COVID-19 has wreaked havoc on nursing across the world. With burnt-out and traumatised staff leaving the profession in droves, a study estimates that 13 million more nurses could be needed in the coming decade – nearly half the current global nurse total. Aggressive poaching by wealthy nations is exacerbating critical nurse shortages in the developing world, says the International Council of Nurses (ICN).
The United Kingdom, Germany, Canada and the United States are among the countries that have been recruiting abroad to fill yawning nursing shortages, it emerged this month. News broke last year of mass recruitment of nurses from Sub-Saharan Africa to work for NHS England, to fill 39,000 nursing vacancies. Most of the nurses appeared to be from Kenya, South Africa and Zimbabwe, including 20,000 Kenyan nurses (See stories below).
The International Council of Nurses called this week for a 10-year global plan that guarantees investments to stabilise and build the nursing workforce. It was imperative, the ICN said, to prevent the mass exodus of nurses leaving because of COVID-19 stresses, and to train a new generation of nurses to meet the anticipated increased future demands of an ageing global population.
Report urges global action to tackle nursing workforce crisis
The ICN published a report on 24 January which, it said, revealed how the pandemic has made the fragile state of the global nursing workforce much worse, putting the World Health Organisation (WHO) aim of Universal Health Coverage at serious risk.
Titled Sustain and Retain in 2022 and Beyond: The global nursing workforce and the COVID-19 pandemic, it suggests that up to 13 million more nurses will be required over the next decade, the equivalent of almost half of the world’s current 28 million-strong workforce.
The ICN statement continues: ICN Chief Executive Officer Howard Catton, who co-authored the report, said the findings underlined the severity of the shortages:
“We knew the situation was fragile because of the persistent historical underfunding of nursing around the world, but with the latest information about nurse vacancies, their rates of intention to leave, and staff sickness rates, it must now be recognised as a global crisis.
“We already had a shortage of six million nurses at the start of the pandemic, but with the immense and relentless pressure of responding to COVID and the Omicron variant, and an avalanche of resignations and retirements anticipated, the world will need to recruit and retain up to 13 million nurses over the next decade,” Catton said, adding later:
“This is a global health crisis, and it requires a fully funded and actionable 10-year plan to support and strengthen nurses and the health and care workforce to deliver health for all.”
The report was published by the International Centre for Nurse Migration (ICNM) in partnership with CGFNS International Inc and the ICN, and provides a blueprint for what needs to be done at the national and international levels to guide nursing workforce planning globally.
The ICN is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. ICNM is a knowledge resource created by CGFNS International Inc, which is a global nurse migration and human resources organisation.
The report says countries should: commit to prioritising nurses for vaccinations; provide safe staffing levels; expand domestic nurse education systems; increase the attractiveness of nursing careers; adhere to ethical international recruitment standards; and monitor their national ability to be self-sufficient to meet nursing workforce requirements.
CGFNS International Inc President and Chief Executive Officer Dr Franklin A Shaffer, another co- author of the report, added: “We can anticipate that there will be a migration tsunami as more than ever before, countries around the world turn to the international nursing supply to meet their workforce needs.
“The pre-existing unequal distribution of nurses around the world will be exacerbated by large-scale international recruitment to high-income countries as they look for a ‘quick fix’ solution to solving their nursing shortages, which will only widen inequalities in access to healthcare globally.”
Lead author of the report, Professor James Buchan of the University of Technology Sydney, and the University of Edinburgh, said:
“COVID-19 has had a terrible impact on the nursing workforce in terms of the personal effect it has had on individual nurses, and the problems it has exposed within many healthcare systems. Pre-existing shortages exacerbated the impact of the pandemic and burned-out nurses are leaving because they cannot carry on any longer.
“Governments have not reacted effectively to the growing worldwide shortage of nurses, and now they must respond to the pandemic, which is an alarming game-changer that requires immediate action.”
The report says a long-term plan is needed to stem the tide of those leaving nursing because of the additional stresses resulting from COVID-19, and to create a new generation of nurses to grow the profession to meet increased future demands of an ageing global population.
The ICN statement continues with words from ICN President Pamela Cipriano, who said: “Nurses have been on the front lines of the pandemic for two years now. The influence they have had on the survival and health of the people they serve has been enormous. Despite enduring heavy emotional and physical burdens of providing care for their patients and communities, they have shown great resilience. But resiliency has its limits.
“Without nurses, it is clear our health systems would collapse. All of the evidence in this report shows that it is vital to act on a new 10-year plan that guarantees investments to stabilise and build the nursing workforce.
“Delivering on commitments to support nurses with safe work environments, staffing levels and workloads, involvement in decision-making, mental health services and equitable compensation will catalyse interest and growth to build the profession.
“Nurses deserve to be recognised and rewarded for their immeasurable contributions to the health of people everywhere.”
Catton added: “We can no longer afford to undervalue and underfund the nursing profession, not only for the sake of the health of nurses, but for the protection and sustainability of our entire global health system.
“Let’s be clear: we are not talking about stop-gap solutions, getting through the current pandemic, or even preparing for the next. We are talking about being able to address all the healthcare needs that have built up and been delayed since the onset of the pandemic.”
Sustain and Retain in 2022 and Beyond: The global nursing workforce and the COVID-19 pandemic
Authors: James Buchan, Adjunct Professor at University of Technology Sydney; Howard Catton, CEO of the International Council of Nurses; and Franklin A Shaffer, President and CEO of CGFNS International Inc and the ICNM Secretariat.
The report was based on a rapid review and data and information from several national nursing associations.
