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Global nurse hunt hits poor countries

Rich countries, such as Australia, are resorting to the “quick fix” of international recruitment as a way of overcoming nurse shortages.

The COVID-19 pandemic has worsened the global nurse shortage and rich countries are using foreign recruitment to quickly raise their nurse numbers, says a leading academic who specialises in the international nursing workforce. Professor James Buchan of the University of Edinburgh says this is still happening despite the risk of relying on high levels of foreign recruits having been exposed when international borders closed during the pandemic. And foreign recruitment is doing serious damage to the health systems of some of the “exporting” countries, Professor Buchan told the NSWNMA annual conference in August. Professor Buchan, who is also Adjunct Professor at the University of Technology, Sydney, is co-author of a 2022 study of COVID-19’s impact on the global nursing workforce. He works as a consultant and policy adviser on health workforce issues for governments and international agencies, including the World Health Organization. He said established importers of nurses, such as the US, UK, Germany and Australia, were increasing their international recruitment activity.

‘High-income countries are essentially solving their nurse shortages by creating shortages in countries that can’t afford it.’

— Professor James Buchan

At the same time, countries such as France that previously took in relatively few foreign nurses, were becoming more active in international recruitment. He said dozens of studies across the world showed that low staffing, high workloads, and the inability to participate in decision-making, were causing stress, burnout, psychological trauma and higher leaving rates among nurses. In the US, about 15 per cent of nurses left their jobs in the first year of the pandemic. “All the indicators are going in the wrong direction for nurses,” he said. Such indicators included COVID infections, COVID-related deaths, mental health problems and “moral injury”, stress, abuse and physical attacks. “One of the underlying major concerns is that many systems are putting a lot of emphasis on individual nurse resilience to somehow continue to get through this. “The reality is the emphasis should not be on the nurse to be resilient, it should be on the system to support the nurse.”

FIVE MILLION EXTRA NURSES NEEDED GLOBALLY

A 2020 WHO report said one in six of the world’s nurses were expected to retire in the next 10 years, and about five million nurses would need to be educated just to replace them. Professor Buchan said high retirement rates would greatly impact rich countries, such

‘The emphasis should not be on the nurse to be resilient; it should be on the system to support the nurse.’

— ProfessorJames Buchan

as Australia, the UK and US, where “a significant proportion of nurses are coming into retirement age.” He said countries such as India and the Philippines now operate schemes to train nurses specifically for export. The number of nursing colleges in India training nurses to bachelor level has grown from a handful in 2000 to over 2000 in 2020 in response to international recruitment programs. The “train for export” model, where students pay for a private sector nursing education on the assumption they will move abroad after qualifying, is likely to be adopted by other countries, he said. At the same time, poor countries with very low numbers of nurses and no private sector training are also being targeted for recruitment. “That is having a negative impact on the ability of those countries to deliver safe care,” Professor Buchan said. “It’s something we need to monitor very closely because there is real damage being done in some countries – and with the potential for more damage. “High-income countries are essentially solving their nurse shortages by creating shortages in countries that can’t afford it. “The countries that have been hit most negatively by (international recruitment) are not politically powerful or influential, so they need to work as a collective with the World Health Organization to get some balance and shine a light on what’s happening to ensure it is ethical.”

Australia depends on foreign-trained nurses

Australia has about 53,000 foreign-trained nurses, or 18 per cent of the nursing workforce. That is the third highest rate in the world, Professor Buchan said. Only New Zealand with 26.6 per cent and Switzerland with 25.9 per cent, are more reliant on foreign-trained nurses. The average rate among the 27 wealthy countries of the OECD is 6.1 per cent. The world had 28 million nurses and a global shortage of about six million nurses – mostly in poor and middle-income countries, according to a 2020 World Health Organization report. England, for example, is unable to fill 10 per cent of its funded nurse vacancies. n

Omission of nurses ‘a major pandemic failure’

Failure to involve nurses in planning for Covid-19 in aged care was a major flaw in Australia’s preparation for the pandemic, says a leading geriatrics specialist.

