State of the world's nursing 2020: investing in education, jobs and leadership

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. SDG 3 SDG 4 SDG 5 SDG 8 FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, and others who contributed to the data reporting process to produce this report. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary State of the world’s nursing 2020x EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020 xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of he world’s nu sing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web appendix) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with care, when adequately trained (208, 209), though data on cost-effectiveness Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various interventions is key to scaling up and sharing such strategies in different Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, found that there is often a greater burden of discrimination in jobs where women 30 State of the world’s nursing 2020 are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 than did countries in other regions. In the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5 Education and nursing workforce supply 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 54 State of the world’s nursing 2020 5.6 Regulation of employment and working conditions 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Note: The number of countries responding yes out of responding countries for each indicator is shown in parentheses next to each indicator. Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce graduation and subsequent recruitment to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods reviews, © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web appendix). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. State of the world’s nursing 2020116

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary State of the world’s nursing 2020x EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with care, when adequately trained (208, 209), though data on cost-effectiveness Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various interventions is key to scaling up and sharing such strategies in different Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, found that there is often a greater burden of discrimination in jobs where women 30 State of the world’s nursing 2020 are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 than did countries in other regions. In the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5 Education and nursing workforce supply 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 54 State of the world’s nursing 2020 5.6 Regulation of employment and working conditions 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce graduation and subsequent recruitment to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary x State of the world’s nursing 2020 EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 care, when adequately trained (208, 209), though data on cost-effectiveness are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce interventions is key to scaling up and sharing such strategies in different practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, 30 State of the world’s nursing 2020 found that there is often a greater burden of discrimination in jobs where women are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education than did countries in other regions. In 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. 5.5 Education and nursing workforce supply Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 5.6 Regulation of employment and working conditions 54 State of the world’s nursing 2020 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing graduation and subsequent recruitment 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary x State of the world’s nursing 2020 EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 care, when adequately trained (208, 209), though data on cost-effectiveness are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce interventions is key to scaling up and sharing such strategies in different practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, 30 State of the world’s nursing 2020 found that there is often a greater burden of discrimination in jobs where women are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education than did countries in other regions. In 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. 5.5 Education and nursing workforce supply Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 5.6 Regulation of employment and working conditions 54 State of the world’s nursing 2020 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing graduation and subsequent recruitment 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary x State of the world’s nursing 2020 EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 care, when adequately trained (208, 209), though data on cost-effectiveness are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce interventions is key to scaling up and sharing such strategies in different practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, 30 State of the world’s nursing 2020 found that there is often a greater burden of discrimination in jobs where women are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education than did countries in other regions. In 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. 5.5 Education and nursing workforce supply Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 5.6 Regulation of employment and working conditions 54 State of the world’s nursing 2020 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing graduation and subsequent recruitment 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary x State of the world’s nursing 2020 EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 care, when adequately trained (208, 209), though data on cost-effectiveness are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce interventions is key to scaling up and sharing such strategies in different practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, 30 State of the world’s nursing 2020 found that there is often a greater burden of discrimination in jobs where women are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education than did countries in other regions. In 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. 5.5 Education and nursing workforce supply Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 5.6 Regulation of employment and working conditions 54 State of the world’s nursing 2020 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing graduation and subsequent recruitment 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Investing in education, jobs and leadership STAT E O F T H E 2020 State of the world's nursing 2020: investing in education, jobs and leadership. ISBN 978-92-4-000327-9 (electronic version) ISBN 978-92-4-000328-6 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1CHAPTER Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Contributors and acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2CHAPTER Nursing in a context of broader workforce and health priorities . . . . . . . . . . . . 5 2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . 5 2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CONTENTS 3CHAPTER Nursing roles in 21st-century health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5CHAPTER 6 Current status of evidence and data on the nursing workforce . . . . . . . . . . . . . 35 5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . .37 5.2 Equity in availability of and access to the nursing workforce . . . . . . . . . . . . . . . . . .43 5.3 International nurse migration and mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 5.4 Regulation of nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.6 Regulation of employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . .55 5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . .61 Future directions for nursing workforce policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Strengthening the evidence base for planning, monitoring and accountability . . . . .68 6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 6.3 Developing and supporting the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . .72 6.4 Building institutional capacity and leadership skills for effective governance . . . . . .82 6.5 Catalysing investment for the creation of nursing jobs . . . . . . . . . . . . . . . . . . . . . . .84 6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Annex 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4CHAPTER Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.1 Pre-service education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 Workforce inflows and outflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.3 Equitable distribution and efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.4 Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 CHAPTER CHAPTER 3.1 Role of nursing in achieving universal health coverage . . . . . . . . . . . . . . . . . . . . . . .11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters . . . . . . . . . .15 3.3 Role of nursing in achieving population health and well-being . . . . . . . . . . . . . . . . .16 iiiContents Tables 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . .38 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . .38 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . .48 5.7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . .60 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . . 111 A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116 Boxes 3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . .21 4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . .27 4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . .33 5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109iv Figures 1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . xiv 3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .xv 4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . xvi 5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii 6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7 2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . .36 5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . .40 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41 5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . .42 5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . .44 5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . .45 5.8 Percentage of responding countries indicating existence of nursing regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . .54 5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . .56 5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Association between GCNO and nursing leadership programme and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . .62 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . .63 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . .64 A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . . 112 A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . . 113 A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114 A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . . 115 vContents Investment in nurses will contribute not only to health-related SDG targets, but also to education (SDG 4), gender (SDG 5), decent work and economic growth (SDG 8). Elisabeth Iro Chief Nursing Offi cer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Cover images Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Tedros Ghebreyesus Director-General, WHO ISBN 978-92-4-000329-3 (electronic version) ISBN 978-92-4-000330-9 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. vi State of the world’s nursing 2020 SDG 3 SDG 4 SDG 5 SDG 8 Tedros Ghebreyesus Director-General, WHO FOREWORD The State of the world’s nursing 2020: investing in education, jobs and leadership comes as the world witnesses unprecedented political commitment to universal health coverage. At the same time, our emergency preparedness and response capacity is being tested by the current COVID-19 outbreak and mass population displacement caused by confl ict. Nurses provide vital care in each of these circumstances. Now, more than ever, the world needs them working to the full extent of their education and training. This fi rst State of the world’s nursing report reveals much to celebrate about the nursing workforce. Opportunities for advanced nursing education and enhanced professional roles, including at the policy level, can drive improvements in population health. At the same time, we continue to see vast inequities in the distribution of nurses around the world which we must address. 2020 is the International Year of the Nurse and the Midwife. This is an opportunity to leverage the evidence in the State of the world’s nursing 2020 report and commit to an agenda that will drive and sustain progress to 2030. To this end, we urge governments and all relevant stakeholders to: • invest in the massive acceleration of nursing education – faculty, infrastructure and students – to address global needs, meet domestic demand, and respond to changing technologies and advancing models of integrated health and social care; • create at least 6 million new nursing jobs by 2030, primarily in low- and middle- income countries, to off set the projected shortages and redress the inequitable distribution of nurses across the world; • strengthen nurse leadership – both current and future leaders – to ensure that nurses have an infl uential role in health policy formulation and decision-making, and contribute to the eff ectiveness of health and social care systems. All countries can take action in support of this agenda. Most countries can accomplish these actions with their own resources. For countries requiring assistance by the international community, we must direct a growing share of human capital investments into the health and social care economy. Such investments will also drive progress across the Sustainable Development Goals, with dividends for gender equity, women’s economic empowerment and youth employment. Let us seize this opportunity to commit to a decade of action that begins with investing in nursing education, jobs and leadership. viiForeword Message from the Co-Chairs The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but also to recognize the daily contributions of nurses and midwives to the health and well-being of populations across the globe. With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to present the first ever State of the world's nursing report on World Health Day. This report provides the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It also presents a compelling case for considerable – yet feasible – investment in nursing education, jobs, and leadership, which is required to strengthen the nursing workforce to deliver the Sustainable Development Goals, improve health for all, and strengthen the primary health care workforce on our journey towards universal health coverage. The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration. In many countries, the drive for data reporting was led by the government chief nursing and midwifery officers, who were supported by the provision of data from ministries of education, labour and finance. Nurse educators and regulators shared and triangulated data. National nursing associations and Nursing Now groups played key advocacy roles in reporting and engagement on the issues that would be addressed in the report. These relationships are critical to robust and routine reporting on nursing and will facilitate even stronger reports in the future. What we have achieved together is impressive. But what we are yet to achieve is vastly more important. We must use the national, regional and global data and the International Year of the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on strengthening the workforce to better provide primary care and progress towards universal health coverage. We must catalyse and sustain investments in nursing education, jobs and leadership. The health of the world requires the commitment of all countries to support and invest in the nursing workforce. We hope you will join this call to action. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now viii State of the world’s nursing 2020 STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING AND ANALYSIS WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, Novametrics (Martin Boyce, Andrea Nove) and others who contributed to the data reporting and analysis process. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson Contributors and acknowledgements Mary Watkins Alternate Co-Chair Nursing Now ixContributors and acknowledgements The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). Glossary x State of the world’s nursing 2020 EXECUTIVE SUMMARY 2020 Above images: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Central role of nurses in achieving universal health coverage and the Sustainable Development Goals EXECUTIVE SUMMARY of the health professions. Nursing is the largest occupational group in the health sector, accounting for approximately 59% Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs). They make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care. No global health agenda can be realized without concerted and sustained efforts to maximize the contributions of the nursing workforce and their roles within interprofessional health teams. To do so requires policy interventions that enable them to have maximum impact and effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment in their education, skills and jobs. Such investments will also contribute to the SDG targets related to education, gender, decent work and inclusive economic growth. This State of the world’s nursing 2020 report, developed by the World Health Organization (WHO) in partnership with the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners, provides a compelling case on the value of the nursing workforce globally. © Shapecharge/Getty Images Current status of evidence in 2020 The nursing workforce is expanding in size and professional scope. However, the expansion is not equitable, is insufficient to meet rising demand, and is leaving some populations behind. 191 countries provided data for this report, an all-time high and a 53% increase compared to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However, there are significant gaps in data on education capacity, financing, salary and wages, and health labour market flows. This impedes the ability to conduct health labour market analyses that will inform nursing workforce policy and investment decisions. The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses. This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms that nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%) professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are not classified either way. The world does not have a global nursing workforce commensurate with the universal health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that account for half of the world’s population. The global shortage of nurses, estimated to be 6.6 million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing personnel to population, with the greatest gaps in countries in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 3Executive summary xiiiExecutive summary Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020xiv State of the world’s nursing 2020 Ageing health workforce patterns in some regions threaten the stability of the nursing stock. Globally, the nursing workforce is relatively young, but there are disparities across regions, with substantially older age structures in the American and European regions. Countries with lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching retirement (aged 55 years and over) will have to increase graduate numbers and strengthen retention packages to maintain access to health services. Countries with a young nursing workforce should enhance their equitable distribution across the country. As shown in Figure 2, countries with higher proportions of nurses nearing retirement compared to young nurses (the countries above the green line) will face future challenges in maintaining the nursing workforce. *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 4 State of the world’s nursing 2020 To address the shortage by 2030 in all countries, the total number of nurse graduates would need to increase by 8% per year on average, alongside an improved capacity to employ and retain these graduates. Without this increase, current trends indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million, primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a number of countries in the American, European and Western Pacifi c regions would still be challenged with nationally defi ned shortages. Figure 3 shows projected increases in numbers of nurses by WHO region and by country income group. EXECUTIVE SUMMARY Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group While the patt erns are evolving, equitable distribution and retention of nurses is a NEAR-UNIVERSAL CHALLENGE. © ICAP/Sven Torfi nn BY INCOMEBY REGION *Includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% 5Executive summary xvExecutive summary The majority of countries (152 out of 157 responding; 97%) reported that the minimum duration for nurse education is a three-year programme. A large majority of countries reported standards for education content and duration (91%), accreditation mechanisms (89%), national standards for faculty qualifi cations (77%) and interprofessional education (67%). However, less is known about the effectiveness of these policies and mechanisms. Further, there is still considerable variety in the minimum education and training levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure limitations and the availability of clinical placement sites. As shown in Figure 4, the duration of nursing education is predominantly three or four years globally. A total of 78 countries (53% of those providing a response) reported having advanced practice roles for nurses. There is strong evidence that advanced practice nurses can increase access to primary health care in rural communities and address disparities in access to care for vulnerable populations in urban settings. Nurses at all levels, when enabled and supported to work to the full scope of their education and training, can provide effective primary and preventive health care, amongst many other health services that are instrumental to achieving universal health coverage. One nurse out of every eight practises in a country other than the one where they were born or trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge. Unmanaged migration © Nazeer Al-Khatib/AFP via Getty 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. Figure 4 Average duration (years) of education for nursing professionals, by WHO region 6 State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summaryxvi State of the world’s nursing 2020 can exacerbate shortages and contribute to inequitable access to health services. Many high- income countries in different regions appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in the health system. Most countries (86%) have a body responsible for the regulation of nursing. Almost two thirds (64%) of countries require an initial competency assessment to enter nursing practice and almost three quarters (73%) require continued professional development for nurses to continue practising. However, the regulation of nursing education and practice is not harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are challenged to keep education and practice regulations updated and nursing workforce registries current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of reporting countries with regulatory provisions on working conditions in place. Nursing remains a highly gendered profession with associated biases in the workplace. Approximately 90% of the nursing workforce is female, but few leadership positions in health are held by nurses or women. There is some evidence of a gender-based pay gap, as well as other forms of gender-based discrimination in the work environment. Legal protections, including working hours and conditions, minimum wage, and social protection, were reported to be in place in most countries, but not equitably across regions. Just over a third of countries (37%) reported measures in place to prevent attacks on health workers. A total of 82 out of 115 responding countries (71%) reported having a national nursing leadership position with responsibility for providing input into nursing and health policy. A national nursing leadership development programme was in place in 78 countries (53% of those responding). Both the presence of a government chief nursing offi cer (or equivalent) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Figure 5 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: National Health Workforce Accounts, World Health Organization 2019. 7Executive summary xviiExecutive summary Countries aff ected by shortages will need to increase funding to educate and employ at least 5.9 million additional nurses. Additional investments in nursing education are estimated to be in the range of US$ 10 per capita in low- and middle-income countries. Further investments would be required to employ nurses upon graduation. In most countries this can be achieved with domestic funds. Actions include review and management of national wage bills and, in some countries, lifting restrictions on the supply of nurses. Where domestic resources are constrained in the medium and long term, for example in low-income countries and confl ict-affected or vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should be considered. Development partners and international fi nancing institutions can help by transferring human capital investments for education, employment, gender, health and skills development into national health workforce strategies for advancing primary health care and achieving universal health coverage. Investments in the nursing workforce can also help drive progress in job creation, gender equity and youth engagement. Future directions for nursing workforce policy TEN KEY ACTIONS 1 © John W. Poole/NPR 8 State of the world’s nursing 2020xviii State of the world’s nursing 2020 Countries should strengthen capacity for health workforce data collection, analysis and use. Actions required include accelerating the implementation of National Health Workforce Accounts and using the data for health labour market analyses to guide policy development and investment decisions. Collation of nursing data will require participation across government bodies, as well as engagement of key stakeholders such as the regulatory councils, nursing education institutions, health service providers and professional associations. Nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders. Partnerships and collaboration with regulatory bodies, health workforce information systems, employers, government ministries and other stakeholders can improve the ability to monitor, govern and regulate international nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training. Nurse education and training programmes must graduate nurses who drive progress in primary health care and universal health coverage. Actions include investment in nursing faculty, availability of clinical placement sites and accessibility of programmes offered to attract a diverse student body. Nursing should emerge as a career choice grounded in science, technology, teamwork and health equity. Government chief nurses and other national stakeholders can lead national dialogue on the appropriate entry-level and specialization programmes for nurses to ensure there is adequate supply to meet health system demand for graduates. Curricula must be aligned with national health priorities as well as emerging global issues to prepare nurses to work effectively in interprofessional teams and maximize graduate competencies in health technology. Nursing leadership and governance is critical to nursing workforce strengthening. Actions include establishing and supporting the role of a senior nurse in the government responsible for strengthening the national nursing workforce and contributing to health policy decisions. Government chief nurses should drive efforts to strengthen nursing workforce data and lead policy dialogue that results in evidenced-based decision-making on investment in the nursing workforce. Leadership programmes should be in place or organized to nurture leadership development in young nurses. Fragile and conflict-affected settings will typically require a particular focus in order to (re)build the institutional foundations and individual capacity for effective nursing workforce governance and stewardship. 