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 & Calman 2004). For example, as we highlight in that paper, the USA, with a reported nurse:population ratio of more than 700 nurses to 10 000 population, is reporting nursing shortages. But so is Uganda, with a reported nurse:population ratio of 6 to 10 000. From a country-level policy perspective, a shortage is usually defined and measured in relation to that country's own historical staffing levels, resources and estimates of demand for health services. It is the gap between the reality of the current availability of nurses and the aspiration for some higher level of provision, however defined, that is the ‘shortage’. As such, it is not easily quantifiable and ‘shortage’ is a label that is applied to different definitions or used differently by different stakeholders even in the same country context (see e.g. Friss 1994, Grumbach et al. 2001, Buchan 2002, Sochalski 2002). In a paper examining the issue of imbalances in the health workforce, Zurn et al. (2002) noted that there are both ‘economic’ and ‘non-economic’ definitions of shortages or skill imbalance, and that these imbalances may be ‘static’ or ‘dynamic’. At its most basic level, a shortage would be identified where an imbalance exists between the requirements for nursing skills (usually defined as a number of nurses) and the actual availability of nurses. ‘Availability’ has to be qualified by noting that not all ‘available’ nurses will actually be willing to work at a specific level of wage or package of work-related benefits (Buchan 1994). Some nurses may choose alternative non-nursing employment or no employment. A ‘shortage’ is therefore not merely about a numbers game or an economic model: it is about individual and collective decision-making and choice. In this case, the shortage is not necessarily a shortage of individuals with nursing qualifications: it is a shortage of nurses willing to work as nurses under present conditions. The reasons why nurses choose to stay or to leave are highly complex but, as a recent JAN paper from the Ontario Nurse Survey highlights, job satisfaction is certainly one of the strongest predictors of nurse intention to remain employed (Tourangeau & Cranley 2006). So the search for solutions to shortage has to focus on the motivation of nurses, and incentives to recruit and retain them, and encourage them back into nursing, as well as focusing on the planning framework. In short, there is no universal definition of nursing shortages – and therefore no single global measure of their extent and nature. What is evident is that the dynamics of supply and demand are out of balance in many countries and regions. Various ‘process’ indicators (such as vacancy rates, and the extent of use of temporary staff and agency nurses) and outcome indicators (such as mortality rates, cross infection, patient accidents) are often used to highlight the existence of nursing shortages, but these indicators are often flawed or inappropriate (Buchan & Calman 2004). And, as Tierney pointed out in her 2003 Editorial, the ‘shortage of nurses and shortage of nursing are not one and the same’. In previous decades, nursing shortages in many countries have been a cyclical phenomenon, usually as a result of increasing demand outstripping a static or more slowly growing supply of nurses (Friss 1994, Buchan 2002, Goodin 2003). Many high-income countries in Europe, North America and elsewhere are now facing a demographic ‘double whammy’– they have an ageing nursing workforce caring for an ageing population. For these countries, the pressing challenge will be how to replace the many nurses who will retire over the next 10 years. In a recent report on health systems, the Organization for Economic Cooperation and Development (OECD 2004) highlighted that ‘nursing shortages are an important policy concern in part because numerous studies have found an association between higher nurse staffing ratios and reduced patient mortality, lower rates of medical complications and other desired outcomes. Nursing shortages are expected to worsen as the current workforce ages’ (OECD 2004). This ‘crisis’ of nursing shortage is now firmly on the policy agenda in many countries and, within nursing itself, initiatives are underway in four main areas. Firstly, improving retention by keeping the scarce nurses who are already in employment. Research indicates that nurses are attracted to work and remain in work because of the opportunities to develop professionally, to gain autonomy, and to participate in decision-making, while being fairly rewarded. Factors related to work environment can be crucial, and there is some evidence that a decentralized style of management, flexible employment opportunities, and access to continuing professional development can improve both the retention of nursing staff and the quality of patient care. Secondly, countries can broaden the recruitment base. Nursing in many countries has often recruited from a narrowly delineated group: namely, young female school leavers. Some countries are now trying to open out access routes into nursing for a broader range of recruits, including more males, mature entrants, entrants from ethnic minorities, and entrants who have vocational qualifications or work-based experience to compensate for fewer conventional academic qualifications. A third strategy is to attract potential ‘returners’ back into the profession. Most countries have relatively large pools of former nurses with the necessary qualifications, on paper at least, to re-enter nursing. They are attractive to governments because they appear to offer a relatively quick fix to the nursing shortage. Nevertheless, attention has to be paid to why these nurses left the health system in the first place and, therefore, what needs to be done to get them back. A fourth intervention is importing nurses from other countries. Active international recruitment of nurses has been growing as developed countries exploit ‘push’ factors which make some nurses in developing countries willing to cross national boundaries. These factors include relatively low pay, poor career structures, lack of opportunities for further education, and in some countries, the threat of violence. The limitation of all of the above solutions is that they focus on nursing as the problem; 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.

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