A letter to The Lancet from Ms Gabriela Cueva and Dr Justin...
WHO has officially designated 2020 as the Year of the Nurse and the Midwife and with nursing clearly on the rise, UHC2030 spoke to Lord Nigel Crisp,
Co-Chair of the Nursing Now campaign to find out more.
Lord Crisp, can you tell us about the Nursing Now campaign and what it wants to achieve?
I am the Co Chair of the UK’s All-Party Parliamentary Group on Global Health and we did a review of nursing globally and published our report ‘Triple Impact’ in 2016. As a result of our review, I became convinced that one of the biggest thing you can do to improve health globally is to empower nurses. We couldn’t get anyone to take our recommendations seriously so we started this campaign.
Very simply, nurses are in many countries well trained but they are not allowed or enabled to work to their potential. Frankly, this is partly because they are women - often how nurses are treated in countries is related to how women in general are treated - and partly it is because they are not doctors. We set up the campaign to say “Look again at nurses. Understand that nurses can do more if we enable them to. Particularly they have a massive contribution to make to achieve universal health coverage.
Nurses are half the professional health workforce; we estimate that there are 24 million nurses in the world. Here they are, an unrecognized massive asset that we should be developing so that they can have an even bigger impact.
There are five practical areas that make a compelling argument for empowering nurses. The first area is the big increase in non-communicable or long-term diseases such as diabetes, dementia, asthma, heart failure. If you look at what is happening in many, but not all, high-income countries, you will see there is a big increase in nurse-led clinics. So for example in the UK most diabetes clinics are run by nurses. Doctors are available but the medical input is only a small part of the care that diabetes patients need. We argue that if you have more nurse-led clinics for these long-term conditions you will see big increases in access to good quality health care.
The second area is the need for more specialist nurses or advanced nurse practitioners. Again in the UK, and in a number of other countries, there are nurses who can prescribe, there are nurses who are first responders for the ambulance service and they can give certain treatments. So there is an extended role here for nurses and a much bigger role than nurses have traditionally played. This allows you to reach out into a much wider world and provide a much wider level of services.
The third area is primary care, and again in the UK you are starting to see more nurses in primary care. This is the start of a trend. In Africa, the first professional that most members of the public see is a nurse. We need to give these nurses more support and develop nursing because you can get nurses into places in primary care where you cannot get doctors. Doctors by and large are not going to work in rural areas. With new electronic and communication technologies you can increasingly expect nurses to provide services.
So for example, in rural parts of Kenya midwives use small ultrasound machines on pregnant women and feed the results straight back to the regional centres in Nairobi, so that doctors can monitor women in pregnancy and pick up the high risk mothers and babies. This is a wonderful example of what midwives can do. There are nursing examples too, where nurses are able to do things, which previously only doctors could do in hospitals.
In primary care, community health workers are very important but of course they are limited in what they can do, they need to be supervised and they need to have people who can take their referrals when it is beyond what they can deal with. Nurses are ideally suited to this.
Our model of primary health care is to have community health workers in more remote areas and villages who are supervised by nurses who then have access to doctors. This way you can really reach large populations, which is important for UHC.
The fourth area is midwifery, which is a separate profession but we are also advocating for midwifery in the same way as we are for nurses. The fifth area is the most underdeveloped, and is about health promotion and prevention in the public health agenda. Here, nurses have a natural advantage as they are part of the local culture and community. So rather than doctors, or specialists, or even journalists coming in and telling people what to do, nurses can go in and people are far more likely to listen.
These are the five areas where we see that nurses and midwives can make a massive contribution to UHC and they can do so in conjunction with other professionals as multi-disciplinary care is important. But nurses can be trained in three years, whereas doctors take nine years to train, and nurses can do so much more than community health workers. So they have to be part of the mix. This set of arguments is pretty compelling really! It is why we do need to get a much bigger focus on nursing.
I’m not a nurse, but my nursing friends say to me, “The trouble is that nurses are taken for granted, they are invisible, they are ‘nice’ women doing things. Therefore they are never involved in policy.” I’m exaggerating all this for effect, but it is certainly how nurses feel; that they are ignored and taken for granted.
Whereas actually we need to make sure we engage nurses in policy so that we can understand how to make those really powerful developments that I just spoke about happen. We need to get more nurses into leadership positions where they can make sure the rest of us understand what is going on. Nurses are there when other people are not.
It’s very important to say that Nursing Now is not a nursing campaign, it is a health campaign. Its strapline is to “Improve health globally by raising the profile and status of nursing”. This goes back to my first point which is one of the biggest things that we can do to improve health globally is to recognize what nurses do and can do, and empower nurses globally.
Who can get involved in the campaign?
The campaign is massive. We started just over a year ago and we now have 282 Nursing Now groups in 89 countries. For example Pakistan launched the campaign in October with their President and Minister of Health committed to more investment in nursing for the reasons we have talked about. Australia, America and Colombia have just launched. Cambodia launched on 20 June, and Ireland launched at the beginning of June. The important thing is that these groups are not just of nurses. It is a multi-stakeholder group. These groups are taking the overall priorities, and are using them to create their own local priorities because what happens in Cambodia is different to what happens in Canada. Countries need to determine their own priorities but within the overall direction of strengthening the role of nurses and enabling them to contribute even more to UHC.
If you want to be a National Nursing Now group, we have five requirements. The first is that you support the campaign. Secondly, that you involve the Chief Nursing Officer if there is one. Thirdly, that you involve the national nursing association if there is one. Fourthly, that you involve some non-nurses. Our Nursing Now board for example is two thirds women, one third men and two thirds nurses, one third non-nurses. And fifthly, that you involve young nurses. And then you can have any other stakeholders that you want. There is only one national group in any country and they register with us, but there are also more local groups who can register too. It is not replicating the national nursing association. Nursing Now is not just about promoting the profession, it’s about improving health and UHC.
But of course, we do promote the profession as a really exciting career for young nurses and midwives, and we have a great Nightingale Challenge where we are asking all health employers to provide some training for young nurses and midwives. We expect to have at least 1000 employers and at least 20,000 young nurses and midwives taking part. This is about showing that nursing and midwifery are exciting careers but also providing support for the next generation who are going to really change nursing as professionals, advocates and leaders.
Can you give an example of what a Nursing Now group’s activities might be?
Yes, Nursing Now Uganda had a two-day workshop to find out what were their most significant priorities and they came out with a number of them. The wanted a new Chief Medical Officer, they wanted greater focus on the education of nurses, they wanted some changes in the regulations so that nurses could play a bigger role in UHC. What’s interesting in Uganda is that the Permanent Secretary and the Minister of Health are very keen advocates of this, they understand the needs of health workers but actually it is the nurses who get everywhere and if you can strengthen nurses then you’ll have a big impact on quality as well as on reach and access. And costs actually, because in general to have a nurse-based primary care service with doctors on tap is a cost-effective way of doing things.
Thank you for your time Lord Crisp.