The Global Nurse Shortage

Nurses Aren’t Like iPhones
Why Western countries can’t rely on imported labor in key professions.
British Prime Minister Boris Johnson (right) shakes hands with a nurse during a general election campaign visit to King’s Mill Hospital in England on Nov. 8, 2019. DANIEL LEAL-OLIVAS/AFP VIA GETTY IMAGES
The United Kingdom is struggling with a debilitating lack of nurses: 1 in 10 posts are vacant. The United States, too, is desperately looking for nurses to fill vacancies. In fact, there’s a nursing shortage across the West. For years, Western countries have been solving such shortages through imports, treating nurses like a commodity that can be sourced abroad. It’s a brutal strategy—and a dangerous one—because foreign supply can run low. Treating nurses like iPhones doesn’t work anymore.
Considering nurses are one of the largest professions in any developed country, they’re conspicuously absent from pop culture. Hollywood has featured a few nurses on shows like ER and M*A*S*H, not to mention the tyrannical Nurse Ratched in One Flew Over the Cuckoo’s Nest, but it’s safe to say these portrayals don’t reflect nurses’ absolutely critical—and positive—role in any country’s daily life. The COVID-19 pandemic has, of course, demonstrated to everyone how imperative it is that countries have enough nurses.
But how does a country staff a profession people may respect and know they depend on when not enough locals want to work in that profession? Wealthy countries have long depended on nurses from less wealthy countries to come and work for them.
Across the Organisation for Economic Cooperation and Development, nearly 16 percent of nurses are foreign-born, with countries such as the U.K. (21.9 percent) and Australia (35.3 percent) registering an above-average share of foreign-born nurses. While the Philippines and India are the main exporters, other countries ranging from Italy to Zimbabwe lose a critical share of nurses. Indeed, Poland, the United Kingdom, and Romania lose many of their nurses to other wealthy countries. Guyana, meanwhile, loses a massive 28 percent of all the nurses it trains.
Wealthy countries have long depended on nurses from less wealthy countries to come and work for them.
“There’s no feasible way of filling the nurse shortfall in the short term without international recruitment,” said Billy Palmer, a senior fellow at the Nuffield Trust—a U.K. health care think tank—and co-author of a recent report about Britain’s nurse shortage. “That raises the question of how to do it. You obviously have to follow the [World Health Organization’s] ethics guidelines.” Those guidelines include not targeting developing countries’ nurses for recruitment to stop brain drain. “But more problematically,” Palmer said, “you can engage in passive recruitment by putting out an advert that you know people from certain countries will respond to.”
During the COVID-19 pandemic, wealthy countries desperate for more nurses simplified the licensing of foreign health care workers. Post-Brexit Britain, meanwhile, also has to contend with a 90 percent drop in new European Union nurses arriving in the country. Unsurprisingly, perhaps, in February, the U.K. government eased the rules for nurse recruitment from more than 100 additional countries.
In Caribbean countries, 40 percent of nursing positions are vacant, mostly as a result of nurse migration.
The global nurse supply chain has been working well for import countries. The United States, for example, first began suffering from a nursing shortage in the 1930s and has been importing nurses since the 1950s. “Promoting unmanaged nurse migration to solve a nursing shortage masks serious workforce issues in source and recipient countries and perpetuates inequity in global health care,” a group of academics noted in the Journal of Professional Nursing 15 years ago. “Even if the effects of nurse migration are beneficial for recipient countries, given the global shortage of nurses, the effects are detrimental to source countries because they destabilize health systems.”
In the food chain of health care staffing, the richest countries occupy the top slot, and poorer countries lose, including countries that are only slightly poorer. Around 7,000 German physicians work in Switzerland, where salaries are higher. “The U.K. recruits from India and the Philippines, which train excess numbers, but also from countries like Italy, Portugal, Poland, though we’re receiving fewer EU nurses now,” Palmer noted. “But each of those countries have their own staffing issues.”
Imagine being the low-income country that painstakingly trains nurses only to see them lured away by richer countries. In Caribbean countries, for example, 40 percent of nursing positions are vacant, mostly as a result of nurse migration. To be sure, the Philippines—the world’s leading nurse exporter—has turned nurses’ departure into an asset by training nurses for the export market. Today, the island nation supplies an estimated 25 percent of all foreign nurses around the world, who in turn send an estimated $1 billion home as remittances every year.
But for most other export countries, the nurse exodus has brought only grief and unnecessary deaths at home. “Over the last three years, Jamaica lost 29% of its critical care nursing workforce to migration, which has severely hindered the capacity to deliver efficient and effective care,” Jamaica’s Ministry of Health noted in its 2016-2017 annual report.
And now, even the Philippines is having to tighten its policy. This summer, the Philippine government introduced a cap that would only allow 5,000 health workers per year to move abroad. In 2019, around 17,000 Filipino nurses took up jobs in other countries. Indeed, depending on critical goods imports—whether they be car components or nurses—means betting that other countries will be able and willing to keep supplying them.
Given the current confrontation between the West and China, it’s a good thing Western countries never grew dependent on Chinese nurses. As things stand, Philippine President Rodrigo Duterte could blackmail many industrialized countries by threatening to completely cut off nurse exports.
What would happen if there simply weren’t enough nurses available when not even government largesse brings results? That reality is already here. Ten percent of U.K. nursing jobs are, for example, currently vacant, and the United States is experiencing its largest ever nurse shortage. Although many nurses take pride in working in a caring profession that is crucial to society’s well-being, many nurses quit as a result of being overworked, with long hours in often dangerous conditions they are not compensated for with generous pay.
“Up to 33 percent of new nurses leave the workforce within the first two years,” American Hospital Association spokesperson Thomas Jordan told me. Last month, Detroit’s Henry Ford Health System announced it had to cut 120 hospital beds due to nursing shortages. “We just don’t have enough folks coming into the pipeline,” the organization’s president and CEO, Wright Lassiter III, told the Detroit News.
The situation is about to get much worse. By 2030, the United States alone will need 370,000 newly qualified nurses. (The world will need another 9 million.)
In fact, the situation is about to get much worse. By 2030, the United States alone will need 370,000 newly qualified nurses. (The world will need another 9 million.) Even if it wanted to, the Philippines would not be able to get the United States, the U.K., Australia, and other countries out of this bind. Africa and Southeast Asia, meanwhile, are suffering the world’s largest nurse shortages.
But the crisis may not be an unmitigated disaster. In fact, it could lead to nursing getting the upgrade it desperately deserves. It’s a highly qualified profession that saves lives, yet most countries reward it with far less money and prestige than sundry desk jobs. The average U.S. stock trader makes $102,000 per year while a nurse in Vermont—smack in the middle of U.S. nurse salaries—makes just $70,000 per year.
But according to Palmer, the main disincentive is the tough working conditions, which cause many student nurses to leave before graduating and working nurses to leave long before retirement. And Jordan said the American Hospital Association wants more efforts “to address suicide, burnout, and behavioral health disorders” among nurses.
If the last 18 months have taught the world anything, it’s that society can keep going without lawyers and accountants but quickly grinds to a halt without nurses, truck drivers, and supermarket workers.
Nurses aren’t iPhones. If we treat them like a commodity, we’ll regret it when we next need medical care.
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