for obtaining a nursing license, with the OIIQ being the organization responsible for issuing practice permits. It’s important to note that many nurses with college-level training continue their education at the university level, while those with a bachelor’s degree sometimes pursue more advanced studies at the master’s level, highlighting the challenge of balancing both initial and continuous education.
Furthermore, similar to most professional regulatory bodies, the Order of Nurses of Québec (OIIQ) implemented a minimum continuing education standard in 2012. This standard requires members of the order to complete a minimum number of hours of education each year, which they must declare during the license renewal process. The standard has been updated several times in recent years, and currently, every nurse must complete a minimum of twenty hours of education, including a minimum of seven accredited hours [39] [40] [41] .
3.3. Employment and Working Conditions of Nurses
The employment and working conditions of nurses have been a topic of discussion long before the pandemic, as the shortage was already a concern. However, the crisis has exacerbated the situation, and it persists despite several government measures. Healthcare professionals are leaving the public healthcare system in large numbers, citing poor working conditions and inadequate work organization [42] . Schedules, among other factors, are a significant issue since they often involve atypical hours [6] . Nurses are frequently required to work evening shifts, day shifts and/or night shifts, on weekends, and sometimes have to work consecutive shifts of up to sixteen hours, all in the context of mandatory overtime due to a staff shortage [28] .
Outside of the hospital sector, various opportunities exist in both the private and public sectors, including rehabilitation centers, extended care facilities, private clinics, pharmacies, businesses, call centers, community organizations, and educational institutions. However, nurses mainly work in hospitals, clinics, and extended care facilities, where labor shortages are acute [38] .
Due to the persistent staffing shortage in recent years, mandatory overtime has been used as a management tool by organizations, to the frustration of nurses. When an employee is absent or when there is a significant staff shortage that threatens patient safety, managers can simply require a healthcare professional to work an additional eight-hour shift of overtime. This puts the individual in a recurring dilemma, caught between two articles of the code of ethics. The first, article 43, states, “Unless there is a serious reason, a nurse providing care and treatment to a client cannot abandon them” (our translation, [39] , p. 10), while the second, article 16, states, “…the nurse must refrain from practicing their profession when they are in a condition that could compromise the quality of care and services” (our translation, [38] , p. 5). Healthcare professionals are thus tasked with trying to balance their personal and family lives with their professional obligations. It should be noted that this management approach is more prevalent in the Francophone system, while the Anglophone system relies more on self-scheduling, allowing professionals to organize their own schedules to cover all shifts, rather than seniority-based scheduling [42] .
A glimmer of hope emerged with self-scheduling following the implementation of a pilot project at Info-Santé in the city of Québec. In early October 2022, nurses were able to manage their schedules through an application that allowed them to view available shifts, request days off, or offer to work half-shifts as overtime. If a shift remains unfilled, the manager makes the final decision. For now, this approach appears to be highly appreciated, and the Minister of Health is considering its expansion across the province based on the results. This is not the case yet in 2023, and was not the case at the time of the research.
Career options are varied for a registered nurse, but in almost all cases, atypical schedules predominate. Working in a clinic or CLSC (Local Community Service Center) may offer more regular hours. Additionally, there are risks associated with the profession, including contact with biological agents and exposure to hazardous chemicals [38] .
One unique employment option available to nurses is through a placement agency. According to INSPQ (Institut national de santé publique du Québec), a personnel placement agency “refers to companies whose main activity is to provide workers for limited periods, long or short, to supplement the workforce of a client company” [43] .
Placement agencies already existed in Québec, but the pandemic saw a significant increase in their numbers and use. While in 2019-2020, establishments spent 443 million dollars on this type of workforce, this number rose to 1 billion in 2020-2021 [44] . This figure continued to rise: “According to data from the Ministry of Health and Social Services, costs attributed to independent healthcare labor increased by 380% in Québec between 216 and 2022” [45] . Despite government criticism, these agencies became increasingly popular because they appeared to offer better working conditions. However, the Minister of Health announced plans to reduce or even eliminate the use of agencies within three years, and this transition seems to be underway in 2023. Additionally, the minister stated that working conditions would be improved in the public sector to attract and retain nurses [45] , but we have yet to see initiatives along these lines.
