‘Solving’ nursing shortages: do we need a New Agenda?

Nursing shortages have been a recurring theme in the literature, but have often been ill-defined and usually cited as a looming problem rather than as a current issue that requires effective and contemporary policy action. A brief assessment of currently available data on nurse supply projections in a range of high-income countries serves to put the world on notice that the problem is already with us, is likely to get worse without remedial policy interventions, and cannot be ‘solved’ just by educating and preparing more staff. The main causes of nursing shortages in most high-income countries are related to demographic change: to an ageing population making increased, and changed, demand on health services (United Nations, 2013); and to an ageing nursing workforce, with more nurses nearing or reaching retirement age. The latter factor has been suppressed in some countries in the last 5 years because of the impact of the global financial crisis. This has forced some nurses to work longer hours, and remain in the labour market for longer than intended, delaying retirement; but this has just postponed the impact of retirement, it cannot reverse the trend. Many high-income countries are facing this ‘double whammy’ of an ageing population and an ageing nursing workforce, The ageing profile of the nursing workforce is highlighted by the International Council of Nurses (ICN), with many high-income countries reporting an ageing nurse workforce profile: Australia (average age 45), Denmark (45), Finland (42), Ireland (44), New Zealand (47), Sweden (46), USA (45) and UK (42) (International Council of Nurses 2013a). ‘Shortages’ are usually defined as the gap between current or projected supply of staff, and current or projected demand for staff. Recent estimates from the World Health Organisation (WHO) suggest a global deficit of 12.9 million health workers by 2035 (World Health Organisation 2014). Nurses comprise the largest professional component of the health workforce in most countries, and as such, the sheer numerical scale of the challenge of shortages is immense. A review of recent supply/demand projections or shortage gap analyses in a range of high income countries serves both to add some grounded detail to the high level global projections, and to highlight the scope of the policy challenge. These analyses use different methods and cover different time periods, but give a sense of the scale of projected change. In Canada there was a shortage of approximately 11 000 full-time equivalent (FTE) Registered Nurses (RNs) in 2007; this number was projected to increase to 60 000 FTE RNs by 2022 (Canadian Nurses Association 2009). Australia's projected shortfall could rise from 20 079 in 2016 to 85 357 by 2025 and 122 846 by 2030 (Duffield et al. 2014). In the United Kingdom, projections between 2011 and 2016 highlighted that nursing workforce supply was expected to decrease from 560–570 000 to 510–560 000, whilst demand in the same period was projected to increase from 550–600 000 to 540–700 000, leaving a shortfall (Centre for Workforce Intelligence 2013). By 2025, Germany projects a supply of 840 FTE nurses per 1000 population but expects a demand of 945 FTE per 1000 (Organisation for Economic Co-operation & Development 2013). Israel expects a slight decline in nurse numbers from 5.51 nurses per 1000 population in 2009 to 5.07 per 1000 in 2025 (Organisation for Economic Co-operation & Development 2013). In Norway projections with a 2010 baseline estimate that demand would exceed supply by 40 nurses per 1000 population in 2030 (Cappelen et al. 2013). Finland is currently facing a demand which far exceeds supply across the health care sector, but particularly in nursing. For example, of the 7828 nursing vacancies in 2013, there were only 992 applicants (Attström et al. 2014). One country that may deviate from this trend of supply shortfall is the USA, where a doubling of annual intakes to RN programmes since 2000 combined with increased participation rates, have led to recent projections that there may be a supply surplus by 2025 (U.S. Department of Health & Human Services 2014). Setting the USA to one side, the size of the estimated shortfall in these other high income countries is variable but daunting, and unprecedented, because, unlike previous shortages, its sheer scale, combined with fiscal tightening, means it is unlikely that nursing can just ‘grow’ its way out of the problem by training more new nurses. Whilst scaling up of education will be part of the solution in many countries, as has occurred in the USA, more policy effort is required to deliver more considered and concerted action. The key here is that policy makers must take account of longer term trends in likely funding and demand for health care, in reconfiguration of health services, in the projections on future supply of nurses, and in the growing need to make more effective and productive use if the nursing staff and nursing skills that are in the labour market. ‘Traditional’ policy responses of improved retention, an expanded recruitment base, targeting returners and international recruitment will continue to be relevant, even if the last of these options may have negative impacts on some low income countries. For example, improving retention by reducing turnover and keeping more scarce nursing skills in employment for longer has a positive impact, both in economic terms and in quality of care (Duffield et al. 2014). Policies to encourage ‘returners’ back to practice can be cost effective – for example the current ‘Return to Practice’ campaign in England calculated the cost to retrain a former nurse at GBP2000, compared with GBP51 000 to train a newly qualified nurse. This is a huge potential saving, as well as being a more rapid intervention than the 3–4 year time lag between planning to train a nurse and that nurse entering the workforce (Health Education England 2015). Another policy lever being used by some governments is raising the retirement age, for example in Australia where it is proposed to increase the age of retirement to 70 years. While this is potentially a way to keep skilled nurses in the workforce it should be recognised that nursing is physically demanding and continued employment may compromise the health status of older nurses (Graham & Duffield 2010). It is important that an increase in retirement age is associated with policies to support older nurses in continuing to work, for example by reducing heavy workloads or offering more flexible working hours, or acknowledging expertise through job enrichment strategies (International Council of Nurses 2013b). The main limitation of these ‘traditional’ solutions is that they focus on nursing as the problem, assume that supply side manipulation can end the problem, and they are often implemented in a piecemeal fashion. Other policy interventions will also be required which are based on the recognition that nursing is also the solution, and that there needs to be a more effective use of available nursing resources. To support effective use of the skills of nurses and other health workers, many countries need to enhance and integrate their workforce policy making and planning capacity across occupations and disciplines to identify the workforce skills and roles required to meet identified service needs. This latter point highlights a major untapped resource in most countries, both low and high income: more extensive use of advanced practice roles for nurses, underpinned by prescriptive authority (Delamaire & Lafortune 2010). This has two positive impacts: it increases the contribution and effectiveness of individual nurses in meeting population needs, and it can also improve retention by offering advanced career prospects and additional training (Duffield et al. 2014, Health Education England 2015). If the growing global challenge of sectoral and geographic shortages of nurses is not firmly addressed by policy makers nationally and internationally, we will continue to repeat a cycle of inadequate, uncoordinated, and often inappropriate policy responses to nursing workforce challenges. The ‘new’ dimensions of the current shortage dynamic demand responsive and integrated policy solutions, with enablement for advanced practice at their core.