COVID-19 and the supply and demand for Registered Nurses.

There are concerns that the future balance between the supply and demand for nurses will result in major nursing shortages around the world. Some think that nurses are leaving nursing because of the COVID-19 pandemic. In the United States, nurses may be leaving their jobs, but not nursing. Enrollments in nursing programs have increased. Nurse migration to the United States has decreased. This paper, using examples from the United States mainly, aims to explore the issue of supply of nurses and argues that it is not clear that we will have a worldwide nursing shortage going forward.

INTRODUCTION

An adequate supply of nurses is vital for achieving health for all. An inadequate supply occurs when the demand for nurses is larger than the supply of nurses willing to work and the inadequate supply would decrease access to health care and affect people's health. Over the last two years there have been articles published in both the popular press and academic journals about future nurse shortages.

The World Health Organization (WHO) estimates that nurses and midwives are about 50% of the global health workforce and that the world will need an additional 9 million nurses by 2030 (WHO, 2022). Among the issues facing nurses around the world, are a shortage of nurses and personal protective equipment (Thobaity & Alshammari, 2020). Buchan et al. (2022) note that many low‐ and middle‐income countries had an inadequate supply of nurses prior to the COVID‐19 pandemic. They also posit that the COVID‐19 pandemic contributed to the risk of higher nurse turnover and summarize studies from a variety of countries about COVID‐19's impact on nurses.

In the short term, the demand for Registered Nurses (RNs) increased in some places primarily because of the increase in hospitalizations related to COVID‐19. In the longer term, increases in the world population are likely to increase the demand for nurses. However, technological and biomedical developments (e.g. COVID‐19 vaccines) may mitigate that demand. Many nurses worry that the future supply of nurses will not meet the demand because of increased turnover and that people do not want to pursue nursing programs because of the prospective students’ observations about how difficult nurses’ work has been during the COVID‐19 pandemic. In addition, there continue to be articles about the ongoing ethical issues of nurses migrating to countries such as the United States, Germany, Australia and the United Kingdom to fill the gaps left by nurses leaving the profession. The importance of these issues varies by country. How these issues are resolved (or not) will impact the global supply of nurses in the future.

But the question is: are nurses really leaving nursing? Turnover is more complex than it would seem. Turnover includes leaving a particular position, leaving an organization and/or leaving nursing. Turnover can be voluntary (I quit!) or not voluntary (They fired me! They furloughed me!). Early in the COVID‐19 pandemic in the United States and other countries worldwide when elective surgeries were cancelled and ambulatory care demand decreased, some organizations laid off and furloughed (laid off) nurses. Furloughed nurses are on employer‐forced temporary leave. The nurses do not work, are not paid and employers say that at some point the nurses will work again in the same job that they had when they were furloughed. Based on US government surveys, Buerhaus et al. (2022) wrote that early in the pandemic nurses’ employment in health care in the United States dropped because of a decrease in demand rather than a lack of supply. And then, Buerhaus et al. (2022) noted that by June 2021 nurses employed in health care almost reached pre‐pandemic numbers except in nursing homes. A recent US survey found that about 23% of health care workers (including nurses) are likely to leave health care in the near future (Crist, 2022). However, how likely the nurses will actually leave is not known.

Some of the popular press use leaving an organization as a proxy for leaving nursing, but that is not accurate. Most nurses who leave an organization, often a hospital, leave to work as nurses in different organizations. When the media use data about leaving an organization as a proxy for leaving nursing, they misstate what nurses are doing. Our own research on the impact of COVID‐19 on Registered Nurses, collected during the Spring of 2020 when the first major surge in COVID‐19 hospitalizations occurred in the United States, and as yet unpublished, found that about 7.3% of RNs surveyed reported that they did not intend to work as RNs in January 2021. While intent is correlated with actually leaving, they are not perfectly correlated and actually leaving is much lower than intent. Many faculty in nursing programs encourage new nursing program graduates to work in hospitals for at least 1 year following graduation even if the graduates want to be school nurses, public health nurses or some other non‐hospital‐based nurses. Our research demonstrated that within 12 months of their first job, 13% of new RNs in the United States had changed employers and 19% planned to stay fewer than 2 years (Kovner et al., 2007). Thus, when some nurses had taken their first jobs in hospitals, they had planned to work in those hospitals for only 1 year or 2 years. Going forward, a major question that remains unknown regarding the supply and demand balance is whether the many nurses who have reached and will reach traditional retirement age will retire.

