6 Persistent Nursing Issues and Challenges We Still Can't Solve

Nursing has come a long way in the past century, but several challenges that nurse leaders named in the late 1800s and early 1900s still face the profession today, even if their exact shape has changed. Most trace back to the same roots: the gender and class barriers women faced in society, and the constant economic pressure of the healthcare industry.

1. Shortage of nurses

The nursing shortage is a global issue discussed almost daily, but it is not new. For more than a century, recruitment and retention have failed to keep up with rising demand, the growing need for specialized services, and population growth, including an aging population with more chronic disease. Add persistent economic pressure in healthcare and the expanding range of other careers open to women, and the gap persists.

"...the shortage of nurses appears to have been a problem from the time when the value of trained nurses in hospitals and the community was recognized."

The shortage dates back to the moment trained nurses were first recognized as valuable. From the mid-1800s, as scientific medicine made successful treatment more common, hospitals shifted from places that housed the sick and destitute to institutions that admitted patients for treatment. When Florence Nightingale introduced formal training, demand for qualified nurses climbed sharply. Training schools multiplied and used students as the main workforce, with actual teaching squeezed into off-duty hours, crammed before exams, or skipped entirely. That reliance on students to fill staffing gaps is why hospital and nursing administrators long resisted moving nursing education into higher education.

2. Inadequate conditions of service

Recruitment and retention have always tracked working conditions: long hours, heavy workloads, low pay relative to other professions, and little recognition of what nurses contribute. Fair hours are largely standardized now, but staff shortages and budget cuts still force mandatory overtime, and nurses worldwide are still fighting for salaries that match their qualifications and skills.

As far back as her history of nursing, Lavinia Dock wrote: "The hours of work both in nursing schools and in private nursing are often too long, and many nurses have not yet as full opportunities as they should have for wholesome recreation and self-improvement." She added: "Graduate nurses in all branches of nursing need to have fair remuneration for their services in order that they may maintain their health and efficiency and provide for the future."

3. The role of nurses vs. doctors

Nurses are now recognized as professionals with a distinct role on the care team. Even so, opposition to expanded roles and prescribing rights within a nurse's advanced training still comes mainly from within the medical profession. The same pattern held a century ago: wherever nurses campaigned for state registration in the early 1900s, resistance came primarily from physicians.

"Resist any undue interference with nurses' duties by medical men; the latter seemed in some cases desirous of making nurses machines for carrying out instructions," Lavinia Dock said during the Nursing Section of the Congress of Women in England in 1899. She also wrote: "While most progressive medical men recognise the newer developments in nursing [...] there are others who are somewhat jealous of what they consider the encroachments of nursing on medicine and who insist on going back to the old discarded system of autocratic authority on the one hand and humble subservience on the other."

4. How and where nurses should be educated

Only in recent decades has professional nursing education been firmly placed within higher education in most countries. Research showing that highly qualified nurses reduce patient complications and deaths has pushed governments to accept that professional courses should run at least four years, preferably at the baccalaureate level. Resistance remains, mainly from hospital authorities, and some countries have seen a proliferation of lower-tier nurse training.

Nurse leaders pushed for an educated workforce from the start. Florence Nightingale believed nursing education should be separate from service, and she built her school on that principle. As more hospital schools opened and students became cheap labor, training quality declined into apprenticeship with little real education, a pattern that spread worldwide. The call for higher education came as early as the 1893 global meeting of nurses at the Chicago World's Fair, where leaders argued for educated nurses over hospital apprenticeships. At the 1899 Congress of Women, Bedford Fenwick opposed two-year programs: "Three years is quite short enough," she said. She also predicted that practical demands would later require further training in special branches of nursing. Delegates argued that the entry age limit of 23 was too high, since it shortened women's careers, noting that women were considered able to become mothers at 18.

5. Professional recognition through licensure and registration

State registration has been settled in most of the world, though the International Council of Nurses still helps local organizations and governments build effective regulation in some countries. Registration has always served two purposes: protecting the public from the untrained, and giving properly trained nurses formal recognition.

Securing state registration was the priority for nurse activists from the 1880s. At the Chicago World's Fair, British nurses introduced leaders from around the world to the idea, along with standards for training schools. The fight for registration also drove the founding of nursing organizations in many countries. It dominated the 1899 Congress too. In her paper on the professional training and status of nurses, Mrs. Neill of New Zealand pressed for a final exam by a central board after three years of training, with the certificate registered: "The value of the hospital certificate is now very low. Certificates and badges are sometimes given by hospital authorities without any examination ... even after a brief hospital residence." Miss MH Watkins of South Africa described how state registration was achieved there in 1891, the first country in the world to register nurses. Delegates noted that the battle for registration was closely tied to women's voting rights, since the social barriers to women having a voice had to fall first.

6. Nursing advocacy in the health of communities

The International Council of Nurses has used the theme "Nurses: A Voice to Lead," urging nurses everywhere to take an active role in achieving the United Nations Sustainable Development Goals. Nurses are the largest group of healthcare professionals and serve even the most remote areas. Because they work most closely with patients, families, and communities, they have intimate knowledge of the underlying causes of ill health, and they can drive real change through activism and innovation.

"Nurses are the largest group of healthcare professionals, serving even in the most remote areas."

This is not a new call. The language is old-fashioned, but Lavinia Dock's words from the 1899 Woman's Congress could have been written today: "There is a call coming for nurses, who, besides professional ability, shall have such wider enthusiasms and capacities as will fit them to help in the wider world-interests concerned with the preservation of health and happiness." In her history of nursing she added that although experts were now being trained to address poverty and other social ills, "...nurses are still in the truest sense social workers, constantly battling with adverse social conditions and needing all the social knowledge and insight they can find to carry out their own social function of healing broken bodies and fighting disease. We need a whole army of energetic and courageous nurses with the spirit of the old pioneers, but with better preparation than theirs, to open up new fields and to challenge the difficult and complicated problems of our own day."

Many of these difficulties still echo what Dock wrote: "It is, however, perfectly plain that many of the difficulties which nurses have faced in the past have been due to the fact that most of them were women [...] We might apply this to the whole history of nursing and say that the status of nursing in all countries and at all times, has depended, not entirely, but to a very large extent on the status of women and on the degree of freedom which they have enjoyed."