Nursing Workforce Policy and the Economic Crisis - Wiley Online Library

PROFESSION AND SOCIETY

Nursing Workforce Policy and the Economic Crisis: A Global Overview James Buchan, MA(hons), PhD1 , Fiona O’May, MA2 , & Gilles Dussault, MA, PhD3 1 Professor, School of Health, Queen Margaret University, Edinburgh, UK 2 Research Officer, School of Health, Queen Margaret University, Edinburgh, UK 3 Professor, WHO Collaborating Centre for Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine (IHMT), Universidade Nova de Lisboa, Lisboa, Portugal

Key words Nursing workforce, workforce policy, labour markets, migration Correspondence Dr. James Buchan, School of Health, Queen Margaret University, QMU Drive, Edinburgh, UK EH21 6UU. E-mail: [email protected] Accepted: February 14, 2013 doi: 10.1111/jnu.12028

Abstract Purpose: To assess the impact of the global financial crisis on the nursing workforce and identify appropriate policy responses. Organizing Construct and Methods: This article draws from international data sources (Organisation for Economic Co-operation and Development [OECD] and World Health Organization), from national data sources (nursing regulatory authorities), and the literature to provide a context in which to examine trends in labor market and health spending indicators, nurse employment, and nurse migration patterns. Findings: A variable impact of the crisis at the country level was shown by different changes in unemployment rates and funding of the health sector. Some evidence was obtained of reductions in nurse staffing in a small number of countries. A significant and variable change in the patterns of nurse migration also was observed. Conclusions: The crisis has had a variable impact; nursing shortages are likely to reappear in some OECD countries. Policy responses will have to take account of the changed economic reality in many countries. Clinical Relevance: This article highlights key trends and issues for the global nursing workforce; it then identifies policy interventions appropriate to the new economic realities in many OECD countries.

This article examines recent trends and dynamics in the nursing workforce in a world deeply affected by economic change and financial recession. Demographically driven change in healthcare systems and policy responses are now compounded by an economic and financial crisis and its aftermath. Our objectives are to present an overview of the current global profile and dynamics of nursing in this changing situation; to provide country examples of the impact of the economic crisis on nursing mobility; and to discuss critical nursing workforce challenges and related policy responses. Databases of the Organisation for Economic Co-operation and Development (OECD) and of the World Health Organization (WHO) are the main sources; selected country level data and information were also analyzed. 298

The New Economic Reality The economic crisis of 2008 and beyond was caused by failures in monetary policies, inadequate regulation of financial institutions, and problems in financial markets (Furceri & Mourougagne, 2009). The crisis manifested itself differently in different countries and regions, but common problems were a reduction in gross domestic product, reductions in government budgets, increases in unemployment, particularly of younger people, and lower inflation rates (Furceri & Mourougagne, 2009; International Labor Organization, 2011). There have also been variations in how countries and regions have responded to the crisis, and in terms of the “knock on” effects on health sector funding and employment. In its postcrisis review of the health sector in

Journal of Nursing Scholarship, 2013; 45:3, 298–307. C 2013 Sigma Theta Tau International

Buchan et al.

its 34 member countries in 2011, the OECD observed that The extent to which public spending on health may be affected will depend on the relative priority allocated to health. It will also depend on the extent to which public spending on health brings demonstrated benefits in terms of better health outcomes. In a context of scarce public resources, there will be growing pressures on Health Ministries and health care providers to demonstrate efficiency (cost-effectiveness) in how resources are allocated and spent. (p. 16) In many countries, financial constraints and public sector “austerity” measures, notably in European Union (EU) countries such as Greece, Ireland, Portugal, Spain, and the United Kingdom, have meant that various elements of public services provision are subject to severe cost containment (Houston, Day, de Lago, & Zaracostas, 2011; McKee, Karanikolos, Belcher, & Stuckler, 2012); this has effects on public sector employment and staffing reductions (Vaughan-Whitehead, 2012). In a labor-intensive sector such as health care, nurse staffing costs are therefore under scrutiny. This may be a direct result of most nurses being employed in the public sector, as in many EU countries, or indirectly as a result of funding for health provision being constrained in mixed health systems, and those countries where health services are insurance based. In many countries in Europe, nurses’ pay rates are being “frozen” or reduced, their pension entitlements have diminished, and in some cases staffing levels have declined (European Federation of Nurses [EFN], 2012). Nurses’ job seeking behavior is changing as they try to hold on to jobs in challenging labor markets (Alameddine, Baumann, Laporte, & Deber, 2012; Bortoluzzi & Palese, 2010; Buchan & Seccombe, 2012; Staiger, Auerback, & Buerhaus, 2012), or they respond to reductions in their pay, status, and job prospects by leaving the health sector or their current country of practice (EFN, 2012). The financial crisis has also led some countries, such as the United Kingdom and Ireland, to increase the barriers to the inflow of migrants, including nurses, which may then be displacing migration flows to other countries and regions less affected by the financial crisis (OECD, 2012). Nurse workforce dynamics and mobility have not stopped because of the crisis, but at the aggregate level the magnitude, directions, and patterns of flows are changing. If this new reality is not well understood, the investment in the next generation of nurses may be undermined. In tight fiscal circumstances, policy makers need to understand what is happening, and what is likely to happen, with the dynamics of the health workforce in general, and in nursing in particular. Journal of Nursing Scholarship, 2013; 45:3, 298–307. C 2013 Sigma Theta Tau International

