The globalisation of the nursing workforce: barriers confronting overseas qualified nurses in AustraliaRecent decades have coincided with the rapid globalisation of the nursing profession. Within Australia there has been rising dependence on overseas qualified nurses (OQNs) to compensate for chronic nurse shortages related to the continued exodus of Australian nurses overseas and to emerging opportunities in other professions. Between 1983/4 and 1994/5, 30 544 OQNs entered Australia on either a permanent or temporary basis, counter‐balancing the departure overseas (...) of 23 613 locally trained and 6519 migrant nurses (producing a net gain of just 412 nurses in all). The period 1995/6–1999/2000 saw an additional 11 757 permanent or long‐term OQN arrivals, with nursing currently ranked third target profession in Australia’s skill migration program, in the context of continuing attrition among local nurses. This pattern of reliance on OQNs is a phenomenon simultaneously occurring in the UK, the US, Canada and the Middle East — the globalisation of nursing reflecting not merely Western demand but the growing agency and participation of women in skilled migration, their desire for improved quality of life, enhanced professional opportunity and remuneration, family reunion and adventure. (shrink)

Nursing professionalization is both ongoing and global, being significant not only for the nursing workforce but also for patients and healthcare systems. For this reason, it is important to have an in‐depth understanding of this process and the factors that could affect it. This literature review utilizes a welfare state approach to examine macrolevel structural determinants of nursing professionalization, addressing a previously identified gap in this literature, and synthesizes research on the relevance of studying nursing (...) professionalization. The use of a welfare state framework facilitates the understanding that the wider social, economic, and political system exercises significant power over the distribution of resources in a society, providing a glimpse into the complex politics of health and health care. The findings shed light on structural factors outside of nursing, such as country‐level education, health, labor market, and gender policies that could impact the process of professionalization and thus could be utilized to strengthen nursing through facilitating increased professionalization levels. Addressing gender inequalities and other structural determinants of nursing professionalization could contribute to achieving health equity and could benefit health systems through enhanced availability, skill‐level, and sustainability of nursing human resources, improved and efficient access to care, improved patient outcomes, and cost savings. (shrink)

Development of the New Zealand nursing workforce has been shaped by social, political, scientific and interprofessional forces. The unregulated, independent and often untrained nurses of the early colonial period were succeeded in the early 1900s by registered nurses, with hospital‐based training, working in a subordinate role to medical practitioners. In the mid/late 1900s, greater specialisation within an expanding workforce, restructuring of nursing education, health sector reform, and changing social and political expectations again reshaped nursing practice. (...) Nursing now has areas of increasing autonomy, expanding opportunities for postgraduate education and leadership roles, and a relationship with medicine, which is more collaborative than in the past. Three current challenges are identified for nursing in New Zealand's rapidly evolving health sector; development of a nursing‐focused knowledge culture, strengthening of research capacity, and dissemination of new nursing knowledge. (shrink)

The average age of women nursing students in Australia is rising. With this comes the likelihood that more now begin university with family responsibilities, and with their lives structured by the roles of mother and partner. Women with more traditionally gendered ideas of these roles, such as nurturing others and self‐sacrifice, are known to be attracted to nursing as a profession; once at university, however, these students can be vulnerable to gender role stress from the competing demands of (...) study. A qualitative research design, guided by Gadamer's hermeneutic philosophy, explored the gendered behaviours and experiences of 22 women nursing students, all of whom had children and began university in a heterosexual intimate relationship. The findings reveal traditional ideas of gender were almost universal among participants, and these ideas had a significant influence on the nursing degree experience. Participants commonly prioritised family over the university and practiced maternal gatekeeping (prevention of male partner involvement in domestic work). These traditionally gendered behaviours, coupled with experiences of gender role stress, had a detrimental impact on participants' capacity to study and their personal wellbeing. The importance of these findings to the burgeoning nursing workforce shortage nursing is considered in terms of student retention and the supply of graduates into the profession. The implications to the nursing profession are also explored against the evidence that nursing students with traditional gender beliefs are less likely to develop as autonomous, critical thinking nurses compared to their gender‐egalitarian peers. The introduction of gender theory via critical pedagogy in the undergraduate nursing degree curriculum is recommended to enlighten and empower women nursing students and promote the competence, agility, and sustainability of the nursing profession. (shrink)

Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview resides in the implications (...) moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention. (shrink)

Increasing globalization of the nursing workforce and the desire for migrants to realize their full potential in their host country is an important public policy and management issue. Several studies have examined the challenges migrant nurses face as they seek licensure and access to international work. However, fewer studies examine the barriers and challenges internationally educated nurses (IEN) experience transitioning into the workforces after they achieve initial registration in their adopted country. In this article, the authors report findings (...) from an empirically grounded study that examines the experience of IENs who entered Ontario’s workforce between 2003 and 2005. We found that migrant nurses unanimously described nursing as ‘different’ from that in their country of origin. Specifically, IENs reported differences in the expectations of professional nursing practice and the role of patients and families in decision‐making. In addition, problems with English language fluency cause work‐related stress and cognitive fatigue. Finally, the experience of being the outsider is a reality for many IENs. This study provides important insights as policy and management decision‐makers balance the tension between increasing the IEN workforce and the delivery of safe patient care. (shrink)

In the years following the COVID‐19 pandemic, issues such as high job demands, burnout, and turnover continue to influence the nursing workforce, with heavier impacts to marginalized groups. Understanding the work and life contexts of nurses of color can help guide strategies for workplace equity and meaningful support. This qualitative study explored the experiences of nurses of color in the United States during the pandemic, focusing on feelings about the profession and job decisions. The overarching theme was “answering (...) the call,” with subthemes of “COVID shone a light,” “being consumed by COVID,” and “is it worth it?” Participants shared how their racial identities shaped their perceptions and job decisions in positive and negative ways, noting how racism impacted many facets of their work and added to the stressors felt in the workplace and the community. Findings provide insight into the underrepresented perspectives of nurses of color and suggest strategies to eliminate racism in nursing. (shrink)

