Addressing Global Nurses’ Shortage Means Tackling Ethics Of Migration, Working Conditions & Gender Equity

The Year of The Nurse And Midwife, 2020 will be a featured topic at the Geneva Health Forum on Monday, opening day of the conference (16-18 November). Raisa Santos discusses the dilemmas facing nurses worldwide – informed by her own experiences. 

“Why does it take a pandemic for them to suddenly recognize nurses?” says Isabelle, a Labor and Delivery nurse in New York City. “We’re on the front lines all the time.” 

Nurses celebrating Nurses Appreciation Week in May 2020 in New York City; Pictured second from right: Isabelle Santos

This is in fact my mother speaking. My mother who, just like my father, has been on the front line of the healthcare workforce since they came to the United States, back in 1994. The sacrifice my parents have made is two-pronged, for not only have they worked tireless hours on behalf of their patients, in both the night and day shifts, but they sacrificed their livelihood and everything they knew when they left the Philippines. 

Both of my parents were doctors in the Philippines, but when they immigrated to the United States took up work as nurses. “When you’re working the night shift, you have no time to study or read. I’m lucky I passed the nursing exam,” says my father Roberto, an ER nurse, who immigrated first to New York City so my mother could follow. In addition to the lack of time, they cited the numerous educational and administrative hurdles that prevented them from achieving the same medical licenses in the United States.

My parents are part of the estimated 150,000 Filipino nurses in the United States, with some regions accounting for an even larger portion of the nursing workforce. In California, nearly 20% of registered nurses are Filipino. Filipinos are one of the largest groups of internationally educated nurses in the country, and are the second largest Asian community in America. 

“It is not an exaggeration to say we literally would not have survived the COVID-19 pandemic without all of you, our Filipino brothers and sisters,” said New York City Mayor DeBlasio. “You keep our city moving forward, and you keep us progressing during one of the greatest challenges of our time.” DeBlasio honored Filipino Americans, especially those in healthcare, during Filipino American History Month, in October. Acknowledging the contributions of migrant nurses also highlights the need for active support of all nurses and healthcare workers. 

It is paradoxically fitting that the first-year dedicated to celebrating nurses coincides with the biggest pandemic that the world has seen in a century: COVID-19.

The World Health Organization (WHO) declared 2020 the International Year of the Nurse and the Midwife, in honor of the 200th anniversary of Florence Nightingale’s birth. The topic is also a featured item at the upcoming Geneva Health Forum (16-18 November), including presentations by WHO’s Elizabeth Iro and Howard Catton of the ICN, who are presenting on The Year of the Nurse and the Midwife 2020 – a catalyst for change, on Monday, 11:00 – 12:00 CET.

According to the most recent ICN data, 1,500 nurses have died from COVID-19 in 44 countries. They estimate, however, that worldwide healthcare worker fatalities from the virus could be greater than 20,000.

“Nurses and midwives have been on the frontlines of the fight against COVID-19, putting themselves in harm’s way. Many have made the ultimate sacrifice in service of humanity,” said Dr Tedros Adhanom Ghebreyesus, WHO Director General, at his opening speech for the resumed 73rd World Health Assembly last week. “Now more than ever, the world needs nurses and midwives.”

Dr Tedros Adhanom Ghebreyesus, Director-General, WHO on International Nurses Day
Applause without Action 

In fact, even before the pandemic, nurses have suffered, and continue to suffer, from long hours, risky working conditions, a gender-based pay gap, and a global shortage of nurses

The largest shortages of nurses are seen in some parts of Latin America, Africa, and Southeast Asia

“Applause without action is no longer acceptable recognition, without rights and proper rumination is not sufficient a resolution, without implementation is not governance,” said HRH Princess Muna al-Hussein of Jordan, in a keynote address at the resumed 73rd World Health Assembly. HRH Princess Muna is a WHO patron of nursing and midwifery in the Eastern Mediterranean Region. “We must invest in fair pay and protection of health and care workers.”

True appreciation for nurses and healthcare workers should be shown in the form of global cooperation that ensures the lives of both patient and provider are protected.

She added: “We must invest in a healthy workforce that will help the world recover. With 70% of the world’s health workers being women. We must truly invest in transformative gender equity and rights policies.”

Global Shortage of Nurses Now and Future 

According to the latest State of the World’s Nursing Report 2020, there is a 5.9 million gap in nurses worldwide – with most of the shortage, or 5.3 million (83%), concentrated in low- and middle-income countries (LMICs).

The report uses findings from analysis of National Health Workforce Account (NHWA) data provided by 191 Member States. 

Among the 28 million nurses working today, 80% are concentrated in countries that account for only half of the world’s population. And while the nursing workforce is expanding, the report projects that the shortage could reach up to 5.7 million by 2030, primarily in the African, South-East Asia, and Eastern Mediterranean regions.

Along with certain areas of Latin America, these regions are where the nursing gap is currently most strongly felt.

These are also regions that have some of the largest populations of migrant nurses.

Projected increase (to 2030) of nursing workforce, by WHO region and by country income

Dr Tedros said: “This report is a stark reminder of the unique role [nurses] play, and a wakeup call to ensure they get the support they need to keep the world healthy.”

