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COVID and the Nursing Shortage




Many health, political, and economic officials have identified COVID as the most urgent health care condition/situation that must be the top priority for policymakers and educators. There is no doubt that with more than 540 million cases and over 6 million deaths worldwide, COVID- related needs immediately must be addressed. But COVID has also complicated the delivery of health care and the problems and pressures faced by healthcare workers across the globe, especially nurses. 


What the COVID pandemic has done is exacerbate the healthcare workforce shortage issues. COVID has exposed the fragility and inadequacy of nursing education and training programs across the globe. One of the most vivid examples of this can be found among neonatal nurses. 


In this piece, we explore how the nursing shortage, the needs of nurses, and the consequences of long-term disinvestment in specialty nursing education and training have impacted neonatal nurses and the delivery of care to one of the most vulnerable patient populations. 


But COVID has also overshadowed and reconfigured how health care is provided. One neonatal nurse noted: “I think globally that’s the hazard…everyone has been focused on “stop COVID” but at the same time it’s stopped everything else, and everything that we know is good for babies has been stopped.”


COVID has changed the world – it has become the dominant theme in health care. It is the issue that is taking up disproportionate resources and attention. It also is the health condition that is triggering healthcare workers around the globe to no longer work as providers and ensuring a decline in future healthcare workers. 


In our attempt to ensure that the pandemic is managed and its consequences/impacts mitigated, we have lost sight of the myriad of other health care issues that must be attended to. Still, before we can attend to issues such as diabetes, maternal mortality, and increasing rates of death from chronic diseases, we must focus on the health care issue that, unless fixed, ensures all other health care needs will go wanting. 


To address the multitude of pressing healthcare needs across the globe, we must first ensure an adequate healthcare workforce. And that workforce is a collection of professionals from

physicians to nurses to technicians, all of whom are found in insufficient numbers. The

inadequate numbers of skilled providers are nothing new; it is a problem plaguing developed,

developing/emerging, and underdeveloped economies for decades. 


Nursing in a Global Context

  •  Estimates place the global nursing workforce at 27.9 million nurses

  • Globally 9 in 10 nurses are female 

  •  With an average of 38.7 graduate nurses per 100,000 population vs. 10.4 per 100,000, high-income countries had more than three times the nurse graduation rate of low-income countries 

  • The projection for the next 10 years is that 1 in 6 of the world’s nurses will retire

  •  These projected retirements mean that 4.7 million new nurses would have to be educated and employed to replace the retirees

  •  1 in 8 nurses practice in a country other than in the country where they were born or educated

The Current and Projected Nursing Shortages

  • The pandemic has exacerbated the existing nurse supply shortfall

  • Before the pandemic, the global shortage of nurses was estimated at 5.9 million; nearly all of these shortages concentrated in low- and lower-middle-income countries. 

  •  The COVID-19 pandemic is a major disruptor of nurse recruitment and retention.

  •  The retention problem is exacerbated by increasing burnout, hours and workloads, risks to one’s health, and resignations of fellow nurses

  • If only an additional 4 percent of the global nursing workforce were to leave because of the pandemic’s impact, then the increased outflow of nurses would be more than one million; this would push the global nurse shortage estimate up to approximately seven million.


What Is Needed: Voices of the Neonatal Nurses


If we are to truly address the causes and the symptoms of the nursing workforce crisis, there is no better place to find the answers than from nurses themselves; to that end, a series of

interviews were conducted with neonatal nurses in low- and middle-income countries. We asked what they needed to do their jobs, care for patients, and ensure quality care. We also sought their ideas for how to better retain neonatal nurses.


Neonatal job training, opportunities for specialized education, equipment, and government

support for specialized care are paramount. 


Encapsulating what was heard from all the nurses, one nurse sufficiently noted:

“…what I need…there are 3 things. “The first thing I need is trained nurses to work with...including me. I need more skills and knowledge.” The second is once hired”… training in [the] job…” And finally, “…basic instruments and medical equipment that would allow [me} to make sure these babies are not only healthy but that they have a chance at a full life.”

 

Another theme was the need for neonatal nurses to care for neonates. Neonatal care is not like caring for an adult or even an older child. One nurse’s observation summed up nicely what we heard from all the neonatal nurses. She noted that it is essential that neonatal personnel be trained and understand that this care setting is a unique situation; and that you can’t just think how you treat a 30-year-old or a 7-year-old is how you treat a neonatal patient. 


Recognizing the uniqueness of the neonatal care setting was highlighted repeatedly as a

necessary condition for quality care and good patient outcomes. A neonatal nurse noted: 

“…[you need] a background [in] neonatal science, so they just [do not] apply general principles of nursing care, they bring [neonatal science} to newborns.”


One neonatal nurse relayed the following story, a story that captures what all the nurses we

interviewed said. In short, you need special training that allows you to understand the needs of the neonate and the mom, and that is the only way you affect change and improve outcomes. 


“…it was about the newborn and mother contact. In our routine practice they used to just have the newborn coming out, then put the newborn on the woman. Probably the newborn when he’s sick or needs some help he goes to neonatal unit, the woman goes to postpartum. Then the newborn is like having no family, and the woman is like having no baby. It can end up like, two, three, four days, the mother just turn around and asking where is my baby, what happened to my baby. Or they know where the baby is, but they don’t know what happened. So, my greatest achievement was to really advocate for the reduction in maternal newborn separations. Keep contact when possible or if the mother needs help and baby need help, let the family know where the baby is, and let the family know that they can come any time to see the baby, so the baby is not really separated from the…from the mother, from the family, from the love, from the breast milk, from everything the mother can provide to the newborn.”


The previous story underscores another point made by the neonatal nurses we interviewed: the system is the problem and what is needed is that the voice of the neonatal nurse is heard and results in appropriate actions. It is important to note that neonatal nurses were not asking that their voice be the only voice listened to, but rather their voices receive amplification as they are the ones with the training and the most direct, consistent, and constant contact with the newborn. They were asking, almost begging, for more training for themselves and all the healthcare personnel responsible for delivering care to newborns. And their insistence on this became more strident as they told stories of loss, personal intervention beyond what anyone would consider required care, and the healthcare system's failures. 

 

All of the interviews underscore that inextricably tied to recruitment and retention issues are

enhanced and continuous specialized training, agency, respect, and the ability to do their job in the healthcare setting. These neonatal nurses put patients above all else. The major contributors to the neonatal nursing crisis are not the stress of patient care but rather the lack of investment in specialized training, necessary equipment, and voice. 


COVID exposed and exacerbated these structural flaws. Rather than blaming COVID for the

nursing crisis perhaps the more effective approach would be to use the COVID crisis to rethink, reprioritize, and reallocate resources so that nurses generally but neonatal nurses specifically can do what they do best: ensure the best outcomes for some of the sickest and most vulnerable patients.

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