Addressing Nurse Shortages and Pandemic Responses to Enhance Patient Safety Within Global Health Challenges

Abstract

Globally, the rapid expansion of the aging population and increasing healthcare demands are intensifying public health challenges (Khan et al. 2024). Paradoxically, while healthcare needs continue to rise, the workforce responsible for service delivery, particularly nurses, is also aging, further exacerbating the ongoing nurse shortage crisis. This shortage is aggravated by rising burnout among nurses, increased workforce churn and a decreasing career lifespan (Haddad et al. 2025). Key contributing factors include excessive workloads, chronic fatigue and sustained occupational stress (Wang et al. 2024), with the additional burden of uncertain long-COVID prevalence further compounding the issue (Tangsathajaroenporn et al. 2024).

As these workforce challenges mount, they set off a self-perpetuating cycle of burnout and attrition. Burnout creates a damaging cycle: as nurses experience reduced job satisfaction and declining physical and mental health, the quality-of-care declines, turnover rises and the nursing workforce shrinks. This cycle not only affects patient care but also places additional strain on healthcare systems, raising serious concerns about the long-term sustainability of healthcare delivery.

The workforce shortage has become a critical issue for healthcare systems, necessitating internal staff reorganisation, increased temporary/contract staffing and international recruitment. Although popular, international recruitment is irresponsible global citizenship, serving only a Band-Aid solution damaging to low- and middle-income countries (LMICs) in the long term. Recent data predict a shortage of 4.5 million nurses by 2030, with the largest gaps expected in Africa, Southeast Asia, the World Health Organisation's (WHO) Eastern Mediterranean region and parts of Latin America (Boniol et al. 2022).

Highly trained nurses and nurse-to-patient ratios are required to ensure patient safety (McHugh et al. 2021). The nursing workforce shortage will become an increasing issue, concerning how we best train, recruit and retain nurses in the future. To address staffing gaps, high-income countries (HICs) are increasingly recruiting nurses from LMICs, even though the global nursing shortage disproportionately impacts LMICs.

Additionally, many countries are grappling with economic inflation as a lasting by-product of the COVID-19 pandemic, making cost-saving in healthcare systems essential. Simultaneously, rising global demand for healthcare services, coupled with the declining gross domestic product (GDP), creates the perfect storm for maintaining high standards of care and patient safety, all while the impacts of climate change on population health further strain healthcare systems.

Climate change is a critical yet often underestimated threat to global health, with both current and projected impacts (Austin et al. 2024). Nurses will increasingly encounter health challenges linked to climate change and the environment, including malnutrition from reduced crop yields, higher rates of infectious and respiratory diseases and trauma from extreme weather events (Watts et al. 2019). Extreme weather events strain healthcare delivery and patients, increasing the demand for emergency care while limiting access to regular medical services due to disruptions and financial challenges. Infectious and chronic diseases, along with mental health issues, may worsen, causing secondary effects such as mass migration, increased poverty, medication shortages due to disrupted supply chains and concerns regarding the safety of available medications (Dewi et al. 2024).

As global health challenges intensify, driven by an aging population, rising healthcare costs associated with decreasing gross domestic product (GDP), nursing shortages and climate change, nurses will need to adapt and innovate models of care delivery, to meet the demands of evolving and increasingly complex patient needs. Adaptation will be required to mitigate the negative health impacts of these dynamic conditions and ensure patient safety (Figure 1). Preventable medical errors and adverse events, such as those considered within patient safety research, lead to avoidable costs and reduced care quality. Given the prominence of nurses as the largest healthcare professional group, it is incumbent upon nurses to seek evidence-based insights and solutions to promote healthcare services' future effectiveness in all healthcare areas.

The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide (Ross 2020), straining resources (Garcia Godoy et al. 2020) and compromising patient care (Jazieh 2020). Due to overburdened healthcare systems, missed care and treatment delays during the pandemic underscore the need for system-wide reforms (Labrague and Kostovich 2024). Reflecting on the lessons learned, five key areas have emerged for improving patient safety.

The pandemic exposed gaps in infection control knowledge and practices, particularly concerning airborne transmission (Garcia Godoy et al. 2020). Despite substantial evidence accumulated since 2020, the inconsistent adoption of safety measures, such as mask-wearing and air filtration systems, underscores the need for greater education and universally adhered-to infection control policies. Establishing consistent biocontainment protocols is critical for mitigating the ongoing spread of infectious diseases and safeguarding both healthcare workers and patients (Ross 2020).

Cultural challenges within healthcare organisations hindered effective responses during the pandemic. These included barriers to transparency in communication, a punitive approach to errors, insufficient teamwork and inadequate leadership support, as highlighted by Brborović et al. (2022). Such factors discourage the reporting of adverse incidents, thereby obstructing opportunities for learning and improvement. Similarly, an integrative review identified additional barriers to reporting medication administration errors, including fear of blame, lack of feedback after reporting and limited organisational support. The study emphasised that addressing these barriers through the implementation of non-punitive reporting systems and fostering a supportive environment can significantly enhance error reporting rates and staff confidence. The research underscores that an open, supportive and collaborative safety culture significantly enhances organisational resilience and patient safety (Afaya et al. 2021). Furthermore, fostering teamwork and leadership support has been associated with enhanced staff satisfaction and improved safety outcomes (Bragadóttir et al. 2023).

The benefits of these practices extend beyond immediate safety outcomes. By fostering a culture of psychological safety and emphasising the value of organisational resilience, healthcare systems are better equipped to adapt to new challenges and innovations. Initiatives such as the WHO Patient Safety Programme demonstrate how improvements in organisational culture can drive measurable enhancements in patient safety indicators (World Health Organization (WHO) 2021).