Nursing ‘Brain Drain’ from Developing Countries to Train More Nurses 
Physicians and nurses wore adapted theatre gowns and used face shields and face masks when attending to patient during the COVID-19 pandemic, Nigeria

The migration of health professionals to high-income countries also risks worsening shortages in LMICs. The ICN warned that high-income countries must train enough nurses to become self-sufficient at a large scale.

Speaking at the World Health Assembly (WHA), it urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply.

Countries such as the United Kingdom have admitted dependence on health worker migration. 

Sacrifices but no Status For Migrating Nurses 

The millions of migrant nurses around the world, including many from the Philippines, also often face issues with their legal status in the very countries they are serving.

While international recruiters for nurses promise signing bonuses, referral bonuses, and relocation bonuses, the protection they are guaranteed is far less concrete.

In a review led by Kaiser Health News, some travel nursing contracts of international nurses have left a trail of wrongful termination claims, claims of discrimination, harassment or retaliation, wage claims, and claims for violation of federal, state or other laws and regulations.

These often were settled out of court, as constituents of organizations such as the Service Employees International Union, the American Nurses Association and National Nurses United were suspended or fired from traveling worker agencies for speaking to the news media, posting on social media, or otherwise voicing concerns about unfair practices.

Nurse treating a child at a medical center in Baghdad

Carey McCarthy, one of the lead authors of the State of the World’s Nursing Report, calls on countries to use this data to guide policy discussions around nurse mobility and many other problems regarding the global nursing shortage.

In a YouTube interview on World Health Day, she said: “We know that [nurse migration] is increasing. We really need better data from all countries around the world to make sure that migration is managed ethically and responsibly and that we can ensure that our migration of health workers doesn’t exacerbate, and make worse, local health challenges that already exist in terms of providing services to the population.”

Improving Nurses Working Conditions, Advancement & Leadership   

Increasing the number of nursing trainees and graduates, and retaining nurses already employed also requires improved working conditions, and avenues for advancement to ensure that veteran nurses remain motivated.

Nursing leaders and their in-country networks are crucial to this process, and their inclusion in policy dialogue that concerns them is critical, nurse advocates say.

McCarthy, who is also WHO’s Nursing and Midwifery Technical Officer, said: “We are asking governments to look at improving nursing leadership. We found chief nurse officer positions as well as leadership development programs to be highly related to improved working conditions and stronger education regulation within countries.” 

Interview with WHO Expert Carey McCarthy on The State of the World Nursing Report, broadcast 7 April 2020

Of the 191 countries who responded to the surveys informing the Nursing Report, more than 80% reported that strong government or employer regulations regarding their working conditions was one of the major drivers attracting them to job opportunities. 

This includes stronger regulation of working hours and minimum wage.

Overall, LMICs reported weaker regulatory frameworks for nurses, as compared to high-income countries. The presence of a government chief nursing officer position and the existence of a nursing leadership programme were associated with a stronger regulatory environment for nursing. 

Gender Equity in Nursing 

Approximately 90% of the nursing workforce globally is made up of women. Gender-related barriers and discrimination can constrain advancements of the nursing profession, as well as deeply impacting the well-being of female health workers and the standard of care.

Conversely, addressing gender perceptions and barriers in nursing is also important in order to empower nurses to obtain proper working conditions, receive fair pay and equal treatment, and become leaders in healthcare. 

By providing more equitable pay to a predominantly female workforce, providing adequate PPE and funding to all hospital and clinical staff, and creating gender-sensitive leadership and development opportunities for women in the nursing workforce, we can slowly ease away the inequities in healthcare and work towards attaining universal health coverage, a long-time nursing advocate has said.  

“Politicians understand the cost of educating and maintaining a professional nursing workforce, but only now are many of them recognizing their true value,” said ICN President Annette Kennedy. “Every penny invested in nursing raises the wellbeing of people and families in tangible ways that are clear for everyone to see.”

She added that The State of the World’s Nursing Report “highlights the nursing contribution and confirms that investment in the nursing profession is a benefit to society, not a cost. The world needs millions more nurses, and we are calling on governments to do the right thing, invest in this wonderful profession and watch their populations benefit from the amazing work that only nurses can do”.

HRH Princess Muna al-Hussein, keynote address to the resumed 73rd World Health Assembly

Princess Muna, in her presentation on Monday’s opening of the WHA, said: “All countries need a system that delivers public health, primary care preparedness and response, a system that delivers integrated health and care services, and a system that delivers health and well-being for all of its population.”

“The best strategies and plans will not succeed without the people to deliver them,” she added. “Invest in health. Invest in health systems. Invest in well being. Invest in people who are the world’s health and care workers.”

Raisa Santos is studying a Masters of Public Health with a global health certificate at Columbia Mailman School of Public Health. She is also an intern writing for Health Policy Watch.

Image Credits: Raisa Santos , R Santos, WHO, WHO, Community Eye Health/Flickr, International Labor Organization/Flickr, WHO, WHO.

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