Global nursing crisis: Addressing the demand-supply gap
November 29, 2024
"One in eight nurses practices outside their country of birth or training, influenced by factors such as remuneration, career opportunities, education, and job security." — Professor James Buchan
 Table 1: Asia-Pacific: Ratio of nurses to doctors, latest year available (OECD, 2022)
The growing demand-supply gap in nursing is a pressing issue that requires urgent attention. While it's not solely due to a decrease in nurse training, the escalating demand for nurses far exceeds our capacity to train and retain them, a trend observed globally.
Professor James Buchan, an ICN Consultant and representative from the Health Foundation/ WHO Collaborative Centre at UTS, Australia, emphasized the need for prioritizing primary healthcare in policy solutions. He noted the significant potential, particularly in advanced roles such as nurse practitioners. However, achieving this requires addressing broader issues surrounding planning, retention, skills development, and teamwork. Professor James spoke at the 22nd Asia Workforce Forum (AWFF) and the 18th Alliance of Asian Nurses Associations (AANA) meeting, hosted by the Malaysian Nurses Association (MNA) and the International Council of Nurses (ICN) from November 20-22. Key global issues facing nursing and midwifery workforces Demographic changes, including an ageing population and workforce, coupled with the impacts of the pandemic, have intensified the need for effective healthcare policies. The pursuit of Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) hinges on a viable and sustainable nursing workforce. Challenges include nurse and midwife shortages, skills mismatches, and geographic maldistribution. The pandemic exacerbated these issues by increasing demand while reducing supply. It also highlighted the significant risks associated with inadequate preparedness and the economic consequences of underinvesting in health. It underscored the inseparable link between population health and economic recovery, revealing our vulnerability to future pandemics. Many countries appear unlikely to achieve Universal Health Coverage (UHC). According to the Institute of Health Metrics and Evaluation (IHME), we will require up to 30 million additional nurses to ensure that populations can access a level of UHC beyond the basic standard. Understanding the global nursing workforce According to the State of the World’s Nursing (SOWN) report from 2019-2020, there were approximately 27.9 million nurses globally, with a significant shortage of 5.9 million nurses, predominantly in low- and lower-middle-income countries. Notably, one in eight nurses practices outside their country of birth or training. Professor James highlighted significant disparities in health expenditure per capita across Asia-Pacific countries, as reported by the OECD in 2022. There is a notable variation between government-mandated spending and voluntary out-of-pocket expenses, which directly impacts the funding available for the health sector. Given that healthcare is labor-intensive, a substantial portion of this funding is allocated to employing, training, and compensating the health workforce. Without a well-managed and adequately equipped workforce, particularly nurses, improvements in health outcomes are unlikely. It’s essential to recognize that funding levels vary significantly among countries, which affects the availability of hospital beds per thousand people. Unfortunately, as we shift towards prioritizing primary healthcare, metrics still predominantly focus on hospitals and acute care services, reflecting a limited perspective on overall healthcare availability. For instance, there is substantial variation in the number of hospital beds per thousand population, ranging from the Solomon Islands to India. India’s situation is influenced by its large population compared to North America, highlighting the distinct differences within the Asia-Pacific region. In terms of nursing resources, Australia, Japan, and New Zealand lead with 10 to 12 nurses per thousand population, while other areas experience a decline in nurse availability that correlates with funding levels. Countries such as Bangladesh, Vietnam, China, India, Macau, and Malaysia face challenges in maintaining adequate nursing resources. This issue is increasingly recognized as a priority, yet data remains insufficient for a comprehensive understanding. In the mental health sector, for example, there are marked variations in the availability of trained nurses per 100,000 population across different countries. High-income nations like New Zealand demonstrate a robust supply of specialist mental health nurses, whereas many lower-income countries experience a rapid decline in availability. Ratio of nurses to doctors The ratio of nurses to doctors is a crucial metric in assessing healthcare systems. For instance (refer to table 1) the Solomon Islands has 11 nurses for every doctor, a reflection of its small population and limited number of doctors. However, this country benefits from well-trained nurses who effectively serve as first responders, often collaborating with specialists in primary care. In contrast, countries like Papua New Guinea and the Philippines show a rapid decline in this ratio. In high-income countries, the