Professor Joseph Ibrahim of the Department of Forensic Medicine at Monash University has criticised the exclusion of nurses from the planning of the aged care sector’s response to COVID-19. Professor Ibrahim said involvement of nurses was “the major thing that was missing” from official pandemic planning for aged care. “No nurses that actually worked in aged care were represented on any of those groups that were making the decisions,” he told the NSWNMA’s professional day in August. Professor Ibrahim is a practising senior specialist in geriatric medicine with over 30 years of clinical experience with elderly people. He has been an expert witness in criminal and coroner’s court cases and a witness at the Royal Commission into Aged Care Quality and Safety. Professor Ibrahim questioned the federal government’s decision to put the aged care regulator – the Aged Care Quality and Safety Commission – in charge of leading the sector through the pandemic. “Why did they (the Morrison government) choose a regulator to lead a public health initiative?” he asked.

‘The greatest failure with this pandemic across the country and across the world, is a failure to understand how work is

done.’ — Professor Joseph Ibrahim

“Why was there not a single geriatrician, let alone a senior nurse in geriatrics, on any of the planning groups?”

SECTOR’S WEAKNESSES A RESULT OF DEREGULATION

Professor Ibrahim said structural weaknesses in the aged care system were well known even before the royal commission, which preceded the pandemic. He said the sector’s structural flaws were brought about by the deregulation of the sector in 1997. The 1997 legislation created a “free market” in aged care and was “the downfall” of the sector. It led to reduced staffing, removal of restrictions on who could do what work, a substantial loss of registered nurses from aged care, work becoming more casualised and “staff having to work at multiple places to earn a livable income”. The royal commission highlighted these problems and the fact that 10 per cent of aged care homes were “unable to fully staff for everyday business”. “We knew from the royal commission that the aged care sector was not equipped to manage day-today business,” Prof. Ibrahim told conference delegates. “But for some reason the Department of Health, the federal government and the regulator all seemed to think that the sector could step up and also manage a pandemic – despite these underlying foundational and structural issues. “The regulator knew before the pandemic that a substantial number of homes were having trouble with governance (such as) infection control and escalation of clinical care. “(The regulator) knew the places

‘Why was there not a single geriatrician, let alone a senior nurse in geriatrics, on any of the planning groups?’

— Professor Joseph Ibrahim

that had those problems and they knew this was not a one-off but another structural issue.” Prof. Ibrahim said providers who did what the regulator told them to do were “well under-prepared for the pandemic when it hit because the regulator’s plans were pretty thin – if you want to call it a plan”. “They essentially put the responsibility for managing an outbreak on the provider.”

STRATEGY BASED ON A FANTASY READING OF WORKPLACE REALITY

Prof. Ibrahim said the relationship between staff and management “wasn’t well thought through” in making plans to deal with the pandemic. Had more control been delegated to senior nursing staff in aged care facilities, “you would have a far better outcome around rostering, managing workforce shortages and talking the talk about reducing the number of places people would work at”. He said even now, it was “very hard” to find out “how many senior working nurses are involved at a state or regional level in advising what’s happening on the ground and what needs to happen, so that we’ve got proper field intelligence so that we can prepare better”. Professor Ibrahim said aged care was characterised by a mis-match between “work as imagined versus work as done”. “What’s written down in policy, what’s on organisational charts, what people put on their flow diagrams, what’s set down from above … doesn’t make a whole lot of sense about how the real world works. “The greatest failure with this pandemic across the country and across the world, is a failure to understand how work is done. “There has been a real mismatch between how senior leaders and advisers thought versus what was real. “People in senior positions and senior roles in decision-making were living in or working from an imaginary place (where) every shift is filled, every nurse is well and able to do the allocated work, if you need a doctor they’re around and are kind, thoughtful and responsive should you ask them any questions; the equipment you need is there, the space for bins is there, the rubbish will be taken out on time [and] that no-one will call in sick.” n

COVID toll mounts in aged care

When Professor Joseph Ibrahim addressed the NSWNMA 77th Annual Conference Professional Day in early August, there were about 10,000 active COVID-19 cases in about 1000 residential aged care facilities. This meant more than one third of Australia’s 2700 aged care facilities were battling outbreaks, Professor Ibrahim pointed out. He said that since 2020 there had been 2670 outbreaks in residential care facilities, meaning almost every single facility in Australia had suffered an outbreak. About 77,000 residents had contracted COVID-19, which had resulted in the deaths of 3394 residents.

The time to build nurse power and win workplace democracy

COVID has exposed gaping fault lines in already overloaded healthcare systems but it has also created new opportunities, global nursing leaders say.