Background: Preparing tomorrow’s healthcare workforce for managing the growing complexity of care places high demands on students, educators, and faculties. In the light of worrying data about study-related stress and burnout, understanding how students manage stressors and develop resilience has been identified as a priority topic of research. In addition to study-related stressors, also moral stressors are known to characterize the students’ first clinical experiences. Objectives: However, current debates show that it remains unclear how healthcare ethics education should address (...) them. In order to clarify this issue, this study first develops the notion of moral resilience as a response to moral stressors involving both situations of moral complexity and moral wrongness. Second, it explores the potential of healthcare ethics education in fostering moral resilience. For this purpose, it defines moral resilience operationally as a reduction of moral distress in a given axis of time measured by a validated tool. Research design, participants, and context: The educational transferability was assessed within an explorative, quantitative pre–post interventional study with a purposive sample of 166 nursing students. The educational intervention comprised a lecture introducing the typology of moral stressors. Before and after the lecture, students were presented vignettes depicting morally stressful situations. Ethical considerations: The competent research ethics committee confirmed that no ethical approval was needed. Informed consent was obtained from participants. Findings: Three of four vignettes showed a modest but statistically significant reduction in measured levels of distress after the lecture (p < 0.05, α = 5%). Discussion: The study shows the potential of healthcare ethics education in providing students with transformative knowledge that fosters moral resilience. Conclusion: In times of global scarcity of educational resources, healthcare ethics education has an important contribution to offer in the promotion of students’ mental and physical health by strengthening the knowledge base of moral resilience. This legitimates its costs for societies, faculties, and professional bodies. (shrink)

Growing nursing workforce maldistributions impede rural healthcare access globally. In‐depth exploration of underlying philosophical ideas about rural health in nursing curricular could support recruitment and retention of nurses who are well positioned to support and advocated for health care and services relevant to their communities. Through a lens of positionality, the purpose of this paper is to explore rural health and nursing within the United States and Australia from the perspective of undergraduate students. Recognizing that both (...) countries have ‘first world’ health services, issues of access to services associated with systemic and structural biases were significant features identified by participants. Their perceptions were supported by discussion with attendees of the 26th International Nursing Philosophy Conference from several countries, during a presentation titled ‘What is different about rural health nursing: A philosophical exploration.’ This international consistency suggests that systemic and structural biases are global phenomena. While exposure to rural health and rural nursing may be beneficial for recruitment, preparing nurses for rural practice requires more than educating students to complete clinical tasks. Uncovering collaboration, advocacy and policy development opportunities for nurses in rural communities could move the dial from recruiting rural nurses to fulfill immediate needs to retention of well‐educated and highly skilled nurses. Building a stronger philosophical base for rural healthcare inclusive of all people, honouring their distinguishing characteristics such as age, gender, ethnicity, is long overdue. Positionality can inform how nurses across the globe relate to other countries' governments, cultures, norms, values, expectations, etc., which can influence the advancement of the profession and address social inequities among rural populations. (shrink)

Background: The concept of conscientious objection is well described; however, because of its nature, little is known about real experiences of nursing professionals who apply objections in their practice. Extended roles in nursing indicate that clinical and value-based dilemmas are becoming increasingly common. In addition, the migration trends of the nursing workforce have increased the need for the mutual understanding of culturally based assumptions on aspects of health care delivery. Aim: To present (a) the arguments for (...) and against conscientious objection in nursing practice, (b) a description of current regulations and practice regarding conscientious objection in nursing in Poland and the United Kingdom, and (c) to offer a balanced view regarding the application of conscientious objection in clinical nursing practice. Design: Discussion paper. Ethical considerations: Ethical guidelines has been followed at each stage of this study. Findings: Strong arguments exist both for and against conscientious objection in nursing which are underpinned by empirical research from across Europe. Arguments against conscientious objection relate less to it as a concept, but rather in regard to organisational aspects of its application and different mechanisms which could be introduced in order to reach the balance between professional and patient’s rights. Discussion and conclusion: Debate regarding conscientious objection is vivid, and there is consensus that the right to objection among nurses is an important, acknowledged part of nursing practice. Regulation in the United Kingdom is limited to reproductive health, while in Poland, there are no specific procedures to which nurses can apply an objection. The same obligations of those who express conscientious objection apply in both countries, including the requirement to share information with a line manager, the patient, documentation of the objection and necessity to indicate the possibility of receiving care from other nurses. Using Poland and the United Kingdom as case study countries, this article offers a balanced view regarding the application of conscientious objection in clinical nursing practice. (shrink)

Workplace bullying is a significant issue confronting the nursing profession. Bullying in nursing is frequently described in terms of ‘oppressed group’ behaviour or ‘horizontal violence’. It is proposed that the use of ‘oppressed group’ behaviour theory has fostered only a partial understanding of the phenomenon in nursing. It is suggested that the continued use of ‘oppressed group’ behaviour as the major means for understanding bullying in nursing places a flawed emphasis on bullying as a phenomenon that (...) exists only among nurses, rather than considering it within the broader organisational context. The work of Foucault and the ‘circuits of power’ model proposed by Clegg are used to provide an alternative understanding of the operation of power within organisations and therefore another way to conceive bullying in the nursing workforce. (shrink)

It is frequently claimed that nursing is vital to the safe, humane provision of health care and health service to our populations. It is also recognized however, that nursing is a costly health care resource that must be used effectively and efficiently. There is a growing recognition, from within the nursing profession, health care policy makers and society, of the need to analyse the contribution of nursing to health care and its costs. This becomes increasingly pertinent (...) and urgent in a situation, such as that existing in Ireland, where the current financial crisis has lead to public sector employment moratoria, staff cuts and staffing deficits, combined with increased patient expectation, escalating health care costs, and a health care system restructuring and reform agenda. Such factors, increasingly common internationally, make the identification and effective use of the nursing contribution to health care an issue of international importance. This paper seeks to explore the nature of nursing and the function of the nurse within a 21st century health care system, with a focus on the Irish context. However, this analysis fits into and is relevant to the international context and discussion regarding the nursing workforce. This paper uses recent empirical studies exploring the domains of activity and focus of nursing, together with nurses perceptions of their role and work environment, in order to connect those findings with core conceptual questions about the nature and function of nursing. (shrink)