Most placement agencies clearly list the advantages for nurses working in the private sector on their websites and do not hesitate to compare themselves with the employment conditions in the public sector. The 24/7 agency, for instance, cites arguments such as fewer constraints, flexible schedules, competitive salaries, group insurance, shifts or replacements according to your preferences. The theme of work-family balance is frequently emphasized as an argument by most of them, highlighting the opportunities to choose schedules, shifts, and work locations.
We now draw our conclusions regarding the primary topics gleaned from the literature review, which have significantly informed the structure of our interview guide.
3.4. Main Issues from the Literature Review
3.4.1. Work-Family Reconciliation in Nursing
Work-family reconciliation is a critical aspect of nurses’ professional lives, especially in regions like Québec where the demands of healthcare work and family responsibilities intersect. The literature underscores that nurses, regardless of their educational background, face significant challenges in balancing their work commitments with family life. These challenges are compounded by the nature of nursing work, which often involves irregular hours, long shifts, and high emotional demands [6] [46] [47] .
3.4.2. Nursing Training Options in Québec
Québec offers two primary pathways for nursing education: college and university programs. College programs are generally shorter and lead to a diploma in nursing, while university programs offer a more comprehensive education, often resulting in a bachelor’s degree in nursing. Our research specifically focuses on nursing students enrolled in university programs, as this group has more important work-family reconciliation challenges.
3.4.3. University Nursing Students and Work-Life Challenges
University nursing students in Québec represent a distinct subgroup, as they are more likely to have family responsibilities, including raising children or taking care of elderly parents. Balancing the demands of rigorous academic coursework, clinical placements, and family life poses unique challenges for this demographic. Existing research suggests that university nursing students, especially those with children, often encounter difficulties in managing their time effectively [15] . The need for practical support mechanisms to facilitate work-family reconciliation is pronounced in this context.
3.4.4. Support Mechanisms for University Nursing Students
The literature reveals that universities and healthcare institutions have a crucial role to play in supporting university nursing students in Québec. Measures such as flexible class schedules, on-campus childcare facilities, and mentorship programs have been proposed to address the specific challenges faced by this demographic [14] . The availability and effectiveness of these support mechanisms in promoting work-family reconciliation among university nursing students warrant further investigation.
3.4.5. Impact on Attrition Rates
Attrition rates among nursing students in Québec, particularly among those with family responsibilities, are of concern. It has been noted that students facing difficulties in reconciling work, family, and academic commitments are more likely to drop out of their nursing programs [15] . The attrition of nursing students contributes to the overall nursing shortage, emphasizing the urgency of addressing these challenges.
In summary, the literature review highlights the critical importance of work-family reconciliation for nursing professionals, particularly university nursing students, in Québec. Balancing academic pursuits, clinical placements, and family responsibilities is a complex endeavor. The available support mechanisms and their effectiveness in addressing these challenges necessitate further investigation to reduce attrition rates and strengthen the healthcare workforce.
3.5. Methodology: Participant Selection and Data Collection
Only nursing students were contacted, as the research focused on studying the reconciliation of work and family but also studies. Various factors were also considered for selection: ongoing studies, the presence of dependent children or a caregiver situation, and employment as a nurse. To represent the varying realities in different regions, all participants are citizens of the province of Quebec, but they are distributed across different regions and attend different educational institutions.
Participation was voluntary, and all participants received preliminary explanations about the process. Volunteers were recruited through social media, specifically on Facebook groups for nurses in Quebec. An additional call for volunteers was made through the nursing science programs at educational institutions in Quebec. Nurses who were interested provided their contact information via email, and communication continued through this channel.
No discrimination was made based on the gender of the participants in the study. However, given the predominance of women in the healthcare sector, the gender distribution among participants was not equal. In 2020-2021, men represented 11.6% of the workforce, and the volunteer sample is representative of this proportion, primarily consisting of women. Among the 20 participants, there was one man and 19 women.
A qualitative method was employed, based on semi-structured interviews. To develop the interview guide, the researchers drew from their past surveys and conducted a literature review to include questions aimed at highlighting gaps in the currently available literature.
The 20 interviews were conducted between October 11, 2022, and November 11, 2022. Due to the pandemic and to facilitate work-family balance, the interviews were conducted via the Teams platform and recorded to facilitate transcription and subsequent analysis.