“Nurses are done being applauded as essential while being treated as expendable,” says Bonnie Castillo. The Executive Director of National Nurses United, in the USA, said nurses, along with other workers on the frontline of pandemic responses, “have come to recognise ourselves as the very foundation of society”. Bonnie was speaking during a panel on professional day at the NSWNMA annual conference, along with Canadian nurse leader, Linda Silas, and Shaye Candish, NSWNMA General Secretary. Bonnie said her union had organised nearly 5000 workplaces and community actions across the US since 2020, including several outside the White House. She said nurses are at the forefront of “an inspiring labour upsurge across America”, one that has included teachers in conservative states striking and workers organising at corporate behemoths, such as Starbucks and Amazon. The anger and militancy coming from health workers is being driven by a hospital industry that “sacrifices nurses’ health and safety to the bottom line”, Bonnie said.

‘Thousands of healthcare workers would still be alive today if our profitdriven employers hadn’t spent decades slashing supply costs’.

— Bonnie Castillo, National Nurses United (USA)

Shockingly, the lack of concern for health and safety during the pandemic has contributed to the deaths of 5200 healthcare workers, including 494 registered nurses. “When COVID hit, instead of rushing in with the protections that we needed our employers kept N95s behind lock and key and tried to implement very unsafe PPE and decontamination processes. Thousands of healthcare workers would still be alive today if our profit-driven employers hadn’t spent decades slashing supply costs.”

A POWDER KEG OF STRESSES

NSWNMA General Secretary Shaye Candish, described a parallel situation in Australia, where a health system that “was already a powder keg of stresses” in the wake of bushfires and shortages of staff and resources, was pushed to breaking point when COVID arrived. Shaye described the Association’s campaigns around airborne transmission and fit-tested masks and eye protection when providing care of suspected or confirmed COVID patients, as among the Union’s significant wins. “The sacrifice and dedication of nurses and midwives across NSW in dealing with the challenges has been nothing short of inspiring,” Shaye said. In contrast, the NSW Government’s decision to freeze public sector wages, including those of nurses and midwives, is “a

‘We nurses need to stop being the martyrs of health care’

— Linda Silas, Canadian Federation of Nurses Unions

stunning slap in the face”. “We all shared collective rage as the NSW Government continued to spin the line that our public health system was strong and supposedly coping. This was repeated over and over while you were exhausted, working excessive overtime, maybe working outside your usual scope or in unfamiliar models of care and catastrophically short-staffed, as patient care suffered.” The NSWNMA’s first statewide strike since 2013, on 15 February this year, was driven by members’ “red hot rage”, Shaye said. More than 150 hospital and community health branches took part in the strike action and then voted for further action just weeks later. “We’ve had ongoing action since and I could not be prouder of the collective determination and commitment to continue our ratios campaign despite, and because of, the incredible adversity that you’re facing,” Shaye said.

NURSES ARE LEAVING IN DROVES

Stress, burnout and unsafe staffing ratios have led to nurses leaving in droves in the US, Canada and Australia, all three panellists said. Since the beginning of the pandemic, nursing vacancies across Canada have risen by 133 per cent said Linda Silas, President of the Canadian Federation of Nurses Unions. “One in two [Canadian] nurses are looking for the exit sign. The number one reason nurses are burning out in my country is because 83 per cent [say] we don’t have enough staff

‘The NSWNMA’s first statewide strike since 2013 was driven by members’ “red hot rage”’.

for them to provide good care.” “We nurses need to stop being the martyrs of health care,” she said. In the US, there are over five million RNs with active licences but only 3.5 million who are working; nearly one in five healthcare workers have quit their jobs since March 2020, Bonnie said. “Not because they can’t cut it but because they can’t handle being systematically denied the resources and protections that they need to do their jobs. Years of organised abandonment has caused an epidemic of moral injury and PTSD in the nursing profession.” Bonnie said that in the US, “we’ve won improvements in health and safety policies, staffing and provisions to advance racial and gender justice. The key to our success has been our ability to organise and flex our collective power in the workplace. Above all, through our willingness to strike”. “So, despite these huge challenges … it is a time of incredible opportunity,” she said. “And we’re in a better position now than maybe at any other point in my lifetime, to build nurse power and win workplace democracy.” n