Nursing and the Economic Crisis

Overview of the Global Nursing Workforce Only limited comparative data are available that enable a global overview of the distribution of nurses and enable international comparison of nursing numbers. The World Health Organization (WHO) global atlas of the health workforce provides basic staffing data and staff:population ratios that allow some comparative analysis of countries and regions (WHO, 2012). There are three main limitations in using this WHO collated data. First, some countries do not provide data, or give out-of-date information. Second, there are variations in the interpretation of the definition of “nursing and midwifery” that the WHO and other international agencies use (Buchan & Calman, 2004; OECD, 2011, p. 72). Third, the calculation of the number of nursing and midwifery personnel is not uniform; for example, some countries report those that are working, others report all that are eligible to practice. The nursing and midwifery personnel: population ratio gives a very broad indication of the level of availability of nursing and midwifery services in a country. Previous research has shown a link between health worker:population ratios and the level of funding, and some correlation between ratios and measures of health outcomes (Wharrad & Robinson, 1999; WHO, 2006). Figure 1 summarizes the minimum, maximum, and average nursing-midwifery personnel:population ratios for each of the six WHO regions. The minimum and maximum are from the countries within the region that reported the lowest and highest ratios. There is considerable variation within and between regions. Africa and Southeast Asia reported the lowest average ratios, and Europe the highest. Some European countries such as Finland and Norway reported more than 20 nursing and midwifery personnel per 1,000 population, while some African countries, such as Niger, Guinea, and Sierra Leone, reported less than 0.2. The use of ratios as a comparator can be misleading when countries with very small populations, such as island states in the Caribbean, micro states (e.g., Niue in the Pacific), and Monaco in Europe are included. The latter countries were excluded from the reporting in Figure 1 as they are outliers that distort the overall picture.

The Impact of the Crisis on the Nursing Workforce in OECD Countries This section looks at recent trends in economic indicators and nurse staffing levels in the 34 OECD countries. There is more information on this cluster of countries, which enables more detailed comparison, 299


Buchan et al.

Figure 1. Unemployment rates (percentage of labor force) in selected Organisation for Economic Co-operation and Development (OECD; 2011) countries in 2007 and 2011.

ering that OECD published data are inevitably “behind the curve” of recent financial events because of the time required to collate, analyzes, and report the country level data. The OECD countries are the main destinations for migrant nurses, and an examination of these countries can give hints about any global changes in migration patterns. Figure 2 highlights the unemployment level in selected OECD countries at two points in time: first, in 2007, before the crisis, and then in 2011, after the initial impact of the crisis. The unemployment level is an indicator of the overall economic situation and of the general labor market conditions in a country. The average unemployment rate in OECD countries has risen from 5.8% in 2007 to 8.2% in 2011. In Spain, unemployment rose from 8.3% to 21.8%; in Greece from 8.4% to 17.9%; and in Ireland from 4.1% to 14.6%. Other countries such as Chile, Germany, and Korea have weathered the economic storm and report little or no growth in unemployment across the period. This emphasizes the extent to which there has been variable impact of the crisis on labor markets in different countries. A second indicator with implications for nursing is trends in funding for health care. Figure 3 shows the change in average annual growth rate of total expenditure on health for a selection of OECD countries across the period since 1996. Figure 3 shows there has been growth in total spending in health per capita in all countries, until the two most recent years, when countries such as Greece and Ireland have reported a reduction, and others, notably in Europe, reported a slowing pace of growth.

