REGIONAL COMMITTEE
Provisional Agenda item 11
Fifty-sixth Session 10-13 September 2003
SEA/RC56/6 3 July 2003
STRENGTHENING OF NURSING AND MIDWIFERY WORKFORCE MANAGEMENT
CONTENTS Page
1.
INTRODUCTION .................................................................................................................. 1
2.
NEED FOR A WELL-MANAGED NURSING AND MIDWIFERY WORKFORCE ........................ 1
3.
WHO IS A NURSE OR A MIDWIFE?...................................................................................... 3
4.
HOW SHOULD THE NURSING AND MIDWIFERY WORKFORCE BE MANAGED? ................. 3
5.
EXISTING SITUATION.......................................................................................................... 5
6.
GLOBAL AND REGIONAL STRATEGIES .............................................................................. 8
1.
INTRODUCTION
Most countries of the Region are experiencing a shortage of skilled nursing and midwifery personnel. The problems are compounded by maldistribution of personnel and inappropriate skill mix in many settings. This inevitably has an impact on the ability of a country to provide equitable and accessible quality health services. The situation persists despite various efforts at national and regional levels in the past few decades to strengthen nursing and midwifery in support of national Health for All goals. This has hampered the contribution of nursing and midwifery to national health development and the health of the population in the South-East Asia Region. The issues confronting nursing and midwifery workforce therefore need to be critically addressed in order to strengthen the health services in the Region. Nurses and midwives, by virtue of their large number and close and continuous contact with the individual, family and community, particularly in times of illness, have a significant role to play in national health development, specially in scaling up health system responses for achieving the Millenium Development Goals. Special consideration has been given to address nursing and midwifery workforce issues in the Region. A multidisciplinary Advisory Group on Management of Nursing and Midwifery Workforce was constituted in 2001 to advise countries on how best to address the problem of continuing shortage and maldistribution of nursing and midwifery personnel as also the inappropriate professional skills mix in the Region. In carrying out its mandate, the Group agreed on a conceptual framework on Management of Nursing and Midwifery Workforce. Consequently, in 2002, all countries undertook an in-depth assessment to determine the gaps or challenges in this area. The country analyses revealed that t here were serious, systemic weaknesses in all areas of nursing and midwifery workforce management. To resolve them would require comprehensive and sustained strategies. Guidelines were then developed to provide directions to countries for effective management of nursing and midwifery workforce, taking into account the challenges identified in the country assessments. As most issues confronting the nursing and midwifery workforce in the Region are system-related, they require system changes. In this regard, commitment from Member States at the highest level is required for intensified support to address these issues.
2.
NEED FOR A WELL-MANAGED NURSING AND MIDWIFERY WORKFORCE
Nursing and midwifery personnel constitute a significant workforce in the health system. They comprise up to two-thirds of the national health workforce in some countries. Thus, they need to be well managed so that countries have competent and motivated nursing and midwifery personnel, where and when needed, providing quality care and contributing to the provision of quality health services that are equitable and accessible.
