We often complain of nursing shortages in developed countries; certainly this has been the case in North America and Europe (Anonymous 2001). However, if we are short of nurses, consider the situation in some parts of Africa and South America where the ratio of nurses per head of population is a magnitude of difference lower. The problem of nursing shortages in some of the less well developed countries is compounded by the fact that even these nurses are not evenly distributed across the country. The nurses tend to work in urban rather than rural areas meaning that ‘Rural areas in developed countries tend to be the most under served areas’ (p. 4). This is a broad summary of a recent report The global shortage of registered nurses: An overview of issues and actions authored by Jim Buchan and Lynn Calman and published by the International Council of Nurses (ICN; 2004). The study was also financed by the Burdett Trust for Nursing and the Florence Nightingale International Foundation.
It is not clear at which point a nursing shortage is taking place but, across a range of countries, it is reported that supply of nurses is failing to keep up with demand. Inadequate nursing staff levels lead to poor care outcomes and the situation of this predominantly female profession is adversely influenced by gender discrimination and violence against women in many countries. Three critical challenges are identified in the report as being: the impact of HIV/AIDS in Sub-Saharan Africa; migration of nurses internally and across international boundaries and the need to achieve effective health sector reform and organizational restructuring. The present report is preliminary to a series of seven further papers which will consider some of the issues arising in the report in more detail, such as those challenges identified above. These papers will inform a global summit on workforce development this year.
As Buchan and Calman point out, nurses are in the ‘front line’ for the provision of health care in most health systems. There is ample evidence in the literature for the negative impact of nurse understaffing and there is copious reference to this in the report. Adverse effects include mortality, postoperative complications and infection rates. It is to be hoped that health planners and government health ministers across the world are paying attention. Of course, one country's relatively high employment of nurses may be another country's shortage and this has been illustrated in the UK by the increasing employment of nurses from the Philippines and Malawi; countries that can ill afford to lose their nurses. Frankly, if nursing shortages are linked to adverse outcomes then the sequestration of nurses from underdeveloped countries in the more developed countries threatens the very fabric of their health care systems. One of the seven subsequent papers in this series will deal specifically with this issue.
The report, as is usual for anything authored by Jim Buchan, is authoritative and full of facts. There are, it is estimated by the ICN, over 12 million nurses in the world. However, as mentioned, there is considerable variation between developed and under developed countries. For example, the ratio of nurses to head of population in Uganda is 10 per 100 000 and in Norway it is 1000 per 100 000. Within regions such as The Americas, there is a clear, decreasing, gradient in nurse to head of population ratios as one moves from North America, through the Caribbean and Central America to South America. These points are well illustrated in the report. Likewise, there is a negative gradient as one moves from Western to Eastern Europe. Drawing on World Bank figures it is clear that the nurse to population ratio is linked to the income of the respective countries. Simply put, those countries with more to spend on health tend to do so and the more they spend the better their nurse to population ratio. This, as also illustrated in the report, applies also to physician to population ratios. The report continues to analyse specific countries and compares Bangladesh and Canada thereby demonstrating that there is a disparity in the distribution of nurses between rural and urban areas.
Other aspects of the report, to be considered in more detail in subsequent papers, include skill mix and some consideration of why there is a nursing shortage. No optimum skill mix is proposed. However, when it comes to the reasons for nursing shortages, there are several propositions, and these are supported by other work in this area. There is a reported shortage of nurses coming into the profession through preregistration programmes and this was certainly observed in the UK towards the end of the last century (Brooks 1998). Nurses are leaving the profession prematurely and the reasons for this are many and varied. Clearly stress and injury play a part (Watson et al. 2003) but it is also the case that those employing nurses should become better employers and, again, this will be the focus of another paper in the series. At the other end of the employment spectrum from recruitment is the fact that the nursing workforce is ageing. In a wide range of developed countries the average age of nurses is rarely below 40 and then it is in the high 30s. In some countries it is approaching 45. Older nurses, in themselves, do not pose a problem for health services. Some of these will have entered the profession late and others will be amongst the most experiences and reliable members of the nursing workforce. However, the older a nurse is the more likely it is that he or she will retire and the older the nursing workforce, with poor replenishment rates through recruitment and poor retention, the more this becomes a problem. In the UK older nurses in the NHS are the focus of at least three projects based in Hull, Leeds and London and funded by bodies such as the UK Department of Health and the European Social Fund. The purpose of these studies is to find out why older nurses leave the NHS and what can be done to prevent this.
The recent report by Buchan and Calman is both interesting and valuable. I look forward to the rest of the series of papers and to the deliberations of the global summit this year.