300

What does the OECD dataset tell us about nursing trends? Figure 4 shows the nurse:population ratios in selected OECD countries for the period 1996–2011. Some countries (e.g., Denmark and Spain) show rather consistent growth in the number of nurses to population, while other countries (e.g., the United States and Australia) have maintained a similar ratio across the period. For most countries, 2010 is the latest year for which data are available. Given that more recent reports highlight reductions in staffing and intakes to nurse education in some countries (e.g., Alameddine et al., 2012; Buchan & Seccombe, 2012; EFN, 2012), it is likely that when data for 2011 and 2012 become available, these may show the beginning of a decline in ratios. Some of the countries that have reported the most negative impact of the crisis on their broader economy and on their unemployment rates (e.g., Greece, Spain, and Portugal) do not show a reduction in the nurse:population ratio. While this may at first appear counterintuitive, the time lag in enacting staffing reduction policies and the delayed effect of any reduction in training intakes need to be considered. The use of ratios as an indicator must also take into account that the overall population growth in many OECD countries is slowing, or in some countries, such as Spain and Ireland, actually decreased between 2010 and 2011 because of outmigration. In summary, Figure 3 gives little indication of staffing decline relative to population size in recent years in OECD countries, but for most of these countries, “recent” means the period only up to 2009 or 2010. More recent reports from specific countries in Europe, such as


Buchan et al.


Figure 2. Nurse:population ratio (100,000 inhabitants)—minimum, maximum, and average by World Health Organization (WHO) region. ∗ Europe: San Marino data excluded as outlier. ∗∗ W Pacific: Niue data excluded as outlier. (WHO Global Health Atlas, http://apps.who.int/globalatlas/default.asp/).

Ireland, Greece, and Portugal, suggest that newly qualified nurses are having great difficulty finding employment, that staffing levels in public sector employment are decreasing, and that there have been cuts in pay rates and pension entitlements (Buchan & Seccombe, 2012; EFN, 2012).

Nurse Migration as an Indicator of Change Patterns of nurse migration have been changing as a result of relative changes in the “push” and “pull” factors acting on individual nurses, both in terms of stimulating them to consider moving and in directing their movement, should they decide to migrate. These changes also reflect relative changes in the labor market conditions in different countries, as well as how countries have responded to the crisis through changes in general migration policy. How these changes have impacted on patterns of nurse migration is illustrated in Figures 5 to 7. Figure 5 illustrates the combined effect of a reduction in active international recruitment and tightened immigration policies. It shows the annual total number of international nurses registering to practice in the United Kingdom since 1993. Nurses from EU countries


are differentiated from those coming from non-EU countries, the main source countries being the Philippines, India, South Africa, and other English-speaking African countries. There was a significant growth in inflow of nurses to the United Kingdom at the beginning of the last decade, but subsequently there has been a drastic reduction. There has also been a growth in those coming from countries of the EU relative to non-EU countries as a result of U.K. government policy aimed at making it much more difficult for non-EU nationals to enter and work in the United Kingdom. In 2012 it was virtually impossible for a non-EU nurse to get a work permit for the UK. In contrast, nurses from the EU have a free right to enter the United Kingdom under EU regulations and cannot be subject to these constraints. The second type of change is that some countries have completely scaled back their international recruitment activity because of local oversupply as a result of reduced employment opportunities. One example is Ireland; Figure 6 shows the annual number of international nurses entering the Irish register between 2005 and 2011. At the beginning of the last decade, Ireland was a major recruiter of nurses. There has since been a marked reduction in annual inflow since 2006. As with the United Kingdom, the Irish data show a bigger reduction in flows from non-EU countries than from EU countries.

301


Buchan et al.

Figure 3. Change in total expenditure on health by average annual growth rate (total expenditure on health/capita in US$) in selected Organisation for Economic Co-operation and Development countries (OECD Health Data, http://stats.oecd.org/Index.aspx?).