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Since 1994, studies in other regions have found that a well-managed nursing and midwifery workforce contributes to reduced hospital morbidity and mortality 1, reduced costs, and strengthening of effective of health services. (Research in nursing and midwifery in the countries of the Region is in a stage of infancy; evidence from the Region is not readily available). The deleterious effects of poor staffing levels and conditions have also been documented; for example, poor staffing levels of nurses were clearly linked to increased hospital infection and insufficient staffing while poor support for nurses led to low quality patient care. 2 Increased workload and shortages of nurses leaves some patients without proper care, patient and community dissatisfaction increases, and eventually ‘health care’ becomes a political and media issue, and public perceptions become increasingly difficult to manage and change. 3 Without a well-managed nursing and midwifery workforce, the sum of all other strategies will not achieve quality health services that are equitable and accessible. The current global nursing shortage provides evidence of this. The shortage is seen as a major threat to the future of the world’s health care systems.4, 5 All countries in the Region face significant challenges in achieving quality health services that are equitable and accessible – financially, geographically and culturally. Infrastructure costs, including costs driven by technological changes, are high and increasing at a time of decreasing resources available to the health sector, and increasing community expectations. A double burden of diseases, continuing high maternal and infant mortality and gender inequity are prevalent in the Region. Poverty is an added complexity, with its impact on ill-health, social issues, and equity and accessibility.6, 7 To address these challenges, health services, particularly at the community level where the needs are greatest, need to improve their accessibility and quality. The Commission on Macroeconomics and Health noted that many of the health care interventions provided at the community level can be carried out by people other than doctors - by nurses, midwives and other paramedical staff with various levels of training. 8 Furthermore, nurses and midwives can significantly contribute to achieving healthrelated Millennium Development Goals. For example, midwives can provide skilled care during pregnancy, childbirth and the postnatal period and thus contribute to improved maternal health and reduced child mortality. Thus, appropriate numbers of qualified midwives and requisite supportive systems that would ensure the safety of mothers and children would need to be in place. For combating HIV/AIDS, malaria and other diseases, an adequate mix of nurses and midwives needs to be made available, taking into account the 1
Aiken LH., Smith HL. and Lake ET. Lower medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32(8): 771-87. 2 World Health Organization. Strengthening Nursing and Midwifery: Report by Secretariat (56th WHA, A 56/19) Geneva, 2003. 3 Australian Institute of Health and Welfare. Analysis of adverse hospital incidents 1996 and 1999. Canberra. 4 Hopkins ME. Critical Condition: special report. Nurse Week 2001 March. [cited 24 April 2003]. <http://www.nurseweek.com/news/features/01-03/shortage.asp> 5 Robusto L. Nursing shortage. [cited 24 April 2003. (Internet communication at http://www.nursing.about.com/cs/currentissues.htm) 6 World Health Organization. The World Health Report 1999: Making a difference. Geneva; 1999. 7 World Health Organization. Health Imperatives for South-East Asia. Speeches by Dr. Uton Muchtar Rafei. Regional Director for South-East Asia. Volume 1: 1994-1996. SEARO. 1997 8 Commission on Macroeconomics and Health. Macroeconomics and Health: Investing in health for economic development. Report of the Commission on Macroeconomics and Health, Geneva, World Health Organization, 2001.
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national human resources available, for increasing access of antiretroviral therapy, malaria treatment and other interventions. A well-managed nursing and midwifery workforce therefore is a major contributing factor for cost containment, quality improvement, community satisfaction, and competent and motivated nursing and midwifery personnel9, and is a strategic government investment.
3.
WHO IS A NURSE OR A MIDWIFE?
“Nursing and midwifery personnel” is a collective term used for a wide variety of health workers in the SEA Region. It includes professionals, technicians and auxiliary health workers, as well as nursing aides and nursing assistants. Titles include Nurse, General Nurse-Midwife, Technical Nurse, Health Nurse, Assistant Nurse, Nurse Aide, Auxiliary Nurse-Midwife (ANM), Midwife, Public Health Midwife, Auxiliary Midwife, etc. The education levels of these personnel vary considerably between countries of the Region - from certificate to diploma and bachelor degree programmes. In most countries, nursing education includes a midwifery component. Some countries have a separate midwifery programme as a direct entry and/or after nursing education. The scope of responsibilities varies between nurse aides, assistant nurses or auxiliary midwife (trained for six months to one year) who work under supervision and nurses, midwives or nurse-midwives (with three to four years of basic preparation) who are accountable for their own duties. The wide range of categories in the Region provides a rich source of data for intercountry and regional analysis in regard to the most cost-effective nursing/midwifery categories and competencies for strengthening national health services. In general, the global experience is that a flexible and well-managed nursing and midwifery workforce has fewer, rather than more, categories of “nursing, midwifery and ‘other’ personnel”. They are well educated, and can be deployed and utilized flexibly and effectively in a variety of settings. In general, motivation is higher, there is greater breadth and depth of clinical competence, standards of care are higher, and their basic training provides a solid foundation for a culture of life-long learning based on professional standards and ethics. Thailand, with only two levels of nursing and midwifery personnel (i.e. professional and technical nurses) is a good example of this approach.
4.
HOW SHOULD THE NURSING AND MIDWIFERY WORKFORCE BE MANAGED?