average nurse-to-doctor ratio hovers around 3 nurses for every doctor, typically ranging from 2.5 to 3.5. Conversely, in nations such as Pakistan, Bangladesh, and Mongolia, there are more doctors than nurses. This trend suggests an outdated model that prioritizes doctor dominance in healthcare policy, funding allocation, and agenda-setting, which may hinder effective healthcare delivery. Overall, there is significant divergence in nurse-to-doctor ratios across different countries, highlighting the varying dynamics within their healthcare systems. Mobility and migration of nurses One in every eight nurses works in a country different from where they were born or trained. Various push and pull factors influence this mobility, including remuneration, career opportunities, education, and job security. The demand for nurses globally has led to large-scale international recruitment, driven by factors such as shared language, cultural similarities, comparable educational curricula, mutual recognition of qualifications, geographical proximity, established migrant communities, and relatively easy entry into host countries. These elements play a significant role in shaping the direction and scale of nurse mobility patterns. For instance, in Ireland, nearly half of the nursing workforce has been trained abroad, reflecting the country's active recruitment efforts in recent years. Given its small size, Ireland doesn't need to recruit many nurses to achieve this percentage. Other countries exhibit similar trends: about one in three nurses in New Zealand are foreign-trained, while Switzerland has one in four, and both Australia and the UK have one in five. On average, OECD countries report around 10% of their nursing workforce as foreign-trained. Conversely, some countries either effectively train enough of their own nurses due to adequate resources or struggle with limited funding or unique languages that hinder recruitment. Professor James noted that rapid recruitment of foreign nurses can be challenging. For instance, language training for nurses from countries like Finland or Bulgaria may take weeks or even months before they can effectively communicate with patients and doctors about treatment in the local language. International recruitment as an active solution Currently, there is a significant increase in the recruitment of nursing graduates, with a growing proportion being hired by various countries. Even nations that have historically had few international nurses are now entering the recruitment arena. For example, Denmark is engaging in bilateral discussions with India to recruit nurses, while Finland is exploring opportunities with the Philippines. These countries are recognizing international recruitment as a proactive solution to address their domestic nursing shortages. While they are not the pioneers in this approach, they are part of a broader trend where more countries are actively pursuing international recruitment. This shift is contributing to a rising demand for foreign nurses across the globe. The WHO Code on International Recruitment of Health Personnel As international recruitment of nurses continues to rise, it is essential to establish a policy framework that ensures this process is both effective and ethical. This framework should prioritize the well-being of individuals moving between countries while minimizing negative impacts on the countries involved. The primary policy instrument addressing this issue is the WHO Code on International Recruitment of Health Personnel, which was adopted at the World Health Assembly in 2010. All WHO member countries have essentially committed to this code and indicated their intention to use it as a guideline for international recruitment practices. Key components of the code emphasize:
Recently, the WHO published a list of countries particularly vulnerable to the outflow of nurses. These nations already face risks to their health systems and could suffer further damage if more health workers leave. The list includes 54 countries, among them:
Impact and costs of high turnover When nurses leave their positions, those who remain often face increased workloads to fill the gaps left by vacancies. This can lead to stress, burnout, and a reduced ability to provide safe care. Poor retention rates among nurses contribute to staff shortages, which ultimately result in unmet patient care needs. A recent report from the U.S. estimated that each percentage point increase in nurse turnover costs the average hospital approximately $328,400. Conversely, if a hospital successfully intervenes to reduce turnover, it could save around $330,000. For hospital executives focused on budget savings, these figures are significant. Such metrics can be invaluable when discussing retention strategies with policymakers. The cost of inaction is substantial,” emphasizes the importance of addressing turnover. Policies to improve nurse retention To enhance nurse retention, a comprehensive approach involving multiple policy initiatives is necessary—rather than relying on single solutions. Key factors influencing retention include:
Additionally, factors related to the pandemic have highlighted the need for:
These elements represent a comprehensive list of considerations for improving nurse retention. It is unlikely that any single factor will suffice; therefore, evaluating the impact of these policies is crucial. This evaluation will inform future decisions about the effectiveness of retention strategies and whether they should be continued or adjusted. Nurse safe staffing To ensure safe patient care, the number of nurses at the national level must translate into the appropriate local staffing levels. Achieving this requires the consistent application of staffing methodologies and tools to determine the necessary number of nurses in specific settings. This approach aims to deliver quality care, enhance nurse retention, and improve operational efficiencies. While there is no one-size-fits-all staffing solution, various options exist, including:
Aligning policy and planning at both the national and local levels is crucial for maintaining safe staffing levels and identifying areas where increased funding is urgently needed to support workforce growth. Regardless of the chosen approach, consistency is key. There must be a clear connection between national policy and localized, day-to-day planning to ensure that nurses are effectively utilized to meet patient care demands. One increasingly important method is the use of staffing ratios, which can be either mandatory or legislated, providing a straightforward way to achieve predictable staffing levels daily. However, many organizations are also exploring data-driven analyses, such as activity, acuity, and workflow assessments, to determine staffing needs on a more granular basis. While these methods can be effective, they rely heavily on data, which may not always be available. Therefore, all staffing strategies should be supported by professional judgment. There is a significant risk when relying solely on computerized systems that generate staffing solutions without input from nursing staff. Professional judgment is essential to ensure that the proposed staffing levels are safe and appropriate. Without this human insight, there is a danger that data alone could dictate staffing decisions, rather than the informed judgment of nurses. Recently, the Australian government published a review focusing on the scope of practice for health professionals, with the goal of optimizing and expanding the roles of nurses, midwives, pharmacists, and other healthcare providers. The review identified six key barriers and enablers: education, legal and regulatory frameworks, technology, employment conditions, funding, and leadership. In Australia, changes to legal requirements are being made to allow nurses to prescribe medications. The role of technology is also crucial, as it can help overcome barriers and enable nurses to take on advanced roles, particularly in rural and remote areas. Employment conditions, including career structure and fair compensation, are vital for attracting and retaining nursing talent. Funding is another critical factor. Understanding existing funding streams and how care is packaged and reimbursed is essential. In fee-for-service models, there is a risk that physicians may resist changes that could affect their income. Conversely, a blended payment system, where financial incentives are more balanced, may foster a more supportive environment for expanding nursing roles. Policy action focus At the national level, the emphasis should be on sustainability, while internationally, there is a need for mutual cooperation between nursing associations and other stakeholders, including organizations like the World Health Organization (WHO). From a national perspective, it is essential to clearly understand how policies and policy changes affect nurses. This includes integrating education and employment with a focus on the rights of planning. Key areas to address include retention, safe staffing, and career structures. These interconnected issues must be tackled to enhance nurse retention and improve the quality of care delivered. It is crucial to empower nurses to take on advanced roles and ensure that data is available to assess whether desired outcomes are being achieved. Collectively, we should advocate for a comprehensive update on the state of nursing worldwide. This involves ensuring that the data collected is accurate and reflective of the conditions in each country. In preparation for future pandemics, it is vital to ensure that nurses receive the necessary vaccinations, addressing gaps that existed during the COVID-19 crisis in many regions. Ethical international recruitment practices should be implemented, guided by established codes and bilateral agreements. Additionally, it is important to evaluate the impact of nursing assessments and to support investments in nursing in other countries. |
EXPLORE FURTHER
|
Global healthcare faces inequities; nurses essential for universal health coverageUrgent call for fair pay and better conditions for healthcare workers
|
|
Civil servants, including nurses, get 15% pay raise starting December 1, 2024Addressing Malaysia's nursing crisis with strategic policy reforms and educational enhancements
|
|
Nursing in the age of uberization: Revolutionizing healthcare deliveryHow innovative models are transforming nursing practice across Asia
|
|
Balancing nursing technology and skills: Where does Malaysia stand?Insights from regional leaders: Upskilling nurses through training programs, simulation labs, EMR and AI
|