Another dynamic that has changed as a result of the crisis is the relative shift in net flows between countries, which can reflect a changed balance of relative career opportunities at either end of the two-way “flow.” Figure 7 shows the annual number of U.K. nurses applying to work in Australia and the annual number of Australian nurses entering the U.K. register since 2000. After a period of relative stability at the beginning of the last decade, the flow from the United Kingdom to Australia increased markedly up to the period 2008–2009, while the flow from Australia to the United Kingdom decreased over the same period to a very low level. Australia avoided recession and continues to recruit nurses actively from other countries; in contrast, the United Kingdom has been reducing its nursing workforce and made immigration more difficult for Australian nurses. Figure 7 clearly shows the outcome of diverging migration flows, as well as significant year-to-year fluctuation in recent years. Migration patterns are in part a symptom of the relative well-being of economies and differing employment opportunities at either end of the migratory flow. As such, the changing patterns of nurse migration evident in some countries are a clear reflection of changed, and often worsened, circumstances and employment opportunities in some of the traditional “destination” countries.

302

The New Reality for Nursing Workforce Policies The underlying drivers for change in the nursing workforce in nearly all high-income OECD countries are, on the demand side, population aging, increasing life expectancy, lifestyle changes, and technological change, which is increasing demand for health care, notably because of the high and increasing prevalence of chronic disease and co-morbidities in older patients (Joumard, Andre, & Nicq, 2010); The main issue on the supply side is the aging of the nurses in the profession. The average age of a working registered nurse in many OECD countries is in the mid-40s, and there is a looming retirement challenge (International Council of Nurses, 2011). In previous decades, nursing shortages in many countries have been a cyclical phenomenon, usually as result of increasing demand outstripping static or the more slowly growing supply of nurses (Buchan, 2008). In a context of economic crisis, the situation appears more serious. Demand for health care is projected to continue to grow, driven by growing and aging populations, while projections of the long-term supply of available nurses points to actual reductions in availability of nurses in some countries. This is true despite the short-term “recession dividend” when nurses postpone retirement or work longer hours because of the worsening general economic



Buchan et al.

Figure 4. Nurses (density per 1,000 population) in selected Organisation for Economic Co-operation and Development (OECD) countries, latest year (OECD Health Data, http://stats.oecd.org/Index.aspx?).

Figure 5. Admissions to the U.K. nursing register from European Union (EU) countries and other (non-EU) countries, 1993–1994 to 2011–2012. (U.K. Nursing and Midwifery Council and Buchan and Seccombe, 2012).

climate. Table 1 highlights recent nurse workforce supply projections from Australia, Canada, the United Kingdom, and the United States. All point to a reemergence of nursing shortages as a major policy challenge: how to meet demands for care as so many nurses reach retirement age over the next 10 years. Journal of Nursing Scholarship, 2013; 45:3, 298–307. C 2013 Sigma Theta Tau International

Policy Responses Until the crisis, most nursing workforce policy focus was on real or anticipated shortages. From a countrylevel policy perspective, a shortage has usually been defined and measured in relation to that country’s own 303


Buchan et al.

Figure 6. Annual number of European Union and other international nurses entering the Irish nursing register, 2005–2011. (An Bord Altranais, n.d.).

historical staffing levels, resources, and estimates of future demand for health services (Buchan & Aiken, 2008; Grumbach, Ash, Seago, Spetz, & Coffman, 2001; Zurn, Dal Poz, Stilwell, & Adams, 2002). In changed economic circumstances, what should be the nursing workforce priorities of policy makers and what are their policy options in addressing skills shortage challenges? At one level it could be argued that the same policy options exist as before the crisis, but with reduced funding availability, and therefore the fiscal room for maneuvering is curtailed. However, a more nuanced analysis, which takes full account of country context, highlights that the balance of realistic policy options has changed. The key here is that policy makers must not be fixated on the short term, but take account of longer-term trends in likely funding and demand for health care, in reconfiguration of health services, in future supply of nurses, and in a growing need to make more effective and productive use of the nursing staff and nursing skills that are in the labor market. It must also be recognized that a different range of policy options is available in different countries. In countries where most nurses are trained and employed by government in public sector–oriented systems, the government has access to a broad range of policy levers, including changes in numbers of new nurses being educated, numbers being employed, pay and conditions, and so forth. In other systems, with private sector or insurance-based systems, national government may have less scope for direct policy intervention; it is noticeable that some of the OECD countries with the most 304

