Ghana flanks Africa’s Gold Coast, a few degrees north of the equator, in low-lying hot lands with a population of 19.5 million and even more chickens, goats and sheep. On average, Ghanaians live less than 60 years. They earn less than $2,000 annually. Most farm and fish and survive against the odds of early infant mortality, poor sanitation and mosquitoborne diseases. People make do with what they have.

What they don’t have is enough nurses.

Ghana exemplifies the lower rungs of a global shortage, with nurses hopping from country to country for better pay and better conditions.

Although training for nurses in Ghana is different than in Western countries, 500 Ghanaian nurses went abroad last year—more than double the number of nurses who graduated, according to a January report in the Wall Street Journal. But the country also exhibits the sort of pluck that prospers in hard times.

"With what they have to work with there, it was a remarkable job they did," said Ann Rood, RN, a retired nurse from Chico, Calif., who volunteered in Prampram, a small coastal village in Ghana.

Chickens and goats roam freely about the clinic, where women give birth in rooms separated only by cloth curtains.

"[It’s] because that’s the way it is." The clinic faces obstacles. "They have terrible conditions to deal with, with the male dominance," said Rood, whose three-week post was organized through Global Volunteers. Workers go from village to village, dispensing care, making do. "The clinics were held under a tree or on a porch."

Barbara DeGroot, senior writer for the Minnesota-based nonprofit group Global Volunteers, said that dire consequences breed inventiveness. "Sometimes, our volunteers go into these communities and they are inspired, too, because there’s a lot of ingenuity," she said. "So it’s not all depressing."

Everyone needs nurses
Ghana is only one country on a planet short of nurses. Everyone needs nurses. Almost every country is scrambling to find and keep them. The result is a trickle train that transports nurses to more money and better working conditions, from poor countries to richer ones that lure them.

"I know there are a lot of organizations where the pressures are, ‘Get the workers in. I don’t care how you get them, get them in,’ " said Cathy Druce, RN, a nurse recruiter at Harrison Hospital in Bremerton, Wash. "It’s very much dog-eat-dog." The train essentially stops in the United States. "In America, they pay top salaries."

The International Council of Nurses notes a shortage that spans the world, from Zambia to the Netherlands and beyond. Canada, for example, will need 10,000 nursing graduates by 2011. Graduates declined to 4,000 last year, said Lucille Auffrey, MN, RN, executive director of the Canadian Nurses Association. For years, the United States lured Canadian nurses, but now Canada wants them back.

"Canada has fallen upon a nurse shortage as well," said Matt Hamm, owner of Texas-based Boles & Co. "So they have made it more attractive to stay home. We can definitely feel that."

Canadian nurses can enter the United States on the TN visa passed under NAFTA, available only to citizens of Canada and Mexico. It’s easier than obtaining a green card.

Nurses elsewhere know that Canada is the quickest route here, Hamm said. "They all seem to trickle through that trail to the United States."

Hamm doesn’t recruit from other countries because it takes too much time, money and red tape, he said. But many recruiters eye Filipino nurses, who have their sights set on the United States.

Surplus of nurses
The Philippines educates more nurses than it needs, Druce said. They work abroad and support families at home. "Their economy is funded on money they send back." That, in turn, raises some questions: Does it promote good health care in the Philippines? Is it ethical?

"I don’t feel good about myself to encourage this," Druce said. Born in London, raised in Scotland and formerly employed in the Middle East, Druce said she feels lucky to have a local supply of nurses near Seattle, and a boss with similar ideals. "When we’re raping other countries to serve our own purposes, how can any of us feel good about that?" she said.

This sort of "poaching" has spurred a flurry of debate. "We don’t look at recruitment of foreign graduate nurses as a solution to our problem," Auffrey said. "That’s not an ethical thing to do. We should be preparing the number of nurses we need to solve our own problems. Let’s not look elsewhere to resolve our problems. Let’s not create problems."

British guidelines prohibit recruiting nurses from countries with shortages, particularly nurses from Eastern Europe, Africa and Asia. "International recruitment should never be carried out against the interests of host countries, and we are clear about how National Health Service organizations should decide from where they should and should not be recruiting," writes Sarah Mullally, director of nursing and chief nursing officer, in the Guidance on International Nursing Recruitment.

Still, a London Guardian article published May 4 reported a 71 percent increase in overseas-trained nurses applying to register in the United Kingdom, including almost 13,750 from the Philippines, 2,459 from India, 2,065 from Nigeria and 2,056 from South Africa.

It’s a large, tangled web of factors. People live longer and need more specialized care. Countries cut funding for hospitals and nursing programs. Fewer people choose a profession with a poor image, working conditions and pay.

Women, traditionally nursing’s backbone, have more career options today. Many nurses are nearing retirement; others want to leave. "I have not ever met a happy nurse—one that’s a staff nurse, mind you," Hamm said.

The International Council of Nurses defines shortage in terms of demand, based on the amount of care people will fund and need. Spain, for example, has 13,000 unemployed nurses—no shortage in demand. But proper care reportedly requires 100,000 more nursing positions—a large shortage in need.

The problem is a shift more than a decline, said Dolores Bower, Ph.D., RN, dean and professor at Niagara University’s College of Nursing in Lewiston, N.Y, said. "There are countries in Africa, for example, that have sufficient nurses," she said, "except that they’re being siphoned off." They have patients but no nurses. "There’s a huge vacuum and a very unsafe environment."

Consequences can be drastic. "The fewer nurses you have, the more likely [it is that] you have serious errors," Bower said.

The British Medical Journal reported last year that nearly half of surveyed nurses in Japan were too busy to follow guidelines, sparking fear of error.

In Britain, Druce said, hospitals are old. "You’re dodging cockroaches at night," she said. "They’re absolutely filthy." Tabloid headlines on health care woes don’t entice new nurses. She voices the attitude she hears from others: " ‘Why would I want to be a nurse? That’s a messy job.’ I don’t think that’s any different over here."

A study that compared 43,000 nurses in the United States, Canada, England, Scotland and Germany, published in the May/June issue of Health Affairs, found between 20 percent and 30 percent of nurses plan to leave their present jobs within the year. Only 30 percent to 40 percent say there are enough nurses to provide good care. "That is not acceptable," Auffrey said.

Long-term solutions
Experts note several areas that need attention: recruitment, retention, policy, education and the strain on current nurses. Solutions must be long-term, and salary isn’t the bottom line.

Jeanna Bozell, RN, president of Professional Resource Group Inc. and author of Anatomy of a Job Search: A Nurse’s Guide to Finding and Landing the Job You Want, said her research shows that half of the top 10 reasons why nurses leave their positions are related to supervision. "It’s not money," she said. "Money was last on the list."

In the end, Druce said, nursing’s true purpose suffers. "I think we’re getting away from ‘What are we here for?’ "

On that, nurses everywhere seem to agree: Nurturing, loving values mark the profession worldwide. "That crosses all cultures and all countries," Bower said.

It shows in people like Rood, in places like Ghana. On paper, Ghana is poor and challenged. But a retired nurse from California found strength among desperation there.

"I loved it," Rood said. "They were warm, they were receptive, they were smiling." She doesn’t need pictures to recall her first meeting in Prampram, where village councilors in vibrant fabrics placed her in the clinic. "That sight is recorded in my mind. It was fantastic."