What exactly is a nurse shortage?
Anyone who has been involved in the healthcare industry for more than a few years has seen nurse shortages come and go. And usually by the time the hospitals implement new hiring, training, salary and retention policies to deal with the most recent “crisis,” the problem seems to disappear on its own. So what is different about today’s nursing shortage? Many things, but the main difference is that the shortage at issue here has not even hit yet. Certainly there are minor problems in some areas, notably California, Texas, and Florida. Florida, for instance, with the highest percentage of elderly resident in the nation, ranks only 31st in number of RN’s per 100,000 population. Understaffed Florida health care facilities are all ready struggling to meet the needs of their aging patients, the number of which is estimated to be growing between 3-5% per year, and this is only a small part of what is to come.
The pending long-term shortage of nurses is primarily a result of overwhelming demographic forces. In 1980 over 25% of RNs were under 30 years old. That figure is now 9%. In ten years more than 40% of the RN workforce will be over 50. The average nurse is now 46.8 years old. By 2020, at least half of today’s RN workforce will have retired.
Of course the nursing shortage is no secret and many Americans would love to join the nurse work force. However, there are major obstacles to using homegrown talent to fill the demand for nurses. The main problem is that the schools are full and there is a lack of qualified faculty. Our nursing schools are graduating fewer new nurses each year, even turning away thousands of qualified students. The American Association of Colleges of Nursing (AACN) estimated that in 2005 over 32,000 qualified applicants were turned away from undergraduate nursing programs, because schools were running at or near full capacity and they simply could not find enough teachers to expand their programs. “The primary barriers to accepting all qualified students at nursing colleges and universities continue to be insufficient faculty, clinical placement sites, and classroom space.” To exacerbate this problem, most nurse educators are moving closer to retirement age, and many will be retiring within the next decade. With increased job openings projected in the hundreds of thousands, the number of new nurses graduating from U.S. institutions cannot even begin to approach filling the need.
An even more powerful demographic factor is the aging of the general U.S. population. The baby-boom generation is rapidly approaching the age where medical care will be increasingly required, and this group of medical consumers is accustomed to continual improvement in the world of medical care, and everyone expects the best care available. “Between 2010 and 2030, America will witness more than a 6 percent decline in the proportion of people aged 18-64, but the proportion of the population aged 65 or older will increase from approximately 13 percent to 20 percent. This represents and increase of approximately 30 million people 65 or older.” It is expected that, with the elderly population growing, the ratio between nurses and the people most likely to require care will decrease by an additional 40% between 2010 and 2030. Even if at this moment, new nurses began replacing retiring nurses at a steady rate, the U.S. nursing force would still be inadequate to stem the pending tsunami of demand for nursing care that will inevitably sweep the nation within the next decade. “[The] traditional solutions will not be enough because the coming shortage will not be temporary or short-term… Other remedies have to be sought.”
Normally such an influx of immigrant workers into any labor market would foster a natural resistance from groups wanting to protect their turf and/or their bargaining position. Certainly, American plumbers would not be happy if thousands of foreign plumbers were entering our country to compete with them. The same could be said of doctors, lawyers, engineers, and just about any other profession. However, with good reason there is little organized resistance to international nurse migration.
Chiefly responsible for this lack of resistance has been the positive affect nurse migration has had on job satisfaction for US nurses. While individual nurses now enjoy more bargaining power than before, the lack of adequate RN staffing has made the nursing profession increasingly demanding and unsatisfying. The fewer nurses to do the job, the lower the quality of work life for American nurses. Nurses across the board are reporting high levels of stress, safety concerns, and emotional and physical exhaustion resulting from long, unsupported hours of work, often including mandatory overtime.
This in turn subjects patients to increased risks, “Most hospital RN’s (93%) report major problems with having enough time to maintain patient safety, detect complications early, and collaborate with other team members.” A recent issue of Nurse Economic$ reviewed several comprehensive surveys regarding the effect of the nursing shortage on patient care, and found the majority of nurses are already reporting that quality-care goals are being undermined and patient care negatively affected. “One study on the nursing shortage by Linda Aiken of the University of Pennsylvania School of Nursing found that an estimated 20,000 people die each year because they have checked into a hospital with overworked nurses.” Twenty thousand every year.