pronounced policy challenges currently are those that have a significant proportion of nurses in public sector employment. “Traditional” policy responses of improved retention, expanded recruitment base, targeting returners, and international recruitment will retain some currency. For example, improving retention by keeping more scarce nursing skills in employment for longer is effective, both in economic terms and in quality of care (Aiken et al., 2012; Bland Jones, 2008; Buchan, 2010; Kelly, McHugh, & Aiken, 2012). International recruitment will also remain on the agenda for some countries. Even postcrisis, high-income countries can continue to exploit “pull” factors of relatively better pay and career prospects to encourage nurses in poorer countries to migrate. However, as the dynamics of migration have been altered by the economic crisis, potential migrant nurses may be frustrated in their attempts to move to some OECD countries such as Ireland and the United Kingdom, which have reduced their demand and, in some cases, have “closed the door” through tougher immigration policies. The limitation of the above solutions is that they focus on nursing as the problem, they assume that supply side manipulation can end the problem, and they are often implemented in a piecemeal fashion. Interventions to improve human resource effectiveness are much more likely to succeed where they are coordinated and“bundled” than are one-off isolated efforts (Buchan, 2004). At a time of cost containment in many countries, Journal of Nursing Scholarship, 2013; 45:3, 298–307. C 2013 Sigma Theta Tau International


Buchan et al.

7000

6000

5000

4000

3000

2000

1000

to Aust

12

11

10

9

8

7

6

5

4

3

2

1

0

from Aust

Figure 7. Flows of nurses between the United Kingdom and Australia, 2000–2012. (U.K. Nursing and Midwifery Council, n.d.).

other interventions will also be required, which are based on a recognition that health care is labor intensive and that available nursing resources must be utilized more effectively. It is not just about nursing numbers—it is about

how the health system functions in order to enable these nurses to use their skills effectively. It is not just about having “more” nurses—it is about making optimum use of the skills of those already in the workforce.

Table 1. Projected “Shortages” in Recent Nursing Workforce Studies Country

Source

Indicator of “shortage”

Measure/timeline

Estimated shortage or “gap”

Australia

Health Workforce Australia (2012) Supply and demand scenarios Baseline of 258,952 in 2009 Registered/enrolled nurses Projections to 2025

2025: “Steady state”/do nothing scenario shows gap shortfall of 90,000 to 109,500 nurses

Canada

Academic researchers (Tomblin Murphy et al., 2012)

Supply/applied needs Baseline of 188,000 FTE, in scenarios, registered nurses 2007; projections to 2022

2022: 259,000 FTE required/199,000 FTE available = 60,000 shortage

United States

U.S. Department of Labor (2012)

Projection of new jobs for registered nurses

Baseline of 2,165,510 in 2010 Estimate for 2020

2020: Projected growth of 711,000 jobs (+26% in demand)

United States

Academic research (Auerbach, 2012)

Supply projections Nurse practitioners only

Baseline of 12,800 in 2008 Projections to 2015

2015: Forecast 94% growth in nurse practitioner jobs

Supply scenarios, NHS qualified nurses

Baseline of 352,104 in 2010 (headcount) Projections to 2021/2022

2021/2022: “Steady state” scenario shows 309,297 nurses, which is a reduction of 42,807 over 2010 baseline (12.2% reduction)

United Academic research (Buchan & Kingdom Seccombe, 2011)

Note. FTE = full-time equivalent; NHS = National Health Service (Health Workforce Australia, 2012; Tomblin Murphy et al., 2012; U.S. Department of Labor, 2012; Auerbach, 2012; Buchan & Seccombe, 2011).