XIAO LD. Nursing Inquiry 2010; 17: 208–220Continuing nursing education policy in China and its impact on health equityThe aim of this study was to evaluate the mandatory continuing nursing education (MCNE) policy in China and to examine whether or not the policy addresses health equity. MCNE was instituted in 1996 in China to support healthcare reform was to include producing greater equity in health-care. However, the literature increasingly reports inequity in participation in MCNE, which is likely to (...) have had a detrimental effect on the pre-existing discrepancies of education in the nursing workforce, and thereby failing to really address health equity. Despite a growing appeal for change, there is lack of critical reflection on the issues of MCNE policy. Critical ethnography underpinned by Habermas’ Communicative Action Theory and Giddens’ Structuration Theory were used to guide this study. Findings are presented in four themes: (i) inaccessibility of learning programs for nurses; (ii) undervaluation of workplace-based learning; (iii) inequality of the allocation of resources; and (iv) demands for additional support in MCNE from non-tertiary hospitals. The findings strongly suggest the need for an MCNE policy review based on rational consensus with stakeholders while reflecting the principles of health equity. (shrink)

The argument that nurses should be Marxists is made by looking at the primary areas of nursing activity in turn, giving an example of how capitalist economic relations negatively impact upon that activity, and providing a Marxist explanation of the reasons why it has that impact. In relation to the nursing activity of health promotion, it is argued that capitalism's generation of social inequality undermines the health of the population. In relation to curative activities, the focus is on (...) how capitalism's reckless pursuit of profit has subverted the sustainability of bactericidal interventions. The argument in relation to comforting and assistive care is that the ownership and control of health services by capitalist corporations undermines therapeutic relationships. Finally, in relation to supportive care, it is contended that capitalism's requirement for a disciplined workforce can compromise healthcare professionals’ support of employees. It is concluded that if nurses aspire to have some control over their activities, then it is a good idea for them to avail of Marxism's capacity to identify the socio‐economic mechanisms by which capitalism affects nursing care. (shrink)

In this article, we clarify and describe the nature of nursing expertise and provide a framework to guide its identification and further development. To have utility and rigour, concept‐driven research and theories of practice require underlying concepts that are robust, valid and reliable. Advancing understanding of a concept requires careful attention to explicating its knowledge, metaphors and conceptual meaning. Examining the concepts and metaphors of nursing expertise, and how they have been interpreted into the nursing discourse, we (...) aimed to synthesise definitions and similarities between concepts and elicit the defining characteristics and properties of nursing expertise. In clarifying the concept, we sought to move beyond the ambiguity that currently surrounds expertise in nursing and unravel it to make explicit the characteristics of nursing expertise from published peer‐reviewed studies and structured literature synthesis. Findings indicate a lack of clarity surrounding the use of the term expertise. Traditional reliance upon intuition as a way of explaining expert performance is slowly evolving. Emerging from the analysis is a picture of expertise as the relationship between networks of contextual reasoning, understanding and practice. Striking absences in the discourse include limited explication of ethical reasoning and theorising a broader interpretation of expertise reflective of contemporary forms of nursing. (shrink)

The global COVID‐19 pandemic challenged the world—how it functions, how people move in the social worlds and how government/government services and people interact. Health services, operating under the principles of new public management, have undertaken rapid changes to service delivery and models of care. What has become apparent is the mechanisms within which contemporary health services operate and how services are not prioritising the person at the centre of care. Person‐centred care (PCC) is the philosophical premise upon which models of (...) health care are developed and implemented. Given the strain that COVID‐19 has placed on the health services and the people who deliver the care, it is essential to explore the tensions that exist in this space. This article suggests that before the pandemic, PCC was largely rhetoric, and rendered invisible during the pandemic. The paper presents an investigation into the role of PCC in these challenging times, adopting a Foucauldian lens, specifically governmentality and biopolitics, to examine the policies, priorities and practical implications as health services pivoted and adapted to changing and acute demands. Specifically, this paper draws on the Australian experience, including shifting nursing workforce priorities and additional challenges resulting from public health directives such as lockdowns and limitations. The findings from this exploration open a space for discussion around the rhetoric of PCC, the status of nurses and that which has been lost to the pandemic. (shrink)

BackgroundRapid advances in medical technology, changing healthcare policies, and increasing patient diversity have exacerbated the ethical challenges. As nursing students are an integral part of the future nursing workforce, ethical sensitivity has a critical impact on their future careers.PurposeThis study aims to promote research in related fields by systematically reviewing the origin and development of the concept of ethical sensitivity in nursing students, comparing currently available tools for assessing ethical sensitivity in nursing students, and exploring (...) their applicability and reliability.MethodsA literature review method was used in this study. A literature search was conducted for assessment tools published between 1995 and 2024. A total of six articles focusing on assessment tools they developed to measure ethical or moral sensitivity were included and analyzed.ResultsOur analysis revealed significant variations in the reliability and applicability of these assessment tools, particularly when used in diverse cultural settings. The study also identified a need for localized modifications of these tools to ensure their accuracy and relevance in different regions.ConclusionThe findings provide valuable guidance for nursing educators in selecting appropriate assessment tools and offer a foundation for developing new tools that are more contextually relevant. This study contributes to the advancement of ethical sensitivity education for nursing students worldwide, ultimately enhancing patient care and professional development. (shrink)