2 3 4 5 9Executive summary xixExecutive summary Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020xx State of the world’s nursing 2020 Planners and regulators should optimize the contributions of nursing practice. Actions include ensuring that nurses in primary health care teams are working to their full scope of practice. Effective nurse-led models of care should be expanded when appropriate to meet population health needs and improve access to primary health care, including a growing demand related to noncommunicable diseases and the integration of health and social care. Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles, leveraging opportunities arising from digital health technology and taking into account ageing patterns within the nursing workforce. Policy-makers, employers and regulators should coordinate actions in support of decent work. Countries must provide an enabling environment for nursing practice to improve attraction, deployment, retention and motivation of the nursing workforce. Adequate staffing levels and workplace and occupational health and safety must be prioritized and enforced, with special efforts paid to nurses operating in fragile, conflict-affected and vulnerable settings. Remuneration should be fair and adequate to attract, retain and motivate nurses. Further, countries should prioritize and enforce policies to address and respond to sexual harassment, violence and discrimination within nursing. Countries should deliberately plan for gender-sensitive nursing workforce policies. Actions include implementing an equitable and gender-neutral system of remuneration among health workers, and ensuring that policies and laws addressing the gender pay gap apply to the private sector as well. Gender considerations should inform nursing policies across the education, practice, regulatory and leadership functions, taking account of the fact that the nursing workforce is still predominantly female (Figure 6). Policy considerations should include enabling work environments for women, for example through flexible and manageable working hours that accommodate the changing needs of nurses as women, and gender-transformative leadership development opportunities for women in the nursing workforce. Females MalesWHO REGION Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 10 State of the world’s nursing 2020 © Yoshinobu Oka via Sasakawa Health Foundation Professional nursing regulation must be modernized. Actions include harmonizing nursing education and credentialing standards, instituting mutual recognition of nursing education and professional credentials, and developing interoperable systems that allow regulators to easily and quickly verify nurses’ credentials and disciplinary history. Regulatory frameworks, including scope of practice, initial competency assessments and requirements for continuous professional development, should facilitate nurses working to the full scope of their education and training in dynamic interprofessional teams. Collaboration is key. Actions include intersectoral dialogue led by ministries of health and government chief nurses, and engaging other relevant ministries (such as education, immigration, finance, labour) and stakeholders from the public and private sectors. A key element is to strengthen capacity for effective public policy stewardship so that private sector investments, educational capacity and nurses’ roles in health service provision can be optimized and aligned to public policy goals. Professional nursing associations, education institutions and educators, nursing regulatory bodies and unions, nursing student and youth groups, grass-roots groups, and global campaigns such as Nursing Now are valuable contributors to strengthening the role of nursing in care teams working to achieve population health priorities. 9 10 Workplace policies must address the issues known to impact nurse retention in practice settings; this includes the support required for nurse-led models of care and advanced practice roles. This report has provided robust data and evidence on the nursing workforce. This intelligence is needed to support policy dialogue and facilitate decision-making to invest in nursing to strengthen primary health care, achieve universal health coverage, and advance towards the SDGs. Despite signs of progress, the report has also highlighted key areas of concern. An acceleration of progress will be required in many low- and lower middle-income countries in the African, South-East Asia and Eastern Mediterranean regions in order to address key gaps. However, there is no room for complacency in upper middle- and high-income countries, where constrained supply capacity, an older age structure of the nursing workforce and an overreliance on international recruitment jointly pose a threat to the attainment of national nursing workforce requirements. CONCLUSION Investing in education, jobs and leadership National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; optimize return on current investments in nursing through adoption of required policy options in education, decent work, fair remuneration, deployment, practice, productivity, regulation and retention of the nursing workforce; accelerate and sustain additional investment in nursing education, skills and jobs. The investments required will necessitate additional fi nancial resources. If these are made available, the returns for societies and economies can be measured in terms of improved health outcomes for billions of people, creation of millions of qualifi ed employment opportunities, particularly for women and young people, and enhanced global health security. The case for investing in nursing education, jobs and leadership is clear: relevant stakeholders must commit to action. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1. The nursing workforce, comprising nursing professionals and nursing associates,1 is the world’s largest single occupation in the health sector and is a foundation of the interprofessional health teams that deliver on the promise of health for all. 2. Nurses’ responsibilities and roles as advanced practitioners, clinicians, leaders, policy-makers, researchers, scientists and teachers are central to the effective functioning of health professionals’ education and practice. Improvements in population health and well-being have been, and will continue to be, ably realized through the industry, innovation and inspiration of the nursing profession. 3. Nursing has existed for centuries and has evolved considerably since the birth 200 years ago of Florence Nightingale, considered the founder of modern nursing. Structured education, clinical 1 As defined by the International Labour Organization’s International Standard Classification of Occupations (https://www.ilo.org/public/english/bureau/stat/isco/isco08/). standards and nurse professional associations emerged in the 1800s, progressively raising the quality, competencies and working conditions of the nursing profession. The 1900s saw the growth of specializations and autonomy, along with stronger professional regulation to ensure public accountability and safety (1). The first international organization for health care professionals, founded in 1899, was the International Council of Nurses. Currently in its 121st year of operation, the International Council of Nurses is a federation of more than 130 national nurse associations, representing more than 20 million nurses worldwide (2). 4. Since its first years of existence, the World Health Organization (WHO) has recognized the enormous value and contribution of the nursing and midwifery workforces (3). Over the years, nurses and midwives have contributed to major global health 1CHAPTER Introduction 1Introduction landmarks, including the eradication of smallpox, the fight against communicable diseases, and the dramatic reductions in maternal, newborn and child mortality and morbidity worldwide (4, 5). Their prominent role has translated into an unparalleled level of attention by the World Health Assembly, which has adopted over a 70-year period 10 resolutions to promote the uptake of international standards to educate, employ and retain nurses and midwives as part of broader workforce development priorities (3, 6). 5. This State of the world’s nursing 2020 report, developed by WHO in partnership with the International Council of Nurses and the global Nursing Now campaign, explores the contemporary evidence with the objective of providing a vision and forward-looking agenda for nursing policy. As the world celebrates 2020 as the International Year of the Nurse 2 http://apps.who.int/nhwaportal. and the Midwife, as designated by the World Health Assembly (7), this landmark report aims to inform national, regional and global actions related to the nursing workforce in the decade remaining to achieve the Sustainable Development Goals (SDGs). 6. The report presents comprehensive, up-to-date evidence on the current nursing workforce globally; takes stock of the main issues, challenges and known evidence regarding the role of the nursing profession in the attainment of health goals; and provides concrete policy options to advance the nursing profession as part of an integrated approach to strengthen the health workforce, primary health care and health systems. 7. An online section available on the WHO website2 contains individual country profiles presenting the data provided by countries for this report. © WHO/NOOR/Sebastian Liste Individual chapter themes CHAPTER 2 Nursing in a context of broader workforce and health priorities The chapter presents the contributions of the health workforce to the 2030 Agenda for Sustainable Development and, in particular, SDG 3 on good health and well-being (8). CHAPTER 3 Nursing roles in 21st-century health systems The chapter outlines the role and contributions of nurses to deliver priority health interventions with respect to the WHO “triple billion” targets of achieving universal health coverage, addressing health emergencies, and increasing health and well-being for all (9). CHAPTER 4 Policy levers to enable the nursing workforce The chapter describes the broader health labour market and workforce policy levers and governance determinants to address the challenges to nurses working to their full potential in health facilities and communities, both in countries and globally. CHAPTER 5 Current status of evidence and data on the nursing workforce The chapter provides an analytical overview of the current nursing workforce, including the areas of greatest relevance for national, regional and global policy development, namely stock, composition and distribution; production capacity; education, regulation, practice, policy and governance environment; leadership; and labour market factors. It also highlights progress and challenges in relation to the nursing contribution to addressing the projected shortfall of 18 million health workers by 2030. CHAPTER 6 Future directions for nursing workforce policy The chapter outlines a forward-looking agenda with policy options and a call to action for Member States, education institutions, regulatory bodies, professional associations, development partners, international organizations and other stakeholders. 3Introduction © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020 2.1 Role of the health workforce in achieving the 2030 Agenda 8. In 2015, the world ushered in the United Nations Sustainable Development Agenda for 2030 with 17 ambitious and interrelated goals in areas of critical importance for humanity and the planet (8). The SDGs include eradicating poverty (SDG 1), achieving good health and well- being for all (SDG 3), ensuring inclusive and equitable education (SDG 4), achieving gender equality (SDG 5), and promoting decent work and inclusive and sustainable economic growth (SDG 8). 9. WHO leads the global health community’s efforts to accelerate progress on SDG 3, which is rooted in the concept of universal health coverage. The progressive realization 3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. of universal health coverage is a goal to which all United Nations Member States have explicitly and unanimously committed, including through the United Nations General Assembly’s Political Declaration of the High-Level Meeting on Universal Health Coverage (10) and the resolution of the International Parliamentary Union (11). 10. Primary health care is the cornerstone of universal health coverage. World leaders marked the 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care with the Astana Declaration3 (12) to firmly establish primary health care as the main approach to achieving universal health coverage. WHO has embedded the SDG and primary health care logic in the development and implementation of its own 13th General Programme Nursing in a context of broader workforce and health priorities 2CHAPTER 5Nursing in a context of broader workforce and health priorities of Work, in the form of “triple billion” targets: 1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being (9). 11. WHO’s 2019 Global Monitoring Report — Primary health care on the road to universal health coverage — found evidence of remarkable progress towards improved service coverage, with countries increasingly establishing legal mandates for universal access to health services and products in their national legal frameworks (13). However, progress has been uneven across and within countries, and financial protection for the most vulnerable remains a challenge. Weak health systems and socioeconomic factors are hindering progress; better data and evidence are needed to identify the investment priorities and track progress. Opportunities exist to shift from rigid delivery models and roles to more agile, accessible and articulated systems. 12. WHO estimates that the overall investments needed to achieve the health targets in SDG 3 by 2030 total US$ 3.9 trillion (10). Over the 12-year period, more than 40% of this investment is for the remuneration, salaries and emoluments of the health workforce required to address the projected shortage of 18 million health workers by 2030 (14–16). Estimates that include the additional investment required in the education and lifelong learning needs of the health workforce indicate that an average of more than 50% of health-related investments will need to be directed at developing, remunerating and maintaining the health workforce. 13. Contrary to the long-standing — and erroneous — notion that the health workforce represents a cost to be contained (17, 18), in 2016 the United Nations High-Level Commission on Health Employment and Economic Growth (the “Commission”) published evidence that jobs and employment in health promote economic growth and increase the productivity of other sectors (17, 18). Investment in the health system and its workforce substantially contributes to inclusive economic growth (SDG 8), particularly through the employment and empowerment of women (SDG 5) and young people (19, 20). Women account for 70% of the social and health care workforce globally (21), and nearly 90% of the nursing and midwifery workforce (22, 23). 14. The Commission provided a rationale for investment in health and social sectors, and a framework on how that investment can expand education capacity to ensure a sustainable supply of health workers and transform their competencies to meet needs, producing a health workforce with the right skills to fill decent jobs in the right places for better health service delivery, and in sufficient numbers to avert the projected 18 million health workforce shortfall. 15. In 2017, WHO Member States adopted a five-year plan to achieve the Commission’s recommendations, encompassed in the Working for Health programme and a Multi-Partner Trust Fund of WHO, the International Labour Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD) (15, 17). WHO implements these recommendations in alignment with the approaches for health workforce strengthening outlined in the 6 State of the world’s nursing 2020 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Figure 2.1 Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Strengthen data for human resources for health monitoring and accountability. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. ST RA TE GI C O BJ ECT IVE 1 STRATEGIC OBJECTIVE 3 STRATEGIC OBJECTIVE 2 STR ATE GIC OB JE CT IV E 4 Global Strategy on Human Resources for Health: Workforce 2030 (Figure 2.1) (16). 16. Accelerating progress towards universal health coverage and achieving SDG 3 is possible by refocusing attention on the investment needs for the health workforce. This necessitates a comprehensive understanding and quantification of supply, demand and needs, which are used to conduct health labour market analyses that inform integrated health workforce strategies and plans. 7Nursing in a context of broader workforce and health priorities 17. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage (24–26). However, there are challenges that are specific to the nursing profession, including issues of gender bias, policy leadership, regulation, and varied levels of education and practice roles (25). A clear understanding of these issues and priorities can facilitate the adoption of appropriate policy and investment decisions. 2.2 Who is a nurse? 18. This report aims to present the best available, internationally comparable evidence and data on the nursing workforce. To that end, it is necessary to be specific about “who is a nurse”. The evidence synthesized in Chapters 3 and 4 represents a broad interpretation of nursing as reflected in the published literature. In Chapter 5, which presents the data gathered and analyses conducted specifically for this report, the terminology specifically and singularly refers to two occupational groups defined by the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221), and nursing associate professional (ISCO code 3221). 19. Countries reported data according to who they determined met the definitions for those two occupations; countries were not asked to report on other occupation groups (such as midwives, nursing assistants or other auxiliary health workers). Some countries classify some of their health workers as “nurse-midwives”, who have a © AKDN/Christopher Wilton-Steer hybrid educational pathway and role. As “nurse-midwife” is not an internationally classified occupational group, the report only included data referring to health workers that countries categorized as professional or associate professional nurses. More information about these definitions and how countries were supported to report on their nursing personnel can be found in the description of methods in Chapter 5, as well as in Annex 1 to this report. 20. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings; it includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people (7, 27). Additional key nursing roles include advocacy, promotion of a safe environment, participation in patient and health services management, shaping health policy, education, and research (27, 28). Nurses provide a wide variety of health care services for people in all health care settings, from tertiary hospitals to health posts in remote communities. The title “nurse”, in its various forms, should indicate a person who has met the legal, educational and administrative requirements to practise nursing. 21. There are a variety of educational pathways to practise with the title “nurse”. After completing an entry-level nursing programme, higher education and specialist qualifications are also often available, usually resulting in different titles and roles. The outcome is an assortment of nursing titles, roles and competencies, even within the same country. The variety seen in any one country is magnified when examined at a regional level and increases further when assessed at a global level (Figure 2.2). Data in the Global Regulatory Atlas (29) suggest there are at least 144 distinct titles of nurses around the world that require a licensure examination, including specialist and advanced practice titles. This reflects a range in the number of types of nurses from 10 different titles in the South-East Asia Region to over 30 in the Region of the Americas and the European Region. 22. The role of a nurse in one country may be different from the role of a nurse with the same title in another country. This underscores the importance of internationally standardized definitions to support discussions of who is a nurse, understand nursing functions, and plan health services in which the contributions of nurses is optimized towards achieving population health goals. Number of distinct nursing titles within each WHO region Figure 2.2 Europe Western Pacific Eastern Mediterranean Americas South-East Asia Africa N um be r o f d is tin ct ti tle s in c ou nt rie s in e ac h W H O re gi on WHO region 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). 9Nursing in a context of broader workforce and health priorities © WHO/Atul Loke 10 State of the world’s nursing 2020 23. This chapter provides a synthesis of the contemporary evidence base (for a detailed synthesis see web annex) on the roles and responsibilities of nurses contributing to SDG 3 and more specifically with respect to WHO’s mission “to promote health, keep the world safe and serve the vulnerable” and the triple billion targets of its General Programme of Work. 3.1 Role of nursing in achieving universal health coverage 24. A Cochrane review has shown nurses to be effective in the delivery of primary health care across a wide range of services for communicable and noncommunicable diseases, including clinical decision-making roles for some conditions, as well as health care education and preventive services (30). The review shows that nursing-led primary care services can, in certain settings and under the right circumstances, lead to similar or in some cases even better patient health outcomes and higher patient satisfaction than other care delivery models; nurses probably also have longer consultations with patients (30). Other Cochrane reviews have shown that nurses are effective in the initiation and follow-up of HIV therapy (31), and that nursing interventions for tobacco cessation increase the likelihood of quitting (32). A further Cochrane review has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia (33). A Campbell systematic review has shown that sexual assault nurse examiners or Nursing roles in 21st-century health systems 3CHAPTER 11Nursing roles in 21st-century health systems forensic nurse examiners are effective in sexual assault forensic examination and documentation, that these nurses could provide sexually transmitted infection and pregnancy prophylaxis, and that this care represents good value for money (34). 25. Nurses are important to ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance (35). This is achieved through carrying out multiple functions, including monitoring patients for clinical deterioration, detecting errors and near misses (36), implementing infection prevention interventions, control monitoring and mentorship (37), and ensuring that good practices involving water, sanitation and hand hygiene are maintained (38). In outbreaks such as COVID-19 where hand hygiene, physical distancing and surface disinfection are central to containment, the infection prevention and control role of nurses is crucial (Box 3.1). 26. The historical contribution of nurses to prevention, treatment and control of communicable or infectious diseases is also well documented (4, 49). For example, nurse-led interventions can lead to an increase in vaccination rates (50). Nurses have been active across the globe in the management and prevention of tuberculosis, and can engage effectively in both clinical and non-clinical tasks, such as health promotion and psychosocial support (51–54), performing voluntary male medical circumcision (55–61), and designing and implementing HIV pre- exposure prophylaxis programmes (62). Nurses can also be effectively engaged in combating neglected tropical diseases through community education, mass chemoprophylaxis, identifying and diagnosing disease cases, determining disease prevalence, screening and confirming suspected cases identified and referred by community health workers, dispensing drugs, performing certain types of surgery (for example Box 3.1 Nursing contribution to patient safe Annually more than 8 million deaths in low- and middle-income countries are attributed to poor quality of care (39). Nurses can contribute to improved quality of care and to patient safety through the prevention of adverse events, but this requires that they work at their optimal capacity, within strong teams, and within a good working environment. Nurses play an essential role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other actions to ensure patients receive high- quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys and ineffective interpersonal relationships has been associated with worsening patient safety (40), whereas good work environments, safe staffi ng of nurses and education in mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers, and catheter-associated urinary tract infections, and reduced overall mortality (41–48). 12 State of the world’s nursing 2020 for trachoma), and providing patient education on managing disease, such as lymphoedema self-care (63). In several settings across Africa, nurses also contribute to improved quality of communicable disease care through the training, mentoring and supervision of community health workers (63–65). 