305


Policy responses may be at the national level or the operational level. Where there is a national health system, operational level responses may be directed or mandated nationally and be part of the overall policy response. Many countries need to enhance and integrate their workforce policy-making and -planning capacity across occupations and disciplines to identify the workforce skills and roles required to meet identified service needs (Alameddine et al., 2012). With cost pressure being paramount, there will also be an operationallevel focus on attempts to improve day-to-day matching of nurse staffing with workload assessment tools. A recent review (Royal College of Nursing, 2010) highlighted that not all of these tools have been validated and noted that while some systems, such as the National Health Service in Scotland, have mandated the use of selected validated tools, in others this is an operational-level choice. There will inevitably also be more emphasis on cost-based flexibility in deploying nursing staff by using shift patterns that optimize their productivity (Buchan & Seccombe, 2012). Heavy-handed implementation of these operational-level solutions can lead to increased workload for nurses and have in the past contributed to longer-term problems of recruitment and retention in some countries (see, e.g., Advisory Committee on Health Human Resources, 2002). Cost will also drive greater scrutiny of staff mix and skill mix. Ensuring that the correct resources and technical and administrative support are available to facilitate nurses to function at the top of their skills range is one factor; another is achieving an effective mix of skills and roles appropriate to patient and client needs. In this latter case, many countries are seeking to introduce advanced roles of nurses, such as nurse practitioners, and extend their skills range and contribution, such as by introducing prescriptive authority. In recent years, for example, both Ireland and Finland have introduced prescriptive authority for nurses, while other countries have introduced advanced practice career paths (Delamaire & Lafortune, 2010). However, nursing will increasingly also have to demonstrate its economic value if it is not to face the risk of skill substitution by less costly nursing assistants. A whole-system perspective is required to achieve clarity of roles and a better balance of registered nurses, physicians, other health professionals, and support workers. Why have these wider-reaching interventions not been more systematically implemented in the past? The very fact that they are wider reaching means that they often confront current practice, health system inertia, and vested interests. The global economic crisis has provided an imperative and an opportunity to tackle these issues. If this is not grasped in a strategic manner, we will continue to repeat a cycle of inadequate, uncoordinated, and often 306

Buchan et al.

inappropriate policy responses to nursing workforce challenges, and in less forgiving economic circumstances than was the case before the crisis.

Clinical Resourcs

r r

Organisation for Economic Co-operation and Development: http://stats.oecd.org/Index.aspx? The World Health Organization Global Health Atlas: http://apps.who.int/globalatlas/default.asp/

References Advisory Committee on Health Human Resources. (2002). Our health, our future. Creating quality workplaces for Canadian nurses. Final report of the Canadian Nursing Advisory Committee. Ottawa, Ontario, Canada: Author. Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., . . . Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: Cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal, 344. doi:10.1136/bmj.e1717 Alameddine, A., Baumann, A., Laporte, A., & Deber, R. (2012). A narrative review of the effect of the economic downturn on the nursing labor market: Implications for policy and planning. Human Resources for Health, 10. doi:10.1186/1478–4491–10–23 An Bord Altranais (Irish Nursing Board). (n.d.). Statistics. Dublin: Author. Retrieved November 2, 2012, from www.nursingboard.ie/en/statistics.aspx Auerbach, D. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50(7), 606–610. Bland Jones, C. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11–18. Bortoluzzi, G., & Palese, A. (2010). The Italian economic crisis and its impact on nursing services and education: Hard and challenging times. Journal of Nursing Management, 18(5), 515–519. Buchan, J. (2004). What difference does (“good”) HRM make? Human Resources for Health, 2. Retrieved November 12, 2012, from http://www.human-resources-health.com/ content/pdf/1478-4491-2-6.pdf Buchan, J. (2008). Evidence of nursing shortages or a shortage of evidence? Journal of Advanced Nursing, 56(5), 457–458. Buchan, J. (2010). Reviewing the benefits of health workforce stability. Human Resources for Health, 8. doi:10.1186/1478-4491-8-29 Journal of Nursing Scholarship, 2013; 45:3, 298–307. C 2013 Sigma Theta Tau International

Buchan et al.

