Why Does RMU exist?

How many doctors are present for every group of 1000 people, in the world?

Say, if doctor to patient ratio is 1:1000, it means that there's a doctor for every 1,000 people. This is the proposed WHO Ratio universally. But, for a World Population (as of 2/23/2020) of 7.7 billion people (7,766,418,848), available statistics show that over 45% of WHO Member States report to have less than 1 physician per 1000 population.

For more data on Physicians (per 1,000 people) - World Health Organization's Global Health Workforce Statistics, OECD, supplemented by country data, for all Countries and Economies, visit the following sites;

https://data.worldbank.org/indicator/SH.MED.PHYS.ZS

http://wdi.worldbank.org/table/2.12

https://www.who.int/gho/health_workforce/physicians_density/en/

The prevalence of disease is increasing alarmingly in the world. For an example, Heart disease is the leading cause of death in India, accounting for 1.7 million deaths annually. According to the global burden of disease report, nearly one-fourth of all deaths in India are related to cardiovascular diseases. Despite the rising burden of cardiovascular diseases in India, there is an acute shortage of trained cardiologists in the country. There are 4000 cardiologists in the country, while the requirement is 88,000.

INDIA

As of 2018 Sep-Oct;

MBBS Doctors: Doctors of Modern Medicine

The Lok Sabha (Parliament) was informed by Minister of State for Health that as per information provided by the MCI, there were a total of 10,22,859 MBBS (Modern Medicine) doctors registered with the MCI or State Medical Councils as on March 31, 2017. After considering attrition, it gives a doctor (modern medicine) and population ratio of 0.77:1,000 as per current population estimate of 1.33 billion. The minister also said that emphasis of the government was to increase the number of doctors in the country to improve the doctor–population ratio. Comparable figures in other countries are as follows: Australia, 3.374:1,000; Brazil, 1.852:1,000; China, 1.49:1,000; France, 3.227:1,000; Germany, 4.125:1,000; Russia, 3.306:1,000; USA, 2.554:1,000; Afghanistan, 0.304:1,000; Bangladesh, 0.389:1,000; and Pakistan, 0.806:1,000. Currently, India hosts a total of 479 medical colleges with an annual intake of 67,218 MBBS students. About 12,870 MBBS student positions have been added only in the last 3 years.

AYUSH: Doctors of Traditional Indian System of Medicine

Apart from MBBS doctors, that is, graduates from the medical colleges teaching modern medicine, there is a spectrum of graduate healthcare providers trained in the traditional Indian systems of medicine. The government has recognized those trained in the traditional system with equivalent status in public funded healthcare delivery system; these graduates are also routinely employed by private sector. Department of AYUSH is a governmental body in India entrusted with education and research in Ayurveda, Yoga, Naturopathy, Unani, Siddha, Homoeopathy, Sowa-rigpa, and other Indigenous Medicine systems. The department was created in March 1995 as the Department of Indian Systems of Medicine and Homoeopathy (ISM & H). AYUSH received its current name in March 2003. That time it was operated under the Ministry of Health and Family Welfare. An independent Ministry of AYUSH was formed on November 9, 2014 by elevation of the Department of AYUSH. Apart from 297 existing Ayurveda-Siddha-Unani Colleges, under CCIM Act, 1970, there is ambitious plan to establish 47 new colleges proposed Ayurveda (42, 3,200 seats) in undergraduate (BAMS) courses, Unani (4, 260 seats) in undergraduate (BUMS) course, and Siddha (1, 100 seats) in undergraduate (BSMS) course. Also, there are plans to increase undergraduate admission capacity by 800 BAMS seats in the existing 32 Ayurveda colleges and 94 BUMS seats in existing 4 Unani Colleges. These training programs are contributing to the accumulating pool of traditional medical doctors by approximately 10,000/year. In total, there were 7,44,563 AYUSH registered graduates as of January 1, 2015, which by 2017 expected to be 7.6 lac approximately.

The World Health Organization (WHO) estimates a shortage of at least 4.3 million physicians, nurses and other health workers worldwide. The WHO produced a list of countries with a “Human Resources for Health crisis”. In these countries, there are only 1.13 doctors for every 1,000 people.

Lowest number of physicians per 100,000

Source: Human Development Report, United Nations. Web: hdr.undp.org.

This clearly demonstrates that there is a great and urgent need for trained physicians and health workers, who can serve the underserved and underprivileged.

RMU exists to bridge this huge gap in the demand for up skilled health care professionals to provide quality medical services and serve communities globally.

Health human resources (HHR) – also known as human resources for health (HRH) or health workforce – is defined as "all people engaged in actions whose primary intent is to enhance health", according to the World Health Organization's World Health Report 2006. Human resources for health are identified as one of the core building blocks of a health system. They include physicians, nursing professionals, midwives, dentists, allied health professions, community health workers, social health workers and other health care providers, as well as health management and support personnel – those who may not deliver services directly but are essential to effective health system functioning, including health services managers, medical records and health information technicians, health economists, health supply chain managers, medical secretaries and others.

The field of health human resources deals with issues such as planning, development, performance, management, retention, information, and research on human resources for the health care sector. In recent years, raising awareness of the critical role of HRH in strengthening health system performance and improving population health outcomes has placed the health workforce high on the global health agenda.

Global situation

The World Health Organization (WHO) estimates a shortage of almost 4.3 million physicians, midwives, nurses and support workers worldwide. The shortage is most severe in 57 of the poorest countries, especially in sub-Saharan Africa. The situation was declared on World Health Day 2006 as a "health workforce crisis" – the result of decades of underinvestment in health worker education, training, wages, working environment and management.

Shortages of skilled for health workers are also reported in many specific care areas. For example, there is an estimated shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. Shortages of skilled birth attendants in many developing countries remains an important barrier to improving maternal health outcomes. Many countries, both developed and developing, report maldistribution of skilled health workers leading to shortages in rural and underserved areas.

