Global nursing workforce challenges: Time for a paradigm shift

On 20 March 2023, the International Council of Nurses (ICN) published a report, highlighting the critical global nursing workforce situation, and warning that it is projected to worsen (ICN, International Council of Nurses, 2023). The COVID-19 pandemic has exhausted the nursing workforce. Reports of occupational fatigue, stress and burnout are everywhere, leading to widespread dissatisfaction, and resulting in significant numbers of nurses leaving the profession (ICN, International Council of Nurses, 2023; Dall’Ora et al. (2020). The report suggests this situation should be considered a global health emergency (ICN, International Council of Nurses, 2023).

As the World Health Organisation has stated, functional healthcare systems cannot exist without adequate numbers of appropriately educated and skilled healthcare workers (WHO, World Health Organization, 2020). The global demand for this workforce is increasing, as health systems try to recover from the pandemic. While the need for this workforce is growing, recruitment has proved a major challenge for affluent nations, as evidenced by the UK’s recent student recruitment records, and the numerous unfilled nursing posts in the NHS, across all four UK countries (McCurdy, 2023, BBC News, Scotland, 2022, The Health Foundation, 2019, Buchan et al., 2020).

Despite many campaigns, and much policy discussion, about making nursing appealing to younger generations of people from diverse backgrounds, the profession’s attractiveness is declining in many affluent nations. Unfortunately, with many nursing positions remaining vacant in rich nations, governments turn to recruit nurses from international sources. Indeed, this strategy has been a ‘quick fix’ solution to a chronic political problem: of nursing being undervalued, low-paid, hard work, and a gendered profession. This editorial argues the importance of not only improving nursing’s professional image, but also of improving inclusivity. By doing so, countries could attract more nurse candidates, at both local and national levels, and affluent nations should not need to consider international recruitment. Perhaps rich nations should also learn a few tips from countries, where nursing remains an attractive profession.

1. Recruitment challenges at home

The most pressing practical issue has been how to make nursing an attractive profession, particularly in those countries facing recruitment challenges. Current patterns of international nurse recruitment reveal a growing dependency on an internationally educated health workforce in the UK, Europe, the Gulf States and North America. Many economically rich nations, such as the Netherlands, the USA, Germany, Australia, New Zealand, Canada, and the UK, have been consistently unsuccessful in attracting enough nurse candidates. Various student recruitment and retention strategies have been developed and implemented but have had minimal impact (Mooring, 2016). Retention of graduate nurses in their healthcare systems has proved another major challenge.

However, contrary to the pattern in affluent nations, nursing is a very attractive profession for a younger generation of women in countries like Nepal, India, and the Philippines. The reasons for these trends are perhaps contextual and complex, and dependent on women’s position in society, the image of the profession, and the opportunities available for women in national and international healthcare labour markets. A commonly suggested driver for the attraction is international opportunity. Unfortunately, this is not the case in rich Western countries. More work is needed to make nursing an attractive profession for future generations.

While India, the Philippines, and Nepal have remained major suppliers of nurses to countries in the Gulf, Europe and North America, they also have health worker retention issues at home, and are under pressure to scale up their nursing workforce to meet Universal Health Coverage (UHC) by 2013 (Liu et al., 2016).

2. Various recruitment and retention campaigns and their impact at national and international levels

Realising the chronic nursing shortage and increased demand for this workforce, the UK’s All-Party Parliamentary Group on Global Health published a report suggesting investing in nursing and strengthening this workforce could make a triple impact (APPG, 2016). As well as achieving UHC, given that it is a gendered profession, nursing employment empowers women, and improves gender equality, and makes a significant contribution towards economic growth. Although it has been fully acknowledged that nursing is a crucial profession, which can achieve these goals, any progress in making the necessary changes has been painfully slow. Most people involved in the healthcare and nursing sectors globally are fully aware of and the nursing shortage has an impact on them.

A further global effort to make nursing an attractive profession, is the WHO declaring 2020 ‘Nurses and Midwives’ Year.’ For this, the WHO prepared a comprehensive report on the ‘State of the World’s Nursing 2020.’ The International Council of Nurses and the WHO jointly planned the ‘Nursing Now’ Global Campaign (2018–2022) (WHO, World Health Organization, 2020). This was for professional solidarity, and to improve the profession’s image, linking this with achieving UHC by 2030. Just as the campaign was launched, with its various activities and strategies in place, the COVID-19 pandemic hit the world, disrupting most of the activities planned for 2020. Instead, resources globally were diverted towards the COVID-19 response. Now the Nursing Now campaign has begun to pick up its momentum. However, anecdotal reports indicate that its messages are still to reach frontline professionals, nurse educators, and nurse employers and policy makers. It raises important questions of how effective and inclusive these campaigns are, and if nurse leaders can raise awareness of, and disseminate messages to, wider professional circle. There is an urgent need to find ways of reaching frontline professional colleagues, and identifying if such a campaign has any relevance in their professional lives, impact on nurse recruitment and retention. It is vital that we improve professional inclusivity.

Amongst many other efforts in the UK, one national level policy attempt to invite students, from diverse and socially disadvantaged backgrounds in the UK, is by widening access to higher education, including nursing education. This has been a praiseworthy social inclusion policy, but the true impact of this is not fully understood yet. No study has been conducted to examine it (Adhikari, 2023). Yet, in this academic year, all the UK countries have not been able to recruit the target number of nursing students, which has raised a major concern.

3. Improve inclusivity and the time for a paradigm shift

There is a huge diversity, and division, within professional nursing: in professional class, race, nationality, religion, gender identify and more (Adhikari et al., 2023, Smith et al., 2006). Now is the time to listen to a wider range of voices, and opinions. More work is urgently needed to address the global nursing workforce crisis for post pandemic recovery. Improving inclusivity can improve the profession’s image, making nursing an attractive career choice for people from wider backgrounds. More nurses are urgently needed across the world, to recover and rebuild healthcare systems, and to meet the Sustainable Development Goal of UHC by 2030. It is the time for a paradigm shift.