Intended for healthcare professionals

Rapid response to:

Feature Data Briefing

Nursing workforce crisis in numbers

BMJ 2019; 367 doi: (Published 05 December 2019) Cite this as: BMJ 2019;367:l6664

Rapid Response:

Nursing crisis: Missed opportunities in promoting the health of the country

Dear Editor,
Appleby is right to highlight the urgent workforce and staffing issues that the NHS is currently facing.(1) We feel that the staffing shortfalls should not be simply seen as numbers on a spreadsheet - they affect real patients and families in hospitals and communities. There will be missed opportunities to maintain and promote health and therefore these workforce challenges merit urgent but careful consideration.

Nurses and midwives are approachable professionals, working in hospitals and community settings, and are central to the effective provision of public health initiatives. Throughout the country there are some excellent examples of nurses working at different levels: individual; community and population.(2-4) They support individuals, are members of health committees that are working to improve health, and can be strong advocates for change. Potentially nurses have unique and important roles to play in tackling the complex public health challenges of our time including: accidents; mental health; obesity; homelessness; and inequalities.

Although over the last three decades there has been considerable literature encouraging nurses to take on more health promoting roles, there has also been a growing body of research describing barriers inhibiting them.(3,5,6) These include: capacity and resourcing of public health; lack of training; high workload; and workforce and staffing issues.

Our colleagues in nursing report that although they feel respected by members of the public unfortunately pressure on numbers and the relentless demand of clinical work often means that health promotion is not given the priority it deserves. Good quality health promotion can be demanding, and the lack of time and resources often coupled with inadequate training further hampers nurses’ health promotion roles.(3,5,6)

We have previously written about health promoting organisations and believe that the workplace can have an influential effect on the health of employees and their attitude and performance at work.(8,9) Others have also written about the costs of ill-health to organisations and the advantages of creating a healthy workplace.(10-12) By creating healthy working environments we feel that the working life of nurses would improve, more students would be attracted into the profession, and hard-working experienced nurses may stay in the profession for longer.

International recruitment has been suggested as one element of a solution to the staffing crisis, and whilst we very much value staff from other countries there are ethical considerations. It is important that we do not strip low and middle income countries (LMICs) of their nursing expertise as their needs will be greater than ours.(13,14) The UK is short of nurses, however, it is apposite to compare the number of nurses and midwives per 1000 population of other countries: UK=8.42, India=2.09, and Philippines=0.24.(15) These two countries are the highest external providers of nurses and health visitors to England.(16) Should we be recruiting from these countries? We recommend that a step change in training undergraduate and postgraduate UK nurses is needed.

Undoubtably many students in the UK now feel they cannot enter the nursing field because of the money required for training. The Nuffield Trust recommends that the government significantly increases the financial support to nursing students by providing cost of living grants and covering the cost of tuition fees.(17) They state that this is essential to address those students who are deterred from starting and to help tackle the high attrition rate during training. Some political parties are now pledging similar steps.

The workforce issues are both acute and critical and have implications for the health of the country and the future of the NHS. Solving the nursing crisis will not be easy and will require significant financial investment. However, it has been estimated that investing in health in general has been shown to give economic returns to the health sector and the wider economy, with an estimated fourfold return on every dollar invested.(18-20)

To solve the nursing crisis, a multifaceted strategy is needed including increasing training places and fiscal measures.(17) Importantly, at its core we believe should be the creation of good work environments that encourage maintaining and promoting the health of nurses. Urgent and concerted action is now required if we are to play our part in solving the global shortage of nurses and tackling some of our pressing public health challenges.


1) Appleby J. Nursing workforce crisis in numbers. BMJ 2019;367:l6664

2) The Queen’s Nursing Institute. The Fund for Innovation and Leadership Impact Report 2013-2014. London: QNI, 2014.

3) RCN. Nurses 4 public health. The value and contribution of nursing to public health in the UK: Final report. London: RCN, 2016.

4) Local Government Association. Health visiting: giving children the best start in life. London: Local Government Association, 2019.

5) Watson M, Kendrick D, Coupland C and Futers D. Childhood injury prevention: the views of health visitors and nursery nurses working in deprived areas. International Journal of Health Promotion and Education 2007; 45(1), 4-10.

6) Winters, L., et al. "Developing public health nursing: barriers perceived by community nurses." Public Health 2007; 121(8): 623-633.

8) Watson, M C. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.

9) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018; 56(2), 73-84.

10) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.

11) Faculty of Public Health and the Faculty of Occupational Medicine. Creating a healthy workplace: A guide for occupational safety and health professionals and employers. London: Faculty of Public Health, 2006.

12) IOSH. Working well. Guidance on promoting health and wellbeing at work. Wigston: IOSH, 2015.

13) Tropical Health and Education Trust. From competition to collaboration: ethical leadership in an era of health worker mobility. 2019.

14) Miller A. NHS global recruitment must not come at the expense of poorer countries, charity warns. BMJ 2019;366:l4588

15) WHO. Key Country Indicators. (Accessed 10th Dec. 2019)

16) House of Commons Library. NHS staff from overseas: statistics. Briefing Paper Number 7783. London: House of Commons, 2019.

17) Beech J, Bottery S, Charlesworth A, et al. Closing the gap: key areas for action on the health and care workforce. Nuffield Trust. Mar 2019.

18) Reeves, A., Basu, S., McKee, M. et al. Does investment in the health sector promote or inhibit economic growth?. Global Health 2013; 9, 43.

19) WHO. The Case for Investing in Public Health: The strengthening public health services and capacity. A key pillar of the European regional health policy framework Health 2020. Copenhagen: WHO, 2014.

20) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.

Competing interests: No competing interests

12 December 2019
Michael Craig Watson
Trustee, Institute of Health Promotion and Education.
Sue Thompson, Secretary Institute of Health Promotion and Education,
Institute of Health Promotion and Education, PO Box 7409, Lichfield WS14 4LS, UK.