Regular statistical updates on the global health workforce situation are collated in the WHO Global Health Observatory. However, the evidence base remains fragmented and incomplete, largely related to weaknesses in the underlying human resource information systems (HRIS) within countries. In order to learn from best practices in addressing health workforce challenges and strengthening the evidence base, an increasing number of HHR practitioners from around the world are focusing on issues such as HHR advocacy, surveillance and collaborative practice. Some examples of global HRH partnerships include:

Health Workforce Information Reference Group (HIRG)

Global Health Workforce Network

Research

Health workforce research is the investigation of how social, economic, organizational, political and policy factors affect access to health care professionals, and how the organization and composition of the workforce itself can affect health care delivery, quality, equity, and costs.

Many government health departments, academic institutions and related agencies have established research programs to identify and quantify the scope and nature of HHR problems leading to health policy in building an innovative and sustainable health services workforce in their jurisdiction. Some examples of HRH information and research dissemination programs include:

• Human Resources for Health journal
• HRH Knowledge Hub, University of New South Wales, Australia
• Center for Health Workforce Studies, University of Albany, New York
• Canadian Institute for Health Information: Spending and Health Workforce
• Public Health Foundation of India: Human Resources for Health in India
• National Human Resources for Health Observatory of Sudan
• OECD Human Resources for Health Care Study

Policy and planning

In some countries and jurisdictions, health workforce planning is distributed among labour market participants. In others, there is an explicit policy or strategy adopted by governments and systems to plan for adequate numbers, distribution and quality of health workers to meet health care goals. For one, the International Council of Nurses reports:

The objective of HHRP [health human resources planning] is to provide the right number of health care workers with the right knowledge, skills, attitudes, and qualifications, performing the right tasks in the right place at the right time to achieve the right predetermined health targets.

An essential component of planned HRH targets is supply and demand modeling, or the use of appropriate data to link population health needs and/or health care delivery targets with human resources supply, distribution and productivity. The results are intended to be used to generate evidence-based policies to guide workforce sustainability. In resource-limited countries, HRH planning approaches are often driven by the needs of targeted programmes or projects, for example, those responding to the Millennium Development Goals or, more recently, the Sustainable Development Goals.

The WHO Workload Indicators of Staffing Need (WISN) is an HRH planning and management tool that can be adapted to local circumstances. It provides health managers a systematic way to make staffing decisions in order to better manage their human resources, based on a health worker's workload, with activity (time) standards applied for each workload component at a given health facility.

Global Code of Practice on the International Recruitment of Health Personnel

The main international policy framework for addressing shortages and maldistribution of health professionals is the Global Code of Practice on the International Recruitment of Health Personnel, adopted by the WHO's 63rd World Health Assembly in 2010. The Code was developed in a context of increasing debate on international health worker recruitment, especially in some higher income countries, and its impact on the ability of many developing countries to deliver primary health care services. Although non-binding on the Member States and recruitment agencies, the Code promotes principles and practices for the ethical international recruitment of health personnel. It also advocates the strengthening of health personnel information systems to support effective health workforce policies and planning in countries.

Physician supply refers to the number of trained physicians working in a health care system or active in the labour market. The supply depends primarily on the number of graduates of medical schools in a country or jurisdiction, but also on the number who continue to practice medicine as a career path and who remain in their country of origin. The number of physicians needed in a given context depends on several different factors, including the demographics and epidemiology of the local population, the numbers and types of other health care practitioners working in the system, as well as the policies and goals in place of the health care system. If more physicians are trained than needed, then supply exceeds demand; if too few physicians are trained and retained, then some people may have difficulty accessing health care services. A physician shortage is a situation in which there are not enough physicians to treat all patients in need of medical care. This can be observed at the level of a given health care facility, a province/state, a country, or worldwide.

Globally, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide, especially in many developing countries. Developing nations often have physician shortages due to limited numbers and capacity of medical schools and because of international migration: physicians can usually earn much more money and enjoy better working conditions in other countries. Many developed countries also report doctor shortages, and this traditionally happened in rural and other underserved areas. Reports as recent as January 2019 show that high growth areas like Phoenix, Arizona are experiencing shortages. Shortages exist and are growing in the United States, Canada, the United Kingdom, Australia, New Zealand, and Germany.

Several causes of the current and anticipated shortages have been suggested; however, not everyone agrees that there is a true physician shortage, at least not in the United States. On the KevinMD medical news blog, for example, it has been argued that inefficiencies introduced into the healthcare system, often driven by government initiatives, have reduced the number of patients physicians can see; by forcing physicians to spend much of their time on data entry and public health issues, these initiatives have limited the physicians' time available for direct patient care

Determinants
Economic theory and trends

Anything that changes the number of available physicians or the demand for their services affects the supply and demand balance. If the number of physicians is decreased, or the demand for their services increases, then an under-supply or shortage can result. If the number of physicians increases, or demand for their services decreases, then an over-supply can result.

Substitution factors can significantly affect the production of physician services and the availability of physicians to see more patients. For example, an accountant can replace some of the financial responsibilities for a physician who owns his or her own practice, allowing for more time to treat patients. Disposable supplies can substitute for labor and capital (the time and equipment needed to sterilize instruments). Sound record keeping by physicians can substitute for legal services by avoiding malpractice suits. However, the extent of substitution of physician production is limited by technical and legal factors. Technology cannot replace all skills possessed by physicians, such as surgical skill sets. Legal factors can include only allowing licensed physicians to perform surgeries, but nurses or doctors administering other surgical care.

Demand of physicians is also dependent on a country's economic status. Especially in developing nations, health care spending is closely related to growth of their Gross domestic product (GDP). Theoretically, as GDP increases, the health care labor force expands and in turn, physician supply also increases. However, developing countries face additional challenges in retaining competent physicians to higher-income countries such as the United States, Australia, and Canada. Emigration of physicians from lower-income and developing countries contribute to Brain drain, creating issues on maintaining sufficient physician supply. However, higher-income countries can also experience an outflow of physicians who decide to return to their naturalized countries after receiving extensive education and training, without ever benefiting from their gained medical knowledge and skill set.

