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Nursing shortage refers to a situation where the demand for nursing professionals, such as Registered Nurses (RN), exceeds the supply, either locally (e.g. within a given health care facility), nationally or globally. It can be measured, for instance, when the nurse-to-patient ratio, the nurse-to-population ratio, or the number of job openings necessitates a higher number of nurses working in health care than currently available. This situation is observed in developed and developing nations around the world.
Nursing shortage is not necessarily due to a lack of supply of trained nurses in a jurisdiction. In some cases, perceived shortages occur simultaneously with increased admission rates of students into nursing schools. Potential factors include: lack of adequate staffing ratios in hospitals and other health care facilities, lack of placement programs for newly trained nurses, and inadequate worker retention incentives.
Globally, the World Health Organization (WHO) estimates a shortage of almost 4.3 million nurses, physicians and other health human resources worldwide - reported to be the result of decades of underinvestment in health worker education, training, wages, working environment and management.
Studies have shown that nursing shortage is a serious issue in the United States and many other countries around the world. Several studies have been done to understand how nurses feel about their career. Sociologist Bryan Turner identified nurses’ most important complaints as subordination to the medical profession as well as over regulation, and difficult working conditions. Also, a report from the Commonwealth of Australia identified some of the dissatisfaction as stemming from frequent schedule changes, overloads, shift work, lack of appreciation by superiors and colleagues, as well as lack of childcare. Inadequate pay was identified as a lesser problem based on the report. Later, a study revealed that the dissatisfaction among nurses focused on conflicting expectations from nurses and managers due to regulation of cost, lack of opportunity to provide comprehensive nursing care, and disillusioned workforce or "loss of confidence in, and frustration with, the healthcare system." Limitations to comprehensive care were identified because nurses are overloaded with the number of assigned patients, massive paperwork for billing purposes, and short staffing to cut cost.
In many jurisdictions, administrative/government health policy and practice has changed very little in the last decades, cost-cutting is still the priority, patient loads uncontrolled, and nurses are rarely consulted when recommending changes through health care reform. The major reason why nurses plan to leave the field, as stated by the First Consulting Group, is because of the working conditions. With the high turnover rate, the nursing field does not have a chance to build up the already frustrated staff. Aside from the deteriorating working conditions, the real problem is "nursing’s failure to be attractive to the younger generation." There’s a decline in interest among college students to consider nursing as a probable career. More than half of currently working nurses "would not recommend nursing to their own children" and a little less than a quarter would advise others to avoid this as a profession altogether.
Australian nursing researchers, John Buchanan and Gillian Considine described hospitals as "being run like a business" with "issues of patient care… of secondary importance." Emotional support, education, encouragement and counseling are integral to the everyday nursing practice. However, these practices are not easily quantified and considered by managers as unjustified cost for the patients, who are also viewed as consumers. Therefore, only clinical responsibilities, such as medication administration, dressing changes, foley catheter insertions, and anything that involves tangible supplies, are quantified and incorporated into the organizational budget and plan of care for the consumers.
The nursing shortage also affects the developing countries that supply nurses through recruitment to work abroad in wealthier countries. For example to accommodate perceived nursing shortage in the United States, American hospital recruit nurses from overseas, especially the Philippines and Africa. This in turn can lead to even greater nursing shortage in their home countries. In response to this growing problem, in 2010 the WHO's World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel, a policy framework for all countries for the ethical international recruitment of nurses and other health professionals.
Foreign nurses that migrate from developing countries to fill the nursing shortage of developed nations pursue their own economic, career, and lifestyle interests but there are risks for immigrant nurses. Unfortunately the media and scholars alike have remained relatively silent on the ethical concerns involving the potential exploitation of foreign nurses. On the level of national sovereignty and global equality, there are ethical concerns about the pull of developed nations on developing countries' skilled workers and assets. U.S. incentives such as signing bonuses can be seen as promoting a brain drain. Activists have spread a new term for this: "Brain drain in the south, brain waste in the north." The President of the Philippines Nurse Association, George Codero, was quoted in a New York Times article as saying "The Filipino people will suffer because the U.S. will get all our trained nurses".
