**5. Gap broadens with COVID-19**

Two-thirds (66%) WHO Member States report pandemic related disruption to health services due to factors related to HCWs [12]. COVID-19 has been devastating on all HCWs but especially nurses who have been front and center, managing heavy workload, long hours with maximum exposure to coronavirus, while caring for their patients. They will remain the mainstay profession in the recovery of post-COVID-19 health systems, even though it comes at a terrible cost of their overall well-being [5, 13]. WHO acknowledges, all though a "conservative" number due to underreporting, 115, 500 HCWs lost their lives because of COVID-19 [12]. Many nurses have died, others are mentally burnout, and many more continue to suffer physically; victims of long-haul COVID-19 syndrome because of poor provision of personal protective equipment (PPE) and inadequate access to vaccines [12, 13].

### **6. Nurse shortage - a multilayered complex problem**

To fully articulate a solution means to consider the gaps and shortfalls in the political, social, economic, and institutional realities on and through which this issue is constructed. For example, if we only consider NS as a problem of numbers – then the temporary fix will be producing more nurses. If the shortage is associated towards nurses being dissatisfied with their working environment – then improvements in their work environment resolves that problem only. Only addressing these problems in isolation is merely a short-term fix and will result in relapse. Upon the request of 73rd World Health Assembly (WHA), WHO engaged with all WHO regions and updated global SDNM 2016–2020 to SDNM 2021–2025 in resolution with 74th WHA for NS policy action [4]. "To identify the most important policy actions, a prioritization exercise was conducted with over 600 nursing and midwifery leaders from ministries of health, national nursing and midwifery associations, regulators, WHO collaborating centres for nursing and midwifery, and the Nursing Now campaign in attendance at the biennial WHO global forum of Government Chief Nursing and Midwifery Officers and at the 'Triad' meeting hosted by WHO, the International Confederation of Midwives, and the International Council of Nurses. Regional and global consultation processes corroborated and helped refine the prioritized policies. The policy priorities are interrelated: the issues and policy responses in one are correlated with the issues and policy responses in the others" [4].

## **7. Pathway to solution**

### **7.1 SDNM encompasses four areas**

Education, jobs, leadership, and service delivery, for strategic direction [4]. Each area comprising of two to four prioritized policy actions are collectively interrelated and interdependent (**Table 1**).


### **Table 1.**

*WHO (2021). Global Strategic Directions for Nursing and Midwifery (SDNM) 2021–2025 [4].*

### **7.2 Nurse practitioners as primary care providers**

One strategy being utilized in decreasing healthcare cost is to expand the scope of practice by shifting the delivery of treatment management to nurses. In 2015, Nebraska became the 20th state to adopt a law that allows nurses with advanced degrees to practice particular medical fields without a doctor's oversight [9]. The law helps rural areas that have trouble recruiting physicians but have high healthcare need due to aging populations to still provide care through nurse practitioners (NPs). "According to the Institute of Medicine, 14 NPs can be trained for the cost of a single physician, and research shows that primary care outcomes by NPs is equivalent to that of physicians" [9]. What this boils down to, evidence based research shows that, for certain forms of primary care, NPs are not only more cost-efficient by providing better value to the healthcare system but have also reduced morbidity and mortality when caring for vulnerable (aging, rural) population [9, 14–16].

### **7.3 Nurse shortage: "quick fix" recruitments a need for policy reform**

Pre-pandemic NS along with pandemic has increased the demand for "fast-tack" international nurse recruitment by some high-income Organization for Economic Co-operation and Development (OECD) countries, which could undermine the ability of some "source" countries to respond effectively to pandemic challenges [17]. Even before the pandemic, the scale of the international flow of nurses was large, and growing. In 2019, OECD analysis highlighted more than 550,000 foreigntrained nurses were working across 36 OECD member countries, which was a marked increase on the 460,000 recorded in 2011 [17]. OECD reports the number and/or share of foreign-trained nurses has increased particularly rapidly in Belgium, France, Germany and Switzerland, with a steady growth also occurring in Australia, New Zealand, Canada [18] and the United States [17]. SOWN highlighted that countries experiencing low densities of nurses are mostly located in the WHO African, South-East Asia and Eastern Mediterranean regions, and in parts of Latin America, with countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria, and Pakistan only to be worsened with population growth [1, 17]. In 2020, World Bank Group study examining nurse labour markets in countries (Botswana, Eswatini, Kenya, Lesotho, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe) of the Eastern, Central and Southern African (ESCA) region reported, that demand for nurses was growing, but high vacancy rates (30–55%) in the public sector remained a problem [19]. Nurses do not fill posts due to "poor wage, remote location, lack of amenities, and poor working conditions" [19]. Additionally, the ECSA study highlighted, by 2030, 4.7 billion dollars would be required to train additional nurses to achieve the number needed in the 14 countries alone [19].

To adjust the supply and demand disproportion, international policy actors will require to reinforce policies upon OECD countries that lure nurses from low-income and lower-middle income countries. There is a growing policy emphasis on the potential of government- to- government bilateral agreements to "manage" international recruitment of nurses — these agreements must be independently monitored to assure full compliance by all parties [17]. Simultaneously, countries will need to invest an extra ~1% of GDP in their health workforce, as part of a broader investment package to boost health system resilience; basing this estimate on benchmarking analysis to estimate additional health workers, higher salaries, and medical reserve needed, said the head of health division at OECD in a presentation to the ICN Congress [20, 21]. Furthermore, one of the most powerful policy levers governments can use to adjust the supply of doctors and nurses to projected demand is so-called *numerus clausus*, that is, the regulation of the number of students entering medical and nursing education programmes; as in several OECD countries, *numerus clausus* policies are still based on weak evidence and opaque decision-making processes [20].

### **8. Conclusion**

The need for collectively intervention with short and long term shared action plan is imminent in supporting global crisis of nurse shortage. Recurrence of NS overtime is perhaps a testament for a more beneficial analysis to address a complex issue, including many overlapping and interconnected problems from a global platform. As advocated by international actors that influence nursing policies and practices, there

### *Nursing – Trends and Developments*

is an overall need to invest in nursing education, jobs, leadership, and service delivery to meet the demand and maintain a steady supply of nurses [2, 3, 17].

The authors recommend following implementations:


Without sufficient well-motivated and supported nurses, the global health system cannot function. A co-ordinated policy response at country level and internationally is urgently needed to improve nurse retention and give hope for the future sustainability of the nursing profession [17].
