New Roles of Nurses within the Healthcare System
Global Health – and what about Nursing?
Von Alexander Bischoff
Developing needs and expectations of the population combined with cost containment measures put nursing in a pivotal role: nurses are key to implement a patient-centered care model. Different challenges in Global Health have at the same time a strong impact on nursing. Can the roles of nurses be redefined within the healthcare system towards a central position between physicians and the community?
Health education class at Colombo Hospital (Sri Lanka. Photo © Dominic Sansoni / World Bank, flickr)
Harvey V. Fineberg and David J. Hunter wrote 2013 in an article for The New England Journal of Medicine: “We adopted the concept of global health as public health for the world. Public health focuses on the health of populations, as distinct from medicine’s focus on the health of individuals. In addition to population-level determinants that are central to public health, the health of populations owes much to the effective delivery of clinical care and also depends on how medical activities affect it.” (Fineberg & Hunter NEJM, 2013)
The ambitious endeavour for the health populations is confronted with an uprising crisis in health systems all over the world. The growing elderly population, the rise of chronic conditions, the availability of new technology and the mounting expectations of the patients contribute all to the development of a demand for services that health systems can no longer satisfy.
Numerous challenges - particularly for the nursing workforce
At the same time, the personnel working in the health system is facing numerous challenges, such as new roles and responsibilities, new technologies and techniques to master, lack of continuous professional development, lack of appropriate equipment, lack of recognition, lack of career opportunities and last but not least insufficient financial reward. This misbalance between the growing demand for health services and the unavailability of qualified and motivated health workforce is especially acute in lower- and middle-income countries.
These elements are particularly dramatic for the nursing workforce. This is because of the simple reason that nurses account for the largest proportion of health professionals in any health system in the world (60% - 80%).
Developing needs and expectations of the population combined with cost containment measures put nursing in a pivotal role: evidence suggests that nurses are key to implement a patient-centered care model. Unfortunately, nurses are not only ill equipped to carry out the jobs they are newly supposed to do; they are also heavily affected by the rise of chronic conditions, both in terms of number of patients and workload by case. Furthermore, the phenomenon of nurse migration is draining a noticeable amount of nurses away from poorer and rural settings to environments with better resources.
In many parts of the world, the activities of nurses are essentially bedside care, injections and medication administration, with little time left for patient education, health promotion and follow-ups of patients. While the carrying out of doctor prescriptions, the episodic interactions with patients, bio-medical and cause-related approach to disease and cure is part of the success story of modern medicine, additional roles should be strengthened.
Acute nurse workforce shortage
These roles can be deduced from the definition of nursing proposed by the International Council of Nursing: “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”
The international literature suggests that “nurses, not doctors, are key to implementing the chronic care model” (Bodenheimer 2005). This means that to face the pandemic of chronic conditions, there would be a need to employ over and above nurses. The situation is therefore even more dramatic: there is an acute nurse workforce shortage, but to cope with the health systems’ double burden (demographic and epidemiological) there should be far more nurses. To make matters still worse, in order to improve health system performance a strong link between physicians and communities would be needed. There is a consensus that it is also the nursing workforce that can build this bridge.
The consequences of the above can be looked at from both the supply and demand side. The following table displays schematically the demand side and the supply side.
The challenge is therefore to redefine roles of nurses within the healthcare system towards a central position between physicians and the community. This redefinition is to take place in the context of the development (or re-launch) of primary health care services and the global epidemic of chronic conditions. Redefining nursing in the age of globalization implies at least four key roles: (i) nurses acting as guarantors of continuity and as providers of long-term care, (ii) nurses as facilitators and coordinators between different professionals and the community, (iii) nurses bringing the healthcare system and the physicians’ knowhow to the community – outreach function to the community, and (iv) nurses as advocates of the needs of population for primary health care services and in particular those of populations affected by chronic diseases
In this issue of the Medicus Mundi Bulletin, we present a number of examples of how nurses contribute to global health endeavours. The papers were written by a group of nurses attending the Geneva Health Forum. Since most of them are Swiss and master students at the Institute of Nursing Science, University of Basel, examples are taken from the Swiss context and put into the context of global health.
Bodenheimer, T., K. MacGregor and N. Stothart (2005). "Nurses as leaders in chronic care." BMJ 330(7492): 612-613.
Harvey V. Fineberg, David J: A Global View of Health — An Unfolding Series Hunter wrote 2014 in an Article for The New England Journal of Medicine N Engl J Med 2013; 368:78-79January 3, 2013 DOI: 10.1056/NEJMe1208801. http://www.nejm.org/doi/full/10.1056/NEJMe1208801?query=featured_global-health
Alexander Bischoff, was born in Boston, Massachusetts, and trained as a nurse in Switzerland. He was involved in primary health care in Angola for several years, received his Masters in Community Health at the Liverpool School of Tropical Medicine, and his PhD in Epidemiology at the University of Basel. His research interests are intercultural communication, community interpreting, and health care disparities.
He carried out short-term assignments and consultancies in countries including Rwanda, Zanzibar, Guinea-Bissau, Angola, Bosnia-Herzegovina, Kosovo, Belarus, Tanzania, Cameroon, South-Africa, Togo and Tajikistan.
He is with the Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, and lecturer at the Institute of Nursing Science, Faculty of Medicine, University of Basel.