On an individual basis, foreign nurses are subject to exploitation by employers. In 1998 six Americans were charged with falsely obtaining H-1A visas and using them to employ Filipino nurses as nurse aides instead of registered nurses. In another case in 1996 a Catholic archdiocese employed some of these foreign nurses as nurse aides instead of nurses. In 2000, Filipino nurses in Missouri received $2.1 million for failure to receive proper wages that an American in the same position would receive. While these cases were brought to court, many similar situations are left unreported thereby jeopardizing the rights of foreign nurses. Foreign nurses have the tendency to receive less desirable jobs, such as entry-level positions because of their immigrant status and they are excluded from jobs that would lead to facilities, and are often not paid proper salaries.
Some U.S. health care facilities push to "ease restrictions" on the immigration law to increase the number of recruited foreign nurses. On the other hand, this recruitment practice is only a temporary solution and does not fully address the nursing shortage as mentioned by American Nursing Association (ANA). Others have taken a stand on ethically recruiting foreign workers. New York University Medical Center was cited in The Search for Nurses Ends in Manila as believing that it is a "poaching exercise" to take nurses from countries in need of their citizens. The former health secretary, Dr. Galvez Tan, in reference to the number of doctors and nurses working for an American green card said, "There has to be give and take, not just take, take, take by the United States."
Nursing shortages have been linked to the following effects:
The nursing shortage takes place on a global scale. Australia, the UK, and the US receive the largest number of migrant nurses to fill the employment gap in the health sector. Australia received 11,757 nurses from other countries between 1995 and 2000. The U.S. Immigration and Naturalization Service (INS) records show that more than 10,000 foreign nurses were given H-1A visas to enter the United States within the same time frame In only four years, the U.K. admitted 26,286 foreign nurses from 1998 to 2002.
Saudi Arabia also depends on the international nurse supply with 40 nations represented in its nurse workforce. Netherlands needed to fill 7,000 nursing positions in the year 2002, England needed to fill 22,000 positions in the year 2000, and Canada will need about 10,000 nursing graduates by the year 2011.
|Country||Number of Nurses||Density per 1,000 population||Year|
|United States of America||2,669,603||9.37||2000|
In an American Hospital Association study, the cost to replace one nurse in the U.S. was estimated at around $30,000 - $64,000. This amount is likely related to the cost of recruiting and training nurses into the organization. Hiring foreign nurses is more financially taxing compared to hiring domestic-graduate nurses; however, facilities save money in a long run because foreign nurses have a contractual obligation to complete their term. The JACHO in the United States wrote in a 2002 research report on the shortage in the US that recruiting foreign trained nurses from abroad (not referring to those who reside in the United States already) does not help the global nursing shortage, and, in fact, perpetuates it.
Countries that send their nurses abroad experience a shortage and strain on their own health care system. In South Africa, accelerated recruitment by developed countries such as United States, United Kingdom and Australia has placed more pressure on the health care system due to prevalence of diseases, such as AIDS, and limited resources. Similar to the U.S., nurses who leave the organization are a financial disadvantage due to the need to fund recruiting and retraining of new nurses into the system. It has been estimated that every nurse that leaves South Africa is an annual loss of $184,000 to the country, related to the financial and economical impact of the nursing shortage.
The following table represents the number of nurses per 100,000-population in Southern African countries.
|Number of Southern African countries||Number of nurses per 100,000 population|
|3||Less than 10|
Retention of nurses by sending (often developing) countries can be addressed by improving working conditions, minimizing wage differentials, and promoting medical tourism. Retention can also be promoted through educational activities to improve job satisfaction. There can be additional unintended impacts of nurses migration abroad. For example, there is growing evidence that physicians in the Philippines have shifted to the nursing field for better export opportunities. The World Health Organization (WHO) representative in Manila, believes the government should invest more into its health sector as it is currently only three percent of the Philippines' GDP. Others have suggested programs which require domestic service or employment upon graduation.
According to the American National Council of State Boards of Nursing, the number of U.S. trained nurses has been increasing over the past decade: In 2000, 71,475 U.S. trained nurses became newly licensed. In 2005, 99,187 U.S. trained nurses became newly licensed. In 2009, 134,708 U.S. trained nurses became newly licensed. Therefore, a 9.8% annual increase of newly licensed U.S. nurses has been observed each year over the past 9 years. It is clear that, nursing enrollment in the U.S. has significantly increased over the past decade relative to the 1.19% annual U.S. population growth.
