Executive Administration Department, Cleveland Clinic Abu Dhabi, Cleveland, Ohio.
Correspondence: Randall Hudspeth, PhD, MS, APRN-CNS/CNP, FRE, FAANP, International Operations, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 (firstname.lastname@example.org).
The author declares no conflict of interest.
THE PAST 3 YEARS as an American chief nurse working internationally and interacting with clinical recruiting agencies in North America, Europe, Asia, and Australia has operationally confirmed what many of us knew about the nursing shortage. Our concerns about the dire predictions of a massive shortage surfacing between 2015 and 2020 were given a temporary reprieve with the economic downturn beginning in late 2008, from which we have not yet fully recovered. People lost jobs and nurses, although they were aging and many were planning to retire, remained in the workforce and some even increased work hours. This gave a false sense that the predicted shortage was just another in the recurring series of intermittent shortages seen in the past. But this time it is global and it is different, and the literature is rich with evidence as to why. The evidence can be grouped into 4 categories: opportunity, reward, demographics, and regulatory requirements to protect the public.
Opportunities are available for nursing education, but they are not always evident and can be difficult to access. Today, nursing schools often report significantly higher numbers of qualified applicants than available student positions; thus, many are denied enrollment in nursing schools and they go elsewhere being lost to nursing. Denial is often a result of limited faculty and/or limited clinical resources. Education costs are also an issue globally and scholarships are not as plentiful or as easily obtained as they were in the past.
In other Western countries, the move from hospitals to colleges and universities has followed the same path it did in the United States during the past 60 years. Since 1999, 47 European countries have signed the Bologna Accord (Declaration) that has altered nursing education in a similar way to the US experience. Signers agree to reform higher education to achieve a system of comparable and understandable degrees throughout the European Union; to establish a clear and standard division between undergraduate and graduate studies; to promote student mobility among different fields of study, institutions, and nations; to develop a quality-assurance process and governing body to ensure standard qualifications and quality throughout participating countries; and to define a European focus for higher education. As a result, European nursing education is following the same moves that occurred in the United States, with hospital schools closing and education migrating to colleges and universities.
In general, we tend to believe that young people have more opportunity for diverse careers, and this has negatively impacted the nursing pool. While it is true that there is more diverse opportunity, young people continue to have the highest unemployment numbers, and new graduate nurses rarely get jobs over experienced nurses. In the United States, there does not appear to be a disinterest in nursing. One measure of nursing supply is licensure. The National Council of State Boards of Nursing reports that the number of US-trained nurses has been increasing since 2000. Numbers show a 9.8% annual increase of newly licensed US nurses in each year for the past 9 years. Still, new graduate numbers are not sufficient to sustain our nursing manpower needs, and with the combination of an aging population increasing demand for nursing care and an aging RN workforce, many who are retiring within 5 years, there is a projected US RN shortage of 800 000 by 2020. The European Commission study forecasts a European Union RN shortage of 590 000 by 2020.
Reward is directly related to need. Where will we get nurses, how much will we have to compensate them, and is global nursing migration sustainable? Nurses from developing countries who work in Europe or North America make comparable salaries to the native nursing workforce. This is not the case in the Middle East and some developing countries where nurse salaries are based on the nurse's home country compensation. Thus, a staff nurse from North America and a staff nurse from Philippines can work side by side in a unit and be paid vastly different salaries.
Immigration is a major consideration for nurses from developing countries and is an issue addressed by the International Council of Nurses. The 2007 International Council of Nurses position paper on “Ethical Nurse Recruitment” speaks to the concerns of depleting a country's nursing workforce, among other issues that impact immigrants. The Philippines is a good example of a university-educated workforce seeking to immigrate, either for temporary work (circular immigration) or permanently. There is an adequate supply for global recruitment without harming the national workforce, and more Filipino nurses work outside of Philippines than any other country. India is emerging as a major supplier of nurses, but there are fewer university-based programs, and the 3-year education often includes a 6-month midwifery section that is not considered a component of basic nursing education, thus posing some issues for acceptance in the West. Visa retrogression has limited US immigration in recent years, but hospitals in Europe and the Middle East increasingly look to Philippines and India to meet their health manpower needs. Even countries such as Jordan, which has a large number of highly skilled national nurses, look to Philippines to meet the need for female nurses. Many RNs from developing regions leave nursing and accept employment as domestic help in more affluent regions just to have the immigration opportunity. The top 3 countries for nurse outward migration are Philippines, India, and Canada (mainly living in Canada and working in US border communities).
The United States employs the greatest number of foreign educated nurses, but they represent only 4% of the RN workforce. The United Kingdom and Ireland both report 8%, and Canada reports 6%.
Demographic is a major factor. We are moving in a direction whereby there are fewer people to work. In 1950, developed countries reported that there were 7.2 people younger than 65 years for each person older than 65 years. In 2011, the number had dropped to 4.1 and by 2050, it will be only 2. Asian countries are also experiencing more older people and their replacement factor continues to decline. The US population is projected to grow at least 18% before 2020, and the population of those 65 years and older is expected to increase 3 times that rate.
Regulatory response internationally has been to help increase access to care, to promote uniform educational and practice standards, to assist with licensure activities, and to help raise public awareness about nursing issues. Not all regulatory boards worldwide are solely focused on public protection, and while many focus on education, licensure, practice, and monitoring workforce supply, many do not have a disciplinary process or removal from practice capability. In the United States, regulation has been intimately involved in the development of uniform RN scopes of practice and implementation of the APRN consensus document. States are seeking to fully implement the recommendations of the Institute of Medicine report and allow full scopes of practice that maximize the educational preparation. A nurse license compact to promote access and ease employment movement has been in place for more than 10 years and 24 states participate.
In summary, we are facing great challenges to meet the global nursing manpower need in the next 7 years. We have a responsibility not to promote a “brain drain” from poorer countries that need nurses, while at the same time we must value those nurses who have the right to use their education and skills to better themselves and their families through immigration.