27. Nurses play a crucial role in health promotion, health literacy and the management of noncommunicable diseases (NCDs) (66–72). With the right knowledge, skills, opportunities and financial support, they are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge brokers for patients and families throughout the life course (73). The success of nurses in NCD care and prevention has been repeatedly demonstrated (66–72) in a range of NCD tasks, including screening and providing primary health care services for multiple NCDs, such as hypertension, cardiovascular disease, diabetes, mental health, neurological conditions, respiratory diseases and cancer (70). In carrying out these tasks nurses have improved health outcomes, such as reductions in blood pressure and lower depression scores, and have offered equivalent care for patients with heart failure or diabetes (30, 70). Nurses have also contributed to behaviour change, such as increased uptake of medications, and patients treated by nurses are more likely to keep follow- up appointments (30, 70). An extended role of nurses within health care teams, enabled by appropriate orientation of nursing education and scope of practice, may support the integration of NCDs into primary care (74, 75). While potentially relevant in a variety of settings, an expanded role of nurses has the potential, in contexts characterized by a shortage of physician specialists, to advance health equity (73, 76). © WHO/Tania Habjouqa 13Nursing roles in 21st-century health systems 28. Nurses contribute to care across the life course. Nurses, working with midwives, obstetricians and other physician specialists, provide antenatal, intrapartum and postnatal care for childbearing women (77). Neonatal nurses with specialized skills in newborn care are effective in delivering special support and timely, high-quality inpatient care, supported by other neonatal specialists. In most countries nurses form the backbone of school health services providing care for children and adolescents (78–81). Nurses offer services across the spectrum of sexual and reproductive health; for example, they safely and effectively provide oral and injectable contraceptives, implants and intrauterine devices (82). Evidence also supports the efficacy of nurses in cervical cancer screening and provision of HIV services for women of reproductive age and beyond (83, 84). Provision of information and advocacy with age- eligible adolescents and their parents or caregivers are central components of the nurses’ role in expansion of human papillomavirus vaccination services (83, 85, 86). Nurses play a central role in the provision of care for older adults and can be instrumental in the delivery of integrated care, which results in better outcomes for older populations (Box 3.2) (87). As primary providers of palliative care, nurses enable an end-of- life experience characterized by dignity and compassion. Box 3.2 Nurse-led model of communi care for ageing populations Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health Foundation began a programme in 2014 to enable nurses to establish and operate community-based home care nursing centres (88). The centres act as community health hubs from which nurses provide services that enable ageing adults to live with dignity at home and to improve the quality of life of people in the community. The Sasakawa Memorial Health Foundation also supports a network to enhance cooperation between centres, collect data, and advocate establishment of community-based home care nursing centres (89). An eight-month programme in elder care and home care nursing prepares nurses to conduct physical assessments, meet the primary health care needs of community residents, and assist families to provide palliative and end-of-life care in the home. Additional coursework focuses on entrepreneurship, management and business plans to develop and operate a home care nursing centre (89). By March 2019, 67 nurses had completed the programme and over 56 of them operate home care nursing centres in 23 districts throughout Japan. Staffi ng at the centres averages 70% nurses and 30% other professionals, attesting to the interprofessional collaborative approach applied in meeting the primary health care needs of the communities served at the centres and in their homes. As a network, the centres averaged 25 000 visits per month. The support of families in providing end-of-life care has contributed to a reduction in health care costs associated with hospital admission and medical procedures (90). 14 State of the world’s nursing 2020 3.2 Role of nursing in dealing with emergencies, epidemics and disasters 29. Nurses are involved in delivering care for clinical emergencies (such as accidents or heart attacks), preventing and responding to epidemic outbreaks, and responding to disasters and humanitarian crises. Nurses are often the first provider that a patient sees in a health facility; their roles may vary depending on context, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures, and initiation of early referral. 30. Nurses have played a pivotal role as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003 (91), the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015 (92), Zika virus disease in 2016 (93, 94), Ebola virus disease in 2014 (95, 96) and the COVID-19 outbreak that began in 2019. Through the WHO Emergency Medical Teams Initiative, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations (97). This may be particularly important to increase the resilience of health systems that have been made more vulnerable through disasters and conflict (98). 31. In settings affected by fragility and conflict, health workers, including nurses, confront a number of both personal and professional challenges, such as the threat of abduction, having to cope with the death of colleagues, fear of their own death, increased workload, and increased complexity in the workload (for example, having to deal with firearm wounds), as well as the erosion of ethical and professional standards (99). Despite these conditions, nurses and other health workers have shown resilience and commitment in the face of these challenges and have continued to deliver essential services (99). With support, nurses in conflict settings or catering to refugee populations have been able to achieve treatment success for a range of diverse conditions, such as pulmonary tuberculosis (100) and other respiratory tract infections, dental caries and post- traumatic stress disorder (101). © National Health Commission of the People's Republic of China 15Nursing roles in 21st-century health systems 3.3 Role of nursing in achieving population health and well-being 32. Enhancing the health and well-being of populations requires nurses and other health workers to address the social determinants of health, and in so doing contribute towards the achievement of the SDGs. The prevention of diarrhoeal diseases through the promotion of handwashing, nutrition and sanitation (102, 103) represent areas with emerging evidence of nursing effectiveness in addressing the social determinants of health (4). Nurses may be among the first to deal with the impacts of climate change (104–106), which will include efforts to strengthen the resilience of the poor and those vulnerable to climate-related events, as well as reducing the mortality from climate-sensitive diseases such as diarrhoeal diseases, malaria, African trypanosomiasis, leishmaniasis, schistosomiasis, intestinal nematode infections and dengue fever. 33. Enabling and sustaining healthier populations is dependent on both ensuring the health of young people through their equitable access to universal health coverage, and ensuring that they are healthy and willing to continue the work of sustainable development into the next generation. Nurses understand and are capable of adopting the approaches needed to be responsive to the expectations of young people, including being trustworthy, non-judgemental, and client centred; meeting them on their own terms; and being accessible (107–110). 34. Nurses have shown positive results in areas that represent a particular challenge to women, such as family planning and abortion care (111, 112). Optimizing their role in the delivery of these services can lead to better access to reproductive health care for many women. Nurses offer social support to women for maternal health care during critical life events (for example, prenatal 16 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Nursing contribution to the triple billion targetsFigure 3.1 NURSES AS PART OF MULTIDISCIPLINARY TEAMS EMERGENCIES, EPIDEMICS AND DISASTERS • Delivering care for clinical emergencies • Responding to epidemics, disasters and humanitarian crises • Recognizing life-threatening conditions and performing life-saving procedures UNIVERSAL HEALTH COVERAGE • Front-line providers of primary care • Preventing and treating wide range of communicable and noncommunicable diseases • Offering care across the life course, from birth to death HEALTH AND WELL-BEING • Addressing the social determinants of health through collaborative action • Addressing and treating the impacts of climate change • Ensuring access for vulnerable groups, including women and youths and postpartum periods (113) and breast cancer) and are key to ensuring that women receive respectful care in health services settings (114, 115). Nurses are also essential to the fight against gender- based violence: studies on screening for intimate partner violence report nurses and midwives as the health professionals who most often (45% and 24%, respectively) conduct in-person identifications (116). In concluding this chapter, Figure 3.1 summarizes the contribution of nursing to the triple billion targets. 17Nursing roles in 21st-century health systems © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020 35. Optimizing the contribution of the nursing profession, as described in the preceding chapter, requires a conducive policy and practice environment. Many of the factors that influence the availability, distribution, capacity, enabling work environment and performance of the nursing workforce can be analysed through a public policy perspective, utilizing the WHO health labour market framework (117) (Figure 4.1). 36. Based on this framework, the report considers four dimensions that characterize the health workforce policy discourse on nursing, consolidating the evidence base from peer-reviewed literature on (a) pre-service education and training; (b) workforce inflows and outflows; (c) equitable distribution and efficiency; and (d) regulation (including the private sector). Also referenced in the framework are societal, economic and population factors that affect the health labour market. Some of these factors (gender bias, country income level) are discussed in detail in this report, while others, such as demographic trends (ageing, growth patterns) and climate change, should be considered more directly in the national-level context when designing and implementing relevant nursing workforce policies. 4.1 Pre-service education and training 37. The purpose of nursing education is to produce a nursing workforce that can meet the health needs of the population, in quantitative, qualitative and distributive terms. The intake and output of nursing education institutions should 4CHAPTER Policy levers to enable the nursing workforce 19Policy levers to enable the nursing workforce therefore be tailored to the needs and absorption capacity of the health sector. Ensuring there is no mismatch can be facilitated by regular dialogue between and coordination among the health, education, labour and finance sectors. 38. The number of students enrolling in and completing nurse education programmes is affected first by the basic education levels of the population and by the educational prerequisites to enrol in a nursing programme (118, 119). Enrolment in nursing programmes is affected by programme location, cost, programme capacity, clinical affiliations and level of nursing education offered. Each of these in turn is influenced by numbers of qualified faculty to accomplish programme mission and objectives, along with infrastructure and capacity for clinical education (120). Squires et al. reported that “macro” factors such as health system capacity for health workers (hospital beds per population) and gender empowerment also affect the production of nurses in a given country (121). 39. Gender issues can affect enrolment of nursing students and thus impact the supply of nurses. The social and economic undervaluing of nursing work limits nurses’ opportunities to participate in decision-making and become leaders within health care systems (22, 23, 122), Public policy levers to shape health labour marketsFigure 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service Education sector Labour market dynamics High school Training in health Training in other fields Pool of qualified health workers Migration Abroad Employed Unemployed Out of labour force Health care sector Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • n enrolment • on selecting students • on teaching staff Other sectors Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to mprove pro uctivity and performance • to improve skill mix compositio • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of t aining • to enhance service d livery Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 State of the world’s nursing 2020 which may undermine efforts to recruit qualified applicants to nursing education programmes. Biased perceptions of women’s role in caregiving and social gender norms make recruitment of male students an ongoing challenge: while a nursing education for women may be regarded as upward mobility, this may not be so for men (123–125). Furthermore, opportunities for women in other occupational groups may be limited by cultural or systemic constraints, making nursing education the only or most obvious pathway for a career in health care for women, instead of a valued option for aspiring health workers of any gender. 40. In some settings, certain race, ethnic or other vulnerable groups may be underrepresented in nursing education (126). This may have negative impacts on the cultural fit between nurses and the communities they serve. Although there is an increasing focus across the nursing profession on ensuring that education and training incorporate cultural competencies, greater efforts are needed to increase the selection and recruitment of students from underrepresented populations (Box 4.1). 41. The location of nursing schools and training programmes also affects the pool of qualified applicants. Nursing education programmes are primarily situated in urban centres with universities and hospitals, leaving potential students from rural and remote areas with far fewer education options (129). With an increasing focus on the geographical distribution of the health workforce, and the social accountability of training institutions, some programmes are incorporating rural training sites or actively recruiting and supporting students from communities historically underrepresented in post-secondary education. Online distance education programmes combined with appropriate opportunities for clinical education may offer effective options for potential students in rural areas (130); while there should be constant attention to monitoring and preserving quality of education, this approach has potential, in some settings, to enhance the diversity of students in nursing programmes (131). 42. Costs (in terms of both tuition fees and living expenses) can affect student ability to attend or complete a nursing education programme. While the cost Box 4.1 Australia: engaging underrepresented populations in the nursing workforce In Australia, Indigenous Australians have been requesting increased care from Indigenous practitioners so as to increase their access not just to care, but to culturally safe care (127). The solution however has not been as simple as increasing the numbers of Indigenous and Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these students face are addressed, such as building an enabling environment, having Indigenous nurse educators, embedding Indigenous content in the curriculum, and addressing the fi nancial needs of students (127, 128). 21Policy levers to enable the nursing workforce of nursing education can vary widely (Box 4.2), public programmes are more heavily subsidized and often less expensive than private programmes that rely on student tuition and private contributions. The cost of living, alongside low or no earnings when studying full time, adds to the personal cost of study. Different countries have varying funding schemes, which may include options or incentives for students from underrepresented groups or for those willing to practise in underserved areas upon graduation. 43. There are a variety of entry-level educational programmes that produce nurses with different qualifications and professional roles but who meet the nursing professional and nursing association classification criteria (ISCO- 08). Entry-level programmes may prepare nurses at the certificate level, diploma level and degree (bachelor’s) level; the academic requirements for an entry-level nursing programme can vary from completion of the ninth grade or below and 17 years of age for a certificate programme to completion of secondary school (12th grade) plus two years of university-level education to enter a degree programme (135, 136). While the variety of programmes and entry requirements can enable a broader range of people to enter the profession, employers often fail to differentiate practice roles based on the level of education, creating a mismatch with the supply system that is producing a generalist and the employer who has structured their services in a specialist or differentiated care context. 44. Some countries around the world educate a substantial proportion of their nursing workforce at the certificate and diploma level, often at stand-alone training institutions that focus on task- oriented clinical skills (137). University degree (bachelor’s) programmes typically include additional coursework in leadership, case management, and socioeconomic factors that affect health and patient outcomes in diverse inpatient and outpatient settings; sometimes a research component is also included. Box 4.2 Cost of nursing education Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and midwifery education (132). While nurses and midwives form more than half of the global health workforce, the spending on nursing and midwifery education is around a quarter of the global expenditure on health worker education. Estimates published in 2010 presented an average cost per nursing graduate of US$ 50 000 globally, with a range from an average of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This variance can be attributed to the proportional share of the public and private sectors in fi nancing, owning and managing educational institutions, as models for fi nancing nursing education differ both within and between countries (133). Another factor driving variability in the cost of nursing education is the different levels of qualifi cation that coexist and diversity in the duration and prequalifi cation of the education programmes (134). More and better data on nursing and midwifery graduates, and the cost of education and training, are needed to guide investments to meet the estimated shortages by 2030. 22 State of the world’s nursing 2020 These programmes also emphasize “critical thinking skills” that can contribute to more advanced clinical judgements and increase the safety of care provision. Research findings indicate that patients who are cared for by a higher proportion of degree-prepared nurses are less likely to die, stay in the hospital for shorter periods, and face lower health care costs (46, 138, 139). However, most studies indicating better patient outcomes for degree-prepared nurses took place in hospitals and have not been replicated in ambulatory and community settings, limiting the generalizability of findings (140). Additional evidence suggests that baccalaureate-prepared nurses may not use the full complement of their knowledge and skills in the workplace (141). 45. Nurses can also be prepared as post- baccalaureate specialists or at the master’s degree level for specialty or advanced practice, or can obtain a doctoral degree in nursing, either the practice-oriented Doctor of Nursing Practice, or the research-oriented Doctor of Philosophy (142). Increasing the educational qualifications of professional nurses will require articulation between different levels of programmes that build on and provide credit for prior learning (143). In countries in which there is demand for degree-prepared nurses, education programmes that “bridge” or “upgrade” an existing nursing credential can represent an important career development mechanism and generate high rates of private return. Of note, preparation of nurses at the bachelor’s level is needed for postgraduate education at the master’s or doctoral level, which in turn can affect quantity and quality of faculty for entry-level nursing programmes. 46. A critical but often challenging component of nursing education is securing adequate time and exposure for students in clinical practice settings. During clinical practicums, students apply and integrate the critical thinking, clinical assessment and nursing care competencies learned in educational settings. Clinical teaching faculty is required to provide appropriate supervision and conduct clinical skills assessment. Because many nursing programmes are located in urban areas, providing appropriate clinical experiences in rural or remote facilities can be challenging. That exposure can be instrumental to a student’s eventual decision on where to practise (144). Some online or distance programmes have been shown to increase access to rural and remote clinical facilities previously not associated with a “brick and mortar” education institution (145, 146). Alternatively, telehealth technology and simulation laboratories can provide appropriate and complementary clinical experiences in primary care (147–150). Online distance education programmes should be monitored and held to the same accreditation and quality standards as other education institutions. 47. Many countries have experienced a substantial growth of private sector health education institutions, both not- for-profit and for-profit (151, 152). The latter group is more often associated with higher tuition fees and may be subject to different regulatory authority requirements and accreditation (152). They may be disconnected from the health and education public policy objectives, and thus may not always be aligned with population–health priorities, especially if the intention is to educate nurses for the growing international 23Policy levers to enable the nursing workforce health labour market. When no quality assurance mechanisms are in place, the content and delivery modalities of the curriculum may not meet national standards, including required clinical experience, producing graduates who are not equipped with the knowledge, skills or behaviours to provide safe and quality care (153). A proliferation of private schools not affiliated with hospitals or academic medical centres can place pressure on existing clinical placement sites and call into question the quality of the training provided therein. 48. One of the biggest challenges in nurse education is the recruitment and retention of sufficient numbers of qualified nurse faculty (19, 20, 154). Challenges include their employment setting (educational organization versus clinical agency), which may involve salary differences and protected time for teaching. A report by the American Association of Colleges of Nursing proposed merging education and clinical practice roles of nurse faculty (joint appointments) to increase the status, remuneration and engagement of expert clinicians in nursing education (155). Other strategies include academic– clinical partnerships in which clinicians receive academic training to prepare them to precept students in their clinical settings, as well as incentives to further their education, such as tuition Box 4.3 Addressing the shortage of nurse educators The challenge of nurse educator shortage, which is experienced across the globe, may be alleviated through more collaborative approaches such as pooling resources across institutions, and possibly even across countries (156). In Thailand, a collaborative approach to increasing the academic credentials of nursing faculty is the Programme of Higher Nursing Education Development, conducted at Chiang Mai University and funded by the China Medical Board (157). This programme, started in 1994, focuses on training masters and doctorally prepared nurse educators to teach in the growing number of baccalaureate nursing programmes across China. The programme has subsequently expanded its impact across 10 countries in East and South-East Asia, allowing the expansion of nurse education programmes and mutual recognition of nurse credentials across the region (157). In the United States, the Veterans Affairs Nursing Academic Partnership programme provides funding for salaries and training of expert nurses as faculty in partner academic institutions to increase the number of graduates prepared to meet the unique health care needs of veterans in acute and primary care settings (158). In Rwanda, the capacity of nursing faculty was strengthened through continuous education focused on advanced teaching methodologies and curriculum development, among other approaches (159). This initiative was supported by an international academic partnership, recognizing that the programme had to be owned by Rwanda, and that cultural humility needed to be practised through the collaboration (159). 24 State of the world’s nursing 2020 remission and access to additional training opportunities. The success of these partnerships often rests on clinical sites providing adequate release time for expert clinical nurses to supervise or engage with students on site. Examples within and across countries are provided in Box 4.3. 49. The shortage of faculty prepared at the master’s and doctorate levels is an impediment to establishing higher degree nursing education programmes, especially when educators’ requirements are specified in accreditation or approval criteria. The lack of faculty trained at doctoral level also impacts the ability of the profession to conduct research needed to develop evidence to inform practice, and to assume leadership roles in academic and health care sectors (20, 154, 160). 50. Among all health care disciplines, nursing has been shown to make the most use of interprofessional education (161). This approach to education is also valued by nursing students, who perceive it as facilitating their achievement of interprofessional collaboration competencies (149, 162). Additionally, the integration of educators from different disciplines into the teaching of nursing has the potential to bring specialized knowledge from other disciplines into nurse education, and may enhance nurses’ competencies required for team-based patient care (163). Currently, this teaching approach is utilized more in high-income than in low- and middle-income countries (159), but the increasing use of technology, even in low-resource settings, creates a real opportunity to enhance interdisciplinary learning (162). 4.2 Workforce inflows and outflows 51. The number of active nurses (or nursing workforce “stock”) is determined by many elements. “Inflows” comprise graduates from domestic nursing programmes who enter practice, nurses who immigrate from other countries and those returning to practice. “Outflows” include nurse graduates who fail to maintain employment in the domestic health sector, nurses who choose to work outside the health sector, retirements and those who migrate abroad. 52. A fundamental determinant of the inflows of health workers into the health labour market is the country’s economic capacity to create funded employment positions (whether in the public or private sector) or opportunities for income through the provision of health services. Job creation is therefore directly correlated with the socioeconomic level of the country, and – within that – the level of prioritization awarded by public sector policy-makers to investments in the health sector and in the health workforce in particular. Other factors that impact demand are demographic changes, such as ageing populations; changing disease profiles, such as growth in chronic disease and multiple morbidities; high rates of nurses leaving employment or shortages of other health professionals; a growth in health facilities, for example through hospital construction or a change in hospital hiring policies; or changes in legislation, such as staffing norms for nurse-to-patient ratios (140, 164). Factors that can reduce demand for nurses include new technologies that affect the need for inpatient or provider care, high levels of retention, 25Policy levers to enable the nursing workforce greater productivity (for example, through use of evidence-based practice or greater use of technology), and role delegation from a nurse to a different occupational group (164). 