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“Our Nurses, Our Future” – a perspective from Low- and Middle-Income Countries

This piece, posted to commemorate International Nurses Day 2023, was written by the Section Editors for PLOS Global Public Health’s Nursing and Midwifery Section, Laila Ladak and Judy Khanyola.

There are approximately 28 million nurses globally making up 60% of the global health workforce [1]. However, there is global mal-distribution of nurse population ratio of 12 nurses per 1 000 population in High Income Countries (HICs) versus 1 nurse or less per 2 000 population in Low and Middle Income Countries (LMICs) [2]. Nurses are often the first point of contact for a patient presenting to a healthcare setting and often spend the most time with the patient compared to other healthcare professionals.  Nurses are intrinsic to the well-functioning of health systems around the world. Without their 24-hour presence and their specialized skills in caring for patients, healthcare as we know it would be in shambles. Indeed, during the heyday of the hospital-based model of care, the axiom was “nurses run hospitals.” Even today, with the move towards health promotion and disease prevention, nurses remain at the forefront of delivering preventive, curative, rehabilitative and palliative care – all with a person- and family-centered approach.

For nurses to function optimally within any healthcare system, nursing leadership which is “leadership by nurses” needs to be nurtured and exercised. The advent of COVID-19 further exposed the gaps in our existing healthcare systems and highlighted the need for a deliberate and intentional inclusion of nursing leadership health systems, especially in preparation for future pandemics. This piece focuses on the International Nurses Day (IND) 2023 theme “Our Nurses Our Future” [3] from the perspective of LMICs.

Nurses and Global Health

Nurses play an extremely important role in global health because the very nature of their work has the potential to reduce health disparities and achieve better health outcomes for the poor, vulnerable and marginalized in society. In lower- and middle-income countries, nurses are often the only health professional a sick person will see. Nurses are there before life and after death, and the scientific underpinning of the profession provides compassion and dignity, cutting across national, political, racial, geographical, tribal, caste and gender boundaries.

Without nurses, the current Sustainable Development Goals (SDG), Universal Health Coverage (UHC), Primary Health Care (PHC), global health security, pandemic preparedness targets and priorities cannot be met, particularly in LMICs where their attainment is of crucial value, but where there is still a struggle to achieve them [4]. The ongoing humanitarian crises faced by the world today requires nurses more than cease fires, peace declarations, UNGA and G – 7 and G – 20 meetings.

Despite their critical role in delivering population health, the profession of nursing faces myriad challenges, particularly in LMICs, including:

  • Professional hierarchy, power and position particularly with the physicians’ community [5]
  • Lack of standardized educational trajectories – entry into nursing, career progression, specialization [6]
  • Legacies of colonialism and patriarchy [5]
  • Severe underfunding [7]
  • Lack of inclusion and representation in decision – making in policy making and leadership spaces [6]

Global health workforce shortages

LMICs are often burdened with gaps in healthcare delivery because of a poor physician to patient ratio, inadequate resources in hospitals and a rapidly growing population. LMICs also continue to face a severe shortage of nurses, which, compounded by the stress and burnout caused by COVID-19 and further exacerbated by brain drain [8]. Investing in education and research in nursing is critical to addressing this severe shortage.

WHO recommends that the nations optimize the use of nurses for the prevention and control of non-communicable diseases [9]. Nurses have the potential to increase awareness regarding diseases to the general population and adherence to screening, management or preventative measures of diseases as they are seen as trusted members of society [10]. Systematic reviews have reported the positive impact of behavioral and quality of life outcomes in nurse – led interventions related to psychosocial and health lifestyle promotions [11, 12], although the majority of this evidence is from high income countries. Nurses in LMICs are still relegated to tasks such as non-specific documentation or mindless, repetitive procedures, continuing to feed into the myth that they do not play a significant role in healthcare. Advancing nursing practice can have a positive impact on population health, particularly in regions with a lack of other health professionals.

While communicable diseases are common in these settings, emerging data has shown that these regions also have a high prevalence of non-communicable diseases such as cancer, congenital heart disease, diabetes, and hypertension [13]. There is a need for capacity building and meeting the health worker-patient gap in these regions. One way to bridge this gap is to invest in increasing the number and capacity of nurses.

Advancing Nursing Practice to advance population health

The Advanced Practice Nurse (APN) classification usually includes nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS) – but these are not sufficient to address and manage the complex health needs at the community level. Proposed roles of advanced practice nurses also include case manager, clinical educator, clinical researcher, clinical assistant, community nurse practitioner and patient care manager [14]. To continue advancing the role of nurses we need a global body of nursing that regulates these roles especially in LMICs where historical and continued injustices keep the profession behind.

Nurses’ rights need to be protected regarding pay, working hours, non-discrimination. Nurses should also play an active role in national level policy regarding healthcare provision. Capacity building of nurses should also include the introduction of  health informatics, digital health, and data science topics in current nursing curriculum so that digital health solutions can be planned and managed by this strata as well [15]. Through these measures, we can empower nurses and promote their critical yet underrated role in existing healthcare systems.