The Advisory Group developed a conceptual framework to assist countries develop strategies to ensure a strong and effective nursing and midwifery workforce. These strategies should help achieve the right numbers of nursing and midwifery personnel with the right knowledge, skills and attitudes at the right location and the right time. A well-managed nursing and midwifery workforce is defined as “having competent and motivated nursing and midwifery personnel who contribute to equitable and accessible 9
Hopkins, M. op cit
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quality health services by providing quality nursing and midwifery care when and where needed.” A well-managed nursing and midwifery workforce requires: • •
effective and efficient workforce policy and planning; effective and efficient education, training and development of nursing and midwifery personnel, and effective and efficient deployment and utilization of nursing and midwifery personnel.
•
The conceptual framework for effective management of nursing and midwifery workforce is presented diagrammatically in the Figure below. Figure. The conceptual framework10
QUALITY, EQUITABLE & ACCESSIBLE HEALTH SERVICES QUALITY NURSING AND MIDWIFERY CARE COMPETENT AND MOTIVATED NURSING AND MIDWIFERY PERSONNEL
1. POLICY AND PLANNING 1.1 Involvement of nurses and midwives in health policy formulation & programme planning 1.2 Strategic planning for nursing & midwifery workforce management as an integral part of human resource planning and health system development 1.3 Financing
2. EDUCATION ,TRAINING & DEVELOPMENT 2.1 Coordination between education & service 2.2 Student recruitment 2.3 Competency-based education 2.4 Multidisciplinary learning 2.5 Lifelong learning culture 2.6 Continuing education system
3. DEPLOYMENT AND UTILIZATION 3.1 Appropriate skill mix and competencies 3.2 Relevant nursing & midwifery infrastructure 3.3 Effective leadership and management 3.4 Good working conditions and efficiently organized work 3.5 Technical supervision systems 3.6 Career advancement opportunities 3.7 Incentive systems 3.8 Job satisfaction
4. REGULATIONS 5. EVIDENCE -BASED DECISION MAKING
The conceptual framework represents the foundation stone of effective management of the nursing and midwifery workforce. It lends synergy and strategy to achieving the goals and outcomes of (a) competent and motivated nursing and midwifery personnel; (b) quality nursing and midwifery care; contributing to the ultimate health system goal, and (c) quality, equitable and accessible health services.
10
World Health Organization. Strengthening nursing and midwifery. Geneva: 54th World Health Assembly. May 2001. Resolution WHA 54.12. World Health Organization. Conceptual Framework for Management of Nursing and Midwifery Workforce. New Delhi, 2002.
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The goal is a suite of effective and integrated strategies that result in a well-managed nursing and midwifery workforce. To deliver/meet this goal requires evidence-based decisionmaking to ensure a strong foundation as well as necessary regulation and legislation. Strengthening the nursing and midwifery workforce is more than simply improving education and training, pay, working conditions, and performance and career development. Strengthening nursing and midwifery is multi-dimensional. It involves interdependency between an individual and the organizational culture, policies and structures, and enabling strategic capacity for linkages between a number of issues such as information, ethics, awareness, motivation and behaviour. 11 This sounds simple but the challenges are system challenges. System change requires multidisciplinary consultation to develop strategies. The strategies must target system change; be robust; be developed for the mid- and long-term; sustained; monitored; well managed; and integrated with a national strategic approach to health system development. Simplistic, single issue approaches have a weak impact at best, and, at worst, fail to stop a decline in the quality of a country’s nursing and midwifery workforce, 12 and thus the achievement of quality health services that are equitable and accessible.
5.
EXISTING SITUATION
All countries in the Region (except Timor-Leste) undertook an in-depth assessment during March – October 2002 to identify gaps or challenges in their nursing and midwifery workforce using the protocols developed by the Advisory Group. The assessment involved multidisciplinary consultations as well as nursing/midwifery-specific consultations, and extensive and thorough approaches using a variety of methods including interviews, documents search and review, focus group and other discussions, surveys and observation. These country analyses provided a wealth of useful information for developing strategies to strengthen effective management of the nursing and midwifery workforce. The assessments revealed that considerable progress has been made in the management of the nursing and midwifery workforce in varying degrees in the countries of the Region. For example, all countries have the capacity to produce nurses and midwives; nursing councils or other regulatory bodies are in place for professional regulation in many countries, and most countries have a national nursing/midwifery strategic plan, etc. Notwithstanding these developments, this section will highlight weaknesses and issues identified in the assessment for focused attention. A summary of the results of the analysis of country assessment reports, against each of the components of the Conceptual Framework (illustrated in Section 4 above) is provided below: (1) Policy and planning: Most countries reported inadequate involvement of nurses/midwives in policy and planning; inadequate capacity and capability of nurses/midwives to effectively contribute; and limited strategies and opportunities to develop capacity and capability. In most countries with a strategic plan for 11
International Labour Office. Joint meeting on human resource development in the public service in the context of structural adjustment and transition . Geneva: 1998. 12 Royal College of Nursing, Australia. Submission to the National Review of Nurse Education. Canberra; 2001.