We need to ask what is happening with nursing program enrolment? Applications to nursing programs are up rather than down in the United States. Because people often apply to more than one nursing program, data are reported as applications rather than applicants. The American Association of Colleges of Nursing (AACN) with more than 850 bachelors and higher degrees schools of nursing members reported that in 2020, 66,274 qualified applications to schools were rejected. Because many people apply to more than one nursing program, these applications reflect fewer than 66,274 applicants. AACN also reported that enrolment in bachelors’ entry level programs in nursing increased by 5.6% in 2020 (AACN, 2021).

Another way to look at the number of new nurses in the United States is the number of first‐time takers (almost all recent graduates of nursing programs) of the RN licensing exam (NCLEX) in the United States. Those numbers increased from 192,428 in 2019 pre‐COVID to 203,557 in 2021 during COVID. Thus, in the United States the future supply of nurses is likely increasing.

So, what is happening with RNs migrating to the United States? Nurses continue to want to migrate to the United States. On the one hand, for some out of the United States nurses migrating deprive that country of nurses. On the other hand, in terms of individual rights, people argue that nurses have the right to do what is in their self‐interest. There are at least two types of migrating nurses: Those who are educated in the destination country and want to stay there to work (or some other reason) and those who are educated in the source country and want to migrate to the United States. At the same time, the number of internationally educated (non‐US) RNs decreased from 38,561 in 2019 to 30,009 in 2021 (National Council of State Boards of Nursing, 2021). The US public radio network, National Public Radio (NPR, 2022), reports that during COVID‐19 there are more visas than ever available for nurses to migrate to the United States. Because of COVID‐19, US consulates were not issuing visas to relatives of US citizens; however, those visas are available for eligible workers. The US State Department told consulates to prioritize visas for workers who could help respond to COVID‐19 (e.g. nurses), according to NPR.

US nursing organizations such as the trade union, National Nurses United, are often opposed to increasing visas for migrating nurses. The unions argue that the migrating nurses depress US nurses wages. In economic terms, shortages of worker usually result in increased wages, but if migrants are increasing the supply of nurses, this increase in wages is less likely to occur. Many health care organizations support increasing the number of migrating nurses, in part, to keep wages down.

The Alliance for Ethical International Recruitment Practices developed a code for ethical recruitment and the Alliance certifies recruiters and employers who have agreed to abide by the code. At the beginning of 2022, the Alliance had certified 11 recruiters. Their names are on the Alliances website.

Huge numbers of US nurses are not leaving nursing. Enrollments in first professional degree nursing programs are up. Fewer nurses are migrating to the United States than in the recent past. For detailed data and a discussion of these issues worldwide, see Buchan et al.’s (2022) report.

The steps to manage the future supply of RNs are as follows: (1) obtain accurate data about the number of Registered Nurses and the number of nurses in the pipeline in nursing programs for all countries, (2) decrease the cost of nursing education and provide relief from student loans, (3) eliminate vaccine mandates and at the same time prioritize nurses for obtaining COVID‐19 and other vaccines, (4) increase support to educate nursing faculty, and (5) improve nurses work environment including adequate nurse staffing numbers and skill profiles. However, it is not clear that we will have a worldwide shortage of nurses as there is a difference between nurses leaving profession and nurses leaving organization. Further research is needed to explore such claims.

CONCLUSION

The complex system that produces skilled and competent nurses for a range of nursing contexts has many aspects that need to work well together to succeed. Interruption of any of the aspects mentioned above can undermine the system that recruits, educates, supports, encourages and hold nurses accountable for their practice. When considering the nursing system that varies widely across the world, and is subject to competing agendas and priorities between and within countries and professions, it is crucial to acknowledge that nursing continues to attract new generations to its ranks, admirable people who have the capacity to adapt and thrive in just about every environment of human need and deliver safe and effective nursing care.

CONFLICT OF INTEREST

Dr. Kovner served on the Board of CGFNS of which Alliance for Ethical International Recruitment Practices is a part until December 2020.