Number of physicians trained

Increasing the number of students enrolled in existing medical schools is one way to address physician shortage, or increasing the number of schools, but other factors may also play a role. Becoming a physician requires either several years of training beyond undergraduate education, or a professional undergraduate degree with a duration longer than that of a typical undergraduate degree. Consequently, physician supply is affected by the number of students eligible for medical training. Students that do not finish earlier levels of education, including high school dropouts and in some places those that leave university without an undergraduate or associate degree, do not qualify for entrance to medical school. The more people that fail to complete the prerequisites, the fewer people become eligible for training as physicians.

In most countries, the number of placements for students in medical schools and clinical internships is limited, typically according to the number of teachers and other resources, including the amount of funding provided by governments. In many countries that do not charge tuition payments to prospective physicians, public funding is the only significant limitation on the number of physicians trained. In the United States, the American Medical Association says that federal funding is the most important limitation in the supply of physicians. The high cost of tuition combined with the cost of supporting oneself during medical school discourages some people from enrolling to become a physician. Limited scholarships and financial aid to medical students may exacerbate this problem, while low expected pay for practicing physicians in some countries may convince some that the cost is not appropriate.

It has been speculated that politics and social conditions can sometimes motivate medical student placements. For example, racial quotas have been cited in some places as preventing some people from enrolling in medical school.[19] Racial discrimination and gender discrimination, either overt or disguised, have also been cited as resulting in people being denied the opportunity to train as a physician on the basis of their race or gender.

Number of physicians working

Once trained, the current supply of physicians can be affected by the number of those who continue to practice this profession. The number of working physicians can be affected by:

The number of medical school graduates who:

• Choose to practice as a physician for their career – for example, some might choose instead to work in medical research, public policy or other areas where medical expertise is required; or they may choose a job where no medical knowledge is required
• Fail to obtain or re-qualify for their license or other professional requirements for legal practice.
• Are unable to find work of their choice – for example, studies in Mexico have found high levels of unemployment among trained physicians in urban areas, even while large rural populations remain medically underserved.

The number of physicians who:

• Exit the workforce, such as by retiring.
• Migrate abroad for better economic and social conditions, also referred to as "Brain drain".
• Work part-time - in particular, while the number working only part-time does not affect the overall number of physicians, it does affect the supply of physician services (e.g. in terms of full-time equivalents). Many physicians may retain their professional license while working part-time or after retiring; consequently, the reported number of active physicians is probably overstated in many jurisdictions.
• in the specialty balance – for example, in many countries, the balance is shifting away from medical students becoming general practitioners (GP) because of more attractive pay for medical specialists, leading to shortages of physicians for primary care.
• Changes in the practice environment – for example, changing legal conditions have been cited in the US, Canada and elsewhere as inciting physician attrition, notably the adoption of laws that require doctors to refer for certain procedures (such as abortion or sex change) with which the doctors disagreed on moral or religious grounds.

Demand for physician services

The demand for physician services is influenced by the local job market (e.g. the number of job openings in local health care facilities), the demographics and epidemiology of the population being served, the nature of the health policies in place for health care delivery and financing in a jurisdiction, and also the international job market (e.g. increasing demand in other countries puts pressure on local competition). As of 2010, the WHO proposes a ratio of at least one primary care physician per 1000 people to sufficiently attend the basic needs of the population in a developed country.

For example, population ageing has been attributed with increased demand for physician services in many countries, as more previously young and healthy people become older with increased likelihood of a variety of chronic medical conditions associated with ageing, such as type 2 diabetes mellitus, hypertension, osteoporosis, and some types of cancers and neurodegenerative diseases.

Patient Protection and Affordable Care Act (U.S.)

In the United States, the Patient Protection and Affordable Care Act has expanded health insurance coverage and access to an estimated 32 million United States citizens, increasing the demand of physicians, especially primary care physicians, across the country. Expanded coverage is predicted to increase the number of annual primary care visits between 15.07 million and 24.26 million by 2019. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase.

The PPACA may have also affected the supply of Medicaid physicians. Incentives and higher reimbursement rates may have increased the number of physicians accepting Medicaid patients leading up to 2014. With the expansion of Medicaid and a decrease in incentives and reimbursement rates in 2014, the supply of physicians in Medicaid may drop substantially, fluctuating the supply of Medicaid physicians. A study examining variation between states in 2005 showed that average time for Medicaid reimbursements was directly correlated with Medicaid participation, and physicians in states with faster reimbursement times had a higher probability of accepting new Medicaid patients.

Effects of physician shortage

Nations identified with critical shortages of physicians and other health care workers Physician shortages have been linked to a number of effects, including:

• Lower quantity of medical care for patients, thereby limiting the ability of health systems to meet primary health care goals, such as the Millennium Development Goals.
• Lower quality of medical care for patients, due to shorter doctor visits.
• Increased workload and too many patients per doctor resulting in overworked and sleep-deprived doctors, thereby compromising patient safety
• Unnecessary patient deaths while waiting for health care.
• Higher prices for practicing physicians due to less competition, by the rules of supply and demand in market-driven health care economies.
• Lower medical costs to consumers. Unlike other industries, as market share grows and competition declines, physicians are less inclined to gross up the frequency or intensity of medical services to maximize reimbursement per limited patient encounter.
• The shortage of obstetricians in parts of the United States has led to coining of the phrase Maternity Desert.

Maternity deserts

There are thousands of women in the United States that live in counties that do not have obstetrical care available. Arizona has two counties where there is no care available for women who are pregnant. Awareness to the lack of access to care is increasing in Arizona as it looks like the Phoenix area is heading toward a maternity desert. From 2009 to 2019 there has been a twelve percent reduction in obstetricians delivering babies in Arizona while the general population has grown.

Proposed solutions

A number of solutions, including short-term fixes and long-term solutions, have been proposed to address physician shortages. Some have been tested and applied in national health workforce policies and plans, while others remain subject to ongoing debate.