The duration of the interviews ranged from 40.47 minutes to 1 hour and 21 minutes. Due to technical issues, two of the interviews were not recorded. To preserve the authenticity of the responses, the interviews were not repeated but rather summarized by the interviewer. To protect the anonymity of the testimonies, all names in the quotations below are fictitious and female, while the actual demographic information is retained.
At the time of the interview, the 20 respondents ranged in age from 27 to 43 years, with an average age of 34.9 years. They had between 0 and 5 children, ranging in age from 3 months to 16 years. Only one participant had children in shared custody. It is noteworthy that 70% of the respondents did not study in the same region as their residence, which can add a challenge associated with commuting for work and studies. On average, the respondents took 2.79 courses per semester, with some taking 1 and others taking 5. It should be noted that they do not always take the same number of courses per semester, which can vary with summer courses, intensive courses, and the presence of internships during a given semester. A little over half worked in a hospital setting, just over a third in an outpatient clinic, and 2 worked for a private company in addition to their nursing work.
In healthcare facilities, shifts are typically 8 hours long, with a meal break and two rest breaks. Some positions allow for 12-hour shifts, either on the day or night shift. Three of the 20 respondents held 12-hour shift positions. The distribution of shifts is as follows: 14 work during the day, 4 during the evening, one at night, and another has variable schedules. Out of the 20 respondents, 13 mentioned working on weekends, usually every other week. 40% stated that they had some flexibility in their schedule.
By “atypical schedule”, we mean “a weekly work schedule that differs from the 9 to 5 Monday to Friday” [38] . According to this definition, 60% of the respondents had atypical jobs at the time of the interview. Among the participants, 18 were in a relationship, and among their partners, 10 had jobs with atypical hours. This also adds complexity to the work-family-study balance.
Respondents were asked if there was mandatory overtime (OT) in their workplace, and 60% answered affirmatively.
4. Results
The primary challenges faced by nursing students’ center around childcare, work-family and social life reconciliation, and the resulting fatigue. While some respondents also raised concerns about their relationships, and conflicts with colleagues, which are interconnected with the challenges of balancing their responsibilities, in this discussion, we will primarily address the three core issues mentioned above and delve into the specific challenges related to their academic pursuits.
4.1. Childcare and School Issues
The majority of parent students rely on home-based daycares or public childcare services (CPE). Respondents mentioned having a lot of difficulty finding childcare, which is a well-known problem in Quebec for the last decade or so. The problems are even more significant for nurses working at atypical hours (evenings, nights) when public childcare services are not open. One participant reported having managed to find childcare for her children just a week before returning to work. Another became very emotional, highlighting the difficulty of leaving her child with a stranger and the lack of childcare options due to the shortage of spaces. Stress is significant in this regard.
“I even thought about opening a childcare myself when I couldn’t find one, a month before going back to work. I was like, okay, I’ll take a year without pay, and I’ll open a daycare.” (Jennifer, 43 years old, nurse, mother of 3 children, and a second-cycle student).
“It’s really an issue for student parents to have access to childcare; it’s important. I had this stress, like, okay, I’m starting a full-time session, I was on maternity leave, but I don’t have childcare, what do I do?” (Stéphanie, 37 years old, nurse, mother of 2 children, second-cycle student).
Three respondents mentioned a per-minute fee if they arrived late to pick up their child. These fees range from $1 to $5 per minute of delay. In case of unforeseen circumstances, road problems, or any other issues, it is very stressful and challenging for parents to find solutions. They must then rely on their support network. “The daycare charges $5 per minute after 6 pm, I believe. So I’d be more likely to call my mother-in-law to pick up my children if we have a flat tire, rather than say, can you keep them longer, and I’ll pay the fees” (Patricia, 36 years old, nurse, mother of 5 children, second-cycle student). It’s important to note that this is the amount for each child. In the case of two children in daycare, the amount is doubled.
Regarding schools, some participants report being able to enjoy excellent support, such as regarding the schedule for parent-teacher meetings, while others experience the opposite and must comply with the school’s schedules and requests.
“The teachers are still flexible. I arrived late at the parent-teacher meeting, and she took me aside, explained everything to me. I arrived late because I had a class; her father was supposed to go initially. I’m lucky.” (Audrey, 32 years old, nurse, mother of two children, first-cycle student).
