- The Global Shortage of Registered Nures: An Overview of Issues and Actions

Published in Te Puawai
July 2004

Below is the executive summary from the full report developed by James Buchan and Lynn Calman for the International Council of Nurses, which is available on the ICN website at www.icn.ch/global/shortage.

Executive Summary

This report on the global nursing workforce was led by the International Council of Nurses (ICN) and its sister organization the Florence Nightingale International Foundation (FNIF), and supported by the Burdett Trust for Nursing. The report is the first output from a programme of work examining the crucial issue of nursing shortages, and identifying a framework for policy interventions.

The world has entered a critical period for human resources for health. The scarcity of qualified health personnel, including nurses, is being highlighted as one of the biggest obstacles to achieving the Millennium Development Goals (MDGs) for improving the health and well being of the global population.

Against this backdrop of growing concern about shortages of health personnel, the report focuses on one of the most critical components of the workforce - nurses. Nurses are the "front line" staff in most health systems, and their contribution is recognised as essential to meeting these development goals and delivering safe and effective care.

In presenting a global overview, the paper reports on key trends, main challenges and potential solutions. The emphasis is on breadth of coverage, but specific nursing workforce issues in different countries are highlighted to illustrate the main challenges facing those responsible for developing and implementing policies on the nursing workforce. The report presents a snapshot of a dynamic and challenging situation worldwide.

A Global Overview

There is huge variation in the nurse:population ratios throughout the world.

At country level, the reported nurse:population ratio varies in different countries from less than 10 nurses per 100,000 population to more than 1,000 nurses per 100,000, a variation of more than one hundredfold.

The average ratio in Europe, the region with the highest ratios, is 10 times that of the lowest regions - Africa and South East Asia.

The average ratio in North America is 10 times that in South America.

The average nurse:population ratio in high-income countries is almost eight times greater than in low-income countries.

The low availability of nurses in many developing countries is exacerbated by geographical maldistribution - there are even fewer nurses available in rural and remote areas.

Skill mix and staff mix vary among organisations, systems and countries, and there is no single "optimal" mix of nurses and other staff to which all can aspire. However, many countries, particularly in Africa, Asia and Central/South America, are struggling to provide a minimum level of nurse staffing. Some countries, most notably in Central/South America, report employing many more physicians than nurses. Even in countries with low nurse:population ratios, there is often a maldistribution of available nurses, which exacerbates the impact of shortages. Rural areas in developing countries tend to be the most underserved areas.

Nursing Shortages and Critical Challenges

Whilst there is no universal definition of a nursing shortage, there is increasing evidence of nurse supply/demand imbalances in many countries.

Supply of nurses in many low-income and high-income countries is failing to keep pace with increasing demand.

One recent estimate is that sub-Saharan African countries have a shortfall of more than 600,000 nurses needed to meet the Millennium Development Goals.

The Organisation for Economic Co-operation and Development (OECD) reports that many of its (high-income) member countries have increasing problems of nursing shortages.

There is a link between adequate nurse staffing levels and positive care outcomes.

Gender-based discrimination continues in many countries and cultures, with nursing being undervalued or downgraded as "women's work".

Violence against health workers persists in many countries, with nurses often taking the brunt because they are in the forefront of the direct delivery of care.

Three critical challenges related to nursing shortages are:
- the impact of HIV/AIDS;
- internal and international migration of nurses;
- achieving effective health sector reform and reorganisation.

Critical Challenge #1: Sub-Saharan Africa - The Impact of HIV/AIDS on the Nursing Workforce

Whilst HIV/AIDS is a challenge throughout the world, its regional impact has, so far, been most pronounced in sub-Saharan Africa. HIVAIDS is impacting negatively on health systems both by increasing demand for health services and by reducing health workforce availability and performance. The impact of HIV/AIDS is also a factor in increasing internal and international migration of health workers from sub-Saharan Africa, which in turn creates heavier workloads for the nurses who remain.

Critical Challenge #2: Internal and International Migration

Migration and international recruitment of nurses have become more prominent features in the last few years. Often as important, but less prominent in policy arenas, is internal migration - from rural to urban areas, from public sector employment to private sector employment, and from nursing employment to non-nursing employment (or no employment). The impact of out-migration of nurses on some developing countries is severe. They are losing scarce, and relatively expensive to train, resources. Levels and quality of care are suffering. Many of the nurse recruits who cross national borders are relatively young and well skilled. Similar problems can be created by internal migration, where nurses take their skills and expertise into other types of employment.

Critical Challenge #3: Achieving Effective Health Sector Reform and Organisational Restructuring

Reform of health systems is often an essential component of improving efficiency, access, and outcomes from health service delivery. Many countries are going through a process of health sector reform, and many health organisations within countries are restructuring. However, whilst some approaches have led to improvements, not all attempts at restructuring have been successful, and some "successful" reforms have paid little attention to the impact on human resources within the health sector. Nurses and others working in dysfunctional or "failing" health systems have to develop various coping strategies to survive. Reforms and restructuring of health systems cannot ignore these factors if they hope to achieve the goals of health improvement and improved access to health care.

Policy Interventions Framework

Four components of a policy framework to address nursing shortages are highlighted in the report:

*Workforce Planning
*Recruitment and Retention
*Deployment and Performance
*Utilisation and Skill Mix

The need for effective policy intervention requires leadership and stakeholder involvement is highlighted.

It is emphasised that policy interventions must be appropriate to the country context and objectives.

Nursing shortages are not just a "problem for nursing". They are a health system problem, which undermineshealth system effectiveness and requires health system solutions. Without effective and sustained interventions, global nursing shortages will persist, undermining attempts to improve care outcomes and the health of nations.