It focuses on the nursing workforce at a time when a global pandemic is raging across the world. The year 2021 had seen unprecedented damage inflicted on health systems and on the nursing workforce, and 2022 marked no change in the continuing relentless pressure of the pandemic on nurses, and on the global nursing workforce.
The brief provides a global snapshot assessment of how COVID-19 is impacting on the nursing workforce, with a specific focus on how changing patterns of nurse supply and mobility will challenge the sustainability of the global nursing workforce.
It sets out the urgent action agenda and global workforce plan for 2022 and beyond that is required to support nurse workforce sustainability, and therefore improve health system responsiveness and resilience in the face of COVID-19.
The following is a small excerpt from the report summary, describing the impacts of COVID-19 on nurse supply.
COVID-19 and its impact on nurse supply
- The global nursing workforce was estimated in 2019-20 as being 27.9 million nurses.
- Prior to the pandemic, the global shortage of nurses was estimated at 5.9 million nurses; nearly all of these shortages were concentrated in low- and lower middle- income countries. The pandemic has exacerbated the existing nurse supply shortfall and has forced rapid and “emergency” policy responses to try to increase nurse supply, at the system level, in all countries.
- There is a growing evidence base on pandemic impact, both on the personal level (stress, workload, infection risks, demands made of nurses to “cope” and be “resilient”, and concern about “moral injury”) and on the implications of the system responses (re-deployment, new responsibilities, access to PPE, etc.).
- The pre-pandemic shortage of nurses has been exacerbated by the impact of the pandemic. Burnt out nurses are leaving employment or taking absence.
- If only an additional 4% of the global nursing workforce were to leave as a result of pandemic impact, then the increased outflow of nurses would be more than one million; this would push the global nurse shortage estimate up to seven million.
- Each health system and country should conduct periodic nursing workforce impact assessments, to provide alerts to pandemic related damage being done at the level of individual nurses, the overall nursing workforce, and health care systems.
Self-sufficiency and nurse supply
- The pandemic has increased the immediate need for nurses in all countries and will further ramp up demand over the next few years.
- Many countries must focus on increased supply of ‘new nurses’, both to meet growing and changing demand created by the pandemic, and because of reduced current supply.
- There is huge variation in the relative size of new supply of nurses from domestic training, across the high-income countries of the OECD.
- Many low- and middle-income countries entered the pandemic with inadequate supply of nurses.
- There is emerging evidence of increased active and ‘fast track’ international recruitment by some high-income OECD countries, which could undermine the ability of some ‘source’ countries to respond effectively to pandemic challenges.
- The pandemic has heightened the risks associated with international recruitment: cutting across international supply to some high income ‘destination’ countries, in the short term, whilst driving up ‘push’ factors and likely outflow from low-income ‘source’ countries.
- There is a growing policy emphasis on the potential of government-to-government bilateral agreements to ‘manage’ international recruitment of nurses – these agreements must be independently monitored to assure full compliance by all parties.
- There is an urgent need to monitor trends in international recruitment flows using a self-sufficiency index which can flag how reliant countries are on international inflows, and how the patterns of flows and impact are changing.
Rich countries’ access to foreign nurses during Omicron raises ethical concerns
There has been an increase in international recruitment to places like the United Kingdom, Germany, Canada and the United States, Catton told Emma Farge in a Reuters interview.
“I really fear this ‘quick fix solution’ – it’s a bit similar to what we’ve been seeing with PPE [personal protective equipment] and vaccines where rich countries have used their economic might to buy and to hoard – if they do that with the nursing workforce it will just make the inequity even worse.”
As mentioned above, even before the pandemic there was a global shortage of six million nurses, with nearly 90% of those shortages in low- and lower-middle-income countries, according to ICN data, said Reuters.
Catton said that some of the recent recruits to rich countries have come from Sub-Saharan Africa, including Nigeria, and parts of the Caribbean. He added that nurses were often motivated by higher salaries and better terms than at home. The ICN report said this process was also being facilitated by giving nurses preferred immigration status.
“The bottom line is that some people would look at this and say this is rich countries offloading the costs of educating new nurses and health workers,” he said.
Even wealthy countries will struggle to cope with the “mountains of backlog of unmet care” when the pandemic winds down, Catton warned, calling for more investment and a 10-year plan to strengthen the work force.
"We need a coordinated, collaborative, concerted global effort underpinned by serious investment, not just warm words and platitudes and applause.”
Massive UK nursing shortage sucks in Kenyan, South Africans, Zimbabweans
As reported by Spotlight last October, the Royal College of Nursing said that NHS England would have to rely on international recruitment to fill 39,000 vacancies. As part of this process, 20,000 Kenyan nurses were due to start working for the NHS that month, supplemented by a “steady flow” of nurses from South Africa and Zimbabwe. Other countries being targeted included Ghana, India and Philippines.
Recruitment consultants said that there was already a steady flow of nurses from South Africa and Zimbabwe seeking work in Britain.
The 20,000 Kenyan nurses were on a three-year contract, under terms of an intergovernmental agreement. The contracts may be renewed after the lapse of the three-year period, depending on their performances.
The UK-Kenya arrangement is based on allowing nurses and health workers who are currently unemployed, a “special route” to work in the UK for a fixed period. Ministers said both countries would benefit from the arrangement through the sharing of experience and knowledge across health services.
NHS leaders have stressed the need for “ethical recruitment” schemes that avoid stripping low- and middle-income countries of much-needed nursing skills. These include ‘train-and-return’ schemes that would see overseas nurses working in the NHS for a set period of time before going back to work their home nation.
Although “ethical recruiting” requirements theoretically discourage the recruitment of nurses, doctors and other health care personnel from underdeveloped countries, the reality is somewhat different. In many developing countries nurses are poorly paid and, despite massive need, often cannot find full-time employment.
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