International Nurses’ Day – a call for action

Despite the established role and contribution of nurses in the health care system, nurses in LMICs face challenges at different levels with regards to empowerment, decision making and inclusiveness. In addition, the solutions highlighted below will make a world of difference:

  • Specifically in Africa, there could be a continent wide harmonization the entry into and progression in practice, as well as a better distinction between the nursing and midwifery professions
    • To address the gaps in workforce created by migration of health workers, African countries could work together to create a “Nurses without borders” network, which has the potential to redistribute both numbers and cadres of nurses within Africa.
    • Creation of the post of the Government Chief Nursing and Midwifery Officer GCNMO in all African countries with a defined budget and authority
    • National Ministries of Health could create a revolving nursing education fund that will allow nurses to study.
    • Clear global workplace protections, including safeguarding the physical and psychological health of nurses
    • Global, multi-sectoral collaboration to attract and keep nurses in the rural, remote and hard – to reach areas.

We need to strengthen the nursing profession through practice, research and academia. Without nurses we have no future.

PLOS Global Public Health welcomes submissions on Nursing and Midwifery, Global Health Delivery, and more! Find out more about our scope here and submit your research today!

About the authors:

Laila Ladak is The Gulshan Bhatia Endowed Associate Professor and the Assistant Dean, Graduate Programs at Aga Khan University School of Nursing and Midwifery (AKU-SONAM). She serves as a co-Section Editor for PLOS Global Public Health’s Nursing and Midwifery Section.

Judy Khanyola is a registered nurse and midwife and nursing leader in Africa. She currently serves as chair of the Center for Nursing and Midwifery at the University of Global Health Equity in Rwanda. She is secretary of AFREhealth, the convening body for health education and research in Africa and a board member of AfriPEN, the Africa interprofessional collaborative. She is also on the advisory council of Africa’s primary healthcare initiative, AfroPHC. She serves as a co-Section Editor for PLOS Global Public Health’s Nursing and Midwifery Section.

References

1.           Organization, W.H. State of the world’s nursing 2020: investing in education, jobs and leadership. 2020  [cited 2023 25th April, 2023]; Available from: https://www.who.int/publications/i/item/9789240003279.

2.           Bank, T.W. Nurses and midwives (per 1,000 people).  [cited 2023 11 May 2023]; Available from: https://data.worldbank.org/indicator/SH.MED.NUMW.P3.

3.           Nurses, I.C.o. Our Nurses. Our Future. . 2023  [cited 2023 27th April, 2023]; Available from: https://www.icn.ch/what-we-do/campaigns/international-nurses-day.

4.           Rosa, W.E., et al., Nursing theory in the quest for the sustainable development goals. Nursing science quarterly, 2020. 33(2): p. 178-182.

5.           Flaubert, J.L., et al., Supporting the Health and Professional Well-Being of Nurses, in The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. 2021, National Academies Press (US).

6.           Nganga‐Good, C., M. Chayhitz, and P. McLaine, Overcoming barriers and improving public health nursing practice. Public Health Nursing, 2023. 40(1): p. 114-123.

7.           Azad, A., et al., Continued nursing education in low-income and middle-income countries: a narrative synthesis. BMJ Global Health, 2020. 5(2): p. e001981.

8.           Boniol, M., et al., The global health workforce stock and distribution in 2020 and 2030: a threat to equity and ‘universal’health coverage? BMJ Global Health, 2022. 7(6): p. e009316.

9.           Organization, W.H., Global action plan for the prevention and control of noncommunicable diseases 2013-2020. 2013: World Health Organization.

10.         Challinor, J.M., et al., Nursing’s potential to address the growing cancer burden in low-and middle-income countries. Journal of global oncology, 2016. 2(3): p. 154.

11.         Spies, L.A., et al., Nurse‐Led interventions for hypertension: A scoping review with implications for Evidence‐Based practice. Worldviews on Evidence‐Based Nursing, 2018. 15(4): p. 247-256.

12.         Li, C., et al., Effects of nurse-led interventions on early detection of cancer: A systematic review and meta-analysis. International journal of nursing studies, 2020. 110: p. 103684.

13.         Gowshall, M. and S.D. Taylor-Robinson, The increasing prevalence of non-communicable diseases in low-middle income countries: the view from Malawi. International journal of general medicine, 2018: p. 255-264.

14.         Heinen, M., et al., An integrative review of leadership competencies and attributes in advanced nursing practice. Journal of advanced nursing, 2019. 75(11): p. 2378-2392.

15.         Booth, R.G., et al., How the nursing profession should adapt for a digital future. bmj, 2021. 373.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

Discussion
  1. I particularly like the viewpoint expressed in “Our Nurses, Our Future.” It is encouraging to see the emphasis on low- and middle-income nations, as well as the critical role nurses play in defining the future of healthcare in these areas. It is an appeal to prioritize nursing education investment, empower nurses, stimulate multidisciplinary cooperation, and enhance working conditions. By doing so, we can establish robust healthcare systems capable of serving these countries’ various and changing healthcare demands.

  2. Great analysis by the authors on “Our Nurses, Our Future”, in relation to LMICs. I strongly believe that development in the educational field will ultimately serve this goal which in turn greatly relies on funding in LMICs.

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