This paper provides a context for this special edition. It highlights the scale of the challenge of nursing shortages, but also makes the point that there is a policy agenda that provides workable solutions.
An overview of nurse:population ratios in different countries and regions of the world, highlighting considerable variations, with Africa and South East Asia having the lowest average ratios. The paper argues that the ‘shortage’ of nurses is not necessarily a shortage of individuals with nursing qualifications, it is a shortage of nurses willing to work in the present conditions. The causes of shortages are multi-faceted, and there is no single global measure of their extent and nature, there is growing evidence of the impact of relatively low staffing levels on health care delivery and outcomes. The main causes of nursing shortages are highlighted: inadequate workforce planning and allocation mechanisms, resource constrained undersupply of new staff, poor recruitment, retention and ‘return’ policies, and ineffective use of available nursing resources through inappropriate skill mix and utilisation, poor incentive structures and inadequate career support.
What now faces policy makers in Japan, Europe and other developed countries is a policy agenda with a core of common themes. First, themes related to addressing supply side issues: getting, keeping and keeping in touch with relatively scarce nurses. Second, themes related to dealing with demand side challenges. The paper concludes that the main challenge for policy makers is to develop a co-ordinated package of policies that provide a long term and sustainable solution.
Relevance to clinical practice
This paper highlights the impact that nursing shortages has on clinical practice and in health service delivery. It outlines scope for addressing shortage problems and therefore for providing a more positive staffing environment in which clinical practice can be delivered.
Keywords: nurses, nursing, workforce issues, workforce planning Go to:
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 health system effectiveness. In January 2004, the High Level Forum on the Health Millennium Development Goals (MDGs) reported, ‘There is a human resources crisis in health, which must be urgently addressed’ (High Level Forum on the Health MDGs, 2004, p. 4). Later in the same year, the Joint Learning Initiative reported that ‘There is a massive global shortage of health workers’ (Joint Learning Initiative 2004; executive summary, p. 3). In 2006, the World Health Organisation devoted the whole of the World Health Report to the negative impact that human resources shortages was having on global health care (WHO 2006).
Against this backdrop of growing concern about shortages of health personnel, this paper focuses on one of the most critical components of the workforce: nurses. As such, it provides a context for the other papers in this special edition of the Journal of Clinical Nursing. These other papers focus in detail on specific nurse workforce issues and priorities facing policy makers and researchers in Australia, Canada, Japan, the USA and elsewhere. They emphasise the need to develop a better understanding of the specific dynamics in organisational and country level nursing labour markets if policy makers are to be well informed about the judgements they must make about what will be effective policy solutions for the nursing workforce. This paper provides a broader perspective, highlighting the scale of the challenge of nursing shortages, but also making the point that there are many common challenges and a policy agenda that points to workable solutions.
Nursing and the global health workforce challenge
WHO has estimated there to be a total of 59·2 million fulltime paid health workers worldwide in 2006, of which about two thirds were health service providers, with the remaining third being composed of health management and support workers (WHO 2006).
WHO also calculated a threshold in workforce density below which consistent coverage of essential interventions, including those necessary to meet the health-related Millennium Development Goals (MDGs), was very unlikely. Based on these estimates, it reported that there were 57 countries with critical shortages equivalent to a global deficit of 2·4 million doctors, nurses and midwives. The proportional shortfalls were greatest in sub-Saharan Africa, although numerical deficits were very large in South-East Asia because of its population size (WHO 2006, p. 12). WHO also highlighted that shortages often coexist in a country with large numbers of unemployed health professionals: ‘Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce this paradox of shortages in the midst of underutilized talent’ (WHO 2006, p. xviii).
WHO concluded that the shortage crisis has the potential to deepen in the coming years. It noted that demand for service providers will escalate markedly in all countries – rich and poor: ‘Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands. Technological advances and income growth will require a more specialised workforce even as needs for basic care increase because of families’ declining capacity or willingness to care for their elderly members. Without massively increasing training of workers in this and other wealthy countries, these growing gaps will exert even greater pressure on the outflow of health workers from poorer regions’ (WHO 2006, p. xix).
Nurses are the main professional component of the ‘front line’ staff in most health systems, and their contribution is recognised as essential to meeting development goals and delivering safe and effective care. One difficulty in making an accurate global estimate of numbers of nurses is the definition of ‘nurse’. Different international agencies, at different times, have developed different definitions, some related to educational level, some to years of training. The primary focus of this paper is on registered nurses, but this focus is hampered by the absence of a clear definition for some data sources, and the overall lack of a single universal definition of ‘nurse’. To give one indication of the size of the nursing workforce world wide, the International Council of Nurses reports 129 national nurses’ associations representing 13 million nurses worldwide (ICN 2007).
This section of the paper provides an overview of nurse:population ratios in different countries and regions of the world. The data must be used with caution. The country level data collated by WHO which is reported in this paper may in some countries include midwives under the broad category of nurses; for some, it is also likely that the data may include auxiliary and unlicensed personnel. There can also be varying interpretations relating to the calculation of the number of nurses – some countries may report working nurses, others may report all nurses that are eligible to practice; some may report ‘headcount’, others may report full time equivalents. The analysis presented below should therefore be taken as illustrative of a broad pattern of regional variations, rather than an accurate representation of each country. Current initiatives by international organisations such as WHO, ILO and OECD to agree to standard definitions and improve the collection of country level HRH data should improve the current unsatisfactory situation.