While the number of U.S. trained licensed nurses has increased each year, the projected nursing demand growth rate from 2008–2018, as reported by the U.S. Bureau of Labor Statistics is anticipated to be a 22%, or 2.12% annually. Therefore, the 9.8% annual growth of new R.N.'s exceeds the current new position growth rate by a net of 7.7% per year with the assumption of consistent growth figures over the next decade.
The United States population is projected to grow at least 18% over two decades in the 21st century, while the population of those 65 and older is expected to increase three times that rate. The current shortfall of nurses is projected at 800,000 by the year 2020.
Professional and related occupations are expected to rapidly increase between years 2000–2012. The demand for healthcare practitioners and technical occupations will continue to increase. It is projected that there will be 1.7 million job openings between 2000 and 2012. The demand for registered nurses is even higher. Registered nurses are predicted to have a total of 1,101,000 openings due to growth during this 10 year period. In a 2001 American Hospital Association survey, 715 hospitals reported that 126,000 nursing positions were unfilled.
However, other research findings report a projection of opposite trend. Although the demand for nurses continues to increase, the rate of employment has slowed down since 1994 because hospitals were incorporating more less-skilled nursing personnel to substitute for nurses. With the decrease in employment, the earnings for nurses also decreased. Wage among nurses leveled off in correlation with inflation between 1990 and 1994. The recent economic crisis of 2009 has further decreased the demand for RN's.
Comparing the data released by the Bureau of Health Professions, the projections of shortage within two years have increased.
Source: Data from the Bureau of Health Professions (2002)
However, emergency and acute care nurses are still in great demand, and this temporary reduction of the shortage is not expected to last as the economy improves. In 2009, it was reported that in places like Des Moines, Iowa that newly graduated nurses are having more difficulty finding jobs and older nurses are delaying retirement due to economic conditions. This hiring situation was mostly found in hospitals; whereas nursing homes continued to hire and recruit nurses in strong numbers.
Some states are have a surplus of nurses while other states face a shortage. This is due to factors such as the number of new graduates and the total demand for nurses in each area. Some states face a severe shortage (such as the Northwestern states, as well as Texas and OK), while other states actually have a surplus of registered nurses.
Source: Data from the Bureau of Health Professions. (2004).
Nursing shortages can be consistent or intermittent depending on the current number of patients needing medical attention. Retention and recruitment are important methods to achieve a long-term solution to the nursing shortage. Recruitment is promoted through ways of making nursing attractive as a profession, especially to younger workers to counteract the high average age of RNs and therefore future waves of retirement. Refining the work environment in a medical setting can improve the overall perception of nursing as an occupation. This can be achieved by ensuring job satisfaction. Writers Lori Candela, Antonio Gutierrez, and Sarah Keating point out in the journal, Nurse Education Today, ways the academic nursing administrators can make a change. "Individual support to attend workshops or conferences, participation in on-campus teaching/learning faculty sessions, the use of consultants with expertise in particular areas around teaching and evaluation, and mentoring networks that include senior faculty with teaching expertise" can all create a strong relationship between staff members therefore developing a better environment. Additionally, financial opportunities such as signing bonuses can attract more nurses.
To assist the health sector, Congress approved the Nurse Reinvestment Act passed in 2002 to provide funding to advance nursing education, scholarships, grants, diversity programs, loan repayment programs, nursing faculty programs, and comprehensive geriatric education. Currently, mandatory overtime for nurses is prohibited in nine states, hospital accountability to implement valid staffing plans in seven states, and only one state implement the minimum staffing ratio.
Other ways of assisting to fill the shortage of nurses in the United States would include giving nurses the opportunity to pick their own overtime as well as their own schedules. Also, it would be a great incentive to young nurses to enter a hospital if they knew there were bonus' for continued excellence.  In order to respond to fluctuating needs in the short term, health care industries have utilized float pool nurses and agency nurses. Float pool nurses are nursing staffs employed by the hospital to work in any unit within the organization. Agency nurses are employed by an independent staffing organization and have the opportunity to work in any hospitals on a daily, weekly or contractual basis. Similar to other professionals, both types of nurses can only work within their licensed scope of practice, training, and certification.