According to the American Nursing Association website NursingWorld, 40% of hospital nurses are dissatisfied with their jobs, with staffing shortages a significant factor compelling many nurses to leave the profession or retire early. Understaffing at hospitals and nursing homes has become such a hot issue that many states are considering legislation to enforce government-mandated minimum patient/nurse ratios. With Assembly Bill 394 California became the first state to pass comprehensive legislation involving minimum staffing levels for nurses. Similar legislation has recently been enacted in Massachusetts “requiring a combination of minimum nurse to patient ratios… augmented by hospital based staffing systems.” Other states promise to follow.
In order to develop a more coherent perspective on the nurse shortage, it helps to take a close look at what we mean by “shortage.” From a purely economic perspective, a shortage exists when the demand for nurses exceeds the supply of nurses. Normally, that demand should be defined not by the number of people who need nursing services, but by the number of people who need the services and can pay for the services. However, the Healthcare industry is viewed by most people as unique, with ever-improving medical products and services that should be provided equally to all people, regardless of their ability to pay.
In this context, we see two different types of shortages. In the U.S. we have an economic, labor-market shortage, where the demand is manifested as actual well-paid job openings just waiting for qualified applicants. In lesser-developed countries there certainly is a need for nurses in the sense that many people do not receive adequate care, but there are no job openings to match this “demand”. This is what ultimately differentiates between the nurse shortage in developing countries and the shortage of nurses in the U.S. Moreover, in lesser-developed countries, the nurse “shortages” are part of a much larger shortage that includes modern medical equipment, sanitary facilities and medicine, as well as nutritional food, decent housing, and education.
The conundrum in countries like India and most African nations is that millions are deprived of basic healthcare, while many thousands of nurses remain unemployed. The Philippines educates many times more nurses than job opportunities exist; still many Filipinos do not have access to quality nursing care. It is an unfortunate fact of life that the need for nurses far exceeds the demand, especially in the developing world. However, without international nurse migration, the result would be highly skilled nurses living in their home countries, unable to put their skills to use to support themselves, their families, or their country’s economy.
Another factor complicating the issue is the fact that this shortage is being driven as much by the supply-side of the equation as the demand side. With more nurses retiring and too few replacements being trained, the economic solutions of the past, such as sign-on bonuses and premium benefit packages, will have limited effect, because they simply redistribute the supply of nurses, not increase it. In the U.S., the gap between need and demand may not be as wide as in many developing nations, but it will get wider. According to the U.S. Department of Heath and Human Services, there are currently about 1,900,000 nurses and 2,100,000 nursing jobs, leaving a shortage of 200,000. By 2010, the supply will remain the same, but there will be an additional 200,000 job openings. By 2015, the supply of the U.S. nurses will actually decrease, while the demand continues to increase, with the shortage growing to about 700,000. By 2020, in just thirteen years, DHHS projects over one million unfilled nursing positions in the United States. The Bureau of Labor statistics (November 2005 Monthly Labor Review), the American Medical Association, (Journal of the American Medical Association, June 14, 2000), the American Hospital Association (April 2006 report on the State of America’s Hospitals – Taking the Pulse), and other organizations project similar vacancy levels.
In the U.S. our major and legitimate concern should be providing sufficient quality healthcare to our growing populations of patients in need. When minor cyclical nurse shortages occurred, and a few thousand foreign nurses arrived as a partial temporary solution, the repercussions seemed small, both here and abroad. That model may soon be changing dramatically. Nurse migration is big and it is going to get bigger. We are now looking at projected nurse shortages in the hundred of thousands in the United States, and in the millions globally. To meet these needs, hundreds more nursing schools are appearing in countries that cannot employ their graduates, often with the express purpose of immigration. As nurses in developing nations feel the increasing push of low (or no) salary and poor working conditions, combined with the pull of high paying jobs in industrialized countries, they will continue to pursue immigration to Western Nations in escalating numbers.
PHILIPPINES
More foreign nurses come to the United States from the Philippines than from any other country. This pattern of nurse migration began soon after World War Two, when the United States established nursing scholarships and visitor exchange programs, and continued throughout the next several decades as the Philippines government established policies and agencies to facilitate the overseas migration of nurses and other workers. There were many factors that contributed to this migration phenomenon: the Philippines have a high literacy rate, one of its two official languages is English (the other is Tagalog), it has a persistent history of high unemployment, and equally persistent poverty levels.
In the late 1950s and 1960s, the Philippines Government began passing legislation to encourage the education of nurses specifically for the purpose of sending these nurse graduates abroad. In 1950 there were 17 nursing schools in the Philippines, and by 1970 they were the world’s top exporter of nurses to the U.S. In 2005 there were 370 schools training Filipino men and women to become registered nurses. The Philippines Overseas Employment Administration (POEA) was eventually established to facilitate labor outflows, and later became active in the rights of these migrants.
