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Leadership needed to address the global nursing and midwifery workforce shortage

      An estimated 4.2 million health care workers are needed to address the global shortage of human resources for health (HRH) to achieve global health and development goals.

      Global Health Workforce Alliance. Global Health Workforce Alliance Home Page. 2011. Available at: http://www.who.int/workforcealliance/about/en/.

      Internationally, nurses and midwives comprise the majority of the global health care workforce,
      • World Health Organization
      Working together for health: The world health report 2006.
      and the World Health Assembly has passed several resolutions over the past 20 years recognizing the importance of strengthening the nursing and midwifery (N&M) workforce. For example, in 2001, Resolution WHA54.12 recommended establishing mechanisms to address the global shortage of nurses and midwives, and to strengthen their contribution at all levels including within the WHO itself.
      • World Health Assembly
      Resolution WHA54.12. Strengthening nursing and midwifery.
      In 2006, Resolution WHA59.27 reaffirmed the essential contributions of N&M professions in health systems.
      • World Health Organization
      Resolution WHA59.27. Strengthening nursing and midwifery.
      In response to this resolution, a meeting was held in Pakistan resulting in the Islamabad Declaration recommending urgent attention in 3 key areas: scaling up N&M capacity, developing country-specific guidelines regarding skill mix and integrating new cadres of health workers, and promoting positive workplace environments.
      World Health Organization
      International Council of Nurses, International Confederation of Midwives, & Pakistan Ministry of Health. Islamabad Declaration on Strengthening Nursing and Midwifery.
      Regional WHO offices have developed specific plans for HRH development such as the 2007-2015 regional HRH goals that have been developed by the Pan American Health Organization.
      • Pan American Health Organization
      Regional goals for human resources for health.
      This paper presents a brief overview of factors influencing the global N&M workforce and recommends ways in which individual nurses and midwives, as well as professional organizations, might work together to address the global N&M shortage.

      Factors Influencing the Global Nursing and Midwifery Workforce

      There are many factors influencing the global N&M workforce, including the perceived status of nursing, salary, working conditions, and opportunities for professional development. The International Council of Nurses (ICN)
      • Buchan J.
      • Colman L.
      The global shortage of registered nurses: An overview of issues and actions.
      published a landmark report in 2004 that suggested that a root cause of the nursing shortage in many countries is the poor image of nursing and issues related to gender equity. It noted 3 key challenges: The impact of HIV/AIDS on the N&M workforce, especially in sub-Saharan Africa; the impact of internal and international migration; and the need for health system reform and organizational restructuring.
      • Buchan J.
      • Colman L.
      The global shortage of registered nurses: An overview of issues and actions.
      Nichols et al
      • Nichols B.L.
      • Davis C.R.
      • Richardson D.R.
      An overview of global nursing workforce issues.
      identified 3 factors influencing the international nursing labor market: demographic and epidemiological changes, technology, and globalization. In many low-resource countries, the shortage of health workers is compounded by the migration of health workers from the public health sector to private nongovernmental organizations supported by international donors. More than 72% of countries in the Americas have experienced a net loss of health workers caused by migration.
      • Pan American Health Organization
      Regional goals for human resources for health.
      International migration, as well as complex economic, social, and political forces, often results in cyclical changes in the supply and demand for nurses and other health workers. Many Asian countries now have a surplus of nurses as the demand for recruiting international nurses in the United States, United Kingdom, and Canada has decreased.
      • Nichols B.L.
      • Davis C.R.
      • Richardson D.R.
      An overview of global nursing workforce issues.
      Current global standards for ethical recruitment of nurses are designed to prevent developed countries from using the migrant nursing workforce as a means to their own ends and doing so in ways that exploit those nurses or damage the health care system of the source country. Destination countries ought to benefit from the labor supply; the migrant nurses ought to benefit from just wages, dignified work conditions, continuing education and experience; and the source country ought to benefit from circular migration that returns more experienced, skilled, and knowledgeable nurses to their own workforce. In May 2010, the 63rd World Health Assembly adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel.
      • World Health Assembly
      Resolution WHA63.16: The WHO global code of practice on the international recruitment of health personnel.
      Compliance with this code by member states is voluntary, but the code outlines important guidelines to ensure ethical recruitment and also recommends strategies by which higher-resource countries can help to prevent further deterioration of the health workforce in lower-resource countries.
      A major obstacle in monitoring N&M workforce issues is the lack of standardized data, and difficulties comparing nursing roles and workforce issues across diverse health systems.
      • Nichols B.L.
      • Davis C.R.
      • Richardson D.R.
      An overview of global nursing workforce issues.
      In 2008, the first global forum on human resources for health was held in Uganda, and the resulting Kampala Declaration and Agenda for Global Action outlined strategies to improve HRH, including the need to “create health workforce information systems…”

      First Global Forum on Human Resources for Health, Global Health Workforce Alliance. Health workers for all and all for health workers: The Kampala Declaration and Agenda for Global Action. Kampala, Uganda: First Global Forum on Human Resources for Health, Global Health Workforce Alliance; 2008. Available at: http://www.who.int/workforcealliance/forum/2_declaration_final.pdf.