Float pool nurses and agency nurses, as mentioned by First Consulting group, are currently used in response to the current shortage. Use of the said services increases the cost of healthcare, decreases specialty, and decreases the interest in long-term solutions to the shortage.
International recruitment is often used to fill the nursing gap but gives rise to concern of late now that the U.S. Homeland Security has stopped the issuance of the H-1C visa, which was deemed specifically for Nurses. "Obama Health Care Reform", which will result in every American being insured, it is estimated that there will be an even greater need for Nurses. U.S. trained nurses are concerned, however, that this recruitment initiative impedes on their ability to obtain positions in the field after completing their training. A nursing shortage does not translate to new nursing jobs. Any increase in demand will likely increase the nurse patient ratio and risk patient safety. It is predicted by the National Healthcare Organization, that the entire U.S. Healthcare system will come crumbling down because nurses are the core foundation of all healthcare. The issue is not in the supply of nurses, but the number of positions available in U.S. hospitals to cover the high nurse to patient ratios. Recruitment focus should geared toward under-served areas.
A growing response to the nursing shortage is the advent of travel nursing a specialized sub-set of the staffing agency industry that has evolved to serve the needs of hospitals affected by the increasing nursing shortage. According to the Professional Association of Nurse Travelers, there are an estimated 25,500 Registered Nurse Travelers working in the U.S. The number of LVN/LPN Nurse Travelers is not known.
There is a nursing recruitment initiative and nursing workforce development program for residents of the United States originally from foreign countries, who were professional nurses in their countries but are no longer in that profession in the United States. This initiative helps these nurses get back into the nursing profession, especially getting through credentialing and the nursing board exams. The original model was developed in 2001 at San Francisco State University in cooperation with City College of San Francisco ("The San Francisco Welcome Back Center") and there are centers in many cities, such as Los Angeles, San Diego, and Boston, Massachusetts, where it is called a "Boston Welcome Back Center for Internationally Educated Nurses". It is a program meant for residents of the United States only, not others who are overseas wishing to practice in the United States. The Boston Welcome Back Center was opened in October 2005 with a $50,000 seed grant from the Board of Higher Education’s Nursing Initiative.
In September 2007, in the 110th Congress, Senator Richard Durbin of Illinois introduced S.2064: Nurse Training and Retention Act of 2007 on the floor of the Senate. It was a bill to fund comprehensive programs to ensure an adequate supply of nurses. It was referred to committee for study but was never reported on by the committee.
In April 2008, in the 110th Congress, H.R. 5924: Emergency Nursing Supply Relief Act was introduced as a bill to the House of Representatives by Robert Wexler of Florida. If it had passed, it would have amended the American Competitiveness in the Twenty-first Century Act of 2000 and would have given up to 20,000 visas per year to nurses and physical therapists until September 2011. Immediate family members of visa beneficiaries would not be counted against the 20,000 yearly cap. The bill was referred to committees for study in Congress but was never reported on by the committees.
On February 11, 2009, legislation was introduced by Representatives John Shadegg (R-AZ), Jeff Flake (R-AZ), and Ed Pastor (D-AZ) in the 111th Congress to the House of Representatives, HR 1001 ("The Nursing Relief Act of 2009" : To create a new non-immigrant visa category for registered nurses, and for other purposes) making a new non-immigrant "W" visa category for nurses to be able to work in the United States. This was to relieve the nursing shortage still considered to be a crisis despite the economic problems in the country. The proposed bill was referred to the Committee on the Judiciary but was never reported on by Committee.
The 2010 Patient Protection and Affordable Care Act includes more strategies for funding and retention. The act provides funding for advanced education nursing grants, diversity grants, and offers a nurse education load repayment program. The program repays over half of the nursing student loans if the nursing student signs a contract stating that they will work for two years at a medical facility that has a nursing shortage. 
The Nurse Reinvestment Act of 2002 had many strategies the law authorized and many provisions that included topics such as loan repayment programs and scholarships providing more grants to the nursing students, making more public service announcements about nursing and educating the public on what a great profession it is and making nursing school more flexible by creating different options for the people who already have a previous degree but would like to go into nursing.