In 1973, Ferdinand Marcos, then president of the Philippines, addressed the Philippine Nurses Association during their annual convention and announced that his government favored the export of nurses: ‘we intend to take care of [Filipino Nurses] but as we encourage this migration, I repeat, we will now encourage the training of all nurses because, as I repeat, this is a market that we should take advantage of. Instead of stopping the nurses from going abroad, why don’t we produce more nurses? If they want one thousand nurses, we produce a thousand more.’ “
A recent estimate shows that 85% of Filipino nurses are working internationally and the primary reason is clearly economic. The Philippines cannot afford to provide jobs for all these nurses, and the nurses who do have jobs could often be making many times their current salary if they were working in the United States.
On May 28, 2006 in a front page New York Times article, George Cordero, the President of the Philippines Nurse Association, bemoaned the migration of Filipino nurses, and was quoted as saying: “The Filipino people will suffer because the U.S. will get all our trained nurses”. The myopic article went on to describe the international demand for RNs, and how the flight of nurses corroded the quality of Philippine health care. How could this be? No other country with a similar economy produces nearly as many nurses as the Philippines. By most accounts, the Philippines educate many times more nurses than it has the resources to employ. In fact, paying jobs are so scarce that young Philippine nurses commonly pay hospitals for the right to work there, so they can gain the essential experience needed to seek jobs abroad. The answer, again, can be found in the distinction between need and economically viable demand. No one questions that Philippine patients need more nurses, but equally true, and unfortunate, is the fact that there is not enough Philippine wealth to create the needed nurse jobs. {Note: Mr. Cordero has since resigned his position in the wake of a scandal in which he was accused of leaking nurse certification questions to students of the nursing school he owns, as well as bribery and other charges.}
INDIA
While the Philippines remains the primary source country for international nurse migration there are limits to how many nurses any single country can offer, and destination countries are increasingly looking to other countries for qualified nurses. Because of it’s size, and history of English education, India is now poised to become a major source of international nurses coming to the U.S. in the near future. Hundreds of Indian nursing schools have opened in the past two decades and while there is unquestionably a serious unmet need for nursing care in that country, 50%-60% of Indian nurses remain unemployed.
A similar migration phenomenon to what we may see with these Indian nurses occurred with computer programmers and systems analysts in India beginning in the 1960s and peaking in the 1990s, as employment opportunities became available to skilled technology workers in Europe and America. Literally, hundreds of thousands of young Indian men and woman went to school to study information technology, and then traveled abroad to hone those skills and build their careers.
As this wave of Indian professionals came to the U.S., most with temporary visas, there was justified concern about “brain drain” on the India economy. There was certainly at least a short-term affect on tax receipts, since most of those talented professionals probably would have earned at least some taxable income if they remained in India. But as a bigger and clearer picture emerged, we were able to see how this international mobility benefited India as well as the U.S. A study of Indian migrants in Silicon Valley in the Public Policy Initiative of California (PPIC) found that these India software workers not only significantly contributed to the growth of U.S. companies, but 74% said they hoped to run their own business someday. The study also found that these fledgling entrepreneurs created important social and economic links to their home countries, and used these international connections to exchange information, jobs, and business opportunities with friends abroad to help businesses grow in India.
Other studies of the software industry confirm the economic complexity of skilled migration. One difficult to measure but powerful aspect of the migration trend was that the possibility of migration induced many to acquire education at home as a means for increasing their chances of moving abroad. “Indian students had little reason to learn computer coding before there was a software industry to employ them. But such an industry could not take root without computer engineers to spearhead it. The dream of a job in Silicon Valley, however, was enough to lure many of India’s bright young things into coding…”
It was a win-win-win situation. First, and most importantly, many people were free to pursue their happiness; it was the American dream on a global level. Secondly, it helped fill skilled worker shortages and fuel the U.S. information technology expansion. Finally, it was ultimately a boost to the Indian economy. Even before the IT “bubble” burst in 2000, Indian technicians and entrepreneurs were already sending home millions of dollars in remittances, and many were returning home to raise families or start their own companies in entrepreneurial hot-spots such as Bangalore. Those remaining in America helped establish social and economic links to their home country, contributing to the recent explosion in India’s economic development. By all accounts, the information technology industry in India is flourishing beyond expectations.