Buchan, J., & Aiken, L. (2008). Solving nursing shortages: A common priority. Journal of Clinical Nursing, 17(24), 3262–3268. Buchan, J., & Calman, L. (2004). The global shortage of registered nurses: An overview of issues and actions. Geneva, Switzerland: International Council of Nurses. Retrieved November 12, 2012, from http://www.icn.ch/ publications/the-global-shortage-of-registered-nurses-anoverview-of-issues-and-actions/ Buchan, J., & Seccombe, I. (2011). A decisive decade: The 2011 UK nursing labour market review. London: Royal College of Nursing. Retrieved November 11, 2012, from www.rcn. org.uk/ data/assets/pdf file/0006/405483/LMR2011 FINAL.pdf Buchan, J., & Seccombe, I. (2012). Overstretched. Under-resourced: The UK nursing labour market review, 2012. London: Royal College of Nursing. Retrieved November 12, 2012, from http://www.rcn.org.uk/ data/assets/pdf file/ 0016/482200/004332.pdf Delamaire, M., & Lafortune, G. (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries. Paris: Organisation for Economic Co-operation and Development. European Federation of Nurses. (2012). Caring in crisis: The impact of the financial crisis on nurses and nursing. Brussels: Author. Retrieved November 12, 2012, from http://www.efnweb.be/wp-content/uploads/2012/05/ EFN-Report-on-the-Impact-of-the-Financial-Crisison-Nurses-and-Nursing-January-20122.pdf Furceri, D., & Mourougagne, A. (2009). Financial crisis: Past lessons and policy implications. Economics Department Working Papers No. 668. Paris: Organisation for Economic Co-operation and Development. Grumbach, K., Ash, M., Seago, J., Spetz, J., & Coffman, J. (2001). Measuring nursing shortages: How do you know a hospital with a nursing shortage when you see one? Medical Care Research and Review, 58(4), 387–403. Health Workforce Australia. (2012). Health workforce 2025. Retrieved November 12, 2012, from www.hwa.gov.au/ health-workforce-2025 Houston, M., Day, M., de Lago, M., & Zaracostas, J. (2011). Health services across Europe face cuts as debt crisis begins to bite. British Medical Journal, 343. Retrieved from http://dx.doi.org/10.1136/bmj.d5266. International Council of Nurses. (2011). ICN workforce forum. Nursing workforce profile. Database summary 2011. Geneva, Switzerland: Author. Retrieved November 15, 2012, from http://www.icn.ch/images/stories/documents/pillars/sew/ DATASHEET SUMMARY NURSING PROFILE 2011.pdf International Labor Organization. (2011). The global crisis: Causes, responses and challenges. Geneva, Switzerland: Author.



Joumard, I., Andre, C., & Nicq, C. (2010). Health care systems: Efficiency and institutions. Economics Department Working Papers No. 769. Paris: Organisation for Economic Co-operation and Development. Kelly, L., McHugh, M. D., & Aiken, L. (2012). Nurse R and non-Magnet hospitals. Journal of outcomes in Magnet Nursing Administration, 42(10 Suppl.), S44–S49. McKee, M., Karanikolos, M., Belcher, P., & Stuckler, D. (2012). Austerity: A failed experiment on the people of Europe. Clinical Medicine, 12(4), 346–350 Organisation for Economic Co-operation and Development. (2011). Health at a glance: 2011 OECD indicators. Paris: Author. Retrieved November 12, 2012, from http:// www.oecd.org/health/healthpoliciesanddata/49105858. pdf Organisation for Economic Co-operation and Development. (2012). OECD multilingual summaries. International migration outlook 2012. Summary in English. Paris: Author. Royal College of Nursing. (2010). Guidance on safe nurse staffing levels in the UK. London: Author. Staiger, D. O., Auerback, D. I., & Buerhaus, P. I. (2012). Registered nurse labor supply and the recession—Are we in a bubble? New England Journal of Medicine, 366, 1463– 1465. Tomblin Murphy, G., Birch, S., MacKenzie, A., Alder, R., Lethbridge, L., & Little, L. (2012). Eliminating the shortage of registered nurses in Canada, An exercise in applied needs based planning. Health Policy, 105, 192–202. U.K. Nursing and Midwifery Council. (n.d.). Annual statistics. London: Author. Retrieved November 12, 2012, from http://www.nmc-uk.org/About-us/Statistics/Statisticsabout-nurses-and-midwives/ U.S. Department of Labor, Bureau of Labor Statistics. (2012). Occupational outlook handbook, 2012–13 edition, projections overview. Retrieved November 11, 2012, from www.bls.gov/ooh/about/projections-overview.htm Vaughan-Whitehead, D. (Ed.). (2012). Work inequalities in the crisis: Evidence from Europe. Geneva, Switzerland: International Labour Office. Wharrad, H., & Robinson, J. (1999). The global distribution of physicians and nurses. Journal of Advanced Nursing, 30(1), 109–120. World Health Organization. (2006). The world health report 2006—Working together for health. Geneva, Switzerland: Author. Retrieved November 12, 2012, from http://www.who.int/whr/2006/en/ World Health Organization. (2012). Global health workforce atlas. Geneva, Switzerland: Author. Retrieved November 12, 2012, from http://apps.who.int/globalatlas/default.asp/ Zurn, P., Dalpoz, M., Stilwell, B., & Adams, O. (2002). Imbalances in the health workforce. Geneva, Switzerland: World Health Organization.

307