Nurses seeking to immigrate to the U.S. can either apply as direct hires or through a recruitment agency. For entry to the U.S. a foreign nurse must pass a Visa Screen which includes three parts of the process. First they must pass a creditable review, followed by a test of nursing knowledge called the Commission on Graduates of Foreign Nursing Schools examination (CGFNS), and finally a test of English-language proficiency.
Foreign nurses compete amongst themselves, with professionals, and other skilled workers for 140,000 employment-based viases (EB) every year. The Filipino nurses are only allocated 2,800 visas per year, thereby creating a backlog among applicants. For example, in September 2009, 56,896 Filipinos were waiting for EB-3 visa numbers. This number contrasts with the 95,000 nurses licensed in 2009, many of whom want to migrate to the U.S. Once a nurse obtains a visa number and is approved for a visa and authorized to work in the U.S., they must pass the National Council Licensure Examination to qualify for U.S. nursing standards. See also Nursing visa retrogression in US
Scholars point out that the use of foreign nurses prolongs the underlying issues of the nursing shortage. As a result, many of the problems with the U.S. health system will continue until addressed by a more long-term solution. For example, the unemployment rate in the Philippines was 7.5% in 2009 according to the CIA World Factbook; it was 10.6% in the US as of February 2009 according to the U.S. Bureau of Labor Statistics. Thousands of U.S. licensed newly trained nurses remain unemployed and are forced to leave the profession while thousands of seasoned nurses return to the profession to help their families make ends meet.
The Philippines is the largest exporter of nurses in the world supplying 25% of all overseas nurses. An Organisation for Economic Co-operation and Development study reported that one of every six foreign-born nurses in the OECD countries is from the Philippines. Of all employed Filipino RNs, roughly 85% are working overseas. This is partially in response to the inability of Filipino nurses to enter their domestic workforce due to a lack of jobs and instead become heavily dependent upon international job markets for nurses. The United States has an especially prominent representation of Filipino nurses. Of the 100,000 foreign nurses working in the U.S. as of 2000, 32.6% were from the Philippines.
The international migration of Filipino nurses takes place in response to "push and pull" factors. The push factors are rooted in the economic conditions in the Philippines in which there is an overabundance of RNs and a lack of open employment positions. The unemployment rate in the Philippines currently exceeds 10 percent. Additionally, health care budgets set up Filipino nurses for low wages and poor benefit packages for employees. There are also fewer jobs available thereby increasing the workload and pressure on RNs. Filipinos often find it in their interest to pursue international employment to avoid the economic instability and poor labor conditions in their native country. The government also highly encourages the exportation of RNs internationally. Filipino nurses are pulled to work abroad for the economic benefits of international positions. While a nurse in the Philippines will earn between $180 and $200 U.S. dollars per per month, a nurse in the U.S. receives a salary of $4,000 per month. Nurses abroad are greatly respected in the Philippines as they are able to support an entire family back at home through the sending of remittances. In 1993, Filipinos abroad sent $800 million to their families in the Philippines thereby supporting the Filipino economy. Additionally, remittances from Filipinos made up 5.2% of the Filipino GDP (gross national product) between 1990 and 2000. Further pull factors stem from the additional economic benefits of signing bonuses in the U.S. In order to attract more foreign nurses, U.S. hospitals increased signing bonuses from $1,000 to $7,000. Positions abroad in the health sector are also enticing for their immigration benefits for individuals and families. Throughout the past 50 years of nurse migration, the U.S. has made efforts to ease the visa application process to further encourage international nurses to fulfill the nursing shortage. Scholars also note that the better living and working conditions, higher income, and opportunities for career advancement draw nurses from the Philippines to work in the U.S.
As the relation between the U.S. and the Philippines stretches back 50 years, Filipino nursing institutions often reflect the same educational standards and methods as the U.S. curriculum. Furthermore, a knowledge of English in the Philippines makes it easier for Filipino nurses rather than nurses from other developing nations to work in the U.S.
Since 1916, 2,000 nurses have arrived each year in the U.S. In 1999, the U.S. approved 50,000 migrant visas for these nurses. Today, on average, there are about 30,000 Filipino nurses traveling to the U.S. each year to escape the push factors of their homeland and enjoy the benefits of the pulls of their new home.
