Key takeaways:

  • Nursing is facing a shortage of 9 million globally.
  • Attracting market rates of pay is a key issue.
  • No country has found a silver bullet, though Norway has had some success marrying profile-raising activity with better renumeration.

Announcing last year that 2020 would be the first ever International Year of the Nurse and the Midwife, director general of the World Health Organisation Dr Tedros Adhanom Ghebreyesus described the professions as “invaluable to the health of people everywhere”, adding that “without nurses and midwives, we will not achieve the sustainable development goals or universal health coverage.”

Few would dispute the importance of nursing, and yet the profession continues to face a crisis as supply fails to keep up with demand. The most recent figures, from the United Nations in 2014, put the global shortage at 9 million, making up 50% of all staffing shortages in healthcare as a whole. While the figure is expected to improve when it is updated this year, experts are unanimous in predicting a significant shortage and one which continues to disproportionately affect low and middle-income countries.

Poor working conditions and high stress levels push nurses out of the workforce and repel new nurses from entering it in the first place

The issue needs urgent attention, says Howard Catton, CEO of the International Council of Nurses, because “the health needs of the world are changing — it’s not just about infectious diseases but climate change, mass migration and mobility, ageing populations. Nursing is central to addressing those demands.”

The reasons for the shortage are manifold, says Professor Alison Leary, Chair of Healthcare and Workforce Modelling at London South Bank University. “Part of this is cultural,” she explains. “it’s a gendered occupation and, despite being knowledge intensive, is still seen as primarily a service job and therefore does not attract market rates of pay.”

Not only does low pay contribute to a high level of turnover, but migration of nurses to higher paying countries can exacerbate the staffing issues faced by low-income ones, sometimes being so severe as to lead to the closure of certain public health services.

As well as the public perception of nursing and its impact on pay, Catton and Leary both point to poor working conditions — health and safety, bullying and harassment — and high stress levels; not only do these issues push nurses out of the workforce, they can also repel new nurses from entering it in the first place. On top of an ageing workforce and challenges with developing the capacity and infrastructure to train enough new nurses, a perfect storm of different factors sustains the shortage worldwide.

Solutions need to address the supply of nurses entering the profession through improved education and training

There is no silver bullet, nor an example of a country that has managed to completely solve the problem, say experts. Countries such as the USA and Australia have made progress by emphasising the value of nursing and strongly promoting it as a highly-skilled and important role, though this, says Leary, is just one half of the equation; expertise and value need to be rewarded as well as just recognised, as it is in Norway where nurses earn an average salary of $52,000 and the workforce is more comparably sustainable.

As well as retention, solutions need to address the supply of nurses entering the profession through improved education and training, including fair remuneration for trainees and availability of placement options. Leary points to the UK’s graduate diploma, a two year training opportunity for graduates, as an approach which increased the number of registered nurses while remaining cost effective. But the diploma was replaced with “a range of expensive other options, of which only a few deliver registered nurses”.

The graduate diploma is one example of why, while the problems and their solutions may be clear, taking the correct approach to policymaking is also vital. “A lot of these problems have long been known and agreed on, and there’s been consensus about what the actions should be,” says Catton. But "we often see short-term approaches to the nursing workforce: governments will commit and invest, and then another priority will come along or the budget is frozen. There’s a lack of long-term and sustained approaches”.

There is also, he warns, a risk of policy being blind to the frontline experiences of nurses themselves. Rather than momentarily consulting with the workforce in the short-term, professionals should be included and valued throughout the workforce development process.

“Their contribution would improve the policymaking process and lead to better policy outcomes for everyone,” says Catton. “They’ll tell you what the issues and challenges are and what needs to be fixed, and they’ll help you design a policy solution that’s got the best chance of working and delivering solutions.” —Eve Livingston

Further reading:

Year of the nurse and midwife (WHO briefing)

(Picture credit: Unsplash)