• Increase the number of medical graduates through increased recruitment of minority students domestically, as well as intensified recruitment of foreign-trained graduates (also known as International Medical Graduates or IMGs).
• Increase the number of medical schools and classroom sizes. To address physician shortages in rural areas, develop, organize, and locate medical schools to increase the propensity of physicians entering rural practice. Accepting medical school applicants from rural areas can also increase the proportion of rural physicians.
• To address physician shortages in high population growth areas in the United States unfreeze the 1996 Graduate Medical Education (GME) freeze/cap instituted by Congress.
• Higher medical school enrollment limits.
• Loosen the requirements for entry to medical school, such as eliminating the need for a pre-med bachelor's degree as required in some jurisdictions, thereby making the education path more attractive for potential students.
• Reduce the costs for students to attend medical school, such as through subsidies for (free or reduced) school tuition and more financial aid.
• Legislate tuition-increase caps for medical schools.
• Increase the role of the National Health Service Corps, which help provide debt-relief opportunities for primary care physicians.
• Improve the political, social and economic conditions in developing countries to prevent brain drain, including fewer wars and conflicts.
• Make better use of other categories of health care professionals, including more Osteopathic Physicians (DOs), nurse practitioners, physician assistants, clinical officers, community health workers, and others.
• Improve physician wages, such as through privatization of health care systems thereby enhancing market attractiveness for people to become doctors. Improve physicians' perspectives of their future career path, such as though reduced use of temporary employment contracts
• Provide better incentives for physicians to practice in underserved areas – for example, in the U.S., this would include expanding incentives for the National Health Service Corps in rural, urban, and suburban areas experiencing shortages.
• Ensure better practice conditions for physicians – for example, medical liability reforms have been cited as an important factor in the U.S.
• Increase the use of e-mail and telephone consultations, which allow physicians to treat patients seeking more traditional forms of care.
• In the United States, to better accommodate the elderly and their demand for healthcare services, increase medical and nursing training in geriatrics and gerontology.
• Increase use of health care or medical teams (i.e. nurse practitioners and physician assistants) to shift physician workload and allow for increased physician times with patients.

Global view

In the US alone, the Association of American Medical Colleges (AAMC) estimates a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025. However, a bias would clearly exist in their estimates as expanding medical education serves the direct financial needs of the AAMC. As previously mentioned, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide. The WHO produced a list of countries with a “Human Resources for Health crisis”. In these countries, there are only 1.13 doctors for every 1,000 people, while in the United States, there are approximately 2.5 doctors for every 1,000 people. One quarter of physicians practicing in the United States are from foreign countries. Thousands of foreign doctors come to practice in the United States each year while only a few hundred doctors from the United States leave to practice in foreign countries even short-term.

There are various organizations that assist United States physicians and others in serving internationally. These organizations may be filling temporary or permanent positions. Two temporary agencies are Global Medical Staffing and VISTA staffing. A locum doctor will serve in the temporary absence of another physician. These positions are typically 1-year placements but can vary by location, specialty, and other factors. Agencies that attempt to provide international aid in various ways often have a strong medical component. Some of these organizations helping to provide medical care internationally include Reach Out Worldwide (ROWW), Doctors Without Borders (Médecins Sans Frontières), Mercy Ships, the US Peace Corps, and International Medical Corps.

Additionally, smaller non-profits that work regionally around the world have also implemented task-shifting strategies in order to increase impact. Non profits, such as the MINDS Foundation educated community health workers or teachers to perform simple medicinal tasks, thereby freeing up health professionals to focus on more pressing concerns.

Nursing shortage refers to a situation where the demand for nursing professionals, such as Registered Nurses (RNs), exceeds the supply—locally (e.g., within a health care facility), nationally or globally. It can be measured, for instance, when the nurse-to-patient ratio, the nurse-to-population ratio, or the number of job openings necessitates a higher number of nurses than currently available. This situation is observed in developed and developing nations around the world.

Nursing shortage is not necessarily due to a lack of supply of trained nurses. In some cases, perceived shortages occur simultaneously with increased admission rates of students into nursing schools. Potential factors include lack of adequate staffing ratios in hospitals and other health care facilities, lack of placement programs for newly trained nurses, and inadequate worker retention incentives.

Globally, the World Health Organization (WHO) estimates a shortage of almost 4.3 million nurses, physicians and other health human resources worldwide—reported to be the result of decades of underinvestment in health worker education, training, wages, working environment and management.

Causes

Nursing shortage is an issue in many countries. To remedy the problem, psychological studies have been completed to ascertain how nurses feel about their career in the hope that they can determine what is preventing some nurses from keeping the profession as a long-term career. In a study completed by sociologist Bryan Turner, the study found that the most common nursing complaints were:

• subordination to the medical profession on all matters, even over standardized regulations
• difficult working conditions A report from the Commonwealth of Australia identified a few other matters that led to nurse dissatisfaction:
• constant schedule changes
• work overloads due to high number of patients and paperwork
• shift work
• lack of appreciation by superiors
• lack of provided childcare
• inadequate pay Another study found that nurse dissatisfaction stemmed from:
• conflicting expectations from nurses and managers due to regulation of cost
• inability to provide comprehensive nursing care due to work
• loss of confidence in the health care system.

In many jurisdictions, administrative/government health policy and practice has changed very little in the last decades. Cost-cutting is the priority, patient loads are uncontrolled, and nurses are rarely consulted when recommending health care reform. The major reason nurses plan to leave the field, as stated by the First Consulting Group, is because of working conditions. With the high turnover rate, the nursing field does not have a chance to build up the already frustrated staff. Aside from the deteriorating working conditions, the real problem is "nursing’s failure to be attractive to the younger generation." There’s a decline in interest among college students to consider nursing as a probable career. More than half of currently working nurses "would not recommend nursing to their own children" and a little less than a quarter would advise others to avoid this as a profession altogether

Australian nursing researchers John Buchanan and Gillian Considine described hospitals as "being run like a business" with "issues of patient care… of secondary importance." Emotional support, education, encouragement and counseling are integral to the everyday nursing practice. However, these practices are not easily quantified and are considered by managers as unjustified cost for the patients, who are viewed as consumers. Therefore, only clinical responsibilities, such as medication administration, dressing changes, foley catheter insertions, and anything that involves tangible supplies, are quantified and incorporated into the organization budget and plan of care for the consumers.