In 2020, due to the Nightingale year and COVID‐19 crisis, nursing is in the public eye more than ever. Nurses often are being seen as compassionate helpers. The public image of nursing, however, also consists of stereotypes such as nursing being a ‘doing’ profession and care being a ‘female’ characteristic. Next to that, nursing is associated with images from the past, such as ‘the lady with the lamp’. Therefore, in the public eye at least, the (...) class='Hi'>nursing identity seems a simple and straightforward enough construct, but nothing less is true. Looking at what a professional identity consists of, historic and social developments influence a group identity as a construct. In addition, individual, professional and contemporary societal moralities, including stereotypes, play its role. Nurses themselves reinforce stereotypes in order to fit into what is expected, even when they believe professional behaviour encompasses other features. They may do so individually as well as in a group context. But nursing actually seems to be better off when viewed upon as a diverse, autonomous profession. Moral values such as compassion motivate nurses to enter the profession. Research shows that if such values are addressed in daily practice, nursing could perhaps be saved from nurses leaving the profession because of feeling unfulfilled. Another aspect concerns the huge nursing body of knowledge. If seen as the ground on which nursing behaviour is standing, it would contribute to a different image of nursing than simplified stereotypes, which do not acknowledge the complex nature of the profession. This paper challenges the idea that the nursing identity is unchangeable and the notion that ‘a nurse will always be a nurse’. By doing so, the paper contributes to a debate on the supposed ‘true’ nature of the nursing identity and opens a discussion on the need for it to change. (shrink)

Recruitment of nurses by industrialized nations from developing countries has been common practice for decades. Globalization, a crucial trend of the 21st century, raises the world’s awareness of the economic and social disparities between nations. The direct impact on nurse emigration emphasizes the ethical, economic, and social inequalities between source and destination countries. It is often more cost-effective for industrialized countries to recruit from developing countries; however, the depletion of source country resources has created a global healthcare crisis. Destination countries (...) are being challenged on the ethical implications of aggressive recruitment and their lack of developing a sustainable self-sufficient domestic workforce. Similarly, source countries are confronting the same challenges as they struggle to fund and educate adequate numbers of nurses for domestic needs and emigrant replacement. This article will review the ethical, economic, and social impacts of continued unrestricted international recruitment of nurses and present a proposal for development of an international treaty addressing global sustainability. (shrink)

Nurses play a crucial role in reducing health disparities and advancing health equity for individuals and communities. The future nursing workforce relies on their nursing education to prepare them to promote health equity. Nursing educators prepare students through a variety of andragogical learning strategies in the classroom and in clinical experiences and by intentionally updating and revising curricular content to address knowledge and competency gaps. This critical review aimed to determine the extent to which health equity (...) concepts are explicitly present in prelicensure undergraduate nursing curricula globally. Of 434 articles screened, 22 articles describing 20 studies met inclusion criteria. Frequency and quantity of health equity content, concepts and topics, teaching strategies, evaluation strategies, and the overall extent of integration varied widely. Notably, only two articles described overall well‐integrated explicit health equity content, and there was little attention to whether students transfer this learning into practice. A focus on individualism rather than population and community was noted, highlighting the presence of whiteness in nursing. Results from this review confirm that nursing education has room to improve with respect to health equity in the curricula. (shrink)

To address longstanding workforce shortages, increase efficiency and control the costs associated with the modern health-care provision, there has been a worldwide policy to promote increased flexibility within the health-care workforce. This is being done primarily by extending the ‘scope of practice’ of existing occupational roles into what is referred to as ‘advanced’ practice. The development of the advanced practice nurse (APN) has occurred within the context of a shortage of medical staff, and the need to control cost. (...) However, the means by which substantially repurposed occupational groups such as these, are incorporated into complex, hierarchical organisations such as the UK national health service (NHS) remains poorly understood. Using modern sociological theory, the development of the APN role has been examined in terms of power, control, professional identity and gender relations. Each of the theoretical approaches used adds to the quality of the discussion, although none provide a comprehensive picture. However, when synthesised, they do provide an enhanced insight into the evolution of the role. It is argued here that by critically examining the development of the APN role, this will enable both a better understanding of, and the means to influence, its future direction of travel. (shrink)

The purpose of this contemporary history study is to analyse nursing strategy documents produced by NHS Trusts in England in the period 2009–2013, through a process of discourse analysis. In 2013 the Francis Report on the Mid-Staffordshire NHS Foundation Trust was published. The Report highlighted the full range of organisational failures in a Trust that valued financial efficiency over patient care. The analysis that followed, however, dwelt heavily on the failings of the nurses. Nursing strategy documents at that (...) time served to set the future direction for NHS Trusts, prescribing specific value frameworks for each nursing workforce. However, the values chosen frequently conflicted with each other pitting nursing values against a managerial trope. It is argued that documents provided a response to wider NHS concerns and high-profile failures in care, particularly the Francis Report, paying lip service to staff engagement whilst maintaining a corporate focus. Nursing values were placed firmly within a managerialist discourse, one that has needed to be re-evaluated in the current Covid-19 pandemic. Wider implications of the research suggest discussion of value conflict may be beneficial within nursing education and a truly local approach to strategy creation would potentially promote staff buy-in to strategy documents. (shrink)

Background The international health workforce crisis had led to an increasing shortage of nurses, which has substantial implications for the quality of patient care. This shortage potentially results in nurse-perceived time pressure, which can be particularly challenging for nurses who provide care for older persons. Objective This study aimed to show how geriatric nurses experience working under time pressure, perceive its impact on care and deal with time pressure in daily care. Research design A qualitative descriptive interview design was (...) used. Participants and research context Purposive sampling led to the inclusion of 11 nurses from three geriatric nursing wards in two general hospitals in Flanders (Belgium). Data were collected using semi-structured in-depth interviews and analysed using the QUAGOL (Qualitative Analysis Guide of Leuven). Ethical considerations The study protocol was approved by the Ethics Committee of the University Hospitals Leuven (Ethics committee of the University Hospitals Leuven). Findings In all interviews, time pressure was described as ubiquitous in the daily care of older persons. A sense of failure in providing care was the common thread in many interviews. Nurses felt compelled to ‘reduce’ good-quality care to basic care by focusing on the physical and visible aspects of care. Nevertheless, personal experiences with time pressure and strategies to cope with it differed among the interviewees. These variations were related to the working environment and the nurses themselves. They underscored the importance of nurses’ perspectives for a good understanding of the phenomenon of time pressure. Discussion and conclusion Working under time pressure in the care of older persons leads to various important challenges for nursing ethics. The findings show that providing care that promotes the human dignity of older persons in busy working environments in which care is rationed is an important ethical challenge. As such, our study offers a baseline for further research and discussion on how to support nurses working under time pressure. (shrink)