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nursing and midwifery development, the implementation is poor or the plan is not being implemented at all. (2) Education, training and development: In the majority of countries, linkages and interdependency between education and service sectors are absent or weak. There are few problems with the numbers of students being recruited, but there are issues in some countries in regard to the quality and potential of those recruited. Achieving competency-based education and modern teaching methodology and skills requires significant effort. There are few multidisciplinary learning opportunities for nurses and midwives. Other than Thailand, all countries reported difficulty in encouraging, promoting and achieving a culture of life-long learning. Continuing education, except in Thailand, is ad hoc and inadequate. (3) Deployment and utilization: Very few initiatives have been taken to strengthen the flexibility of the nursing and midwifery workforce. Rosters are non-evidencebased and in need of revision. Basic equipment is lacking in many countries. Sustainable funding is problematic and inequitably distributed, particularly between urban, rural and remote areas. Most countries reported that nursing/midwifery professional associations were essential, but that they needed strengthening, as did leadership and management of nursing/midwifery. Working conditions need improvement; salaries are low in the majority of countries; health facilities are often poor and unsafe for staff; there are inappropriate nurse/midwife:patient ratios; nurses and midwives are subjected to physical and verbal abuse; housing and transport are often unsatisfactory; incentives are poor; mutual respect between nurses/midwives, and nurses/midwives and other members of the health team needs strengthening. Technical supervision is generally poor and there is an overall weak approach to continuous quality improvement and encouraging motivation. There are few opportunities for nurses/midwives to improve their technical supervision skills. Career advancement opportunities are weak and higher-level nurse/midwife clinical practitioner training is largely absent. Countries reported an inadequate evidence base to accurately assess job satisfaction levels. However, in Bangladesh, a DFID-conducted survey showed that 90 per cent of nurses are dissatisfied. (4) Regulations: The enforcement of regulations for nurses/midwives is uneven across the Region despite the extensive evidence base now available on the impact of strengthened regulations, and best-practice approaches to regulations. (5) Evidence base for decisions: The information systems available in the countries of the Region are limited. Opportunities for local research and access to evidence bases being developed in other countries are limited, with financial constraints cited as the most common reason for the weaknesses.13 The above summary underscored a common theme across all countries: serious, systemic weaknesses in all components that require comprehensive and sustained strategies as well as broader and more vigorous leadership and support to resolve. Statistics also indicate that shortage and maldistribution of nursing and midwifery personnel, along with inappropriate professional skill mix, persist in most countries of the 13
World Health Organization. Advisory Group on Management of Nursing and Midwifery Workforce Management: Report of the Second Meeting, 13-15 December 2002, Bangkok, Thailand. New Delhi, 2002.
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Region (see Table). Although the numbers of nurses and midwives have increased slightly in a few countries in the past few years, they have yet to reach the desirable level. As a rule of thumb, the ratio of nurses to doctors should exceed 2 to 1 as a minimum, with 4 to 1 or higher considered more satisfactory; nurses and midwives could deliver most of the minimum essential public health and clinical services, with doctors providing clinical supervision and direct care of complex issues and complications.14 The shortage of nurses and midwives, to some extent, is one of the causes of inequity in health of the population in the Region. The weaknesses in all components of the workforce management mentioned above have contributed to this problem. Apparently, l ow pay, low status and poor working conditions, together with competition from developed countries who themselves suffer from shortages of nurses and midwives, among others, appear to be the root cause of the problem. In countries where nurses have a low social status and low pay, it is difficult to attract qualified men and women into the profession. At present, because of the shortage of nurses, they are used primarily in hospital services and mainly in urban areas in many countries of the Region, whereas the need is greatest at district and community levels. Their roles in community health services have been rather limited. Thus, they are not optimally utilized. Furthermore, midwifery personnel in the periphery in many countries are required to function as multipurpose health workers. They, sometimes, do not pay adequate attention to the provision of midwifery care which is often left to the traditional birth attendants. In addition, the education provided during their pre-service training does not adequately prepare them to function as an independent midwife. Special efforts have thus to be made to ensure the availability of competent midwives for the community to help combat the problem of continuing high maternal and infant deaths in the Region.