“As for parent-teacher meetings, I’ll be honest, I don’t really attend when it’s just general. When it’s a specific teacher, it’s fine; they’ll arrange for us to meet on Teams for 15 minutes, which is fine” (Jade, 42 years old, nurse, mother of 2 children, first-cycle student).
It’s important to remember that the work of a nurse requires extreme concentration, and a small lapse in attention can have fatal consequences. One respondent explained that her daughter’s school called her during her shift to demand that she pick up her child because she had forgotten to sign a document. She was preparing a blood transfusion for a patient who was not doing well: “I have a patient who depends on me, […] I don’t work behind a desk, I can’t just leave whenever I want” (Caroline, 37 years old, nurse and bachelor’s student). She suggested to the school to send it in the next day, but the school demanded that the situation be resolved immediately. The nurse had to try to resolve the situation and then regain her concentration to care for her patient, whose life depended on her.
Weekends and pedagogical days scheduled in the school calendar are also challenging for nursing student parents. It’s already difficult to find time to study, and they must additionally take days off for these frequent school calendar days or rely on their network to take care of their children.
“On weekends, the daycare is closed, so it’s the grandparents. I also have people in my circle who can help out, or if the grandparents can’t, it’s my husband who might miss work” (Lucie, 32 years old, nurse, mother of 2 children, first-cycle student).
4.2. Personal, Family, and Social Life Challenges
During the interviews, 95% of the respondents stated that they had sacrificed their social life to manage the demands of work, family, and studies. For instance, Audrey, a 32-year-old mother of two and a bachelor’s student, mentioned: “My social life is practically non-existent, I would say. Social life has taken a backseat.”
Mélanie, an undergraduate nursing student and mother of one, shared: “I would say it’s mostly me who bears the brunt, more than family activities. I rarely have time for myself. I can’t just say, ‘Okay, I’m taking a break, resting, or going out with friends.’ That doesn’t happen because I’m always short on time. We take care of others, and taking care of ourselves will have to come at some point, I guess.”
Joanie, a 39-year-old nurse, mother of two, and second-cycle student, expressed: “I don’t have a social life, but, wait, excuse me, I have a family social life. But do I have dinner with my best friend? No. It’s all about family life; socializing with friends, all that has taken a backseat. It’s been a while since I’ve dyed my hair; I don’t know if that counts, but those are things I used to do before, so no, those have been somewhat neglected.”
One participant mentioned that she had moved to a new region three years ago and, due to the pandemic, hadn’t had time to rebuild her social network. She stayed in touch with an old friend through occasional text messages but didn’t know anyone in her new area and didn’t have time to build a new network.
Participants in relationships emphasized the importance of their partners supporting their return to studies, as it would be very challenging without their contributions and flexibility. Audrey, for example, said, “He needs to support me because I couldn’t have gone back to school without him. Financially, it’s essential. Working just two days a week, it’s as if I were still on maternity leave, I was only making 55% of my salary.”
Complications arise when both partners have atypical work schedules, requiring parents to be resourceful. Among the twenty respondents, ten mentioned having a partner with an irregular schedule. In such cases, when the partner is away for several days due to work, they must take on all responsibilities themselves.
Regarding household chores, responses varied significantly. Over 75% of the respondents stated that they couldn’t keep their homes as clean as they would like and only did the minimum required chores. Vicky, a 33-year-old nurse, mother of three, and first-cycle student, explained: “Household chores often take a backseat because they don’t bother the children. I’d rather be patient with them than rush to do housework. I prefer spending quality time with them.”
The level of household work varied depending on the type of dwelling, with some homeowners hiring external help for tasks like lawn maintenance or snow removal to free up time for other responsibilities.
Caroline, a 37-year-old nurse and undergraduate student, described her situation: “I can’t manage it… And you know, I can’t reduce my work hours; I need the money. Sometimes, I don’t even do the groceries. I don’t have the time. Sometimes, I stop at the grocery store after my work shift… I buy essential items, try to get some meat, etc. Something is always missing. But you know, I can go three weeks without going to the grocery store.”
Anna, a 39-year-old nurse and second-cycle student, humorously admitted: “I’m not good at cooking. If we want to survive, my partner has to take care of it!”