      The Kampala Declaration was reaffirmed during the second global forum on HRH in Bangkok in January 2011.
      • Global Health Workforce Alliance, Japan International Cooperation Agency, World Health Organization
      Report on the Prince Mahidol Award Conference 2011: 2nd Global Forum on Human Resources for Health.
      In addition, the WHO has developed draft guidelines for data to be collected to monitor the implementation of the Code that was adopted on the international recruitment of health personnel.
      • World Health Organization
      A global survey monitoring progress in nursing and midwifery.
      These projects will make important contributions to collection of essential data to monitor the extent to which strategic goals are achieved and guide strategic planning to address global nursing workforce challenges.
      Ultimately, however, the shortage cannot effectively be addressed without multinational policy changes. As noted in a report recently published by the Milbank Memorial Fund:“One country’s domestic and foreign policies can significantly affect health worker shortages in other countries. These policy choices are often made without regard for the potential negative impacts on the health workforce in other countries. … Developed countries, for example, often rely significantly on foreign-trained health workers to staff their health systems. These developed countries…know that many workers come from countries that desperately need more health professionals themselves. …The United States has not demonstrated a commitment to pursue a policy of national self-sufficiency (or at least a high level of self-sufficiency) in the production of local health workers. Because of its failure to plan for the education of American health workers, the United States relies on large numbers of migrant health workers to keep its health system fully operational. … Data suggest that all rich countries… must recognize their role in the shortage and take remedial steps as a matter of urgency.”

      O’Brien P, Gostin LO. Health worker shortages and global justice. New York: Milbank Memorial Fund; 2011: 121. Available at: http://www.milbank.org/reports/HealthWorkerShortagesfinal.pdf.

      The Way Forward: Strategies for Addressing the Global Nursing and Midwifery Shortage

      One way that nurses can address global nursing workforce issues is to advocate for strong nursing leadership at all levels in the WHO and in national health systems. This is consistent with the goals outlined in the Nursing and Midwifery Services Strategic Directions for 2011-2015 that focus on addressing priority health issues by “ensuring the active engagement and leadership of nurses and midwives at every level of health policy/programme development and decision-making.”
      • World Health Organization
      Nursing & midwifery services: Strategic directions 2011-2015.
      Although there are regional N&M advisors working within each of the 6 WHO regions to implement regional plans for development of N&M resources, there is a critical shortage of nurses and midwives in other leadership positions within the WHO.
      • Muecke M.A.
      Nursing at the World Health Organization: The (in)visibility of chief nurses 1951-2009.
      For example, the position of WHO Chief Scientist for Nursing and Midwifery has been vacant since 2010. In May 2011 the governing body of the ICN passed an emergency resolution calling on the WHO Director General to “empower and finance nursing leadership positions throughout WHO and immediately recruit suitably qualified expert nurses and appoint them to the vacant positions at WHO Headquarters, regional and national offices in order to support an organisation wide structure that facilitates the full contribution of nurses to the entire range of the WHO responsibilities.”
      • International Council of Nurses
      Who is missing at the WHO? The nursing voice excluded from policy at World Health Organization.
      Other nursing organizations have sent similar requests to the WHO Director General, including the American Academy of Nursing and the Global Network of Nursing and Midwifery Collaborating Centers.
      In addition to advocating for nursing leadership at all levels, we propose the following action items for individual nurses and for professional nursing organizations:
      • 1.
        Advocate for strengthening N&M leadership at all levels of the WHO and in state, local, and national governmental organizations responsible for health policy;
      • 2.
        Support policies for the ethical recruitment and retention of nurses/midwives;
      • 3.
        Implement policies to promote safe and just working environments for nurses;
      • 4.
        Strengthen professional nursing organizations and interorganizational communication and collaboration to promote policies and funding priorities to support critical global health workforce needs;
      • 5.
        Partner with health-related nongovernmental organizations to address global health care and nursing workforce needs; and
      • 6.
        Promote policies and standards to ensure that nursing educational curricula incorporate concerns for global citizenship and political participation in a substantive way.

      Conclusion

      The global shortage of nurses and midwives serves only to weaken health care systems in virtually all nations. Addressing this shortage will require concerted, committed, and coordinated action and partnerships to promote policies that address the key factors responsible for the shortage. Furthermore, it is essential that there be a public commitment by the world’s highest health authorities to implement and advocate solutions to the global nursing and midwife shortage. Meeting population health needs at the local, national, and global levels requires urgent action and leadership to address the critical shortage of nurses and midwives.

      Acknowledgment

      The authors express appreciation for the review of an earlier version of this paper by Dr. Silvina Malvárez, RN, PhD, Regional Advisor for Nursing and Health Technicians, Pan American Health Organization.

      References

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        • World Health Organization
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        • World Health Organization
        Resolution WHA59.27. Strengthening nursing and midwifery.
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        • World Health Organization
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        • Pan American Health Organization
        Regional goals for human resources for health.
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        The global shortage of registered nurses: An overview of issues and actions.
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        • Davis C.R.
        • Richardson D.R.
        An overview of global nursing workforce issues.
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        • World Health Assembly
        Resolution WHA63.16: The WHO global code of practice on the international recruitment of health personnel.
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        • Global Health Workforce Alliance, Japan International Cooperation Agency, World Health Organization
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        • World Health Organization
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        • World Health Organization
        Nursing & midwifery services: Strategic directions 2011-2015.
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        • Muecke M.A.
        Nursing at the World Health Organization: The (in)visibility of chief nurses 1951-2009.
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        • International Council of Nurses
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