There is a global shortage of nurses, leading many countries to recruit internationally qualified nurses (IQNs) to fill the gap. However, IQNs encounter challenges in integrating into their new professional environment, particularly in their interactions with locally qualified nurses (LQNs). Intraprofessional cultural competence (IPCC), defined as ‘a set of congruent behaviours and attitudes that enable professionals to work respectfully and effectively in cross‐cultural situations’, may be a strategy to address these challenges. Content analysis was used to examine nursing regulatory (...) documents (Standards for Practice [Standards] and Codes of Conduct [Codes]) from the United Kingdom, New Zealand and Australia. Data were extracted and organised based on four key themes relevant to IPCC. The analysis revealed a focus on ‘Mutual collaboration and professional relationships’ in six regulatory documents, with explicit commitments to preventing racism and discrimination in the Australian and NZ Codes. However, issues such as racism, discrimination, bullying and harassment faced by IQNs are not comprehensively addressed, as the documents mainly prioritize culturally appropriate patient interactions over relationships between colleagues. Using regulatory documents to address IPCC may influence positive change such as improving communication, and preventing racism, bullying, discrimination and harassment within nursing. (shrink)

Background: Nursing practice takes place in a social framework, in which environmental elements and interpersonal relations interact. Ethical climate of the work unit is an important element affecting nurses’ professional and ethical practice. Nevertheless, whatever the environmental circumstances, nurses are expected to be professionally competent providing high-quality care ethically and clinically. Aim: This study examined newly graduated nurses’ perception of the ethical climate of their work environment and its association with their self-assessed professional competence, turnover intentions and job satisfaction. (...) Method: Descriptive, cross-sectional, correlational research design was applied. Participants consisted of 318 newly graduated nurses. Data were collected electronically and analysed statistically. Ethical considerations: Ethical approval and permissions to use instruments and conduct the study were obtained according to required procedures. Data were rendered anonymous to protect participant confidentiality. Completing the questionnaire was interpreted as consent to participate. Findings: Nurses’ overall perception of the ethical climate was positive. More positive perceptions related to peers, patients and physicians, and less positive to hospitals and managers. Strong associations were found between perceived ethical climate and self-assessed competence, turnover intentions in terms of changing job, and job satisfaction in terms of quality of care. Nurses at a higher competence level with positive views of job satisfaction and low turnover intentions perceived the climate significantly more positively. Conclusion: Nursing management responsible for and having the power to implement changes should understand their contribution in ethical leadership, as well as the multidimensional nature of nurses’ work environment and the interaction between work-related factors in planning developmental measures. Future research should focus on issues in nurse managers’ ethical leadership in creating ethical work environments. There is also a need for knowledge of newly graduated nurses’ views of factors which act as enhancers or barriers to positive ethical climates to develop. Interventions, continuing education courses, and discussions designed to promote positive ethical climates should be developed for managers, nurses, and multi-professional teams. (shrink)

This study explores the experiences of nurses that provide ‘complex’, generalist healthcare in hospital settings. Complex care is described as care for patients experiencing acute issues additional to multimorbidity, ageing or psychosocial complexity. Nurses are the largest professional group of frontline healthcare workers and patients experiencing chronic conditions are overrepresented in acute care settings. Research exploring nurses’ experiences of hospital‐based complex care is limited, however. This study aims to add to what is known currently. Four ‘complex care’ nurses undertook in‐depth (...) semistructured interviews and their narratives were analysed using the conceptual framework of complex adaptive phenomenology. Two overarching themes constituting the ‘essence’ of complex care nursing were identified: Contextual factors and attribute/value‐based elements. Creating meaningful patient outcomes and feeling part of a team were experienced as fulfilling, whereas time constraints, institutional settings and systemic barriers to comprehensive caregiving diminished the experience of providing complex care. Overall, work meaning presented as a dynamic phenomenon, shaped by personal and professional values, local settings and systemic factors. It is recommended that more expansive research be undertaken to explore the experience of complex care for nurses. Such knowledge can contribute to initiatives that draw a skilled, effective and engaged hospital‐based complex care nursing workforce. (shrink)

Immigrant nurses make up a large percentage of the Australian nursing workforce. Since the support in the workplace is expected to be inclusive for all nurses, the aim of this article is to explore how support and opportunities for professional growth, learning and development are distributed across different categories of nurses working in a neonatal intensive care unit (NICU). An ethnographic approach has opened an examination of the everyday workplace practices in the NICU to gain insight into how (...) nurses made sense of the social and power relations occurring between themselves and their senior colleagues and how they experienced the support and opportunities they received in their workplace. As today's workplaces such as the NICU are diverse in races, culture and experiences, the concepts of intersectionality and cultural safety assisted in identifying inequality and injustice related to such diversity. The results showed how patronage relations rendered nurses with immigrant status with major disadvantage and left them clinically and culturally vulnerable. Such inequity defeats the reasons for encouraging skilled migration of nurses and poses questions on the cultural competency of recruiting organisations. Considering how cultural safety might guide staff development offers opportunities for authentic support to culturally diverse nurses. (shrink)

How nursing as a profession is valued may be changing and needs to be explored and understood in a global context. We draw on data from two empirical studies to illustrate our argument. The first study explored the value of nursing globally, the second investigated the experiences of overseas trained nurses recruited to work in a migrant capacity in the UK health care workforce. The indications are that nurses perceive themselves as devalued socially, and that other health (...) care professionals do not give nursing the same status as other, socially more prestigious professions, such as medicine. Organizational and management structures within the NHS and the independent care home sector devalue overseas nurses and the contribution they make to health care. Our conclusions lead us to question the accepted sociocultural value of the global nursing workforce and its perceived contribution to global health care, and to consider two ethical frameworks from which these issues could be discussed further. (shrink)