53. The international mobility of the nursing workforce is increasing, with significant effects on the pool of health workers in countries. Reasons for nurse migration include availability of better jobs, salary, working conditions, health infrastructure, clinic or hospital resources, and education opportunities. In addition to these pull factors, destination countries’ visa provisions for family petitions may also be an incentive to migrate. Push factors include absence of job opportunities, poor working conditions and terms of service, and insecurity in source countries. Remittances from nurses working abroad can account for a Box 4.4 Global skills partnerships Adoption of the Global Compact for Safe, Orderly and Regular Migration in December 2018 by 152 States Members of the United Nations advanced a comprehensive approach to addressing international migration. A central tenet of the Global Compact is building global skills partnerships – bilateral agreements to leverage opportunities from migration through matching the demand for and supply of workers with targeted educational support in countries of origin (166). The format of the partnerships is designed to channel the pressures of migration into tangible, mutual and fairly shared benefi ts for both source and destination countries, which is consistent with the principles of the WHO Global Code of Practice. Through such an agreement, the country of destination agrees to provide technology and fi nance to train potential migrants with targeted skills in the country of origin, prior to migration, while the country of origin agrees to provide that training, and also receives support for the training of non-migrants (166). As part of this partnership, nurses may for example be trained on a “home track” and an “away track”, where the home track nurses receive skills training appropriate to the needs of the country of origin, while the away track nurses are prepared for working in the destination country. Depending on the needs of each partner, this partnership may not be limited to single occupations. The partnership between Health Education England (of the United Kingdom National Health Service) and the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce. Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years, then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses will spend time in Jamaica to support health system strengthening activities, including service delivery, quality improvement and training. The exchange programme was initiated in 2019. The International Organization for Migration has similar projects across the globe, linking countries of origin and destination countries through programmes that promote effective management of health worker migration, health systems capacity-building in countries of origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration with national governments and other stakeholders. The International Organization for Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of Practice as well as relevant policies and World Health Assembly resolutions (167). 26 State of the world’s nursing 2020 substantial source of revenue for families and a sizable contribution to some source countries’ economies. Policy solutions, such as agreements between countries (bilateral agreements), must be mutually beneficial to source and destination countries, consistent with the policy provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel (165) on support and safeguards (see Box 4.4 on global skills partnerships). 54. The number of foreign-trained nurses working in OECD countries increased by 20% over the five-year period from 2011 to 2016, outpacing doctors to reach nearly 550 000 (168). The vastly improved data indicate a blurring of traditionally recognized “source” and “destination” countries (169). While there is still high economic demand for nurses in high-income countries (see Box 4.5 for examples), there are emerging migration patterns from Asia, Africa and the Caribbean to other regions and countries (such as the Gulf States) (170), as well as South–South migration amongst countries within the same region. 4.3 Equitable distribution and efficiency 55. Once in the health sector, nurses are employed in a range of settings across the continuum of health service delivery points, both public and private (175–178). The distribution of nurses in different types of facilities and facility ownership is not systematically documented. However, nurses may prefer to work in hospital and acute care settings as opposed to primary care settings, and in some contexts, nurses choose to work in the private sector due to the better remuneration compared to public facilities (175, 177). 56. Care models should strive for the optimal skill mix in integrated primary health care teams (179), allowing nurses to work to the full scope of their nursing education (180, 181). Nurses are a cornerstone of integrated care teams, often leading care provision and taking on expanded practice roles, including, where relevant, collaboration with and oversight of community health workers (182–193). Allowing nurses to practise at the top of their education and experience can result Box 4.5 Examples of economic demand for nurses in high-income countries Demographic, epidemiological and health policy shifts point to a growing demand for nurses in high-income countries. Examples include: • The Health Foundation in the United Kingdom estimates a need to recruit at least 5000 nurses per year from abroad until 2024 (171). • In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers, including 60 000 nursing aides (172). • The German Government reported approximately 36 000 vacancies in elderly and sick care (173), noting that they would need to recruit from abroad (174). 27Policy levers to enable the nursing workforce in greater job satisfaction and greater patient satisfaction with care (194). Enabling factors are training in primary health care, development of standardized practice guidelines or standing orders, and data systems to track patient care outcomes (195, 196). 57. Many countries have prescribing as part of the professional or registered nurse’s scope of practice (197, 198). Nurse prescribing can be restricted to specific groups or medication schedules established in legislation or the professional regulatory framework (199). In other circumstances, the prescribing of drugs is specific to population health priorities, such as first-line antiretroviral treatment in high-burden HIV countries in sub-Saharan Africa, antimicrobial resistance, or addressing chronic conditions (200–202) (see Box 4.6 on prescribing in Poland). Nurses also play an important role in encouraging medication compliance, monitoring prescription decisions and reducing prescribing errors (203, 204). 58. The advanced practice registered nurse role was developed to increase access for underserved and remote populations and to address understaffing in primary care settings (192, 207). The most common type of advanced practice nurse role is the nurse practitioner, with a clinical scope that includes the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications (207). Certification by professional organizations and master’s level education are usually required (208). In a small number of high-income countries, there is strong evidence on the effectiveness of nurse practitioners and advanced practice nurses in providing quality care, enhancing access to care and improving patient satisfaction with Box 4.6 Expanding access via nurse prescribing in Poland Among the national health priorities for Poland was to improve community-level management of chronic conditions and to increase accessibility to treatment and medicines in primary health care settings. Policy decisions around nursing education and regulatory mechanisms effectively expanded the function of nurses in the health care system, and increased patients’ access to health services (205). In 2016, nurses with specifi c qualifi cations were granted authority to prescribe medications under certain conditions. To prepare graduating nurses for this role, prescribing was incorporated into every initial nursing and midwifery education programme, and regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe a predetermined list of medications (206). In parallel with this, a new national strategy on developing nursing and midwifery introduced organizational standards for the different roles and professional competencies of nurses and improved working conditions. Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them to prescribe. By December 2018, nurses and midwives had independently issued 2538 prescriptions and authorized the continuation of 363 288 previous prescriptions. 28 State of the world’s nursing 2020 care, when adequately trained (208, 209), though data on cost-effectiveness are limited (208–210). The number of masters in nursing programmes and nurse practitioners is growing in other countries as well (159, 211–214), though regulations affecting educational preparation and certification or licensing vary significantly (192). Recognition of the definition of the advanced practice nurse role and the related competencies also differ widely by country (192, 215), though country experience suggests that advanced practice roles increase the attractiveness of nursing as a career (211, 214). A nurse prepared at the baccalaureate level with expertise in the care of defined patient populations may also be eligible for certification as a specialist, though not licensed as an advanced practice nurse (see Box 4.7 for an example of a specialist nursing role). 59. The geographical maldistribution of the health workforce between rural and urban areas is a universal challenge. Countries employ a variety of policy measures in multiple domains (education, regulatory, financial and professional) in attempts to equitably deploy and retain health workers in rural or remote areas (217) (see Box 4.8 on rural retention). Given that a multipronged approach is required to address this multifaceted problem, understanding the impact of various Box 4.7 Example of a specialist nursing role in the African Region A growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality. A children’s health specialist is a registered nurse who has undertaken post-basic training leading to an additional recognized qualifi cation as a specialist paediatric or child health nurse. The most common route is to specialize after completing basic training (an advanced diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate diploma in paediatric nursing. The resulting title and credentials vary by country – typical formulations include registered nurse paediatric specialist, or professional nurse with paediatric specialization. There are approximately 3650 registered children’s nurses in the region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216). The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually. Three more programmes (Botswana, United Republic of Tanzania and Zimbabwe) are in development (216). Few country information systems in the region are currently set up to disaggregate by nurse specialism. The Children’s Nursing Workforce Observatory supports national planning for an optimized skill mix that meets the special health needs of children in the region. Since 2015, researchers, nursing educators and other stakeholders have been collaborating to capture and report on the role of the children’s nursing workforce in eastern and southern Africa. 29Policy levers to enable the nursing workforce interventions is key to scaling up and sharing such strategies in different practice settings and geographies (144). In a country study, additional measures were found to be important for rural providers, most notably fairness, transparency, predictability of management of human resources for health by the Ministry of Health, and employment status (permanent versus contract) (218). Studies in middle- and high-income countries found that organizational commitment, as well as intensive support from nurse managers, was linked with nurse retention in rural practice (219, 220). Recruiting nursing students from hard-to-reach communities may result in better retention if they return to work in their community (146, 221). 60. The retention of nurses in their practice settings can be challenging. Nurse turnover is an inevitable consequence of market forces that can have both positive and negative effects on health care organizations, patients, and the nurses themselves (220, 222). For instance, modest turnover rates can be beneficial for professional competency development and organizational alignment, for example when nurses exit their roles to pursue career advancement within an organization or health system (223). On the other hand, job resignations and turnover almost always involve organizational costs and can have negative impacts on patient care. 61. Both organizational and individual factors impact a nurse’s intention to leave or stay in a given job. Individual factors include changes in personal or family life or health, educational goals, work stress, job dissatisfaction or, conversely, a sense of empowerment in decision-making (224, 225). Organizational factors that affect retention include work environment, working relationships, working conditions, salary, managerial style and effective supervision (226). In studies covering Australia, Egypt, Islamic Republic of Iran, Jordan and the Philippines, research found that leadership styles of clinical managers and organizational culture directly impact nurses’ job satisfaction and turnover, and may affect quality of care, in both hospital settings (227–229) and rural settings (219, 220). Decent work 62. According to the ILO, decent work “involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men” (230). Typical challenges to the decent work agenda in the context of the nursing profession include gender issues, risk of attacks, excessive working hours and unfair treatment of migrant nurses. 63. Female nurses, together with other women in the health workforce, face more barriers at work than their male colleagues (21, 231). These include biased perceptions of women’s roles in caregiving, social gender norms, gender bias and stereotyping, all of which undermine nurses’ ability to obtain good working conditions, receive fair pay and equal treatment, participate in decision- making, and become leaders within health care (21, 22, 122). A 2019 WHO report, Delivered by women, led by men, 30 State of the world’s nursing 2020 found that there is often a greater burden of discrimination in jobs where women are in the majority: 36% of nurses in one context reported that they were not being respected by their seniors, while 32% of nurses said they would like to be heard or listened to (21). These barriers undermine the well-being and livelihoods of female health workers, and constrain progress on gender equality (21). Gender discrimination also has a direct impact on care, as institutional support and respect for nurses improves the quality of care (232). Sexual harassment in the workplace is a problem faced by women across the health workforce, including nurses (25%) (233) and midwives (37%) (21). 64. In some settings, nurses and health workers are at risk of attack. Between 1 January 2019 and 1 January 2020, WHO, through its Surveillance System for Attacks on Health Care, recorded 1005 attacks on health care, resulting in 198 deaths and 626 injuries of health care workers and patients in 11 countries facing complex emergencies (234). 4 Note that these guidelines are currently being updated. 65. Health service delivery requires constant responsiveness to patients, which poses particular challenges in relation to long and irregular hours, with potential negative repercussions for the nurses themselves (including burnout) and for patients (including increased medical errors) (235). The ILO Nursing Personnel Convention, 1977 (No. 149), commits signatories to ensuring that nurses enjoy working hours equivalent to other workers, and that overtime, inconvenient hours and shift work are regulated and compensated. 66. Migrant nurses are also at particular risk of not having decent working conditions. Migrant nurses and nurses from ethnic minorities are at higher risk of work- related injuries and discrimination than nurses from the destination country or from the ethnic majority (236). Discrimination is reported as the leading cause of impaired health amongst migrant and minority nurses (236). However, a lack of decent work at home may also be a push factor in encouraging nurses to migrate (237–240). Box 4.8 Rural retention guidelines Attraction, recruitment and retention of nursing staff in rural and remote areas is a growing concern in many countries. In 2010, WHO produced the global policy recommendations on increasing access to health workers in remote and rural areas through improved retention (217).4 The recommendations cover four main intervention areas: education, regulations, fi nancial incentives, and personal and professional support. Although research specifi c to rural nursing is growing, it is still very limited. This evidence comes mostly from high- income countries (notably, Australia, Canada and the United States), but it suggests that fi nancial incentives, personal and professional support, and accelerated health career pathways infl uence the retention of nurses in rural areas. 31Policy levers to enable the nursing workforce 4.4 Regulation 67. Regulation serves to protect the public through setting and enforcing conduct, education and practice standards. It can also benefit providers and help advance quality in nursing education (241, 242) and practice across the public and private sectors. Regulatory bodies are also increasingly generating and maintaining health workforce data and evidence (243): in the past 15 years there has been a marked increase in the generation of regulatory research evidence across several disciplines, with nursing being the most prolific (244, 245). 68. Education regulation can include setting national standards for nursing education, approval of nursing education and training programmes by the nursing regulatory body, and accreditation of institutions by external agencies. Accreditation, whereby institutions are evaluated against the standards for the delivery of education, incentivizes institutions to produce graduates that can enhance quality, equity, relevance and effectiveness of health services for the population (246). However, standards and accreditation cycles must keep pace with changes in health care science and delivery models and be affordable or cost neutral for institutions. Enforcement of standards is needed to remediate programme deficiencies or, as an extreme but sometimes necessary measure, discontinue programmes that cannot be brought up to acceptable standards. A 2013 study in 17 sub-Saharan African countries found that there was a strong legal mandate for nursing education accreditation; however, accreditation levels were low in the programmes that produced the majority of the nurses in the region and were higher in public programmes than private ones (247). In some cases, the private sector has challenged accreditation findings on the basis that those making the decisions have a conflict of interest; as a result, governments are changing the composition of decision-making bodies to increase lay member participation (248). 69. Within countries, accreditation can vary by type of programme (249). In some countries, government agencies establish and oversee public universities, and only private institutions are required to be accredited; elsewhere, if there is no government mandate, private institutions may not have to be accredited at all. Accreditation can be mandated directly by law or indirectly by requiring that graduates applying for enrolment or registration with the council or sitting for licensure exams have graduated from a programme that was approved by the nursing council or accredited by an appropriate organization. 70. Most standards for nursing education specify the minimum number of clinical hours and minimum competencies to ensure the integrity and breadth of the programme content. The standards for nursing education are often specific to an individual jurisdiction (for example, a country, state, or other area where a particular set of laws or rules must be upheld), which can impact the mobility of nurse graduates. Mutual recognition agreements and harmonized education requirements are increasing standardization and the safe and efficient mobility of practitioners. Examples include the United States Nurse Licensure Compact (250, 251), the Caribbean Regional Examination for Nurse Registration (252), the European Union Professional Directive (253, 254), the 32 State of the world’s nursing 2020 Association of Southeast Asian Nations agreement (255), and the Trans-Tasman agreement (256). Box 4.9 presents examples of harmonization of education standards and licensure examination. 71. With respect to the individual nurse, professional regulation involves (a) establishing the requirements for initial recognition for the title of “nurse” (that is, registered or registered and licensed), which could include a licensure examination; (b) the requirements for re-enrolment, registration or licensure, which could include a requirement for continued professional development; (c) setting the scope of practice for nurses and the code of conduct and ethics; and (d) facilitating the investigation of and potential disciplinary action against nurses (259). Regulatory bodies also increasingly have a mandate and responsibility to maintain an up-to-date registry of the active nursing workforce. 72. Over 60% of countries use a licensure examination to assess and enforce a minimum level of initial knowledge or “fitness for practice” of nursing graduates before credentialing them to enter practice (29). Another assessment method for initial fitness for practice is the objective structured clinical examination, which attempts to directly observe competence in a simulated clinical environment; however, this can be expensive and labour intensive to administer (260–262). There is debate about whether fitness for practice examinations should be used for re- licensure, for re-entry into the profession, or for foreign-trained nurses. Box 4.9 Examples of harmonization of education standards and licensure examination In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the initial task of establishing a shared pool of qualifi ed educators to alleviate bottlenecks in holding competency assessments for graduate nurses (252). When analyses indicated that nursing education curricula objectives, content and methods of teaching were similar throughout the subregion, countries agreed to a singular and shared examination for nurses, which began in 1990. The Regional Nursing Body coordinates the examination, which is based on mutually agreed competencies for a registered nurse to practise; governance is shared between the chief or principal nursing offi cers, nurse tutors, and nursing council of each country, as well as educators from the universities of the subregion (257). The examination allows for standardization and improvement of nursing education, as well as reciprocity and ease of movement for registered nurses among the countries of the subregion. In the European Union, efforts to harmonize the diversity and complexity in nursing degree structures and curricular programmes started with the introduction of the sectoral directives in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent updates that introduced a standard set of competencies (Directive 55) (253, 254). These changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational structure of bachelor’s, master’s and doctoral qualifi cations, with harmonized academic qualifi cations across all disciplines (258). 33Policy levers to enable the nursing workforce © WHO/Sergey Volkov 34 State of the world’s nursing 2020 73. This chapter reports, for the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardized indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach. 74. Data were collected on the availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce.5 In total, data for over 30 indicators were collected and analysed. The data collection efforts included various stakeholders such as ministries of health, other ministries such as labour and education, human resources for health observatories, national public health institutes, nursing professional organizations, government chief nursing and midwifery officers, and other national, regional and international organizations. Data were collected 5 Using the ILO definition of the nursing workforce: see Annex 1. Current status of evidence and data on the nursing workforce 5CHAPTER through a single system for data definition and reporting, the NHWA platform, which serves as an online repository for Member States to report, monitor and use their human resources for health data. Detailed methods are presented in Annex 2. 75. The focus of the analysis was on the current nursing workforce, but the last part of this chapter considers future possible scenarios of the nursing workforce under different assumptions to assess progress towards the objectives outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030, and in relation to the 2030 Sustainable Development Goal (SDG) and universal health coverage agendas (16). 76. The number of countries reporting on nursing stock is unprecedented, representing the most comprehensive 35Current status of evidence and data on the nursing workforce and updated data set on the nursing workforce ever compiled (Figure 5.1). The information on nursing has particularly increased for the period 2013–2018 as compared to other occupations thanks to the momentum created by designating 2020 the International Year of the Nurse and the Midwife. Data on the stock of the health workforce have increased in recent years, not only in quantity of information but also in the timeliness of reporting, with a majority of countries having reported data on the five occupations included in SDG indicator 3.c.1 (medical doctors, nursing and midwifery personnel, dentists, pharmacists) within the last five years. The availability of actual and retrospective data has enabled previous estimates to be updated retrospectively, and the data limitations of prior analyses and reports to be addressed. 77. Of 36 indicators on the nursing workforce used for this report (see Table A2.1 in Annex 2), almost all WHO Member States were able to report data on their nursing stock and the majority on other key indicators, such as age distribution, gender composition and duration of training. Around 80% of countries provided data for at least 15 indicators, and 23% of countries for at least 25 indicators. This chapter reports on selected indicators with a large response rate by Member States (the full list is available in Annex 2). Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data N um be r o f c ou nt rie s 160 140 120 100 80 60 40 20 0 191 countries with recent data 83% for years 2017 and 2018 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Notes: (a) Considering the last fi ve years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Number of countries with workforce data available in the WHO NHWA (1990–2018)Figure 5.1 36 State of the world’s nursing 2020 5.1 Nursing workforce availability, composition and distribution 5.1.2 Global and regional stocks of nurses 78. Data for 191 countries indicate a global stock of almost 28 million nursing personnel, comprising both the public and private sectors (Table 5.1). This translates to a global density of 36.9 nurses per 10 000 population. However, this global figure masks deep variations within and across regions.6 79. While the Region of the Americas and the African Region have similar population 6 See section 5.2 on equity. numbers, there are almost 10 times more nurses in the Americas than in the African Region, with 83.4 and 8.7 nurses per 10 000 population, respectively. The Eastern Mediterranean and South-East Asia regions have the second and third lowest density (15.6 and 16.5 nurses per 10 000 population, respectively), but this is still almost double the density observed in the African Region. 