The nursing shortage affects the developing countries that supply nurses through recruitment to work abroad in wealthier countries. For example, to accommodate perceived nursing shortage in the United States, American hospital recruit nurses from overseas, especially the Philippines and Africa. This, in turn, can lead to greater nursing shortages in their home countries. In response, in 2010 the WHO's World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel, a policy framework for all countries for the ethical international recruitment of nurses and other health professionals.

Impacts on healthcare

Nursing shortages (including low hospital-level nurse-to-patient ratios) have been linked to the following effects:

• Increased nurses’ patient workloads
• Increased risk for error, thereby compromising patient safety
• Increased risk of spreading infection to patients and staff
• Increased risk of adverse outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections[
• Increased risk for occupational injury
• Increase in nursing turnover, thereby leading to greater costs for the employer and the health care system
• Increase in nurses' perception of unsafe working conditions, contributing to increased shortage and hindering local or national recruitment efforts

Global shortage and international recruitment

The nursing shortage takes place on a global scale. Australia, the UK, and the US receive the largest number of migrant nurses. Australia received 11,757 nurses from other countries between 1995 and 2000. The U.S. Immigration and Naturalization Service (INS) records show that more than 10,000 foreign nurses were given H-1A visas in the same time frame. The U.K. admitted 26,286 foreign nurses from 1998 to 2002.

Saudi Arabia also depends on the international nurse supply with 40 nations represented in its nurse workforce. Netherlands needed to fill 7,000 nursing positions in 2002, England needed to fill 22,000 positions in 2000, and Canada would need about 10,000 nursing graduates by 2011.

Source: Data from the World Health Organization (2006).
In an American Hospital Association study, the cost to replace one nurse in the U.S. was estimated at around $30,000–$64,000. This amount is likely related to the cost of recruiting and training nurses into the organization. Hiring foreign nurses is more financially taxing compared to hiring domestic-graduate nurses; however, facilities save money in the long run because foreign nurses have a contractual obligation to complete their term. The JACHO in the United States wrote in a 2002 research report on the shortage in the US that recruiting foreign trained nurses from abroad (not referring to those who reside in the United States already) does not help the global nursing shortage and, in fact, perpetuates it.

Countries that send their nurses abroad experience a shortage and strain on their health care systems.

In South Africa, accelerated recruitment by developed countries such as United States, United Kingdom and Australia has placed more pressure on the health care system due to prevalence of diseases, such as AIDS, and limited resources. Similar to the U.S., nurses who leave the organization are a financial disadvantage due to the need to fund recruiting and retraining of new nurses into the system. It has been estimated that every nurse who leaves South Africa is an annual loss of $184,000 to the country, related to the financial and economical impact of the nursing shortage.

The following table represents the number of nurses per 100,000-population in southern African countries.

In India international migration has been considered as one of the reasons behind shortages of nursing workforce. Social, economic and professional reasons have been cited behind this shortfall

Retention of nurses by sending (often developing) countries can be addressed by improving working conditions, minimizing wage differentials, and promoting medical tourism.[citation needed] Retention can also be promoted through educational activities to improve job satisfaction. There can be additional unintended impacts of nurses migration abroad. For example, there is growing evidence that physicians in the Philippines have shifted to the nursing field for better export opportunities. The World Health Organization (WHO) representative in Manila believes the government should invest more into its health sector as it is 3% of the Philippines' GDP.[citation needed] Others have suggested programs which require domestic service or employment upon graduation.

Ethical concerns

Foreign nurses that migrate from developing countries to fill the nursing shortage of developed nations pursue their own economic, career, and lifestyle interests, but there are risks. The media and scholars have remained relatively silent on the ethical concerns involving the potential exploitation of foreign nurses.[according to whom?] On the level of national sovereignty and global equality, there are ethical concerns about the pull of developed nations on developing countries' skilled workers and assets. U.S. incentives such as signing bonuses can be seen as promoting brain drain. Activists have spread a new term for this: "Brain drain in the south, brain waste in the north." The president of the Philippines Nurse Association, George Codero, was quoted in a New York Times article as saying "The Filipino people will suffer because the U.S. will get all our trained nurses".

On an individual basis, foreign nurses are subject to exploitation by employers. In 1998 six Americans were charged with falsely obtaining H-1A visas and using them to employ Filipino nurses as nurse aides instead of registered nurses. In a case in 1996, a Catholic archdiocese employed some of these foreign nurses as nurse aides instead of nurses. In 2000, Filipino nurses in Missouri received $2.1 million for failure to receive proper wages that an American in the same position would receive. While these cases were brought to court, many similar situations are left unreported thereby jeopardizing the rights of foreign nurses. Foreign nurses have the tendency to receive less desirable jobs, such as entry-level positions, because of their immigrant status; they are excluded from jobs that would lead to facilities and are often not paid proper salaries.

Some U.S. health care facilities push to "ease restrictions" on the immigration law to increase the number of recruited foreign nurses. On the other hand, this recruitment practice is a temporary solution that does not fully address the nursing shortage as mentioned by American Nursing Association (ANA). Others have taken a stand on ethically recruiting foreign workers. New York University Medical Center was cited in The Search for Nurses Ends in Manila as believing that it is a "poaching exercise" to take nurses from countries in need of their citizens. The former health secretary, Dr. Galvez Tan, in reference to the doctors and nurses working for an American green card said, "There has to be give and take, not just take, take, take by the United States."