Background: Compassion has long been advocated as a fundamental element in nursing practice and education. However, defining and translating compassion into caring practice by nursing students who are new to the clinical practice environment as part of their educational journey remain unclear. Objectives: The aim of this study was to explore how Chinese baccalaureate nursing students define and characterize compassionate care as they participate in their clinical practice. Methods: A descriptive qualitative study design was used involving a (...) semi-structured in-depth interview method and qualitative content analysis. Twenty senior year baccalaureate nursing students were interviewed during their clinical practicum experience at four teaching hospitals. Ethical considerations: Permission to conduct the study was received from the Institutional Review Boards and the participating hospitals. Results: Baccalaureate nursing students defined and characterized compassionate care as a union of “empathy” related to a nurse’s desire to “alleviate patients’ suffering,” “address individualized care needs,” “use therapeutic communication,” and “promote mutual benefits with patients.” Students recognized that the “practice environment” was characterized by nurse leaders’ interpersonal relations, role modeling by nurses and workloads which influenced the practice of compassionate care by nursing personnel. Conclusion: Compassionate care is crucial for patients, nurses, and students in their professional development as well as the development of the nursing profession. In order to provide compassionate care, a positive practice environment promoted by hospital administrators is needed. This also includes having an adequate workforce of nurses who can role model compassionate care to students in their preceptor role while meeting the needs of their patients. (shrink)

Providing ethically competent care requires nurses to reflect not only on nursing ethics, but also on their own ethical traditions. New challenges for nurse educators over the last decade have been the increasing globalization of the nursing workforce and the internationalization of nursing education. In New Zealand, there has been a large increase in numbers of Chinese students, both international and immigrant, already acculturated with ethical and cultural values derived from Chinese Confucian moral traditions. Recently, several (...) incidents involving Chinese nursing students in morally conflicting situations have led to one nursing faculty reflecting upon how moral philosophy is taught to non-European students and the support given to Chinese students in integrating the taught curriculum into real-life clinical practice settings. This article uses a case study involving a Chinese student to reflect on the challenges for both faculty members and students when encountering situations that present ethical dilemmas. (shrink)

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert (...) rationing/missed care/care left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. (shrink)

Nurse engagement, empowerment and strong relationships among staff, residents and families, are essential to attract and retain a suitably qualified and skilled nursing workforce for safe, quality care. There is, however, limited research that explores engagement, empowerment and relational coordination in long‐term care (LTC). Nurses from an older persons’ mental health and dementia LTC unit in Australia participated in this study. Forty‐one nurses completed a survey measuring psychological empowerment, work engagement and relational coordination. Twenty‐nine nurses participated in individual (...) interviews to further explore these concepts. Although nurses reported high psychological empowerment and work engagement, their relationships with key stakeholders varied. Our findings suggest that nurses in LTC require both supports and opportunities to contribute as active members of the multiprofessional care team that includes tailored education, professional development and positive interactions within the care team. Regular support is needed to enable nurses to feel empowered, foster relationships and communication, and facilitate work engagement. Based on these findings, we suggest that it is important to find ways to ensure that all who provide care perceive that they are part of the whole care team and able to contribute to the care and well‐being of people in LTC. (shrink)

Clinical practices are considered one of the cornerstones in nurses' education. This study provides a framework to determine how factors in the academic environment, influence nursing student's satisfaction with their practices. A cross-sectional analytical study was conducted in a convenience sample of 574 nursing students at a private university in Valencia, during the 2016/2017 academic year, 79% were women. Two statistical methodologies were used for data analysis: hierarchical regression models and fuzzy sets qualitative comparative analysis. The HRM indicate (...) that the students' mean score influences all dimensions of satisfaction. Furthermore, in the fsQCA, the type of service and center, as well as the type of management, the preference in the choice of the practice center and the number of students per period per clinical educator influence satisfaction with clinical practices. These results could be used to understand how academic factors influence nursing students' satisfaction with their clinical practices and to create intervention programmes that improve it. This will help prepare students to be the future nursing workforce. (shrink)

Background: Determination of the factors affecting missed nursing care and the impact of ethical leadership is important in improving the quality of care. Aim: This study aims to determine the missed nursing care and its relationship with perceived ethical leadership. Research design: A cross-sectional study. Participants and research context: The sample consisted of 233 nurses, of whom 92.7% were staff nurses and 7.3% were charge nurses, who work in three different hospitals in Turkey. The study data were collected (...) using a personal and professional characteristics data form, the Missed Nursing Care Survey, and the Ethical Leadership Scale. Ethical considerations: The study was approved by the non-interventional ethics committee of Dokuz Eylül University Ethics Committee for Noninvasive Clinical Studies. All participants’ written and verbal consents were obtained. Findings: The most missed nursing care practices were ambulation, attending interdisciplinary care conferences, and discharge planning. According to the logistic regression analysis, sex, the number of patients that the nurse is in charge of giving care, the number of patients discharged in the last shift, and satisfaction with the team were determined as factors affecting missed care. No significant relationship was found between ethical leadership and missed nursing care (p > 0.05), and a weak but significant relationship was found between the clarification of duties/roles subscale and missed nursing care (r = −0.136, p < 0.05). Discussion: Ethical leaders should collaborate with policy-makers at an institutional level to particularly achieve teamwork that is effective in the provision of care, to control missed basic nursing care, and to organize working hours and at the country level to determine roles and to increase the workforce. Conclusion: The results of this study contribute to the international literature on the most common type of missed nursing care, its reasons, and the relationship between the missed care and ethical leadership in a different cultural context. (shrink)

Toward evidence‐based policy decisions: a case study of nursing health human resources in Ontario, CanadaThis paper reflects how health services research ‘evidence’ was used to influence decisions in the province of Ontario, Canada. The process involved interaction among a variety of stakeholders and decision‐makers with researchers to reduce uncertainty and to substantiate emerging service provision issues in the province. The issues presented here focus specifically on an analysis of the nursing situation completed in 1998 for the Minister of (...) Health’s Nursing Task Force, which examined key issues in service delivery. The issues were: restructured work environments; nurse supply and declining enrollments; labour trends and utilization of the nursing workforce; patient acuity and complexity of work environments and the influence on workload; and the paucity of reliable and valid data bases for analysis of nursing’s contribution to the health system. Ontarians can be confident that the Task Force recommendations were born from solid research‐based evidence and now the challenge becomes to monitor the implementation of these resolutions over time. (shrink)