This adaptability became particularly evident during the pandemic, which acted as a catalyst for the widespread adoption of remote patient monitoring (RPM), virtual care and individualised care based on patient risks. Hospitals utilised home monitoring of patients' oxygen saturation during the pandemic to prevent overcrowding and manage patient care effectively at home (Pronovost et al. 2022). RPM programs during the COVID-19 pandemic had a significant impact. They reduced hospitalisation rates, ICU admissions, mortality and healthcare costs for high-risk patients who actively participated (Haddad et al. 2022). These developments underscore the pandemic's role as a catalyst for integrating advanced remote monitoring and personalised care strategies into healthcare delivery. Building on these advancements, further research is necessary to establish protocols that ensure effective remote monitoring, enabling expanded care delivery while prioritising patient safety.

The pandemic exacerbated existing burnout issues among nurses due to the intense demands of COVID-19 care, extended work hours and emotional stress. Burnout rates, previously increasing gradually, surged significantly during the pandemic (Ge et al. 2023). This situation highlights the urgent need for healthcare institutions to improve working conditions and prioritise staff wellbeing and mental health to prevent burnout. Comprehensive well-being initiatives, like the American Nurses Foundation's Nurse Well-Being: Building Peer and Leadership Support Program, funded with a three-year, $3.1 million grant from the United Health Foundation, focus on managing and recovering from stress and burnout. Early survey results indicate that this program successfully mitigated burnout and stress among nurses (American Nurses Association (ANA) n.d.). Programs like these underline the importance of addressing health risks through proper nutrition, rest, physical activity and emotional care, contributing to a more resilient nursing workforce (Ross 2020).

The COVID-19 pandemic emphasised the critical role of nurses and nurse leaders in managing health crises, reducing excess mortality and sustaining the resilience of healthcare systems. Despite their contributions, inadequate protection for nurses and other healthcare workers led to a 2%–8% increase in healthcare expenditures. Nurse leaders are pivotal in guiding teams, fostering collaboration and maintaining morale under intense pressure. Supporting and empowering this workforce is essential for strengthening crisis preparedness and response (Jackson et al. 2024).

The responses to the pandemic and lessons learnt should drive meaningful and sustained innovations in healthcare (Wynne et al. 2021). By implementing robust infection control measures, fostering a culture of transparency, advancing remote monitoring technologies and empowering nurse leadership, healthcare systems can better address future global health challenges. These insights provide a roadmap for building a more resilient, responsive and patient-centered healthcare system, better equipped for future crises (such as environmental disasters and pandemics).

Overcoming these complex interrelationships requires a comprehensive understanding of healthcare systems, an appreciation of existing evidence, and the development of new, innovative solutions. Despite global challenges such as pandemics, climate change, resource scarcity and aging populations, the nursing profession is witnessing positive developments. This includes the emergence of new and specialised advanced practice nursing roles, such as Nurse Practitioners focusing on global health and disaster response, which are vital to addressing growing and complex healthcare demands. Such a role is essential to address the growing and complex healthcare demands driven by global challenges. There is a need for safety education and training, through the integration of innovative digital technologies and virtual simulations into nursing programs to ensure a well-trained and adaptable nursing workforce prepared for future challenges. Safety education and training using digital technologies and virtual simulations have demonstrated significant improvements in clinical reasoning, error prevention, and decision-making skills among nursing students (Liu et al. 2023). These approaches enhance the ability to recognise and mitigate patient safety risks in controlled, risk-free environments, fostering a well-prepared and confident workforce.

Furthermore, nursing curricula must address climate change education focusing on its impact on mental and physical health, while promoting a reduction in the environmental footprint of healthcare, as a key contributor to carbon emissions (Levett-Jones et al. 2024). Protecting the mental and physical well-being of nursing staff is crucial to maintaining a healthy healthcare system. This includes measures to prevent occupational risks, structural violence and burnout, as well as the establishment of psychological and emotional safety. Early identification of climate-related mental health impacts is also integral to implementing safety interventions to mitigate both the acute and chronic psychological trauma caused by climate change. Diverse workforce models and flexible scheduling can help reduce nurse shortages while fostering a balanced and healthy workforce. Nurse leaders play a pivotal role in fostering a culture of safety, teamwork, and guiding healthcare teams, especially during crises. By serving as role models and promoting open communication without the fear of punishment, nurse leaders help build psychological safety, strengthen team resilience, enhance organisational safety culture and improve patient outcomes. Governments should implement evidence-based strategies to strengthen nurse–patient relationships and support growing a local and sustainable healthcare workforce, rather than relying on international nurse recruitment. Ensuring the competence of recruited nurses, particularly those with diverse educational backgrounds, is crucial. A healthcare team of diverse nursing roles can help alleviate nurse shortages. Healthcare should be transformed by integrating hospital-level monitoring at home as a long-term model, expanding care accessibility while managing costs. Remote monitoring through digital health solutions can provide safer, more efficient care for patients outside traditional hospital settings. Engaging patients, families, and communities in the patient safety conversation also remains critically important. Nurses are well-positioned to foster trusting relationships, diminish power differentials, advocate for patients to share concerns and begin co-designing solutions to the looming climate crisis.

In conclusion, enhancing patient safety amid global health challenges demands strategic responses to nurse shortages and robust pandemic preparedness. By empowering nurses with specialised training and resilient support systems, healthcare systems can better meet future challenges and improve outcomes for patients globally.

M.G. and C.F. made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. M.G., M.V., A.S., C.F. and M.P. involved in drafting the manuscript or revising it critically for important intellectual content. M.G., M.V., A.S., C.F. and M.P. given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. M.G., M.V., C.F. and M.P. agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The authors declare no conflicts of interest.