80. Around 81% of the world’s nurses work in three regions (Americas, Europe and Western Pacific), which collectively 5.1.1 Key findings Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69%) professional nurses. There was a 4.7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data. Professional and associate professional nurses represent approximately 59% of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data. Nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries. There are also large variations in distribution within regions. In the Region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57% of the population. In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries. One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24%), posing a further replenishment challenge. 37Current status of evidence and data on the nursing workforce account for 51% of the world’s population. 81. A cautious interpretation is required in comparing this total estimate of 27.9 million nurses for 2018 with the estimation in the Global Strategy on Human Resources for Health, which had estimated 20.7 million nurses and midwives (of which 18.8 million were nurses) using 2013 data. Part of the increase in the number of nurses from 2013 to 2018 is due to improvement of data availability (accounting for 4.4 million nurses), while the actual increase is estimated at 4.7 million nurses (Table 5.2), of which 3.6 million were professional nurses, assuming a constant WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Number of nurses globally and density per 10 000 population, by WHO region, 2018Table 5.1 Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions)SOURCE Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millions) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Changes in nursing stock due to better data and actual increase between 2013 and 2018Table 5.2 38 State of the world’s nursing 2020 proportion of professionals to associate professionals (Figure 5.2). 82. The total stock of 27.9 million nurses reported for 2018 therefore highlights two separate positive trends: • improved availability of nursing workforce data, which allow a better interpretation and reappraisal of prior analyses; • an actual increase in the nursing workforce stock globally, reflecting growing labour market demand for and Member States’ investment in this occupational group. 83. When comparing the stock of nursing personnel with the aggregate stock of medical doctors, midwifery personnel, dentists and pharmacists in the 172 countries with available data, nurses represent on average 59% of health professionals, ranging between 49% in the Eastern Mediterranean Region and 68% in the Western Pacific Region (Table 5.3). WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region Table 5.3 84. Sixty-six countries were able to report recent health workforce stock for at least 10 occupations; when considering nurses compared to all of these possible health workers, the nursing stock represented a share of the health workforce ranging between 40% and 50%. 5.1.3 Composition 85. Of the world’s 27.9 million nurses, 19.3 million (69%) are categorized as professional nurses (ISCO code 2221), and 6.0 million (22%) as associate professional nurses (ISCO code 3221). This leaves 2.6 million (9%) not classified either way, indicating possible challenges in alignment between national data systems and the ISCO system. These nurses are either nursing professionals or nursing associates, and this category does not include nursing aides or health care assistants. The relative proportions of the different nursing workforce categories vary substantially by region, as illustrated in Figure 5.2. 39Current status of evidence and data on the nursing workforce 5.1.4 Nursing demography: sex and age distribution SEX DISTRIBUTION 86. Gender mainstreaming in health workforce strategies is needed to ensure that evidence-based gender- sensitive approaches are undertaken in health workforce planning and management. The sex composition and ageing dimensions of nursing have long been overlooked for various reasons, including the lack of quality data for national planning and regional and global comparison. Of 194 WHO Member States, 132 provided data disaggregated by sex, and 106 provided data on age. In these 132 countries, around nine nurses out of 10 (89%) are female, with significant regional disparities. The share of women in nursing is highest (95%) in the Western Pacific Region, and lowest (76%) in the African Region. Thirteen countries reported more male nurses than female (Table 5.4). 7 Herewith called young nurses. AGE DISTRIBUTION 87. Global patterns of population and workforce ageing make it necessary to factor in the age structure of the workforce in projections. In many countries, planners rely on a standard retirement age, but this approach has limitations, given differences in actual retirement age across occupations, sex and grade levels. Data on the age profile from 106 countries were used to illustrate the current trends in nursing demographics. Overall, available information indicates a relatively young nursing workforce: 38% of nurses are aged under 35 years,7 compared with 17% who are aged 55 years or above (the latter group considered to be retiring over the next decade) (Figure 5.3). Regional variations are however important: in the Eastern Mediterranean Region there are 14 young nurses for every one approaching retirement; by contrast, in the Americas this ratio Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Global Percentage of total nursing personnel headcount Professional nurses Associate professional nurses Nurses not further definedWHO REGION 0% 20% 40% 60% 80% 100% Proportion of nursing headcount within each occupation group, by WHO regionFigure 5.2 40 State of the world’s nursing 2020 WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of female nursing personnel, by WHO regionTable 5.4 Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 0% 20% 40%80% 60% 40% 20% WHO REGION Global (n=106) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Figure 5.3 41Current status of evidence and data on the nursing workforce is 1.2:1, and in Europe and Africa it is 1.9:1, indicating a much smaller replacement pool. 88. As 17% of nurses globally are aged 55 years or over – and therefore expected to retire within the next 10 years – 4.7 million new nurses will have to be educated and employed over the next decade just to maintain the status quo. To keep pace with population growth and eliminate nursing workforce shortages, even more will be required (see section 5.8). 89. To illustrate the ageing of the nursing workforce, the ratio of the younger to the older nursing workforce is reported in Figure 5.4. While several countries have a high proportion of young nurses, several are barely at equilibrium (similar proportions of nurses aged less than 35 years and over 55 years, as indicated by the green line in Figure 5.4), and 18 countries (one in six of those with available data) face a particularly challenging situation, having an ageing workforce with fewer young nurses than nurses approaching retirement. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Percentage of nurses less than 35 years 70% 60% 50% 40% 30% 20% 10% 0% Pe rc en ta ge o f n ur se s ag ed 5 5+ y ea rs 60%0% 10% 20% 30% 40% 50% 70% 18 countries at risk of an ageing workforce Each dot represents a country Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years 42 State of the world’s nursing 2020 5.2 Equity in availability of and access to the nursing workforce 5.2.1 Key findings Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population. Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America. Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies. There are significant disparities within countries: in 35 countries with data disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector. 90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce. 5.2.2 Equity across regions 91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America. 5.2.3 Equity in nursing availability within regions 92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South- East Asia and Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population 43Current status of evidence and data on the nursing workforce Figure 5.5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. not reportednot applicable 0 1,000 2,000 3,000 4,000500 km < 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + 0 50 100 150 200 Ratio maximum: minimum density 100:1 22:1 18:1 10:1 12:1 33:1 WHO regions Africa Eastern Mediterranean EuropeAmericas South-East Asia Western Pacific N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) 44 State of the world’s nursing 2020 in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7). 93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning” or “alert” categories) according to the Fragile States Index.8 Box 5.1 presents further information on equity within countries. Level of income Low-income Lower middle- income Upper middle- income High-income 0 50 100 150 200 N um be r o f n ur se s pe r 1 0 00 0 po pu la tio n Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018. Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018) 45Current status of evidence and data on the nursing workforce Box 5.1 Equi within countries Nursing availability in rural areas The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)9 provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there. Nursing availability in public and private sectors Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions. INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowestOverall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. Density of nursing personnel per income group (2018)Table 5.5 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). 9 46 State of the world’s nursing 2020 5.3 International nurse migration and mobility 5.3.2 Challenges in quantifying international nurse mobility 94. Demographic, epidemiological, financial and health policy trends have driven an acceleration in the international mobility of health workers in recent decades, and this mobility is expected to increase (18). The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, is a key international legal instrument to strengthen ethical management of international health worker mobility. 95. The movement of health workers from lower-income to higher-income countries, as well as associated challenges, has long been recognized and debated. Data to inform policy decisions have however been largely limited to select high-income countries. Recent improvements in data availability, particularly through the system of NHWA, suggest a less clear- cut distinction between origin (in the global South) and destination (in the global North) countries than previously thought. 96. As of 2018, a total of 86 countries had provided data on the proportion of nurses who are foreign born or foreign trained as a proxy indicator of the magnitude of the migratory phenomenon (Table 5.6) through the NHWA and the OECD, Eurostat and WHO Regional Office for Europe reporting systems. Among countries reporting, one in every eight nurses (13%) was born or trained in a country other than the one in which they currently practise. Applying this share to the stock of nursing personnel gives an estimated 3.7 million nurses foreign born or trained globally. Foreign-born or foreign-trained nursing personnel are mainly found in high-income countries, with a share of 15.2%, compared to a share of less than 2% in countries of other income groups. 5.3.1 Key findings Based on data from 86 countries, one nurse out of eight (13%) was born or trained in a country other than the one in which they currently practise. Among the responding countries, there was significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. Despite improvement in availability, data on migration and mobility are still insufficient to enable a comprehensive assessment of the complexity of migration patterns. 47Current status of evidence and data on the nursing workforce INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. Percentage of nursing personnel foreign born (or foreign trained) per income group Table 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 State of the world’s nursing 2020 5.4 Regulation of nursing education and practice 5.4.2 Analysis of results 97. The Global Strategy on Human Resources for Health: Workforce 2030 includes a milestone for the year 2020 stating that countries should have regulation and accreditation mechanisms for health workforce education. This section provides a synthesis of nine self- reported indicators relating to regulation of nursing education and training (Figure 5.8). 98. The vast majority of countries reported having standards for the duration and content of nursing education, accreditation mechanisms for education institutions and a master list of accredited education institutions (91%, 89% and 81% of responding countries, respectively). Of responding countries, 77% reported having standards for faculty qualifications and 73% reported having continuing professional development systems. About two thirds of responding countries had standards for interprofessional education, fitness for practice examinations and a national association for pre-licensure students (67%, 64% and 62%, respectively). Of 95 countries responding, 53% reported having advanced practice nursing roles. The existence of these regulatory processes or systems does not necessarily mean, however, that they function adequately. 99. Table 5.7 presents data on the existence of regulatory mechanisms and systems on education and training in the different WHO regions. Countries in the African, American and European regions more frequently reported existence of regulations on education than did countries in other regions. In 5.4.1 Key findings Nearly all countries reported on indicators for regulation of nursing education, and more than 50% of countries responded positively to each of the nine related indicators. The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions. There is more attention to regulation of the contents of education (such as standards for duration and content or education institution accreditation mechanisms) than to education leadership and governance. Nursing education systems appear more regulated in the European Region and less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific regions, particularly in relation to fitness for practice examination and standards for faculty qualification. 49Current status of evidence and data on the nursing workforce Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre-licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region Table 5.7 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 50 State of the world’s nursing 2020 the Eastern Mediterranean Region, countries reported greater availability of fitness for practice examinations and the existence of advanced nursing roles. Fewer countries in the South- East Asia Region reported existence of continuing professional development systems, national associations for pre-licensure students or standards for interprofessional education than did countries in other regions. These regional variations may to some extent reflect different interpretations of these indicators. 100. Data for the nine indicators were used to derive a composite “regulation of education and practice” score for each country (see Annex 2). Each indicator could be scored from 0 (absence) to 1 (presence), with a value of 0.5 for partial; missing answers were considered as 0. These scores were then summed up to a maximum of 9. Because the analysis implicitly considers that a missing answer for an indicator gives a score of 0, a sensitivity analysis was conducted to explore the implications of classifying the missing values differently, and this did not change the interpretation of the results. Figure 5.9 reinforces the finding that the reported existence of regulatory mechanisms examined in this report points towards a relatively stronger education regulatory environment in North America, western Europe and sub-Saharan Africa. 5.5 Education and nursing workforce supply Map of nursing education regulation scores, by countryFigure 5.9 4 and less 5 6 7 8 9 not reportednot applicable Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. 0% 20% 40% 60% 80% 100% Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes 91% 53% 62% 64% 67% 73% 77% 81% 89% Figure 5.8 Percentage of responding countries indicating existence of nursing regulations and standards 51Current status of evidence and data on the nursing workforce 5.5.2 Education pipeline 101. Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational needs. 102. To assess the adequacy of the education pipeline, countries were asked to provide the number of nursing graduates in the most recent available year. In total, 88 countries, of which almost half (41) were in Europe, reported on this indicator. The “total” figures in Table 5.8 should therefore be interpreted with the utmost caution, as they are skewed by the data from South-East Asia and Europe, and are not representative of the situation in other regions. 103. Similar to the association with nursing density, the level of income was a factor associated with an increased number of graduates per 100 000 population. 104. A simulation based on the available data and applying to the world population the overall density of 22.6 graduates per 100 000 population would yield an estimate of 1.72 million nursing graduates per year. This analysis should be viewed as a pure illustration, as stemming from a small number of countries per region, with the exception of the European Region. However, the data, while limited in coverage, did not show a wide variation in the ratio of graduates to nursing stock. In addition, these results estimated on stock were compared to the share of the age group aged under 35 years, that is, roughly the workforce starting employment within the previous 10 years. Using one tenth of this younger category as a proxy to stock entering the market annually, this would correspond to a stock of 1.06 million to be compared with the present estimation of 1.7 million graduates. As not all workers are employed, the order of magnitude seems plausible. 5.5.1 Key findings A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year. Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively). Relative to their population, the Region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions. Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75% of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions. 52 State of the world’s nursing 2020 Number of countries reporting/total Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 populationBY WHO REGION Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. Production of graduate nurses, by WHO region and income groupTable 5.8 © WHO/Yoshi Shimizu 53Current status of evidence and data on the nursing workforce Average duration (years) of education for nursing professionals, by WHO regionFigure 5.10 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific WHO REGION Global Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 5.5.3 Duration of pre-service education 105. Data on the duration of nursing pre-service education programmes were obtained for 157 countries from various sources. A few countries, mainly in the African, Eastern Mediterranean and Western Pacific regions, have two-year programmes, while the majority of countries in all regions have three- or four-year programmes; five- year programmes are rare across regions (Figure 5.10). In the African and Western Pacific regions about three quarters of countries have three-year programmes, and in the South-East Asia Region almost three quarters of countries have four-year programmes. 106. In an era of expanding nursing scopes of practice, nursing education beyond pre-service is important to consider, as well as variable entries via direct entry pathways (with defined prerequisites). Reporting pre-service education programme length is affected by these inherent limitations, constraining the ability of the data presented to describe the rich variety of nurse education globally, particularly for advanced practice roles. 5.6 Regulation of employment and working conditions 54 State of the world’s nursing 2020 5.6.2 Analysis of results 107. Employment characteristics and working conditions are major drivers of attractiveness of employment, performance and productivity, and retention of the health workforce. The Global Strategy on Human Resources for Health: Workforce 2030 calls for upholding “the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion and violence”. To assess this dimension, six indicators related to regulation of employment characteristics and working conditions were examined (Figure 5.11). It should be noted that three indicators (regulation on working hours and conditions, nursing council, existence of advanced nursing roles) are specific to nursing: the rest apply to the health workforce as a whole, including nurses. 108. Of the responding countries, more than 80% reported having regulation on working hours and conditions, social protection and minimum wage, and having a nursing council or equivalent, but fewer responding countries (53%) had advanced nursing roles. A total of 55 countries responded to the indicator on the existence of measures to prevent attacks on health workers, of which just over a third (37%) said that such measures were in place. 109. Table 5.9 indicates that countries in the Eastern Mediterranean Region reported higher levels of employment regulations for nurses examined for this report: over 70% of countries responded positively to all six indicators. The South-East Asia and Eastern Mediterranean regions were the only two regions in which the majority of countries reported having measures in place to prevent attacks 5.6.1 Key findings The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses. Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations. Just over a third of countries (37%) reported having in place measures to prevent attacks on health workers, mostly in the South-East Asia and Eastern Mediterranean regions. The existence of an advanced nursing role (reported by 53% of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors. 55Current status of evidence and data on the nursing workforce Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region Table 5.9 Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Source: NHWA 2019. Figure 5.11 Percentage of countries with regulatory provisions on working conditions 56 State of the world’s nursing 2020 on health workers, probably reflecting the relatively high incidence of such attacks in these regions.10 The African, American and European regions also reported positively on most indicators tracked; only 30% of responding European countries, however, reported having advanced nursing roles and 26% reported having measures in place to prevent attacks on health workers. 110. High proportions of countries in the Western Pacific Region reported having regulation on working hours and conditions and a minimum wage, and a nursing council or equivalent. However, they reported lower levels of existence of the other three regulation mechanisms. The South-East Asia Region reported the lowest rate of positive responses to indicators assessing the regulatory environment, although half of 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. the countries in this region responded positively to each of the six indicators. As noted in section 5.4, these regional variations may to some extent reflect different perceptions of the meaning of these indicators, as well as the different reporting rates across regions. The data collected do not provide information on the adequacy of regulations or the level of implementation of the relevant provisions. 111. Data for the six indicators were used to derive a composite “regulation of working conditions” score for each country using a similar methodology to that used in section 5.4, and with methods described in Annex 2. Figure 5.12 reinforces the finding that, as for the education system analysed in section 5.4, the regulatory environment was reported to be relatively stronger in Map of regulation of working conditions scoreFigure 5.12 1 or no 2 3 4 5 6 not reportednot applicable Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. 57Current status of evidence and data on the nursing workforce North America, sub-Saharan Africa, and the European Region. 112. Advanced nursing roles were found to be more frequent in countries with lower density of medical doctors, as shown in Figure 5.13. Figure 5.13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Pe rc en ta ge o f c ou nt rie s w ith ad va nc ed n ur si ng ro le 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Source: NHWA 2019. © AKDN/Christopher Wilton-Steer 58 State of the world’s nursing 2020 5.7 Governance and leadership 5.7.2 Analysis of results 113. The future development of the nursing profession requires strong nursing leadership and governance (264, 265). Two State of the world’s nursing 2020 indicators were used to assess the state of nursing leadership and governance: the existence of a GCNO position within the national government, and the existence of nationally supported programmes to develop nursing leadership, research or policy literacy skills (115 and 76 countries responded, respectively). 114. Of the 115 responding countries, 71% reported having a GCNO position, ranging from 54% in the Eastern Mediterranean Region to 86% in the European Region (Table 5.10). Fewer countries (53% of the 76 responding countries) reported having a nursing leadership development programme, ranging from 40% in the South-East Asia Region to 64% in the African Region. 115. There are significant correlations between a strong reported regulatory environment and the reported nursing leadership and governance environment. Figure 5.14 shows that, on average, countries with a GCNO and a nursing leadership programme achieved higher scores for regulation of working conditions for nurses and regulation of nursing education. 116. Although existence of a GCNO position and a nursing leadership development programme are both associated with a strong regulatory environment, the association is slightly stronger for leadership programmes than for GCNOs. In other words, the existence of a high-level nursing position within the national government does not necessarily lead to actions such as the introduction of leadership programmes: indeed, 37% of the countries with a GCNO did not have a leadership development programme. 117. To test the hypothesis as to whether leadership and governance in nursing also translate into increased investments, as evidenced by acceleration of nursing graduation and subsequent recruitment 5.7.1 Key findings Of the 115 and 76 responding countries, respectively, 71% reported having a government chief nursing or midwifery officer position and 53% a nursing leadership development programme. Both the presence of a government chief nursing officer (GCNO) position and the existence of a nursing leadership programme are associated with a stronger regulatory environment for nursing. Neither GCNO positions nor leadership programmes are however associated with increased rates of production of nurses. 