The transnational migration of Filipino RNs has profound effects on the economy and workforce dynamics in both sending and receiving nations. The departure of nurses from the domestic workforce represents a loss of skilled personnel and the economic investment in education. In addition, the "scarce and relatively expensive-to-train resources" invested are lost when a worker chooses to work abroad. When RNs migrate internationally, the country from which they emigrate loses a valuable resource and any financial or educational support that was invested in the individual that travels overseas.
Unfortunately, according to many Filipinos working in hospitals, the most educated and skilled nurses are always the first to go abroad. There is disagreement among scholars on the extent to which the Filipino health sector is burdened by its own nursing shortage. While the numerical data are inconsistent about whether the nurse supply is in excess or a shortage, it is clear that there is a short supply of the most skilled nurses who choose to go abroad. As a result, operating rooms are often staffed by novice nurses and nurses with more experience work extremely long hours at one time As skilled nurses decline in the urban areas, nurses from rural areas migrate to hospitals in the cities for better pay. As a result, rural communities experience their own drain of health resources. Stories and studies alike demonstrate that a treatable emergency in the provinces may be fatal because there are no medical professionals to help treat them outside of the cities. In fact "the number of Filipinos dying without medical attention has been steadily increasing for the last decade." The lack of attention from medical professionals has increased over time despite advances in technology and medicine and the increasing number of trained nurses in the Philippines.
Not only have nurses departed their positions in rural communities, but so too have doctors changed professions and joined the international mobility trend. Filipino doctors have begun leaving their professions to train as nurses under the title MD-RN with the hope of immigrating to the U.S. or other developed nations more easily. Since 2000, 3,500 Filipino doctors have migrated abroad as nurses. The U.S. incentives for nurse migration encourage doctors to train as nurses in the hopes of increasing their economic prospects. As a result, the Philippines have a lower average of doctors and nurses with .58 and 1.69 respectively for a population of 1,000. The average statistics globally in contrast are 1.23 and 2.56. Between 2002 and 2007, 1,000 Filipino hospitals closed due to a shortage of health workers. A study conducted by the former Philippine Secretary of Health, Jaime Galvez-Tan, concluded that close to 80 percent of all government doctors have become nurses or are studying nursing. Of the 9,000 doctors-turned-nurses, otherwise known as MD-RNs, 5,000 are currently working overseas. The extraordinary influence of this international migration has had devastating effects on the health of Filipinos. The number of deaths that were not prevented with medical attention have only increased over time as hospitals are shut down and rural areas are deprived of any medical treatment.
Due to the high interest in international mobility, there is little permanency in the nursing positions in the Philippines. Most RNs choose to sign short term contracts that will allow for more flexibility to work overseas. The Filipino nurses also feel less committed to the hospitals as they are only temporary staff members. This lack of attachment and minimal responsibility only worsens the health of Filipino patients.
In addition to the negative effects of RN emigration on the health sector, the educational system has also been hurt by the outrageous increase of nurses in the Philippines. As Filipinos are attracted to the opportunities that come from working as a nurse, the number of nursing students has steadily increased. As a result, the number of nursing programs has grown incredibly quickly in a commercialized manner. In the 1970s, there were only 40 nursing schools in the Philippines but by 2005 the number had grown to 441 nursing colleges. While the educational opportunities for nursing students has grown tremendously, the quality of education has declined. This can be seen by the low rate (50%) of students who pass the nursing exam since the 1990s. Furthermore, the Technical Committee on Nursing Education of the Commission on Higher Education (CHED), determined that 23 percent of the Filipino nursing schools failed to meet the requirements set by the government.
In summary, the emigration of Filipino nurses has encouraged doctors to switch to nursing, created a shortage of skilled specialized and experienced nurses, affected the educational system, and distorted health care delivery and attention to medical issues in rural areas. While remittances, return migration, and the transfer of knowledge support the Philippines they fail to fully compensate the loss of health workers, which disrupts the Filipino health and educational sector.
Dr. Jaime-Galvez Tan, the former Philippine Secretary of Health, warns that if the U.S. passes legislation allowing for freer immigration of nurses the health service of the Philippines could bleed to death and collapse.