Couples employed various strategies to manage household responsibilities based on their situations. Some couples, where one partner was away for work for several weeks, delegated household maintenance to that partner upon their return. In other cases, tasks were divided according to each person’s strengths. Respondents highlighted the importance of working as a team when managing household chores.
Some families faced heart-wrenching choices. For instance, Maria, a 27-year-old nurse, mother of three, and first-cycle student, explained: “I was pregnant, working until 38 weeks, and dealing with confused geriatric patients. We decided, given the high-risk pregnancy, to take unpaid leave.” Her employer was aware of the risks but suggested she delegate tasks to auxiliary nurses. However, Maria felt she couldn’t care for her patients without direct contact, as auxiliary nurses lacked the necessary training to assess patients. She and her partner decided that she would stop working to complete her pregnancy. This decision left her with significant debts.
It’s essential to remember that nurses themselves may have personal health conditions that affect their work. For example, Virginie, a 29-year-old nurse, family caregiver, and first-cycle student, mentioned, “I have medications to take at extremely precise times, and I can’t even manage that.”
4.3. Fatigue Issues
Some nurses explained that they spend as much time as possible with their children but sacrifice sleep to make progress in their studies and home maintenance. The following interview excerpts illustrate this situation:
“One time, I sat my son on my lap while I was working on an assignment, or sometimes I’d do it at night when he was asleep, just to have a few hours of sleep and be able to get through my day.” (Sophie, nurse, mother of 1 child, undergraduate student).
“I don’t necessarily want my kids to pay for the fact that I decided to go back to school and work. Often, I study a lot when they’re in bed. I often study from 8 p.m. to 1-2 a.m. I sacrifice a lot of my sleep. I would say I often go to bed around 1 a.m. and still wake up at 6 a.m. with the kids.” (Audrey, 32 years old, nurse, mother of 2 children, undergraduate student).
“It’s just that it doesn’t work, it doesn’t work; it’s like you don’t have a choice but to do it, so you don’t ask questions, and you keep going. But I feel like in the end, I’m going to pay the price.” (Vicky, 33 years old, nurse, mother of 3 children, undergraduate student).
“Nights are often difficult; there’s never a night where I don’t get woken up by a child… Mommy, put the blanket on me, Mommy, I want a sip of water, Mommy, I want to sleep with you… Last night, I was woken up three times, so it also affects cognitive performance.” (Stéphanie, 37 years old, nurse, mother of 2 children, second-cycle student).
Overtime adds to the fatigue, as there may not be a day off the next day. They try to catch up whenever there’s an opportunity:
“When I finish at 10:30 in the evening, the next day, I start at 6 a.m., and it takes a toll on me. There are days when I’m more tired than others. I try to recover by going to bed earlier… I go to bed at the same time as the kids.” (Patricia, nurse, mother of 5 children, second-cycle student).
Professionals also work different shifts, often within the same week:
“I’m not in my twenties anymore. I can’t go to sleep because, you know, when I finish at midnight, I don’t go to bed until 3 or 4 in the morning. But the next day, you start again. You say, ‘I’ll do a little 12-hour shift, help out in the evening.’ But I don’t know if you can see the bags under my eyes, but I’ve been exhausted lately, especially with university.” (Jade, 42 years old, nurse, mother of 2 children, second-cycle student).
“Sometimes, I would move from one center to another… It wasn’t easy, and the next day, I had to work and finish at 11:30 p.m., then go home and return to school at 8 a.m., so I missed a lot of sleep. But it helped me, you know, pay my bills and maintain a good credit record.” (Geneviève, 32 years old, nurse, mother of 3 children, college student).
One participant mentioned being motivated by all this stress and drawing a form of energy from it:
“For me, stress is weird, but it gives me more energy. When I have a lot to do, it’s like I perform better. I don’t know, it’s a good dose of adrenaline that comes from having a lot on our plate, but no, I feel, since I started my master’s, there’s no lack of energy. I’ve even lost weight.” (Joanie, 39 years old, nurse, mother of two children, Master’s student).
The participants clearly expressed their feeling of sacrificing study time in favor of balancing work and family. Many mentioned that they would achieve better results because they have the ability and interest to learn, but they lack sufficient time to do research, readings, exercises, and so on.