59Current status of evidence and data on the nursing workforce to tackle shortages, the ratio of graduates in countries with leadership and governance measures was compared with that in countries without. No statistically significant association was identified, suggesting that strong nursing leadership and governance does not necessarily translate into accelerated production of nursing graduates. Chief nursing officer position Nursing leadership development programme WHO REGION Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region Table 5.10 0 2 4 6 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme 0 2 4 6 8 10 No GCNO GCNO 0 2 4 6 8 10 No leadership programme Leadership programme GCNO N ur si ng w or ki ng co nd iti on s co re Leadership programme N ur si ng e du ca tio n re gu la tio n sc or e N ur si ng w or ki ng co nd iti on s co re N ur si ng e du ca tio n re gu la tio n sc or e Working conditions Education regulations P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) GCNO Leadership programme Source: State of the world’s nursing 2020 specifi c indicators, 2019. Figure 5.14 Association between GCNO and nursing leadership programme and the regulatory environment 60 State of the world’s nursing 2020 5.8 Assessing the current trajectory towards 2030 SDG outcomes 118. To achieve the health-related SDGs, WHO Member States will need to educate enough nurses to (a) compensate for losses to the profession (for example, due to death, migration or retirement); (b) meet the increased demands in many parts of the world due to population growth and ageing and changing health care needs; and (c) eliminate the existing global shortage. 5.8.2 Projection of nursing stock and density to 2030 119. A basic “stock and flow” model for each country was developed, taking into account the current nursing headcount, the estimated retirement rate (based on the age distribution of the nursing workforce), the population growth, and assumptions on the entry in the labour market (see Annex 2 for description of scenarios). On current trends, the stock of nursing personnel is projected to increase from 27.9 million in 2018 to 35.9 million nurses in 2030. 120. The increase of the nursing stock by 2030 will be concentrated in high- income countries, with very limited growth in low-income countries (Figure 5.15). The disparities documented in 5.8.1 Key findings We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89%) concentrated in low- and lower middle-income countries. If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70% of this projected increase, however, is expected to occur in upper middle- and high-income countries and not where gaps are greatest. Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population. Density in the African Region is projected to improve only marginally. Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8% from 2018 to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%. Scaling up education of nurses to address gaps may cost approximately US$ 10 per capita for the period 2018–2030 in affected low- and lower middle-income countries. 61Current status of evidence and data on the nursing workforce Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 2018 (see section 5.2) are projected to continue largely unabated to 2030. 121. The growth trajectory of the projected stock is not sufficient to fully address the needs, particularly in the African Region, where a population growth of 34% is expected. Also, the Eastern Mediterranean Region is projected to see only marginal increases in nursing personnel stock (Table 5.11). 122. Projections were conducted with different assumptions and scenarios, relying on data availability and data quality for factors used in the analysis. Potential limitations are discussed in Annex 2. 123. In contrast, the nursing stock is projected to significantly increase in the American, South-East Asia and Western Pacific regions. When grouping by level of income is considered, 88% of the increase in stock is projected in middle- income countries (Figure 5.16). 5.8.3 Nursing workforce shortage 124. The WHO Global Strategy on Human Resources for Health estimated in 2016 that by 2030 there would be a global shortage of 7.6 million nurses and midwives in countries with a density below a benchmark of 4.45 physicians, nurses and midwives per 1000 population; this threshold value excluded most high-income countries. Adopting the same methodology and benchmark values, but using more recent data, a shortage of 5.9 million nurses was estimated for 2018, and of 5.7 million 62 State of the world’s nursing 2020 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Figure 5.15 0 1,100 2,200 3,300 4,400550 km <10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 + not reportednot applicable Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. ENGLISH Lower middle income 27% Upper middle income 61% High income 6% Low income 6% Americas 43% Europe 7% Africa 6% Eastern Mediterranean 4% Western Pacific 22% South-East Asia 18% Note: Income grouping is from the World Bank classifi cation as of 2018. Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group BY INCOMEBY REGION Stock observed in 2018 (million) Stock projected to 2030 (million) WHO REGION SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region Table 5.11 63Current status of evidence and data on the nursing workforce Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. 9.0 million nurses and midwives 8.2 million nurses 7.6 million nurses and midwives 6.9 million nurses Consistent estimation of shortage by 2030 1 Correcting for nurses only 2 Correcting for improved data 5.7 million nurses5.9 million nurses 6.6 million nurses 2013 2018 2030 5.6 million nurses by 2030. The countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan. Income level is strongly associated with shortages in the nursing workforce (Annex 2, Table A2.2), with 89% of the gaps in 2018 concentrated in low- and lower middle-income countries. 125. This estimation can be compared with the findings of the Global Strategy in 2016 by correcting the previous estimate to only display shortage of nurses (that is, excluding the midwife component) and to account for improvement of data (Figure 5.17). 126. The shortage was estimated considering the benchmark value used in the Global Strategy. As such, all countries above the benchmark are excluded from this estimation. This is not to suggest that countries above the benchmark are not experiencing shortages of nurses. Most actually do experience a significant level of shortage defined against nationally identified service delivery targets and health system configurations. For these countries, specific estimations of shortages should be conducted. These should apply methodologies that account for population and workforce ageing, changing epidemiological patterns, implementation of retention strategies, and other labour market dynamics. For instance, an analysis based on nationally defined population needs and health system requirements identified a potential shortfall of up to 3.2 million nurses in 31 high-income OECD countries to 2030 (266). Similar estimates of future shortages of nurses have been reported in Japan (270 000 nursing staff by 2025) (267), Germany (approximately 500 000 health workers 64 State of the world’s nursing 2020 by 2030, especially elder care personnel and nurses) (268), and the United Kingdom (shortage of over 108 000 nurses by 2030) (269), among others. 5.8.4 Production and cost required to tackle nursing shortage by 2030 127. The required increase in graduation and jobs to fully address the shortage by 2030 was estimated under different hypotheses. • On current trends, an average of around a 10% increase per year in number of graduates (ranging from 1.5% to 14.9%) would be required. • If the labour market absorption capacity of nursing graduates were improved, using an absorption rate of 70% of graduates into the labour market, the average increase per year in graduates would be 8.8% (ranging from 0.2% to 13.4%) to address the gap. • In a scenario with a further improved labour market absorption capacity 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. (80% of graduates), the required average increase in the graduation rate would be 8.1% per year (from 0.03% to 12.2%) to address the nursing shortage by 2030. 128. To estimate the investment required to eliminate the shortage by 2030, the additional number of nurses (projected under the scenario of employment of 80% of graduates) from 2018 to 2030 was multiplied for each country by an average cost to train a nurse (270). Based on published and grey literature on education costs in low- and lower middle-income countries, three different assumptions for average cost of training per nurse were used: US$ 5000, US$ 10 000 and US$ 20 000 (271). The required investments to train additional nurses to eliminate the shortage were respectively US$ 5.2, US$ 10.5 and US$ 21 per capita on average.11 Considering the sensitivity of the analysis to the assumptions made and the paucity of the evidence, it can be reasonable to adopt a central estimate of approximately US$ 10 per capita to develop illustrative simulations. 65Current status of evidence and data on the nursing workforce © WHO/Yoshi Shimizu 66 State of the world’s nursing 2020 129. The evidence presented in this report, building on both existing frameworks and published literature (Chapters 2, 3 and 4) and the analysis of the current status of the nursing workforce (Chapter 5), provides a compelling case for a radical change in the way the nursing workforce is educated, deployed, managed and supported, as part of broader health workforce and health system policies. 130. The investments required will be substantial, but even bigger will be the returns for societies and economies in terms of improved health outcomes for hundreds of millions of people, creation of millions of qualified employment opportunities, particularly for women and young people, and enhanced global health security. 131. Harnessing this potential requires concerted efforts spanning different sectors at the local, national and global levels. In this chapter, we discuss in turn the main findings emerging from the global discourse and the specific evidence collated for this report; on that basis, we outline the actions required to stimulate sustainable investments, build institutional capacity, and catalyse policy action in support of a fit-for-purpose and fit-to-practise nursing workforce. 132. These policy options are addressed to both Member States and, where relevant, other stakeholders. Their applicability and relevance should be considered by countries on a case- by-case basis, depending on their health system’s objectives, underlying conditions and implementation capacity. Future directions for nursing workforce policy 6CHAPTER 67Future directions for nursing workforce policy 6.1 Strengthening the evidence base for planning, monitoring and accountability Synthesis of results 133. The State of the world’s nursing 2020 report represents the most comprehensive global data and evidence specific to nursing. While 80% of countries reported on at least 15 indicators, the data gaps identified reflect the varying capacity of countries’ health workforce information systems and represent valuable opportunities for focused attention moving forward. 134. Data availability was highest for indicators such as active nursing workforce stock and age composition (191 and 132 countries, respectively), but reporting of indicators relating to education, financing and health labour market flows was substantially lower, hindering the capacity to conduct comprehensive health labour market analyses. For instance, only knowing stock data without understanding in quantitative terms production capacity, vacancy rates, unemployment and attrition may leave policy-makers uncertain about whether production should be scaled up or is already adequate. Policy-makers and planners should know whether production by the education sector and absorption in the health labour market are evenly matched or leading to any form of disequilibrium (shortage versus unemployment) (see Box 6.1 on the health labour market in Scotland). Box 6.1 Scotland health labour market analysis In December 2019, the Government of Scotland released an integrated health and social care workforce plan for Scotland (272). The plan includes a vision to enable people to stay at home rather than being hospitalized. However, implementation requires an increase in the number of district nurses. The Scottish Government used data from NHS National Services Scotland, Information Services Division, to create modelled scenarios of how many additional nursing students would be required. The government also considered the supply and shortages in other health occupations, how the shortages impact what care needs to be delivered, and how this may be addressed. The data and fi ndings were shared with the Nursing and Midwifery Student Intake Reference Group and other stakeholders. This dialogue led to decisions to take a proactive approach to training district nurses, increase investment in education and training of district nurses, and consider staffi ng arrangements that will allow for nurses already in service to receive such education and training. This represents the government’s fi rst attempt at addressing health and social workforce issues in an integrated manner at the national level and shifting from planning for a single profession towards planning for multidisciplinary team-based care. 68 State of the world’s nursing 2020 135. Factors influencing the availability of data and ability of countries to report across these indicators include the level of coordination across the ministries of health, labour, education, and finance, as well as engagement with other stakeholders, such as professional associations, councils and educational institutions. Policy options 136. Countries should accelerate the implementation of their National Health Workforce Accounts (NHWA), including disaggregated reporting for the nursing workforce. Of particular urgency is addressing gaps in essential data elements to conduct national health labour market analyses. This should be accomplished through a comprehensive effort at strengthening and building the capacity of the human resources for health information system (273). The description of the global nursing workforce was feasible due to global efforts to implement NHWA and a commitment to diversify data sources. Institutional capacity-building for human resources for health information systems may entail establishing permanent mechanisms to convene stakeholders, including nursing leaders, to establish clear mechanisms for collation and exchange of data, to discuss data availability, quality, and challenges, and to implement interoperable data systems. Coordination among different sectors and stakeholders may also present opportunities to formalize the political mandate for data collection and sharing, and for intersectoral policy dialogue to translate the data into meaningful policy changes. Countries should leverage strengthened nursing and health workforce data to be included in health labour market analyses to guide policy and investment decisions at the national level (see Box 6.2 on nursing leadership teams using NHWA indicators for a nursing labour market analysis). 6.2 Mobility and migration Synthesis of results 137. Approximately 3.7 million nurses (or one in eight) are practising in a country other than the one in which they were born or trained as a nurse. The findings indicate a high international mobility of nurses, fuelled by a strong dependence on migrant nurses in countries with low domestic production. The demand from high-income countries (where over 15% of nurses are reportedly foreign born or foreign trained) can attract the most qualified nurses from lower-income countries and deepen quality and distribution divides that are detrimental to population health (see Box 6.3 on Germany’s approach to managing migration). 138. Very high levels of out-migration (when they are not the result of a deliberate policy to export the nursing workforce overseas) can be interpreted as a symptom of unattractive labour conditions at home. The policy prescription should therefore focus on treating the underlying causes (in terms of improving the work environment, support systems and remuneration), rather than attempting to address in isolation the migratory phenomenon. Similarly, in the preparation of nurses an appropriate balance must be struck between the skills and competencies required to prepare a nurse to work in their local context and in primary care, versus the interests of students to learn skills that will allow them to maximize income 69Future directions for nursing workforce policy Box 6.2 East, Central and Southern African Health Communi : national collaboration on nursing data reporting using NHWA indicators The East, Central and Southern African Health Community (ECSA-HC) is an inter- governmental health organization that fosters and promotes regional cooperation in health (274). Nursing shortages are common in the subregion. Poor working conditions and high caseloads contribute to lack of incentives for nurses to enter the workforce and high levels of out-migration. Often-fragmented education systems struggle with inadequate faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses. The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and the ECSA College of Nursing on a study to assess nursing labour and education markets. The objective was to estimate the magnitude of the challenges in these systems and to identify policies to scale up nursing education in the region through targeted public and private investments. The study examined how the interaction between the education system and the health system was mediated by the labour market for nurses, considering governance and regulatory challenges. The data collected were indicators from the WHO-developed NHWA (273) as well as additional qualitative data collected during regional consultations. The country teams coordinating data reporting for the study were national nursing leadership “quads” with additional support from WHO in the review process (see also subsection 6.3.3). Results revealed an imbalanced market, and a critical misalignment of demand for and supply of nurses in the subregion. While nursing supply has grown faster than population growth over the past 10 years, it coexists with low absorption rates of nurses into public sector positions (often due to recruitment ineffi ciencies or undesirable working conditions) in many countries, and large needs-based shortages. The projections analysis estimated that effective demand would grow by 33% between 2019 and 2039, but still leaving a surplus of over 220 000 nurses that the public and private sector were not able or willing to employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030, expanding the current imbalances in the nursing labour market. The study concluded that increasing the supply of nurses to respond to the SDGs in ECSA countries would require scaling up nursing education, improving the quality of nursing schools (including enforcement of quality assurance mechanisms), and increasing resources needed to absorb nurses into the local and regional labour markets. This can be facilitated by adequate investments in physical and human resources, nursing governance, regulation, and the production of data and analytical capacities to empower countries to monitor the impact of investments. 70 State of the world’s nursing 2020 opportunities and migrate to work in a more specialized or global professional setting. 139. With the vastly increasing numbers of nurses migrating, the typical approach of single-jurisdictional solutions to public protection are inadequate, and reformed systems need to provide and enhance regional and global solutions (245, 278, 279). Furthermore, because many countries are simultaneously countries of both origin and destination, it is essential to better understand the patterns of movement in order to effectively manage mobility and plan for future health workforce requirements. However, only 86 Member States reported on the percentage of foreign-born or foreign- trained nurses in their workforce, one of the basic reporting requirements envisaged in the WHO Global Code of Practice on the International Recruitment of Health Personnel. Box 6.3 Germany’s approach to managing migration On 9 November 2018, the German Parliament passed the Care Strengthening Act, which aims to improve the attractiveness of health care and long-term care for employees and care staff in hospitals and residential homes (275). Improving staffi ng in these facilities was at the heart of the new government’s health policy. For many years health care and long- term care had suffered from a severe shortage of nurses, with widespread understaffi ng in hospitals and residential homes. Numbers of professionals leaving the health service due to retirement and dissatisfaction were greater than the numbers entering the workforce upon graduation from vocational training. Furthermore, understaffi ng was perceived to lead to deteriorating working conditions for staff and poor quality of care. In 2012 it was projected that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030 (276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy comprising a scale-up in education, the creation of new nursing jobs and the optimization of international recruitment of migrant health workers, such as nurses from central and south-eastern Europe (277). For this last element, Germany has taken steps to harness opportunities for mutual benefi ts with source countries from international health worker mobility, including through technical cooperation and bilateral agreements that create training and investment opportunities in the source country (168). Policy options 140. Countries and regulators should strengthen the implementation of regulations governing international mobility of health personnel, including the nursing workforce. The regulators in the destination jurisdictions need to establish that the nurse’s preparation, qualification and disciplinary history meets the required licensure, educational and ethical standards and codes of conduct, in the interest of public protection. Enhanced models of regulation can facilitate mobility through harmonization of requirements to enter a nursing programme and of the educational content required to earn and maintain nursing credentials. Regional experiences of agreements on mutual recognition of nursing professional qualifications provide a potential basis for broader agreements in the future. 71Future directions for nursing workforce policy 141. Countries and international stakeholders should reinforce the implementation of the WHO Global Code of Practice. The ability to effectively monitor, govern and regulate international mobility of the nursing workforce may require capacity- building, leveraging partnerships, and collaboration between regulatory bodies, health workforce information systems, employers, government ministries, and other stakeholders such as professional associations. Countries experiencing an excessive loss of their nursing workforce through out-migration should consider putting in place mitigating measures, such as improving the salaries (and pay equity) and working conditions, ensuring decent work, and implementing tailored retention packages where warranted. 6.3 Developing and supporting the nursing workforce 6.3.1 EDUCATION Synthesis of results 142. The findings of this report illustrate a complex situation with respect to the production of nursing programme graduates. The lowest proportion of graduates in relation to existing stock was in the European and Eastern Mediterranean regions and high- income countries. Unless middle- and high-income countries can increase production, the data suggest a potential continued reliance by high-income countries on international recruitment, potentially exacerbating existing shortages and raising related access and equity issues. 143. There is considerable variety in the duration of nursing education and training programmes in different regions of the world. However, countries overwhelmingly (154 out of 169 responding countries) reported standards for the content and duration of education and training. Critical considerations when developing such standards include whether they help educators provide students with competencies required to meet population health needs, including preparation for primary and preventive care services, disaster, emergency, and conflict competencies where indicated, leadership skills, and appropriate use of technology (see Box 6.4 on technology in nursing education and practice). 144. Most countries (89%) also reported accreditation mechanisms in place for education institutions and maintaining a master list of accredited institutions. This indicates, for most countries, an opportunity to focus on strengthening key areas of accreditation, including efficient and affordable models, and ensuring the social accountability and relevance of programmes to population health priorities. Robust accreditation mechanisms can cover content, curriculum, student clinical experiences, faculty qualifications and interprofessional learning. Our findings indicated that 67% of responding countries have standards for interprofessional learning, but in some regions this was less than half or as low as 20%. 145. Ensuring a representative health workforce, with a composition mirroring that of the population to be served, requires diversity of those entering and completing nursing programmes. Findings from this report indicate that that the nursing workforce is still largely female, particularly in the American and Western Pacific regions. Fostering an appropriate composition of the nursing 72 State of the world’s nursing 2020 workforce will require not just increased enrolment of diverse student groups; it will also require addressing the structural and organizational challenges that either exclude some students from nursing (for example, completion of secondary education) or prevent the completion of their studies (for example, excessive costs) (126). Demand for nursing programmes may also be affected by the gendered occupational segregation and the low status of nursing in some countries. Addressing these challenges is required to make nursing an attractive career choice, especially in regions such as the Americas, where graduates are fewest relative to population. Policy options 146. Countries should ensure nursing education and training programmes equip nurses with competencies to deliver high-quality, integrated, people-centred services. A priority Box 6.4 Technology in nursing education and practice Technology is playing an increasing role in both education and practice of the nursing workforce. Technology can be harnessed to access clinical decision support, conduct provider-to-client telemedicine, and receive provider-to-provider training and consultation (280) in ways that can enhance access, enable remote care, improve primary health care service delivery and empower patients. Nurses should be equipped and conversant with the digital determinants of health: these include their level of digital literacy, access to technological equipment, and Internet infrastructure, including broadband where available (281). Digital health technologies, be it artifi cial intelligence or other forms such as augmented reality and the use of robotics, are already transforming nursing and patient care (282). Personalized medicine and genomics have the potential to better tailor patient care (283). One of the greatest potentials for digital health lies in lifelong learning opportunities. Technologies such as artifi cial intelligence can allow learning to be personalized, relevant and up to date. Findings from a Cochrane systematic review of health worker experiences of mHealth in primary health care suggest that health workers, including nurses, have appreciated the benefi ts of using mobile technology in their delivery of care, but have also encountered challenges (284). The benefi ts described included being more connected to each other, taking on new tasks, improving coordination and quality of care, improved communication with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health worker accounts described multiple and complex challenges, which could be personal (such as poor digital literacy), relational (preferring face-to-face contact with clients and colleagues), professional (feeling that their clinical skills were threatened by digital clinical support tools), contextual (clients not being able to afford mobile phones), or infrastructural (lack of electricity) (284). While technological advances offer many benefi ts, health worker accounts included in this systematic review suggest that health system decision-makers need to think carefully about how it is implemented in their context so as to minimize the challenges experienced by health workers, including nurses. 