Table: Medical and nursing personnel in the SEA Region, by country Number per 10 000 population Country Year Physicians Bangladesh Bhutan DPR Korea India Indonesia 1997 2001 1995 2001 1995 2001 1992 1998 1994 1998 2.0 2.51 1.6 1.7 29.7 32.0 4.8 5.2 1.6 1.1 Nurses/Nursemidwives 1.1 1.4 3.9 2.16 a
Midwives/ ANMs and others n/a n/a 5.6 3.85 6.0 2.5 n/a 3.18 2.6 3.0 c d b
18.0 31.0 4.5 6.4 4.0 c
5.0 c
14
World Bank. World Development Report. Washington, DC, 1993.
SEA/RC56/6 Page 8 Maldives Myanmar Nepal Sri Lanka Thailand 1995 2000 1995/96 2000/01 1995 2002 1995 2002 1995 2000 Timor-Leste a b
4.0 8.4 2.89 2.92 0.4 1.55 3.27 3.75 2.4 2.97 0.55 j m g
11.3 13.25 2.20 2.87 0.5 1.81 7.40 8.96 8.7 11.71 7.34 k n h e
18.5 7.55 f
1.82 2.82 0.74 1.45 3.68 3.83 n/a 6.07 2.66 l o i
2002
Number 174 for 2001, ratio computed on population estimate 805 000 for 2000 Number 310 for 2001, ratio computed on population estimate 805 000 for 2000 c Data for 1997, n/a = Data not available d Number 301 691 for 1997, ratio computed on population estimate 949 878 000 for 1997 e Number 358 for 2000, ratio computed on population estimate 270 101 for 2000 f Number 204 for 2000, ratio computed on population estimate 270 101 for 2000 g Number 7 226 for 2002, ratio computed on population estimate 19 287 000 for 2002 h Number 17 285 for 2002 , ratio computed on population estimate 19 287 000 for 2002 i Number 7 396 for 2002, ratio computed on population estimate 19 287 000 for 2002 j Number 18 025 for 2000, ratio computed on population estimate 60 607 000 for 2000 k Number 70 978 for 2000, ratio computed on population estimate 60 607 000 for 2000 l Number 36 773 for 2000, ratio computed on population estimate 60 607 000 for 2000 m Number 47 (12 nationals and 35 international) for 2002, ratio computed on population estimate 850 000 for 2002 n Number 624 for 2002, ratio computed on population estimate 850 000 for 2002 o Number 226 for 2002, ratio computed on population estimate 850 000 for 2002 Source: Data as reported by countries to WHO/SEARO 1. WHO/SEARO, Health Situation in the South-East Asia Region 1994-1997 2. WHO/SEARO, Health Situation in the South-East Asia Region 1998-2000 3. WHO/SEARO, Country submission to the 2 nd meeting of SEAR advisory group on management of Nursing and midwifery workforce, Bangkok, December 2002 4. Timor-Leste, Health Profile, Democratic Republic of Timor-Leste , Dili, October 2002
6.
GLOBAL AND REGIONAL STRATEGIES
Nursing and midwifery have been on the WHO agenda for more than 40 years. World Health Assembly resolution WHA54.12 on “Strengthening Nursing and Midwifery” recognized the essential role of nurses and midwives in reducing mortality, morbidity and disability and in promoting healthy lifestyles. The resolution further highlighted the need to maximise the contribution of the nursing and midwifery workforce to quality health services that are equitable and accessible by involving nurses and midwives in health policy development, planning and implementation at all levels; establishing comprehensive human resource development programmes that support the recruitment and retention of a skilled and motivated nursing and midwifery workforce; developing and implementing policies and programmes that ensure healthy workplaces and quality of work environments for nurses and midwives, and developing and enhancing nursing and midwifery’s evidence base.15
15
World Health Organization. Strengthening nursing and midwifery. Geneva: 54th World Health Assembly. May 2001. Resolution WHA 54.12.