The phenomenon of the IT economic migrant is now beginning to be paralleled by the nurse migrant. As observed by Mireille Kingma, internationally known expert in the filed of RN migration, the nurse migrant “is attracted by a better standard of living or by the possibility that she can provide additional income for family members who remain behind in the source country. Sometimes this latter motivation is so important that nurses actually accept a lower standard of living in the destination country in order to send a greater percentage of their income back to the family.” The migration trends in the software industry do not exactly mirror the migratory nurse market, but they do shed light on some the complexities and even unexpected benefits that can result from skilled migration.
AFRICA
One of the most ethically challenging areas of international nurse migration involves sub-Saharan Africa. Healthcare conditions in this area are among the worst in the world. Even before the AIDS/HIV epidemic, these countries suffered from widespread epidemics of other serious diseases such as tuberculosis and malaria, with proper medical care unavailable to the vast majority of the ill. With the AIDS crisis, the problems have only worsened. According to UNAIDS (Joint United Nations Programme on HIV/AIDS), there are currently an estimated 38.5 million adults and children living with HIV/AIDS, and 24.7 million of those people are living in sub-Saharan Africa.
Those of us in the health industry know even more about the heath care crisis and the severe shortage of skilled health care workers in Africa, and we are justifiably concerned. In Ghana, for example, between 1995 and 2002 almost 70% of its doctors, and 20% of its newly trained nurses migrated abroad in search of work. Only 50 of the 600 doctors trained in Zambia since its independence have stayed there. Kenya loses, on average, 20 medical doctors per month. One third of Ethiopian medical doctors have left the country. This is part of the over-all trend of professionals migrating from their homes in Africa in search of political and intellectual freedom, better wages, better work conditions, and higher living standards.
Reliable statistics are hard to come by, but there is strong anecdotal evidence that nurses are increasingly leaving sub-Saharan Africa for better opportunities in richer countries. The reasons are obvious. Nursing in sub-Saharan Africa is a horrible job. The very diseases they are fighting, in particularly AIDS, kill many of those who do not migrate or quit nursing. “The main cause of attrition among health workers in Malawi is not migration but death, mainly from HIV/AIDS.” Clearly, “pay is not the sole motive for leaving the country. Other factors include poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity” {id at pg 3} In the wake this leaves critical nurse shortages. The Ghana Ministry of Health estimates its nurse vacancy rate at 57%. The World Health Organization recommends at least 100 nurses per 100,000 persons in developing countries; seventeen sub-Saharan countries have fewer than 50 per 100,000.
Yet again, the contrast between the “need” for nurses, and the “demand” for nurses arises. One third of all Kenyan nurses are unemployed. In Tanzania, there are no jobs at all for new graduates of nursing schools. In other regional countries there is rarely enough money available to pay nurses a decent wage. The job opportunities either do not exist, or working conditions are so poor that many skilled nurses remain out of the job market, or seek employment elsewhere.
The unfortunate reality is that the patients in these developing nations (or their families, communities, insurance companies or governments) cannot afford to pay for the level of medical or nursing care that even approaches what we take for granted in the west.
BRAIN DRAIN, BRAIN CIRCULATION, and REMITTANCES
The traditional paradigm for measuring the source country affect of professional migration is known as “brain drain,” the self-explanatory observation that when well-educated people leave a country, the people they leave behind suffer from their loss. This was clearly the perspective of my Congressman describing the flight of Indian software programmers.
This is part of a larger trend that includes all sorts of educated workers, but touches a particularly sensitive nerve when it involves health care workers coming from nations where the sick are routinely denied adequate care. Filipino, Indian and Africa nurses are showing up throughout developed nations, and raising concerns that the source countries are being exploited.
Serious academic interest in the trend is growing, but “there is still almost no solid evidence on the economic importance of the phenomenon, which is not surprising in view of its elusive nature.”
An underlying assumption of the brain-drain calculation is that these worker leaves a poor country to work and stay in a rich country. Recent studies indicate that a large percentage of these migrants do not make this simple and permanent poor to rich country journey. The phenomenon is clearly much more complex than a zero-sum calculation. More recently, a more holistic perspective, that looks to other factors such as travel patterns, remittances, and migration opportunity incentives, describes the international migration experience as “brain circulation”, and even as “brain gain”.