Shortage by country

Morocco

Morocco has far fewer nurses and other paramedical staff per capita than other countries of comparable national income. The number of nurses in Morocco was 29.025 in 2011, two thirds being registered nurses and one third auxiliary nurses, a ratio of 8 nurses per 10,000 population. As a result, Morocco has been classified among 57 countries suffering from a glaring shortage of medically trained human resources.

A recent study by the European Institute of Health Sciences (Institut Européen des Sciences de la Santé) in Casablanca based on scientific modeling of future needsindicates that the situation will worsen and that to bridge the nursing gap, Morocco needs to produce between 40,000 and 80,000 new nurse graduates until the year 2025.

Philippines

The Philippines is the largest exporter of nurses in the world supplying 25% of all overseas nurses. An Organisation for Economic Co-operation and Development study reported that one of every six foreign-born nurses in the OECD countries is from the Philippines. Of all employed Filipino RNs, roughly 85% are working overseas. This is partially in response to the inability of Filipino nurses to enter their domestic workforce due to a lack of jobs and instead become heavily dependent upon international job markets for nurses. The United States has an especially prominent representation of Filipino nurses. Of the 100,000 foreign nurses working in the U.S. as of 2000, 32.6% were from the Philippines.

Reasons for international migration

The international migration of Filipino nurses takes place in response to "push and pull" factors. The push factors are rooted in the economic conditions in the Philippines in which there is an overabundance of RNs and a lack of open employment positions. The unemployment rate in the Philippines exceeds 10%. Additionally, health care budgets set up Filipino nurses for low wages and poor benefit packages. There are fewer jobs available, thereby increasing the workload and pressure on RNs. Filipinos often pursue international employment to avoid the economic instability and poor labor conditions in their native country. The government also highly encourages the exportation of RNs internationally. Filipino nurses are pulled to work abroad for the economic benefits of international positions. While a nurse in the Philippines will earn between $180 and $200 U.S. dollars per month, a nurse in the U.S. receives a salary of $4,000 per month. Nurses abroad are greatly respected in the Philippines as they are able to support an entire family at home through remittances. In 1993, Filipinos abroad sent $800 million to their families in the Philippines thereby supporting the economy. Additionally, remittances from Filipinos made up 5.2% of the Filipino GDP (gross national product) between 1990 and 2000. Further pull factors stem from the additional economic benefits of signing bonuses in the U.S. To attract more foreign nurses, U.S. hospitals increased signing bonuses from $1,000 to $7,000. Positions abroad in the health sector are also enticing for their immigration benefits. Throughout the past 50 years of nurse migration, the U.S. has made efforts to ease the visa application process to further encourage international nurses to relieve the nursing shortage. Scholars note that the better living and working conditions, higher income, and opportunities for career advancement draw nurses from the Philippines to work in the U.S.

As the relation between the U.S. and the Philippines stretches back 50 years, Filipino nursing institutions often reflect the same education standards and methods as the U.S. curriculum. Furthermore, a knowledge of English in the Philippines makes it easier for Filipino nurses (rather than nurses from other developing nations) to work in the U.S.

Since 1916, 2,000 nurses have arrived each year in the U.S. In 1999, the U.S. approved 50,000 migrant visas for these nurses. Today, on average, there are about 30,000 Filipino nurses traveling to the U.S. each year.

Effects of migration

The transnational migration of Filipino RNs has profound effects on the economy and workforce dynamics in both sending and receiving nations. The departure of nurses from the domestic workforce represents a loss of skilled personnel and the economic investment in education. In addition, the "scarce and relatively expensive-to-train resources" invested are lost when a worker chooses to work abroad. When RNs migrate internationally, the country they emigrate from loses a valuable resource and any financial or educational support that was invested in the individual.

According to many Filipinos working in hospitals, the most educated and skilled nurses are the first to go abroad. There is disagreement among scholars on the extent to which the Filipino health sector is burdened by its nursing shortage. While the numerical data are inconsistent about whether the nurse supply is in excess or a shortage, it is clear that there is a short supply of the most skilled nurses who go abroad. As a result, operating rooms are often staffed by novice nurses, and nurses with more experience work extremely long hours. As skilled nurses decline in the urban areas, nurses from rural areas migrate to hospitals in the cities for better pay. As a result, rural communities experience a drain of health resources. Stories and studies alike demonstrate that a treatable emergency in the provinces may be fatal because there are no medical professionals to help treat them. In fact, "the number of Filipinos dying without medical attention has been steadily increasing for the last decade." The lack of attention from medical professionals has increased despite advances in technology and medicine and the increasing number of trained nurses in the Philippines.

Doctors, too, have changed professions and joined the international mobility trend. Filipino doctors have begun leaving their professions to train as nurses under the title MD-RN with the hope of immigrating to the U.S. or other developed nations more easily. Since 2000, 3,500 Filipino doctors have migrated abroad as nurses. The U.S. incentives for nurse migration encourage doctors to train as nurses in the hopes of increasing their economic prospects. As a result, the Philippines have a lower average of doctors and nurses with 0.58 and 1.69 respectively for a population of 1,000. The average statistics globally in contrast are 1.23 and 2.56. Between 2002 and 2007, 1,000 Filipino hospitals closed due to a shortage of health workers. A study conducted by the former Philippine Secretary of Health, Jaime Galvez-Tan, concluded that close to 80% of government doctors have become nurses or are studying nursing. Of the 9,000 doctors-turned-nurses, 5,000 are working overseas. The extraordinary influence of this international migration has had devastating effects on the health of Filipinos. The number of deaths that were not prevented with medical attention have increased as hospitals are shut down and rural areas are deprived of any medical treatment.

Due to the high interest in international mobility, there is little permanency in the nursing positions in the Philippines. Most RNs choose to sign short-term contracts that will allow for more flexibility to work overseas. Filipino nurses feel less committed to the hospitals as they are temporary staff members. This lack of attachment and minimal responsibility worsens the health of Filipino patients.