4.4. The Difficult Balancing Act between Children and Studies
One of the participants mentioned that she no longer corrects her writing errors; she accepts losing points because she doesn’t have the necessary time to revise a paper. “I want to have a better job, not work at night… I do it for my children. Instead of correcting the writing mistakes in my assignments, I’ll play PatPatrol with my kids.” (Maryse, 32 years old, nurse, mother of 2 children, undergraduate student).
Another participant admitted to listening to pre-recorded lectures at an accelerated pace to save time. Most of them are certain that they could achieve better results but have to settle for less in order to balance everything.
“I can’t neglect my patients… and I can’t neglect my children; they only have one childhood, so it’s my studies that take a hit.” (Lucie, 32 years old, nurse, mother of 2 children, undergraduate student).
“I skim through my readings, and my notes are not extraordinary either, but I tell myself it’s not a master’s degree. I think to myself: I have to do it, pass it, and progress as a bachelor.” (Jade, 42 years old, nurse, mother of 2 children, undergraduate student).
“I try to take as many notes as possible, but I can’t spend three days studying. In the evening, at the end of my routine, I’m really exhausted, and all I want to do is sleep. Some days I’ll ask my mom to give me a hand, and that’s when I give it my all. That’s pretty much how I study. I could have better grades, but I have to balance it with my life.” (Patricia, 36 years old, nurse, mother of 5 children, second-cycle student).
“Of course, I can’t do all the recommended readings. Generally, it works well, but I could perhaps have slightly higher grades… if I really had the time to do everything.” (Mélanie, 40 years old, nurse, mother of 1 child, undergraduate student).
A recurring theme in the testimonies is the disappointment of not being able to dedicate more time to their learning, which is relevant to their jobs and for which they have a keen interest. Indeed, several participants mention returning to studies to increase their knowledge and the quality of care provided to their patients. Due to a lack of time, they sacrifice certain aspects of their learning, even though the very purpose of returning to school is to enhance it.
4.5. Possible Solutions
We also discussed possible solutions with nursing students regarding the various issues they face, and we have summarized them in the following tables, listing potential solutions and best practices.
The existing literature primarily emphasizes two main problems: work-life balance issues and work organization, including aspects related to Lean management and job control in the workplace. As we add the challenges related to studies, we also explore the importance of support from educational institutions, particularly in terms of internships and courses, as well as employer support through flexible working arrangements and work organization. By addressing these elements, we aim to shed light on how they can effectively contribute to the retention of nursing students and nurses within the healthcare system.
Table 1 explored the educational institutions’ environment and Table 2 outlines potential solutions that the employers, i.e. Health Department, clinics or hospitals can try to implement to increase the attraction and retention of nurses while specifically focusing on retaining nursing students in the early years of the career, which appear to be determinant.
![]()
Table 1. Summary of issues and best practices in educational institutions.
![]()
Table 2. Summary of issues and best practices in workplace settings.
5. Conclusions
In light of the current shortage of nurses in Canada, as well as in many other countries, addressing the challenges related to the attraction and retention of young nurses is of paramount importance. To tackle this issue, our study focused on nursing students, seeking to understand the support systems available to them as they navigate the complex balance between their studies, work commitments, and family responsibilities. This investigation led us to two fundamental research questions: Firstly, what are the specific challenges that nursing students encounter when trying to reconcile their academic pursuits with work and family obligations? Secondly, what potential solutions do they envision, both from their educational institutions (typically universities, though some nurses may possess college degrees) and their employers (given their involvement in internships and existing roles within the healthcare system)?
In pursuit of these objectives and to address our research questions, we conducted qualitative research, consisting of interviews with nursing students. This approach allowed us to supplement a previous quantitative study involving practicing nurses and obtain insights from younger nurses, who are of particular concern due to their higher attrition rates. Our findings shed light on the factors contributing to the early departure of nurses from the profession, a phenomenon often occurring within the first five years post-graduation, as highlighted earlier.
As demonstrated in Table 1, we have identified potential solutions that educational institutions can implement to facilitate the reconciliation of work, family, and studies for nursing students. Similarly, Table 2 outlines strategies that the Health Department and hospitals can adopt to support work-life-studies integration. By focusing on these solutions, we aim to contribute to the overall goal of attracting and retaining nurses within the healthcare system, with a particular emphasis on retaining nursing students during the crucial early years of their careers, where attrition rates are most pronounced.