Although the international nurse workforce has increased by about two million between 2018 and 2023, there is still a huge global shortage concentrated in poorer nations, according to the State of the World’s Nursing 2025 report published on Monday.

There was a global shortage of around 5.8 million nurses in 2023, an improvement on 2018 when there was a 6.2 million shortage, but the shortage is felt most acutely in low-and middle-income countries (LMICs).

Close to half (46%) of all 29.8 million nurses globally are concentrated in high-income countries (HICs), which represent only 17% of the population, according to the report.

LMICs face “challenges in graduating, employing and retaining nurses in the health system” and need to raise domestic investments to create and sustain nursing jobs, according to the report, which was compiled by the World Health Organization (WHO) and the International Council of Nurses (ICN).

Meanwhile, HICs need to “manage high levels of retiring nurses and review their reliance on foreign-trained nurses, strengthening bilateral agreements with the countries they recruit from”, it adds.

In 20 mostly high-income countries, retirements are expected to outpace new entrants, which raises “concerns about nurse shortfalls, and having fewer experienced nurses to mentor early career nurses”.

Migration is depleting fragile workforces

Almost a quarter (23%) of nurses in high-income countries are foreign-born, in contrast to upper-middle-income countries (8%), lower-middle-income countries (1%), and low-income countries (3%).

“When wealthy countries recruit from low-income nations, they risk depleting already-fragile nursing workforces,” warns the ICN, noting that migration is also driven by the under-employment of nurses in low-income countries. 

“The combination of workforce shortages, poor working conditions and compensation, and imbalanced distribution all fuel the vicious cycle of inequitable migration patterns,” notes the ICN.

The report stresses that all countries need to adhere to the WHO Global Code of Practice on the International Recruitment of Health Personnel, and where recruitment from one country to another occurs, there should be “bilateral agreements that translate into mutual and proportional benefits for source countries”.

Although low-income countries are increasing nurse graduate numbers at a faster pace than high-income countries, in many countries, this is “not resulting in improved densities due to the faster pace of population growth and lower employment opportunities”.  

To address this, countries should create jobs to ensure graduates are hired and integrated into the health system and improve working conditions.

“The report clearly exposes the inequalities that are holding back the nursing profession and acting as a barrier to achieving universal health coverage (UHC),” said ICN president Pam Cipriano. 

“Delivering on UHC is dependent on truly recognising the value of nurses and on harnessing the power and influence of nurses to act as catalysts of positive change in our health systems.”

“We cannot ignore the inequalities that mark the global nursing landscape. On International Nurses Day, I urge countries and partners to use this report as a signpost, showing us where we’ve come from, where we are now, and where we need to go – as rapidly as possible,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

At a media briefing on Monday, Howard Catton, ICN CEO, said real progress has been made in areas such as “advanced practice nursing, increased Chief Nursing Officer roles, increased graduate preparation of nurses, and reducing outdated gendered associations and attracting more men to the profession”. 

But little progress has been made on “the global health emergency of nursing shortages, hugely worrying indicators of inadequate working conditions and pay, troubling patterns of inequalities and nurse migration, and continued failures to fully enable nurses as leaders working to their full scope of practice and influence”, he added.

Pay and working conditions

The global median entry-level wage of nurses in 2023 was $774 per month in 82 countries, with significant differences by WHO region and by income group. 

Median wages in HICs were twice as high those of upper-middle-income countries, and three times as high LICs. 

Wages adjusted for purchasing power parity indicated that the European and Eastern Mediterranean regions have the highest median entry wages, and the WHO African and South-East Asia regions have the lowest. 

Most countries reported laws on minimum wages (94%), social protection measures (92%) and health worker safety (78%).  But only 55% had regulations on working hours and conditions, and even fewer had provisions for mental well-being.

“Mental health and workforce well-being remain areas of concern. Only 42% of responding countries have provisions for nurses’ mental health support, despite increased workloads and trauma experienced during and since the COVID-19 pandemic,” according to the report.

Policy proposals include empowering nurses to contribute to the climate agenda through education, advocacy, climate-conscious practice in health settings and leadership. 

South East Asian countries had the highest percentage of protections in place (70%) while Western Pacific countries had the lowest (21%). 

By income group, HICs had the most countries (63%) reporting provisions regarding working conditions and hours, while LICs had the fewest (48%). Other sources have described a related pattern in that excessive working hours, defined as working over 48 hours per week, were more frequently reported by nurses and midwives in low- and lower middle-income countries, many in Africa.

Attacks on healthcare workers

Measures to prevent attacks on health workers were reported in 59% of the responding countries, representing an increase from the 37% of countries reported on this in 2020. 

This was found to be highest amongst the responding countries in South-East Asia (90%) and lowest in the Americas (36%)

“Data from WHO’s Surveillance System for Attacks on Health Care indicate that between 1 January 2018 and 31 March 2025, there were more than 8,300 incidents of attacks reported from 22 countries/territories with over 3,000 deaths and over 6,000 injuries of health workers and patients,” according to the report.

The report recommends measures to support nurses and other health workers in post-conflict settings and reduce attrition including providing opportunities for professional development, incorporating financial incentives and allowing flexibility.

Image Credits: World Bank/Flickr, WHO, MSF/ Dr Obaid.