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The resolution also requested the Director-General, among others, to assist countries in their efforts to address the problem of global nursing shortage and to “rapidly prepare a plan of action for strengthening nursing and midwifery and to provide for the external evaluation at the conclusion thereof.” As a follow-up, WHO headquarters, in close consultation with the Regional Offices and partners within and outside the UN system developed the “Strategic Direction for Strengthening Nursing and Midwifery Services, 20022008”. The five Key Result Areas (KRA) that WHO and its partners will work with countries are: (1) Health planning policy and political commitment: National development and health plans provide for adequate nursing and midwifery services and expertise. (2) Management of health personnel for nursing and midwifery services: National employment policies are implemented for the nursing and midwifery workforce that are gender-sensitive, based on healthy and safe work environments and conditions, provide for equitable rewards and recognition of competencies, and are linked to a transparent career structure. (3) Practice and health system improvement: Nursing and midwifery expertise is fully integrated into decision-making processes at all levels, and health systems use best available practices for the care of individuals, families, and communities. (4) Education of health personnel for nursing and midwifery services: Competent practitioners with an appropriate skill mix are available to deal effectively with the current and future challenges of practice. (5) Stewardship and governance: Stewardship and governance of nursing and midwifery services involve the government, civil society and the professions to ensure the quality of care. 16 The Regional Office established the SEAR Advisory Group on Management of the Nursing and Midwifery Workforce to help countries to address nursing and midwifery workforce issues. The establishment of this group supports the global strategic directions and complements the global plan of action. The group developed guidelines for effective management of nursing and midwifery workforce to provide directions to countries on how best to address priority issues confronting their nursing and midwifery workforce. These guidelines will assist countries to lead and manage the required organizational or system changes at the operational level as well as at the strategic and attitudes and behavioural levels. The Advisory Group also recommended that the Regional Committee adopt a resolution so that the countries give intensified support to strengthen nursing and midwifery workforce management and nurses and midwives can be optimally utilized for national health development. WHO will promote and facilitate the adoption, adaptation, and application of the newlydeveloped guidelines in the countries of the Region. In this connection, a new regional advisory group on nursing and midwifery is now being formed to assist in the facilitation, coordination, monitoring and evaluation of the implementation of the guidelines for effective workforce management. Specifically, the group is to advise the Regional Office and the countries on priority areas of work for addressing selected issues in nursing and midwifery in
16
World Health Organization. Nursing Midwifery Services: Strategic directions 2002-2008. Geneva; 2002.
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order to enhance the contribution of nursing and midwifery to national health development, among others. Countries will have to adapt the guidelines for effective management of nursing and midwifery workforce based on country issues, needs and context. A national action plan should be developed for implementing the selected strategies. WHO will specifically work with countries for strengthening the nursing and midwifery workforce in the Region in the following areas: •
Advocating and supporting proper planning for nursing and midwifery resources in the national human resource for health master plan for quality, accessible, equitable and cost-effective health care in the countries of the Region. Advocating and supporting the development and management of organizational environments that reflect, and continuously improve, good working conditions, effective incentive schemes and comprehensive career structure for nurses and midwives. Continuing to build capacity of nurse and midwife leaders to enable them to facilitate, lead and direct nursing and midwifery development in the country as well as to be actively involved in the decision-making processes for national health development. Building national capacity for evidence-based practice in nursing and midwifery, including strengthening the integrated nursing and midwifery management information system and building research capacity of nurses and midwives. Strengthening quality improvement/management, including accreditation, in nursing and midwifery services and education, including advocating for fewer categories of personnel and comparable educational standards in the Region. Fostering strategic alliances between various sectors and major stakeholders in nursing/midwifery, e.g. education and service sectors, national centres of excellence, WHO collaborating centres, professional associations/councils. Promoting and facilitating intercountry and regional collaboration for sharing experiences, expertise and resources to further strengthen nursing and midwifery in the Region, particularly on regional priority issues such as evidence-based practice, quality management in nursing and midwifery services and education.
•
•
•
•
•
•
The Regional Committee is requested to provide guidance on how to address the problem of continuing shortage and maldistribution of skilled nurses/midwives in the countries of the Region.