In sub-Saharan Africa for instance, many of the nurses leaving countries such as Zambia and Ghana are actually going to work in other sub-Saharan nations. “The popular legend of immigration is that migrants move to a receiving country, settle there permanently and are assimilated into a baffling new culture. The reality is that this story represents only a very small proportion of all migration: much migration is circular (migrants return to their sending country, once or many times over a period of time) and most is transnational (migrants move to migrant communities in the receiving country and maintain strong social, business and political ties to the sending country).” Increased labor mobility in general, and high-skilled migration in particular have long been viewed by economists as generally beneficial trends. In fact, more economists now embrace the “brain circulation” perspective over the old zero-sum game “brain-drain.” “New research suggests that knowledge acquired abroad by talented migrants and the benefits that derive from that knowledge are returning home more often than in the past, even when the “brains” themselves do not. What’s more, under some conditions, the prospect of migration may enhance, rather than reduce, human capital formation within source countries.” “One point of consensus should be to abandon zero-sum terminology for conceptualizing high skill migration. It’s time to stop using he phrase “brain drain” as a synonym for high skill migration. The emerging concept for a global ‘war for talent’ is even worse. The creation and exchange of knowledge are the greatest positive-sum game that humanity has invented. High skill migration is a vital part of that game, a joint venture from which both source and receiving countries have the potential to gain.”
One important, yet often overlooked, economic aspect of migration is the amount of money that is sent back home in form of remittances. “In developing countries, workers’ remittances have become such an important source of economic security and stability that they are a part of a remarkable new economic development.” “Officially recorded remittances received by developing countries exceeded $93 billion in 2003. The actual size of remittances is even larger” because “more than half of the remittances go unrecorded.” “Moreover, the payments go directly to the final recipient, in contrast to government-to-government foreign aid which is often is so diluted by bureaucratic costs and plain corruption that much of it fails to do much good”.
Another unstudied, under-researched aspect of migration is the incentive it provides to young men in woman in source countries, who have very little opportunity in their restricted domestic economies, but see previously unimaginable prospects through the stories of their relatives and neighbors who have flourished abroad. It will always be impossible to quantify factors such as incentive and stimulus in judging individual behaviors, but these are staples of economic theory, and undoubtedly have some influence on young people in source countries, as they plan their futures.
As the nursing shortage grows, many U.S. health care facilities that have in the past resisted foreign nurse recruiting may be faced with the task of developing international recruiting policies that reflect their ethical concerns. Many hospitals, especially religious facilities, simply will not hire nurses from any poor countries, unless the nurse has already left the poor country. Others have lists of specific countries that are out-of-bounds for recruiting. Still others will accept nurses from certain countries, but only if the hospital is not directly or actively involved in the recruitment.
When a senior recruiter or Director of Nursing reads that thousands of children are dying from AIDS and malaria in a poor country, and there are too few nurses in the area helping these patients, how can he or she in good faith “steal” one of “their” nurses? On the other hand, denying those nurses work in the US is denying them an important opportunity and fundamental right to move. Refusing to offer a qualified nurse a job because she comes from Africa would be called racial discrimination if it involved a nurse in the U.S., but this is in fact the “company policy” at many hospitals.
Of course it would be to everyone’s benefit to encourage more people around the world to become nurses, but that is not an easy task when work conditions look so bleak. Again, hard data is hard to come by, but migrating nurses bring stories to the United States of unemployed or underemployed nurses in lesser developed nations working long hours in substandard (or worse) conditions for no pay, or a pittance. This is no one’s fault, at least not directly. These are poor countries and they cannot afford the level of care provided in richer countries. And there are limits on what we can expect from nurses, even in these poor countries. Nurses, as individuals, have basic needs, and families, and dreams, just like everyone else. In places like Kenya and Tanzania, with rampant unemployment for nurses, and poor work conditions for those lucky enough to find work, why would a smart young man or woman go into nursing? Ideally, based on the same motives that have drawn them to nursing for centuries: heart-felt compassion for the sick, and a desire to make a difference, one patient at a time. But in reality there are many other factors that will contribute to this decision. The young person must ask herself: can I find work in this profession, can I support myself and/or my family? If they have the chance to work abroad, the answer to this question is an overwhelming yes.
This is not a zero-sum game. The number of nurses in the world is not fixed. It is continually changing. Hopefully it will continue to grow. Nursing may be a special calling, attracting the most selfless and dedicated to serve the needy, but it is also a profession and a vocation. While nurses are willing to give and to make sacrifices, in return they need to be recognized and compensated for their work, just like the rest of us. It would be unthinkable to try and restrict professionals from developed nations from working abroad; individual freedom is just too important. The world needs more nurses, and the way to encourage people to become nurses and to stay in nursing is to give them the opportunity to nurse.
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Global Nurse Migration 