73Future directions for nursing workforce policy issue is to critically appraise the skills mix within the nursing profession and decide whether the levels of nurses and the types of specializations are relevant to the health system objectives, and ensure availability of adequate numbers of training posts based on health system needs and absorption capacity. Creating or increasing the number of higher levels of nursing education – for example, bachelor’s or master’s programmes, or Doctor of Philosophy – has structural implications, such as developing new educational programmes, staffing them with appropriate faculty, and ensuring nurses with this type of educational pathway will have a defined role in the health system. 147. Countries should consider mechanisms to increase the demographic and geographical diversity of students in nursing school. This may mean addressing biases that negatively impact nursing as a career choice for men, young people, or specific ethnic groups, and accommodating those wanting to enter nursing as a second or subsequent career choice. Developing a “rural pipeline” to foster a gender-balanced intake and appropriate number of students from rural, remote and otherwise underserved areas and communities may be required in some contexts. Targeted financial support and incentive mechanisms can also be used to increase opportunities for formal education for minority and vulnerable groups and disadvantaged populations, and to attract faculty that reflects student and community populations. Accreditation criteria that reinforce social accountability measures are one such mechanism. 148. Health education institutions and regulators should adopt competency- based curricula and leverage appropriate technology. Quality in nursing practice should be reflected throughout the curricula. In addition to the technical knowledge and procedural skills for individual clinical interventions, nurses should be equipped to work in interprofessional teams; to demonstrate empathy and compassion to patients; to make decisions under pressure; and to acquire the tools to keep learning over a career spanning decades. Curricula should be matched to both the scope of practice of graduating students and the population health needs. The digital provision of educational and training content can usefully complement traditional methods. The success of such efforts at “distributed learning” will require ensuring that students acquire a minimum level of digital health literacy as part of their education, that the curriculum design makes use of relevant digital and telehealth learning for the requisite competencies with support and supervision for clinical training (285), and that the institutional and infrastructural resources needed to enable a bridging of the digital divide are in place (286). 149. Governments and stakeholders should develop and leverage intersectoral partnerships and cooperation to advance the nursing education agenda. Cooperation with regulatory bodies can facilitate review of entry requirements to nursing programmes and the minimum education standards for nurses (given the current and future professional roles in the health system) and can promote harmonization of standards at regional level. Intersectoral dialogue 74 State of the world’s nursing 2020 with accrediting bodies can help identify mechanisms to further the social accountability aspects of accreditation, for example by ensuring that nursing education institutions prioritize the production of graduates able to deliver quality health services, rather than their institutional income and status, through tuition fees and government grants. Relevant line ministries (education, health) can strengthen formal coordination to promote science and technology as fundamentals of the nursing profession, to market nursing as a STEM (science, technology, engineering, mathematics) field, and to put in place mechanisms to attract a diverse range of secondary school students to nursing. Public–private partnerships can help source sites for clinical training in primary health care settings; engagement with other health occupation education programmes can help make these clinical practicums interprofessional. 150. Nursing education institutions should strengthen their capacity by addressing inadequacies in faculty numbers or competencies, infrastructure limitations, and the availability of appropriate clinical practice sites (see Box 6.5 on commitments from Pakistan on producing more nurses). In order to increase training posts while preserving quality, investment in faculty development programmes may be needed. High-income countries or countries relying on international recruitment should increase the domestic production and deployment of nurses. 151. Countries should consider applying relevant financing levers to expand (where needed) or strengthen the quality of nurse education to address health labour market failures. Financial mechanisms have great potential for increasing the diversity of the student pool, the faculty pool, or the number of seats in nursing programmes, and addressing some of the current limitations in clinical training. Financial subsidies for post-basic education programmes are sometimes used to promote pathways Box 6.5 Pakistan e orts to increase nurse education capaci Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched its national Human Resources for Health Vision for 2030, aimed at addressing the health workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in Pakistan, highlighting the contributions of nursing to population health (287). In launching the Year of Nursing, President Alvi announced that a nursing university would be established in Islamabad, which aims to provide training to 25 000 students each year (287). The country plans to double the size of the nursing sector within two years, to overcome the national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid, Parliamentary Secretary for National Health Services, as an impediment to attaining universal health coverage, with adequate numbers of well performing nurses needed for an effective health system (288). 75Future directions for nursing workforce policy to higher levels of nursing practice. Governments, however, must be able to make informed decisions on whether it is a cost-effective investment to subsidize nursing education, under what circumstances, and in what ways, prioritizing scarce resources on investments that can directly contribute to equity and efficiency objectives (289). For example, a health labour market analysis should identify the settings where nurses are underproduced or overproduced as compared to health system needs. Where a systematic underproduction is documented, there is a case for government intervention to relax unnecessary barriers to entry and if needed to subsidize pre-service education, particularly if priority is awarded to the group of disadvantaged students, in order to facilitate education pathways leading to a preferential career in the primary health care setting, and in exchange for a minimum guaranteed period of exclusive service within the public sector (140). 6.3.2 NURSING PRACTICE Synthesis of results 152. The report findings indicate a nursing workforce larger than previously estimated — nearly 28 million in 2018, comprising a minimum of 69% professional and at least 22% associate professional nurses. The growth, compared to previous 2016 estimates in the Global Strategy on Human Resources for Health, is due in roughly equal portions to vastly improved nursing workforce data availability and quality, and to actual growth in stock. 153. Even with the growth in stock, inequitable geographical distribution of health workers, including nurses, is a universal challenge. This report found significant differences in the distribution of nurses across and within countries and regions. The findings of the report further indicate that 53% of responding countries have advanced practice roles in nursing. These roles are more frequently found in countries with low density of medical doctors. This highlights the flexibility and responsiveness of the nursing workforce in relation to the broader health workforce situation of a country. These nurses may be well placed to provide care to populations in rural and remote settings, if the existing skills mix suggests such a move would increase efficiency. 154. Within countries, the data point to a continued need to focus on addressing the maldistribution of nurses located in rural versus urban areas to improve equity of access. The retention of health workers is related to a variety of complex and interrelated factors such as working conditions, occupational safety, remuneration levels and non- monetary incentives. Sustained success in improving nurse retention is likely to be the result of planned, sequenced, multi-policy interventions tailored to the local context. Retention should not be examined or addressed in isolation from the context of other features of the working and living conditions of nurses. Policy options 155. Countries should enable nurses to work to the full extent of their education and training (180). This objective should be part of broader national efforts to adopt care models that optimize the division of tasks in integrated primary health care teams (179). This entails maximizing the contribution of nurses to enhance primary health care in priority areas 76 State of the world’s nursing 2020 (see Box 6.6 on expanding access to community health services in Oman). Possible approaches could include advanced practice roles, expansion of nurse-led clinics, and developed or expanded authority for prescribing, with the commensurate development or strengthening of education and training required. Nurses with advanced practice credentials should be in settings that optimize their productivity in providing patient care or leadership and management to other clinicians. Nurses functioning in advanced practice roles or in nurse-led clinics should be supported with mentorship or collaborative partnerships as needed, be provided with adequate supplies and medications, have clear clinical and facility guidelines for practice, and have access to the required resources, including online reference materials and appropriate technology. Embedding the required reforms in relevant education, health, labour and other policies requires institutional capacity for effective collaboration and coordination; supportive institutional structures and dedicated resources; leadership and political will; effective managerial oversight; and effective organizational culture. It is also important that the roles and functions of nurses based on scope of practice and competencies are accurately communicated to other health care providers and the public. 156. Countries should optimize their modalities and mechanisms for effective deployment and management of their nursing workforce. The efficiency, equity and transparency of hiring and deployment are key elements of the decent work agenda (16). Box 6.6 Expanding access to communi health services in Oman The country of Oman provides an example of reorienting nursing and midwifery education and emphasizing primary care competencies, which was a component of the call for action to strengthen the nursing workforce adopted by the 66th session of the Regional Committee for the Eastern Mediterranean (October 2019) (290). Oman has experienced a rapid growth in population and life expectancy. The improvements in socioeconomic status, however, have come with an increase in the burden of chronic illness. To address this population health issue, the government decided to invest in community health nurses (291). The Department of Nursing and Midwifery at the Ministry of Health initiated a 16-week on-the-job training programme, fi rst piloted in the capital, Muscat, and then extended to other governorates. Community health nursing services were integrated into primary health care structures in line with the services provided in the primary health centres (292). Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus on community health nursing, and then to a post-basic diploma in community health nursing specialty (291). This specialty programme has contributed to maintaining the supply of qualifi ed community health nurses to meet primary care service needs in the country. 77Future directions for nursing workforce policy Policy-makers and managers should have access to reliable metrics that assess the efficiency and timeliness of the employment process, such as the percentage of new graduates that are employed three months, six months or one year after licensure, the average time between graduation and licensure, and the average time between licensure and employment. A low rate of employment of graduates may be symptomatic of saturation of the labour market, but if concomitant with excessively long lag times between graduation, licensure and employment, it can instead suggest rigidities and bureaucratic hurdles in the administrative system. The modalities of deployment also matter: unless the public sector can guarantee the absorption of all qualified candidates, competitive recruitment following the publication of vacancies and a meritocratic assessment of candidates’ competencies remains the modality of choice (289). Career advancement and promotion opportunities should also be linked to merit and capacity, rather than primarily based on seniority (years of service). As for other occupational groups, the limits of compulsory deployment and rotation schemes should be taken into account when considering such schemes. Wherever possible, deployment of nurses should be based on voluntary career choices and preferences in relation to duty station. Reconciling nurses’ preferences with health system needs, in particular in relation to geographical equity, can be challenging. When tensions emerge between the two, a range of related and mutually reinforcing strategies for rural deployment and retention is desirable from the perspective of both effectiveness and workers’ rights (289). 157. Countries should explicitly and proactively anticipate challenges in the retention of nurses and put in place relevant policies. Evidence- based approaches to enhance retention include opportunities for leadership development, mentorship (293, 294), flexible scheduling, non-monetary incentives and lifelong learning. A formalized preceptorship for new graduates entering the workforce can improve their transition to practice, clinical competence, job satisfaction and professional socialization, all of which may affect retention of new nurses in the workforce (295). The effect of preceptorship on role competence and retention is similar for new nurses in rural or urban settings (296). Specific policies should be in place for increasing the roles of women in leadership, addressing gender discrimination, and preventing sexual harassment, which, in addition to being a violation of workers’ dignity and rights, is linked to increased attrition (122, 297, 298). © Kieran Dodds 78 State of the world’s nursing 2020 6.3.3 REGULATION Synthesis of results 158. Nursing regulation plays an essential role in protecting the public and empowering health systems to respond to changing patient and population needs. It can also provide a framework for advancing the profession (243, 299). The findings of this report indicate that 164 Member States (86%) have an authority responsible for the regulation of nursing education and practice. The strength and effectiveness of the regulations issued, however, must be examined on an individual country level. For example, 73% of countries indicated they had a regulatory requirement for lifelong learning, but fewer (64%) indicated presence of regulations that required a licensure or fitness to practise examination. 159. Professional regulations are also important to preserve quality care in a context of growing international professional mobility, ensuring incoming health workers have competencies that match the needs of the population, and the ability to practise without compromising public safety. Real-time, web-based systems that can facilitate expedited recognition of credentials and provide collated information on the current licence status and professional history of the practitioner are emerging as useful tools on a regional basis and could potentially be developed into global solutions (168, 300–302). Policy options 160. Countries should develop and enhance nursing regulation to support safe, sustainable, and high-quality education and practice. The authority to regulate nursing may need to be established through new or updated primary legislation that establishes the role and functions of the regulatory authority and key provisions and standards for nursing education and practice. One recurring challenge is the need to strike the right balance — ensuring that regulations are the least restrictive while achieving the desired public protection benefit (303–306). Countries should consider establishing requirements for lifelong learning to ensure nurses at various levels are exposed to learning opportunities appropriate to their role. The use of a licensure examination to assess a minimum level of initial knowledge before a nurse is allowed to practise is increasingly common (255, 307). While stronger evidence of the comparative effectiveness of different approaches is still needed, there is a broad consensus on the need for the competency assessment to be valid, fair, independent, and based on the knowledge and skills that nurses will need in a variety of practice settings. 161. Countries should invest in the capacity of regulatory systems to strengthen and enhance the quality of nursing education and practice. A key aspect is to ensure regulators have and maintain live registries that are interoperable with other databases in the health system and other regulators. One way of maintaining up-to-date registries is through the requirement for re-registration or re-licensure, which can also be instrumental in incentivizing lifelong learning as well as generating income for the regulatory body. The individual capacity of nurse regulators also requires strengthening. Nurse regulators, as is also typical for other health occupations, may have received 79Future directions for nursing workforce policy little or no formal training in professional regulation prior to assuming that role. Regulators can learn from the experience of other countries and regional-level efforts that have been successful at strengthening regulatory frameworks (see Box 6.7 on the African Health Profession Regulatory Collaborative). 6.3.4 DECENT WORK Synthesis of results 162. Ensuring decent work conditions is relevant and necessary for all health occupations, but the nursing profession faces particular challenges. As a mostly female workforce and considering the negative legacy in some contexts of a traditionally subordinate role, the nursing workforce is inherently more prone to facing gender bias and discrimination at work. Nurses are also subject to long working hours, risk of attack in some settings, sexual harassment and unfair treatment as migrant workers. The existence of regulations on working hours and conditions was reported by 94% of countries, on social protection by 91%, and on minimum wage by 89%, although less is known about the adequacy and actual level of implementation of such policies. A total of 55 countries (36%), mostly in the South-East Asia and Eastern Mediterranean regions, reported measures to prevent attacks on health workers. Policy options 163. Countries should implement the Decent Work Agenda and invest Box 6.7 African Health Profession Regulatory Collaborative The African Health Profession Regulatory Collaborative (ARC) was created to help countries update nursing and midwifery regulations to facilitate safe and sustainable nurse-led models of care and treatment for patients with HIV. The collaborative involved 17 countries, comprising most members of the East, Central and Southern African College of Nursing (ECSACON) (308). ARC convened the government chief nurse, the president of the national nursing association, a leader in academia, and the registrar of the national nursing and midwifery council from each country and supported prioritization of and collaboration on nationally identifi ed regulatory challenges. The country leadership teams, who called themselves “quads”, worked together on their regulatory priority (for example, scope of practice inclusive of HIV tasks, continuing professional development requirements for HIV content) on annual cycles. Quads met frequently in country as well as with regional colleagues working on similar priorities. Progress was measured regularly and with diverse measures (309). Over the course of fi ve years (2011–2016) nursing and midwifery regulations were strengthened, and quads reported substantial increases in leadership skills, organizational capacity, and collaboration among national nursing and midwifery organizations (310). While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized in ECSACON countries and serves as a continuing mechanism to leverage nursing and midwifery leadership to address national health priorities. 80 State of the world’s nursing 2020 in enabling working conditions for nurses. Essential elements include adequate remuneration, social protection, fair working conditions, reasonable working hours, occupational safety, non-monetary incentives, and transparent and merit-based opportunities for career progression. These conditions are closely related to nurse retention and should apply to nurses irrespective of their gender, social background, country or region of origin, ethnic group, or language, and should be enforced through clear accountability mechanisms. Health workers’ rights, including appropriate pay and adequate working conditions, are some of the most common reasons for industrial action or strikes by health workers (see Box 6.8 on health worker strikes). 164. Countries must protect and support nurses who are directly affected by humanitarian crises. Ministries of health, professional nursing organizations and nongovernmental organizations need to engage with relevant authorities and parties involved to ensure the protection of and support for nurses who may be providing care in severely underresourced or harsh conditions (such as refugee camps or shelters), or who may be part themselves of a population displaced across a border and providing care in jurisdictions where they are not formally recognized to practise. This will help ensure the security of all health workers and health facilities in all settings, particularly for women, who may be at greater risk of attack or harassment during the crises. Box 6.8 Health worker strikes In many countries across the globe, workers are legally entitled to strike, and this is widely considered as a civil right (311). However, for health workers, exercising this right is complicated because doing so creates a tension with patients’ rights to care, and with citizens’ rights to universal health coverage, and may or may not lead to increased mortality (311–314). Notwithstanding, health worker strikes, including by nurses, take place across the world, in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income countries found that health workers were reported to be on strike for 875 working days, in 23 low-income countries, between 2009 and 2018 (311). The study reported that strikes could last days or months, and could also be recurrent over months or years (311). The primary causal factors leading to these strikes were complaints about remuneration and delayed payments, followed by protest against the unsatisfactory implementation of a previously reached agreement, or against the health sector’s governance and policies, as well as complaints about working conditions and security issues. Reducing health worker strikes will require multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research is needed to understand the causal factors in individual cases, as well as patterns across regions, and which actors should be engaged to reach a positive resolution (311). However, it is clear that multisectoral action, with the support of political leadership, is needed between health and other sectors to address the upstream factors associated with health worker strikes (314). Investment in decent working conditions for health workers, where they are assured of a safe, enabling and effective working environment, is vital for the achievement and protection of the right to universal health coverage (314). 81Future directions for nursing workforce policy 6.3.5 GENDER AND WOMEN’S RIGHTS Synthesis of results 165. Approximately 90% of the nursing workforce globally is made up of women. The high level of gender segregation in nursing leads to complex patterns of remuneration: in many countries there is a “gender pay gap”, although the evidence is largely from high-income countries (21). The effective implementation and monitoring of gender wage gap policies are required to deliberately promote gender equity within the health workforce, and overcome the historical legacy that has undervalued nurses’ work, including through gender bias (121, 232). Analyses by WHO found that health leadership positions continue to be dominated by men, with only 25% of leadership positions in health globally being held by women (21). A study of leadership barriers and facilitators in nursing commissioned by the Nursing Now campaign described not only a “glass ceiling” for women, but also a “glass elevator” for men, who hold a disproportionately high number of senior nursing roles (122). This is just the most visible manifestation of deep-seated gender imbalances that permeate health systems at all levels and affect all facets of the management of the nursing workforce. Policy options 166. Countries should address the gender pay gap affecting female nurses. In some countries the inequitable remuneration between genders may be driven by the high levels of occupational segregation in nursing as compared to other occupations. Addressing this can start with an analysis of national pay scales and a commitment to progressively implement a more equitable and gender-neutral system of remuneration among health workers. It must include sound policies and a reconsideration of fiscal arrangements with respect to health worker remuneration. While recognizing the need for market forces to influence pay levels, policies and laws addressing the gender pay gap should apply as relevant to the private sector as well. Nursing leadership must be included in the assessments of remuneration equity and development of policies to redress the issue. 167. Countries should prioritize and enforce policies addressing sexual harassment and discrimination within nursing and the overall health workforce. This should include a zero tolerance policy towards violence and verbal, physical and sexual harassment; policies that create decent working environments for women, including flexible and manageable working hours that accommodate the changing needs of nurses as women; and gender- sensitive leadership development opportunities for women in the nursing workforce. 