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed (...) by the ethics of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice. (shrink)

The Covid‐19 pandemic has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. The decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. Our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. This essay discusses three overarching ethical issues that create a myriad of concerns and will likely affect nurses (...) globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses’ relationships with patients and families. We urge policy‐makers to ensure that nurses’ voices and perspectives are integrated into both local and global decision‐making so as to minimize the structural injustices many nurses have faced to date. Finally, we urge nurses to seek sources of support throughout this pandemic. (shrink)

Repeating history? Public and community health nursing in AustraliaDespite the long history in Australia of public and community health nursing, it has never been regarded as important as hospital‐based nursing. Notwithstanding the establishment of nursing organisations in the very early years of the 20th century and subsequent efforts to develop the nursing workforce, public and community health nursing has been neglected in terms of policy, research into public health nursing practice and (...) class='Hi'>workforce development. Even in the present day, public and community health nurses are marginalised from mainstream nursing interests and there is a lack of conceptualisation about the value of nursing’s contribution to the primary health sector. This sector is experiencing a new wave of reforms driven by a combination of managerialism and systems change for improved responses to address health inequalities. Because there is not a strong institutionalised professional policy and support base for public and community health nurses, they are vulnerable in these reforms to increased domination and appropriation of their practice by stronger professional interests. There is an urgent need for professionally organised support from mainstream nursing to ensure that public and community health nurses are positioned as a unified force in efforts to advance the health of the community. (shrink)

Background: Double degrees in nursing and midwifery have evolved in Australia as a proposed solution to possible impending shortages of qualified midwives in the healthcare workforce. The double degree is seen as a more acceptable option in non-metropolitan areas in particular. Concern has been expressed however, about dilution of midwifery philosophy and graduates opportunities in respect of future clinical practice. Aim: This study aimed to provide a better understanding of motivations and intentions of students who undertake the Bachelor (...) of Nursing Science/Bachelor of Midwifery double degree. Methods: A cross-sectional survey design was employed at four universities that offered double degrees in nursing and midwifery in three states of Australia. Students enrolled in first and fourth year of a double degree and graduates of a double degree were invited to complete an online survey comprised of Likertscales and items requiring free text responses. Quantitative data was analysed using SPSS and thematic analysis was used to analyse the qualitative data. Findings: Participants indicated a clear preference for midwifery as a career with this preference increasing for each cohort at each stage of study. Discussion: Primary reasons for selecting a double degree were perceived increased opportunity for employment and use of nursing skills to enhance midwifery practice in a population with growing co-morbidities. A strong identification with midwifery philosophy and identity was also demonstrated.Conclusion: An understanding of motivations and career intentions of students undertaking double degree studies can inform future program development and workforce planning. (shrink)

Globally, one of every eight nurses is a migrant, but few studies have focused on the healthcare experiences of migrant nurses (MNs) as consumers or recipients of healthcare. We address this gap by examining MNs and their acculturation, barriers to healthcare access, and perceptions of healthcare encounters as consumers. For this mixed‐methods study, a convenience sample of MNs working in Europe and Israel was recruited. The quantitative component's methods included testing the reliability of scales contained within the questionnaire and using (...) Hayes Process Model #4 to test for mediation. The qualitative component's methods included analyzing interviews with iterative inductive thematic analysis. Quantitative findings on MNs (n = 73) indicated that the association between acculturation and perception of the healthcare encounter, which MNs experienced as healthcare consumers, was mediated by barriers to healthcare access, even after adjusting for age and gender (p = 0.03). Qualitative interviews with MNs (n = 13) provided possible explanations for the quantitative findings. Even after working in the host country's healthcare system for several years, MNs reported difficulties with their healthcare encounters as healthcare consumers, not only due to their limited knowledge about the culture and healthcare resources but also due to the biased responses they received. (shrink)

Background: The first wave of the COVID-19 pandemic caused a shortage of qualified nurses in Spain. As a result, the government authorized the hiring of senior students. Objectives: To explore the ethical dilemmas and ethical conflicts experienced by final-year nursing students who worked during the first outbreak of the COVID-19 pandemic in Spain. Research design: A qualitative exploratory study was conducted using purposive sampling. Semi-structured interviews were carried out using a question guide. Interviews took place via a private video (...) chat room platform. A thematic, inductive analysis was performed of the information gathered. Participants and research context: Eighteen nursing students were recruited from two universities of Madrid, aged between 18 and 65 years old, enrolled in the fourth year of nursing studies and who were hired under a relief contract for health professionals during the pandemic. Ethical considerations: The present study was carried out in accordance with the Declaration of Helsinki, and the study was approved by the Local Ethics Committee of Universidad Rey Juan Carlos. Results: Three specific themes emerged: (a) coping with patient triage, (b) difficulties in providing end-of-life care, and (c) coping with patient death. Nursing students participated in the process of patient selection for resource allocation and ICU bed occupancy. They were shown how to care for patients who were not admitted to the ICU, in their last moments and were faced with the difficulties of applying end-of-life care. Finally, the nursing students were confronted with the death of their patients, in overwhelming numbers and under adverse conditions. Conclusions: These findings can help shed light on the ethical dilemmas and ethical conflicts faced by novice nursing students, incorporated into the workforce during the COVID-19 pandemic. Moreover, it was described that students may normalize the death due to the exhaustion and overwhelmed routine. (shrink)

Background: Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses. Objective: The aim of this study was to illuminate and interpret the meaning of the lived experience (...) of troubled conscience among registered nurses (RNs) working in nursing homes. Research design: This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach. Ethical considerations: Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data. Findings: The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers. Discussion: Troubled conscience meant experiencing continuous and simmering tension between one’s ideals and realities and feeling a drive to preserve accountability and one’s moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation. Conclusion: Nurses’ troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state’s intentions can be realised within the given framework are important for individual nurses’ occupational health as well as the quality of care provided to patients. (shrink)