The education system has also been hurt by the increase of nurses in the Philippines. As Filipinos are attracted to working as nurses, the number of nursing students has steadily increased. As a result, the number of nursing programs has grown quickly in a commercialized manner. In the 1970s, there were only 40 nursing schools in the Philippines; by 2005 the number had grown to 441 nursing colleges. While the education opportunities for nursing students has grown tremendously, the quality of education has declined. This can be seen by the low rate (50%) of students who pass the nursing exam since the 1990s. Furthermore, the Technical Committee on Nursing Education of the Commission on Higher Education (CHED) determined that 23% of Filipino nursing schools failed to meet the requirements set by the government.

In summary, the emigration of Filipino nurses has encouraged doctors to switch to nursing, created a shortage of skilled specialized and experienced nurses, affected the education system, and distorted health care delivery and attention to medical issues in rural areas. While remittances, return migration, and the transfer of knowledge support the Philippines, they fail to fully compensate the loss of health workers, which disrupts the Filipino health and education sectors.

Dr. Jaime-Galvez Tan, the former Philippine Secretary of Health, warns that if the U.S. passes legislation allowing for freer immigration of nurses the health service of the Philippines could collapse.

United Kingdom

In October 2015 The UK Government announced that Nurses will be added to the government’s shortage occupation list on an interim basis. In December 2015, 207 out of 232 English hospitals (90%) reported nursing shortages.

In January 2016 the RCN stated that more than 10,000 nursing posts went unfilled in 2015. This represented a 3% increase year on year from 11% in 2013, 14% in 2014 and 17% in 2015 of all London nursing positions and 10% as an average nationwide. According to a BBC article the Department of Health said it did not recognise the figures.

United States

According to the American National Council of State Boards of Nursing, the number of U.S. trained nurses has been increasing over the past decade: In 2000, 71,475 U.S.-trained nurses became newly licensed. In 2005, 99,187 U.S.-trained nurses became newly licensed. In 2009, 134,708 U.S.-trained nurses became newly licensed. Therefore, a 9.8% annual increase of newly licensed U.S. nurses has been observed each year over nine years. It is clear that, nursing enrollment in the U.S. has significantly increased over the past decade relative to the 1.19% annual U.S. population growth.

While the number of U.S. trained licensed nurses has increased each year, the projected nursing demand growth rate from 2008 to 2018, as reported by the U.S. Bureau of Labor Statistics, is anticipated to be 22%, or 2.12% annually. Therefore, the 9.8% annual growth of new RN's exceeds the current new position growth rate by a net of 7.7% per year with the assumption of consistent growth figures over the next decade.

The United States population is projected to grow at least 18% over two decades in the 21st century, while the population of those 65 and older is expected to increase three times that rate.[9] The increase in the number of elderly is projected to lead to an increase demand for nurses in senior care facilities as well as the need to fill the positions of nurses as they reach retirement age. Projections suggest that by 2020 to 2025 one third of the current RN and LPN workforce will be eligible to retire. The current shortfall of nurses is projected at 800,000 by the year 2020.

Professional health and related occupations were expected to rapidly increase between 2000 and 2012. The demand for health care practitioners and technical occupations will continue to increase. It is projected that there will be 1.7 million job openings between 2000 and 2012. The demand for registered nurses is even higher. Registered nurses are predicted to have 1,101,000 openings due to growth during this 10-year period. In a 2001 American Hospital Association survey, 715 hospitals reported that 126,000 nursing positions were unfilled

Other research findings report a projection of opposite trend. Although the demand for nurses continues to increase, the rate of employment has slowed down since 1994 because hospitals were incorporating more less-skilled nursing personnel to substitute for nurses. With the decrease in employment, the earnings for nurses decreased. Wage among nurses leveled off in correlation with inflation between 1990 and 1994. The recent economic crisis of 2009 has further decreased the demand for RNs

Comparing the data released by the Bureau of Health Professions, the projections of shortage within two years have increased.

However, emergency and acute care nurses are in great demand, and this temporary reduction of the shortage is not expected to last as the economy improves. In 2009, it was reported that in places like Des Moines, Iowa newly graduated nurses were having more difficulty finding jobs and older nurses were delaying retirement due to economic conditions. This hiring situation was mostly found in hospitals; nursing homes continued to hire and recruit nurses in strong numbers.

Some states have a surplus of nurses while other states face a shortage. This is due to factors such as the number of new graduates and the total demand for nurses in each area. Some states face a severe shortage (such as the northwestern states, as well as Texas and Oklahoma), while other states have a surplus of registered nurses.

Patching up the shortage

Nursing shortages can be consistent or intermittent depending on the number of patients needing medical attention.

Retention and recruitment are important methods to achieve a long-term solution to the nursing shortage. Recruitment is promoted through making nursing attractive as a profession, especially to younger workers, to counteract the high average age of RNs and future waves of retirement. Refining the work environment can improve the overall perception of nursing as an occupation. This can be achieved by ensuring job satisfaction. Writers Lori Candela, Antonio Gutierrez, and Sarah Keating point out in the journal, Nurse Education Today, ways the academic nursing administrators can make a change. "Individual support to attend workshops or conferences, participation in on-campus teaching/learning faculty sessions, the use of consultants with expertise in particular areas around teaching and evaluation, and mentoring networks that include senior faculty with teaching expertise" can all create a strong relationship between staff members therefore developing a better environment. Additionally, financial opportunities such as signing bonuses can attract nurses.

To assist the health sector, Congress approved the Nurse Reinvestment Act in 2002 to provide funding to advance nursing education, scholarships, grants, diversity programs, loan repayment programs, nursing faculty programs, and comprehensive geriatric education.[44] Currently, mandatory overtime for nurses is prohibited in nine states, hospital accountability to implement valid staffing plans in seven states, and only one state implements the minimum staffing ratio.

Other ways of assisting to fill the shortage in the United States would include giving nurses the opportunity to pick their own overtime and schedules. Also, it would be a great incentive to young nurses to enter a hospital if they knew there were bonuses for continued excellence.

