Evidence of nursing shortages or a shortage of evidence?

When preparing her Editorial to accompany the publication in JAN of Janiszewski Goodin's (2003) review of the literature on nursing shortage, Alison Tierney had ‘googled’ the topic but she was disappointed not to find robust and concise analyses of the issue (Tierney 2003). So I undertook a similar exercise and, on typing ‘nursing shortages’ into Google Scholar, I was provided with ‘about 22 200’ results to play with. A cursory scan highlighted immediately three salient features. Firstly, the vast majority of the Google-identified literature is from the USA. Secondly, much of it is descriptive and takes as a given that there is a shortage, without defining it or demonstrating its existence. The emphasis, often unsupported by any hard evidence, is on explaining why there is a shortage, highlighting the negative impact it is having on patient care, and ‘listing’ what should be done about it (e.g. ‘improve pay’, ‘train more nurses’). Thirdly, the minority of papers that do make use of an evidence base usually betray too much faith in the power of that evidence to shape or change policy. They rarely address the fundamental issue: namely, that nursing shortages are neither caused by, or can be solved, in isolation from broader health system issues. The issue of defining, measuring and addressing nursing shortages has to take account of the huge disparity in the current availability of nursing skills in different countries, sectors and regions (Buchan they assume that supply-side manipulation can end the problem; and they are often implemented in a piecemeal fashion. Interventions to improve human resource effectiveness are much more likely to succeed where they are co-ordinated and ‘bundled’ than when they are in the form of one-off, isolated efforts (Buchan 2004). The reality is that nursing shortages are often a symptom of wider health system or societal ailments. Nursing in many countries continues to be undervalued as ‘women's work’, and nurses are given only limited access to resources that would enable them to be effective in their jobs and careers. For sustainable solutions, other interventions will also be needed. Some must focus on the demand side. These should be based on the recognition that health care is labour intensive and that available nursing resources must be used effectively. Shortage is not just about numbers, but about how the health system functions to enable nurses to use their skills effectively. Many countries need to enhance and align their workforce planning capacity across occupations and disciplines to identify the skills and roles needed to meet identified service needs overall. They can also improve day-to-day matching of nurse staffing with workload. Flexibility should be about using working patterns that are efficient, but which also support nurses by maintaining a balance between their work and personal life. A wider perspective is needed to achieve clarity of roles and a better balance of registered nurses, physicians, other health professionals, and support workers. The evidence base on skill mix is developing, and many studies highlight the scope for effective deployment of clinical nurse specialists and nurse practitioners in advanced roles. Nursing shortages are a health system problem, which undermines health system effectiveness and requires health system solutions. Until this is understood, and until we make better use of the available evidence, we are doomed to endlessly repeat a cycle of inadequate, uncoordinated, obsolete and often inappropriate policy responses.