Political action has a long history in the health workforce. There are multiple historical examples, from civil disobedience to marches and even sabotage that can be attributed to health workers. Such actions remain a feature of the healthcare community to this day; their status with professional and regulatory bodies is far less clear, however. This has created uncertainty for those undertaking such action, particularly those who are engaged in what could be termed ‘contentious’ forms of action. This study explored (...) how advocacy and activism were presented in nursing and medical codes of ethics, comparing disciplinary and temporo‐spatial differences to understand how such action may be promoted or constrained by codes. The data for this study comes from 217 codes of ethics. Because of the size of the corpus and to facilitate analysis, natural language processing was utilised, which allowed for an automated exploration of the data and for comparisons to be drawn between groups. This was complemented by a manual search and contextualisation of the data. While there were noticeable differences between medical and nursing codes, overall, advocacy, activism and even politics were rarely discussed explicitly in most codes. When such action was spoken about, this was often vague and imprecise with codes speaking of ‘political action’ and ‘advocacy’ in general terms. While some codes were far more forthright in what they meant about advocacy or broader political action (i.e., Nursing codes in Denmark, Norway, Canada) more forceful language that spoke in specific terms or in terms of oppositional or specific actions (e.g., civil disobedience or marches) was almost completely avoided. These results are discussed in relation to the broader literature on codes and the normative questions they raise, namely whether such action should be included in codes of ethics at all. (shrink)

Attempts to ‘modernize’ the English National Health Service (NHS) have included significant workforce re‐design, including the development of new, advanced roles in nursing. There is a wealth of evidence documenting and evaluating such roles in hospital and, to a lesser extent, in community settings. This paper builds on this work, drawing on recent post structural and sociological analyzes to theorize these roles, locating them within broader social and cultural changes taking place in healthcare and exploring how understandings of (...) new roles in community nursing are in the process of being constructed. Building on a literature review, the paper draws out what an analysis of new advanced nursing roles in the community reveals about competing conceptualizations of the nursing mandate, the ambivalence and ambiguity that practitioners experience in shaping ‘new’ identities (the shaping of subjectivities), and the often implicit ideological positions that underpin such developments. (shrink)

Over the past two decades, the competency movement has been gathering momentum internationally within the ranks of professional nursing. It can be argued that this momentum is in response to government initiatives aimed at improving consistency in workforce training and accreditation, and fostering national and international portability of qualifications. At the same time, the competency movement has provided the opportunity for regulators, service providers and government to develop mechanisms to reconstitute competent nurses as accountable, self‐regulating subjects and to (...) monitor this transformation in particular ways. The ways in which competencies have been taken up to do this transforming work in Canada are unique and deserving of some detailed description and analysis.We argue that Canadian nursing regulatory authorities have chosen to view competence as the rehearsal of ethical attributes consonant with the professional role,as opposed to the enactment of skilled conduct. As a result, reflective practices rather than skill and knowledge have become the cornerstone of nursing competency formulation and review. We argue that this distinctly Canadian approach to competency serves three ends. First, it privileges the ‘attribute’ element of the nursing competency model and side steps the ever‐problematic ‘nursing knowledge’ issue; second, self‐surveillance by nurses shifts the onus for professional development from industry to the individual; and third, it concedes responsibility for skill assessment by the regulatory authorities to industry control, leaving employers free to determine skill base and skill mix requirements for practice. Finally, we argue that the reflective component of the regulatory framework for Canadian nurses radically fails as a tool for auditing quality and assessing competency. Rather, it functions as a governmental practice that furthers the deregulatory and economic rationalist aims of the Canadian health reform agenda. (shrink)

Australia, along with other countries, has introduced New Public Management (NPM) into public sector hospitals in an effort to contain healthcare costs. NPM is associated with outsourcing of service provision, the meeting of government performance indicators, workforce flexibility and rationing of resources. This study explores the impact of rationing of staffing and other resources upon delivery of care outside of business hours. Data was collected through semistructured interviews conducted with 21 nurses working in 2 large Australian metropolitan hospitals. Participants (...) identified four strategies associated with NPM which add to workload after‐hours and impacted on the capacity to deliver nursing care. These were functional flexibility, vertical substitution of staff, meeting externally established performance indicators and outsourcing. We conclude that cost containment alongside of the meeting of performance indicators has extended work traditionally performed during business hours beyond those hours when less staffing and material resources are available. This adds to nursing workload and potentially contributes to incomplete nursing care. (shrink)

Indonesia is recognized as a nurse exporting country, with policies that encourage nursing professionals to emigrate abroad. This includes the country’s adoption of international principles attempting to protect Indonesian nurses that emigrate as well as the country’s own participation in a bilateral trade and investment agreement, known as the Indonesia–Japan Economic Partnership Agreement that facilitates Indonesian nurse migration to Japan. Despite the potential trade and employment benefits from sending nurses abroad under the Indonesia–Japan Economic Partnership Agreement, Indonesia itself is (...) suffering from a crisis in nursing capacity and ensuring adequate healthcare access for its own populations. This represents a distinct challenge for Indonesia in appropriately balancing domestic health workforce needs, employment, and training opportunities for Indonesian nurses, and the need to acknowledge the rights of nurses to freely migrate abroad. Hence, this article reviews the complex operational and ethical issues associated with Indonesian health worker migration under the Indonesia–Japan Economic Partnership Agreement. It also introduces a policy proposal to improve performance of the Indonesia–Japan Economic Partnership Agreement and better align it with international principles focused on equitable health worker migration. (shrink)

Health care depends on people. It is the health workforce — doctors, nurses, pharmacists, lab technicians, and nursing assistants, to mention a few — that, in large measure, determine the quality and effectiveness of any health enterprise. The nature of the health workforce was integral to the health care reform debates of the early 1990s and will surely be central in proposals to improve the quality, accessibility, and cost of U.S. health care in the future. Therefore, as (...) we enter a new period of health reform deliberations and as we face the inevitability of an aging population, it is important to consider the problems and potential remediation necessary for the health workforce of the future. This article focuses particularly on physicians and nurses while recognizing the importance and frequently parallel concerns that arise across all health care disciplines. Understanding how the composition, capacity, and activities of a health care workforce must change as part of health reform requires an understanding of the context in which health professionals practice. What are the factors that govern health care today, and what are their impact on the health workforce? (shrink)