To respond to fluctuating needs in the short term, health care industries have used float pool nurses and agency nurses. Float pool nurses are staff employed by the hospital to work in any unit. Agency nurses are employed by an independent staffing organization and have the opportunity to work in any hospitals on a daily, weekly or contractual basis. Similar to other professionals, both types of nurses can only work within their licensed scope of practice, training, and certification.

Float pool nurses and agency nurses, as mentioned by First Consulting group, are used in response to the current shortage. Use of the said services increases the cost of health care, decreases specialty, and decreases the interest in long-term solutions to the shortage

International recruitment is often used to fill the nursing gap but gives rise to concern now that the U.S. Homeland Security has stopped the issuance of the H-1C visa, which was deemed specifically for nurses. Because of the Affordable Care Act, which will result in an increased number of insured Americans, it is estimated that there will be an even greater need for nurses in the near future. U.S. trained nurses are concerned, however, that this recruitment initiative impedes on their ability to obtain positions in the field after completing their training. A nursing shortage does not translate to new nursing jobs.

A growing response to the nursing shortage is the advent of travel nursing a specialized sub-set of the staffing agency industry that has evolved to serve the needs of hospitals affected. According to the Professional Association of Nurse Travelers, there are an estimated 25,500 working in the U.S. The number of LVN/LPN nurse travellers is not known.

There is a nursing recruitment initiative and nursing workforce development program for residents of the United States originally from foreign countries, who were professional nurses in their countries but are no longer in that profession in the United States. This initiative helps them get back into the nursing profession, especially getting through credentialing and the nursing board exams. The original model was developed in 2001 at San Francisco State University in cooperation with City College of San Francisco ("The San Francisco Welcome Back Center"). There are centers in many cities, such as Los Angeles, San Diego, and Boston—where it is called a "Boston Welcome Back Center for Internationally Educated Nurses".[49] It is a program meant for residents of the United States only. The Boston Welcome Back Center was opened in October 2005 with a $50,000 seed grant from the Board of Higher Education’s Nursing Initiative.

Legislation

In 2004, California became the first state to legally mandate minimum nurse-to-patient staffing ratios in acute care hospitals. A subsequent study evaluated the effect on outcomes for nurses and patients by comparing outcomes in California in the subsequent two years with those of New Jersey and Pennsylvania — two similar states without such mandates. There was substantial compliance with the mandate in California, with over 80% compliance rates reported across several different units of surveyed hospitals; equivalent levels of non-mandated compliance in the comparator states were considerably lower, at 19%, 52%, and 63% compliance in medical/surgical, pediatric, and intensive care units (ICUs) in New Jersey and 33%, 66%, and 71% in Pennsylvania. After extensive adjustment for patient and hospital characteristics, the study revealed statistically significant relationships between the nurse-to-patient ratio and 30-day mortality and failure to rescue (FTR — that is, failure to prevent a clinically-important deterioration, such as death or permanent disability, from a complication of an underlying illness or of medical care) in all three states. Across all three states, facilities with nurse-to-patient ratios consistent with those mandated in California were associated with lower rates of nursing burnout, and nurses reported consistently better quality of care.

In September 2007, in the 110th Congress, Senator Richard Durbin of Illinois introduced S.2064: Nurse Training and Retention Act of 2007 on the floor of the Senate. It was a bill to fund comprehensive programs to ensure an adequate supply of nurses. It was referred to committee for study but was never reported on by the committee.

In April 2008, in the 110th Congress, H.R. 5924: Emergency Nursing Supply Relief Act was introduced as a bill to the House of Representatives by Robert Wexler of Florida. If it had passed, it would have amended the American Competitiveness in the Twenty-first Century Act of 2000 and would have given up to 20,000 visas per year to nurses and physical therapists until September 2011. Immediate family members of visa beneficiaries would not be counted against the 20,000 yearly cap. The bill was referred to committees for study in Congress but was never reported on by the committees.

On February 11, 2009, legislation was introduced by Representatives John Shadegg (R-AZ), Jeff Flake (R-AZ), and Ed Pastor (D-AZ) in the 111th Congress to the House of Representatives, HR 1001 ("The Nursing Relief Act of 2009": To create a new non-immigrant visa category for registered nurses, and for other purposes) making a new non-immigrant "W" visa category for nurses to be able to work in the United States. This was to relieve the nursing shortage still considered to be a crisis despite the economic problems in the country. The proposed bill was referred to the Committee on the Judiciary but was never reported on by Committee.

The 2010 Patient Protection and Affordable Care Act includes more strategies for funding and retention. The act provides funding for advanced education nursing grants, diversity grants, and offers a nurse education loan repayment program. The program repays over half of the student loans if the nursing student signs a contract stating that they will work for two years at a medical facility that has a nursing shortage.

The Nurse Reinvestment Act of 2002 had many strategies. The law authorized and had provisions that included topics such as loan repayment programs and scholarships, providing more grants to the nursing students, making more public service announcements about nursing and educating the public on what a great profession it is and making nursing school more flexible by creating options for the people who already have a degree but would like to go into nursing.

Immigration process to U.S.

Nurses seeking to immigrate to the U.S. can apply as direct hires or through a recruitment agency. For entry to the U.S. a foreign nurse must pass a Visa Screen which includes three parts of the process. First they must pass a creditable review, followed by a test of nursing knowledge called the Commission on Graduates of Foreign Nursing Schools examination (CGFNS), and finally a test of English-language proficiency.

Foreign nurses compete amongst themselves, with professionals, and other skilled workers for 140,000 employment-based (EB) visas every year. Filipino nurses are only allocated 2,800 visas per year, thereby creating a backlog among applicants. For example, in September 2009, 56,896 Filipinos were waiting for EB-3 visa numbers. This number contrasts with the 95,000 nurses licensed in 2009, many of whom want to migrate to the U.S. Once a nurse obtains a visa number and is approved for a visa and authorized to work in the U.S., they must pass the National Council Licensure Examination to qualify for U.S. nursing standards. (See also employment-based visa retrogression.)