6.4 Building institutional capacity and leadership skills for effective governance Synthesis of results 168. Over 80 countries reported a leadership position for nursing at the national level with responsibility for providing input into policy decisions related to health and nursing. Government chief nurses should work as full partners with other health professional leadership in making strategic decisions that impact 82 State of the world’s nursing 2020 health service planning, care delivery and working conditions (316). Capacity in labour market and fiscal space analysis, workforce policy, planning and governance is needed to identify priorities and develop evidence-based solutions to strengthen education capacity, create jobs and retain nurses. The findings of this report indicate that of 76 responding countries, 53% had national programmes for leadership development of nurses – though distribution was unequal as a majority of the countries reporting such programmes were in the WHO regions of Africa and the Eastern Mediterranean. 169. Governance capacity for sound design and implementation of nursing and health policies also requires institutions, mechanisms, policies and procedures to ensure that the nursing workforce priorities are considered and embedded in broader government actions in the health sector and beyond. The findings of this report have highlighted that a chief nurse position and the presence of leadership development programmes for nurses were correlated with a stronger regulatory environment for nursing. However, the existence of a chief nursing officer was not necessarily correlated with the existence of leadership programmes. This may be due to the fact that leadership programmes have often been driven by the professional associations as either a service to their members or as an income generation opportunity. Policy options 170. Nurse leadership must be developed at country, regional and global levels. Nurses must have opportunities to develop their leadership potential and participate in decision-making forums. Nurses should be considered, on par with other health professions, for appointment to leadership positions within national and state governments, as well as within local and other organizational structures. This effort will require budgetary allocation specifically for the development of nursing leadership. Country-based award and recognition mechanisms can be created to recognize nursing contributions to the advancement of universal health coverage and serve as role models to younger nurses (see Box 6.9 on a leadership fellowship programme in the Western Pacific Region). © Janice Mullings-George 83Future directions for nursing workforce policy 171. National policy-making forums should consider the nursing perspective in health system decision-making. Policies should ensure that nurses are represented at all levels of decision-making and have a voice in influencing key health system decisions and public health policy matters. Nurses should also be included in population-level clinical decision-making, which implies, for instance, including nurses in guideline development teams and guideline review panels to reflect nursing research and insight on the feasibility and acceptability of clinical recommendations. 6.5 Catalysing investment for the creation of nursing jobs Synthesis of results 172. This report provides additional evidence for the inclusion of a greater focus on nursing as part of the broader investment case for the health workforce for achieving universal health coverage. Despite a positive trend recorded over the last few years, unless the production and absorption of nurses increase substantially, nursing density will improve only marginally in most regions over the next decade, with substantial needs-based shortages persisting in low-income and lower Box 6.9 Leadership fellowship in the Western Pacifi c Region Health systems in the Western Pacifi c Region are managing a double burden of noncommunicable and communicable diseases, while also facing signifi cant economic, social and environmental challenges. Nurses provide approximately 78% of the care in the Western Pacifi c Region (317), so it is crucial that they are empowered and educated to a level that gives them the infl uence they need to improve community health outcomes. However, the Western Pacifi c Region has traditionally experienced a lack of leadership programmes (318, 319), including few for health professionals (320–322), and existing programmes have not been culturally contextualized (317, 323, 324). From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships leadership and mentorship programme in partnership with the South Pacifi c Chief Nursing and Midwifery Offi cers Alliance (318). The leadership programme focused on human resources for health, collective cultures, teaching mentorship, policy implementation and links with universal health coverage. Impact assessment involved more than 300 stakeholders and programme participants from 14 countries (318). Initial fi ndings show that 85% of the participants of the leadership model have had major career developments and assumed senior roles in nursing and midwifery. They have also implemented projects in their home countries in areas such as succession planning, professional development, regulation and refresher training (319). Another major fi nding is that these professions are now represented at global summits, infl uencing policy on global, regional and national levels (325). Nine nursing and midwifery offi cers from the leadership programme attended the Seventy-second World Health Assembly. Six have become government chief nurses in their countries, and two are the health ministers of their countries. 84 State of the world’s nursing 2020 middle-income countries, especially in the African, South-East Asia and Eastern Mediterranean regions. 173. Intersectoral policy dialogue will be needed to identify and commit adequate budgetary resources for investments in education, skills and job creation, recruitment, deployment and retention policies, and capacity-building of relevant national institutions, such as licensure and accreditation bodies. Expanding health labour markets creates opportunities for employment, particularly for women. Expanding jobs in nursing could help bolster the female labour force participation – which is only 48% globally for women, compared to 75% for men – and the female employment rate (326, 327). The benefit of investing in the creation of nursing jobs is supported by overwhelming evidence that speaks to the “triple dividend” – for health, gender equality, and development (21). Policy options 174. Countries should coordinate intersectoral action and sustainable financing to enable an expansion of economic demand for the creation of nursing jobs. The 5.9 million new nursing jobs needed (only focusing on those required to fill current gaps) can be created in most countries with existing domestic funds by effective management of wage bill growth. National planners should consider the efficiency of nursing investments vis- à-vis that of other occupational groups and optimize the productivity of the current and future nursing workforce through appropriate incentives and management systems. Public funds can meet the recurrent costs of © WHO/Yoshi Shimizu health workers in most high- and middle-income countries (assuming normal fiscal growth and ability to prioritize health) (328). Some high- and middle-income countries can address shortages and unlock demand by lifting restrictions on the supply of health workers, while at the same time reducing overreliance on international labour mobility and immigration. 85Future directions for nursing workforce policy 175. Development partners should align official development assistance for nursing education and employment with national health workforce and health sector strategies. Some low- and lower middle-income countries will face challenges to create nursing jobs due to insufficient fiscal space. The harmonization and alignment of donors’ and development partners’ support can expand sustainable financing for strengthening the health and social workforce while ensuring that the wage bill can be expanded and sustained to accelerate progress towards universal health coverage (see Box 6.10 on investing in human capital). Where domestic resources are estimated to be insufficient in the medium and long term, for example in low-income countries and in fragile, conflict-affected, and vulnerable contexts, and governance conditions allow it, mechanisms such as fund-pooling institutional arrangements can be considered. 176. Countries should address the question of how much nurses should be remunerated considering prevalent local, national and international labour market conditions. Policy-makers and regulators, such as the civil service or health service commission, should deliberately avoid some typical pitfalls. These may include keeping remuneration levels too low (which can lead to demotivation, excessive turnover and Box 6.10 Investing in human capital To increase access to quality primary health care services, as the cornerstone for achieving universal health coverage, substantial investments are needed in infrastructure (for example, hospitals and health centres) and the associated human capital (the health workforce, including knowledge and skills) (14, 328). A number of human capital initiatives are focused on helping countries invest more — and more effectively — in their people to improve outcomes in health, nutrition, quality education and skills. • The World Bank committed to invest US$ 15 billion to support human capital reforms in low- and lower middle-income countries, with a particular focus on Africa; 63 countries have signed on as human capital project countries. • The International Monetary Fund is reinforcing all programmes with a social spending initiative as a core objective. They will provide additional technical assistance in the areas of social spending, social protection, education and health. • Within the context of universal health coverage, the European Investment Bank and WHO are partnering on the human capital agenda through development of a fi nancial instrument that links European Investment Bank investments with targeted support for education, skills and jobs in the health sector. • The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to pool resources for implementation of recommendations stemming from the United Nations High-Level Commission on Health Employment and Economic Growth related to transformative education, skills and job creation. 86 State of the world’s nursing 2020 illicit coping strategies), too high (which can lead to wage inflation and problems of sustainability of the wage bill), or perpetuating gender pay disparities. The modality of remuneration also matters: nurses are typically paid a fixed income through a salary in most settings, and the income through dual practice is less substantial than for other occupational groups. Attention should be paid to avoiding the known drawbacks of disease-specific or programme-specific top-up incentives that distort national priorities and tend not to be sustainable. Policy-makers should also consider the coherence of the remuneration across health professions in order to avoid, for instance, creating disincentives for choosing a nursing career. Ultimately, nurses should be remunerated at a level that attracts, retains and motivates them sufficiently to meet the country’s needs. 6.6 Research and evidence agenda 177. This report has provided an unprecedented wealth of data and an overview of the research evidence on the nursing workforce, allowing the development of policy options for consideration by Member States and other stakeholders. At the same time, its development was affected by several limitations in both data and evidence of effectiveness. The main gaps we identified are reported below and can be considered as part of a forward-looking research agenda. 178. Nursing-specific quantitative and semi-quantitative evidence. One of the most important findings in the State of the world’s nursing 2020 report is not from the data, but about the data. There are large and important gaps in information needed to comprehensively understand the nursing workforce and conduct a health labour market analysis, particularly in relation to production capacity, attrition, wage levels and absorption in the health labour market. The support systems that underpin collation, analysis and use of this type of evidence need to be strengthened. The use of NHWA, which hinges on strong intersectoral engagement, can support the policy dialogue and decision-making on planned, sustainable investments to catalyse progress in key areas for nursing. 179. Evidence on nursing workforce effectiveness in primary health care and universal health coverage. This report has summarized evidence on the contribution of nurses across different clinical interventions and public health areas. The strongest evidence comes from a systematic review that included 18 randomized controlled trials that showed the effectiveness of nurse-led interventions across a range of primary care functions (30). However, 17 of the 18 included studies were conducted in high-income countries, with only one from a middle-income country and none from low-income countries. Further Cochrane and Campbell reviews have also been conducted for specific clinical or programme areas, including antiretroviral therapy, tobacco cessation, mental health and sexual assault examination. Among these, one included only randomized controlled trials, while the others included both experimental and quasi-experimental studies, including controlled trials (randomized or non- randomized), controlled before and after studies, cohort studies (prospective or retrospective), and interrupted time series studies, thus enabling comparison between intervention and control (31, 33, 87Future directions for nursing workforce policy 34). The Campbell review was focused on practices in the United States and the United Kingdom and was thus limited to studies from those countries. The review on antiretroviral therapy only included studies from Africa. All studies in the review on tobacco cessation were from high-income countries, mostly the United States. The mental health review only focused on low- and middle-income countries, including seven studies from low-income countries and 15 from low- and middle-income countries (31, 33, 34). The overview also highlights specific gaps in the evidence on effectiveness, such as nursing interventions with respect to the social determinants of health, including climate change, and nursing interventions in complex emergency settings. 180. Leveraging different research settings and methodologies. While the aforementioned evidence reviews are essential to establishing the effectiveness of nursing interventions, the setting of the included studies limits their generalizability and global applicability. Furthermore, experimental and quasi-experimental investigations most typically compared nurses to other health professionals. While this may offer useful insights, the method is ill suited to illustrate and fully understand the team-based nature of efforts and interconnected processes required for the successful delivery of quality health care. A broader range of studies, comprising quantitative (experimental and non-experimental) and qualitative primary studies, mixed methods © WHO/Yoshi Shimizu 88 State of the world’s nursing 2020 reviews, and field descriptions, provide a more comprehensive overview of nursing policy issues across the globe (see web annex). However, most of this evidence was generated in high-income country settings (30, 329), including the generation of research priorities (330). 181. More needs to be done to support the documentation of nursing interventions in low- and middle-income countries and to support nursing science within low- and middle-income countries, so that nurses themselves drive their research agenda based on their own experience of working in health service delivery. Nurses already make a very substantial contribution to health care science, including developing innovative research methods and using these methods to investigate issues of importance to improving global health (331). Research has shown that the quality of evidence for effective strategies to improve health worker practices in low- and middle-income countries is low (332). Investment in nursing research must therefore focus not only on increasing quantity of output, but also on increasing the quality of the science, as this will contribute to our overall health workforce knowledge. 182. Evidence on effective policy and system support to optimize the role of nursing. This report has highlighted the evidence on the effectiveness of policy options to optimize the contribution and impact of nursing, including diverse areas such as education, regulation, deployment, practice and retention. At the same time, the evidence on other areas was less strong. For instance, the return on investments in nursing and the broader health workforce could be better understood and should be studied in a variety of settings and policy contexts, including through studies of cost-effectiveness of nursing care, particularly in primary care settings in low- and middle-income countries. There is also room to strengthen the evidence on effectiveness of policy interventions to retain nurses in practice settings, regulatory and governance approaches to enable nurses to practise to their full scope in primary health care service delivery, and effective mechanisms to regulate private sector education and practice. A more robust evaluation of policies intended to address the negative effects of migration would enable a better design and a more realistic targeting of policy responses. Across all these areas, an explicit gender lens should be applied to the analysis. As most of the reviewed studies have typically a short time horizon, longer-term longitudinal studies might help develop a greater level of confidence in the relevance of the findings to real-life policy settings. 89Future directions for nursing workforce policy © AKDN/Christopher Wilton-Steer 90 State of the world’s nursing 2020 183. This State of the world’s nursing 2020 report has underscored the centrality of nurses as part of integrated teams in making critical contributions towards universal health coverage and other national and global health objectives. Nurses represent the largest occupational group, with a headcount estimated for 2018 of approximately 28 million, representing a central element of primary health care and health systems in countries of all levels of socioeconomic development. 184. The data and evidence collated for this report are stronger than ever before. A total of 191 countries reported on workforce stock — an all-time high and a 53% increase on the health workforce data released in 2018. For the first time, 80% of countries provided WHO with data on at least 15 nursing indicators spanning different workforce policy dimensions. An analysis of stock data trends indicates a shortage of 5.9 million nurses in 2018, concentrated primarily in the African, South-East Asia and Eastern Mediterranean regions. This represents an improvement in the nursing workforce stock in the countries affected by shortages, as compared with the baseline situation identified by the Global Strategy. 185. Despite signs of progress, the report has also highlighted key areas of concern. In line with the projections made by the Global Strategy in 2016, an acceleration of progress will be required in low- and lower middle- income countries and the African and Eastern Mediterranean regions in order to address key gaps. The largest shortfall in absolute numbers remains in the South-East Asia Region. The American and European regions face an additional threat in light of their ageing nursing workforce. Several high-income countries in the American, European and Eastern Mediterranean regions appear excessively reliant on international nursing mobility. CONCLUSION 7CHAPTER 91Conclusion 186. National governments, with support where relevant from their domestic and international partners, should catalyse and lead an acceleration of efforts to: • build leadership, stewardship and management capacity for the nursing workforce to advance the relevant education, health, employment and gender agendas; • optimize return of current investments in nursing through adoption of required policy options in education, decent work, deployment, practice, productivity, regulation, and retention of the nursing workforce; • generate massive investment in the health workforce, and in nurses as part of this, and leverage them for multiple development outcomes, including job creation, gender and youth empowerment. 187. Translating the evidence of this report, the policy options recommended, and the strategic directions above into concrete policy and investment decisions will require coordination among government sectors and collaboration with the most critical stakeholders. 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Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis. Lancet Global Health. 2019;7:e961–7. doi:10.1016/s2214-109x(19)30188-3. 314. Salama P, McIsaac M, Campbell J. Health workers’ strikes: a plea for multisectoral action. Bulletin of the World Health Organization. 2019;97:443. doi:10.2471/BLT.19.238279. 315. Muma Nyagetuba JK, Adam MB. Health worker strikes: are we asking the right questions? Lancet Global Health. 2019;7:e831–2. doi:10.1016/s2214- 109x(19)30222-0. 316. Global strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: World Health Organization; 2016. 317. Fung P, Montague R. A qualitative evaluation of leadership development workshops for mental health workers from four Pacific island countries. Australasian Psychiatry. 2015;23:218–21. 318. Homer C, Copeland F, Rumsey M. Papua New Guinea Maternal and Child Health Initiative: monitoring and evaluation report. Sydney, Australia: DFAT and World Health Organization; 2012. 319. Apia outcome: Tenth Pacific Health Ministers Meeting, 2–4 July 2013. Manila: WHO Regional Office for the Western Pacific; 2013. 320. Asante A, Roberts G, Hall JJ. A review of health leadership and management capacity in Solomon Islands. Sydney, Australia: Human Resources for Health Knowledge Hub; 2011. 321. Roberts G, Dewdney J. Future trends for human resources for health in the Asia Pacific region. Health Professions Education in the Pacific. 2012;138. 106 State of the world’s nursing 2020 322. Homer CS, Turkmani S, Rumsey M. The state of midwifery in small island Pacific nations. Women and Birth. 2017;30(3):193–9. doi:10.1016/j. wombi.2017.02.012. 323. Hayward-Jones J. The future of Papua New Guinea: old challenges for new leaders. Lowy Institute; 2016 (https://www.lowyinstitute.org/publications/ future-papua-new-guinea-old-challenges-new-leaders, accessed 25 February 2020). 324. Stewart S. Leadership and mentoring for Pacific island midwives. Australian Midwifery News. 2016;16:17. 325. Rumsey M, Rhodes D. An innovative approach to supporting health service delivery in the Pacific appears to be ticking health policy and development boxes. Health Systems and Policy Research. 2016;3:1–6. 326. Labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/SL.TLF.CACT.FE.ZS, accessed 27 February 2020). 327. Labor force participation rate, male (% of male population ages 15+) (modeled ILO estimate). Washington (DC): World Bank (https://data. worldbank.org/indicator/sl.tlf.cact.ma.zs, accessed 28 March 2020). 328. Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle- income countries: a modelling study. Lancet Global Health. 2019;7:e1500–10. doi:10.1016/s2214- 109x(19)30416-4. 329. Griffiths P, Norman I. The impact of nursing: a self-evident truth? International Journal of Nursing Studies. 2018;78:A1–2. https://doi.org/10.1016/j. ijnurstu.2017.10.016. 330. Bassalobre Garcia A, De Bortoli Cassiani SH, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas. Revista Panamericana de Salud Pública. 2015;37:162–71. 331. Baltzell K, McLemore M, Shattell M, Rankin S. Impacts on global health from nursing research. American Journal of Tropical Medicine and Hygiene. 2017;96:765–6. doi:10.4269/ajtmh.16-0918. 332. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 107References Annex 1 . Who is a nurse? 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles and educational pathways. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it inappropriate to use job title as a method of classification and analysis at international level. This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and validated by WHO Member States. To help achieve this aim, National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). Of note, the present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group.12 ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others. Nursing associate professionals provide basic nursing and personal care and generally work under the supervision or in support of medical, nursing or other health professionals. However, in some countries, the distinction between professional nurses and associate professional nurses is blurred. Similarly, the distinction between associate professional nurses and nurse aides is not always clear. In these cases, therefore, an element of judgement was required from national stakeholders. Countries were advised to consider both the roles and responsibilities and the duration of pre- service education when deciding whether to classify an occupation group as professionals or associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years. In case a country was not able to decide which category to use, NHWA includes a “nurses: not further defined” option, and some countries opted to place some or all of their nursing workforce into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analysed in the present report. 108 State of the world’s nursing 2020 NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE: • Planning, providing and evaluating nursing care for patients • Coordinating the care of patients in consultation with other health professionals • Developing and implementing care plans for the treatment of patients in collaboration with other health professionals • Planning and providing personal care, treatments and therapies, including administering medications and monitoring responses to treatment or care • Cleaning wounds and applying dressings • Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs • Planning and participating in health education programmes, health promotions and nurse education activities • Answering questions from patients and families and providing information about prevention of ill-health, treatment and care • Supervising and coordinating the work of other health workers • Conducting research on nursing practices and procedures • Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals • Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and their families to a health professional for specialized care as needed • Cleaning wounds and applying dressings • Updating information on patients’ conditions and treatments received in record-keeping systems • Assisting in planning and managing the care of individual patients • Assisting in giving first-aid treatment in emergencies ISCO definitions of nursing personnelBox A1.1 Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training arrangements for nurses vary widely between countries and have varied over time within countries. Source: Adapted from ISCO-08. 109Annex 1 Annex 2 . Methods 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Indicators used in the State of the world’s nursing 2020 report WHO member states were invited to submit from July 2019 to November 2019 the most recent available data on the nursing workforce through 36 indicators, 30 from the NHWA and six additional specific indicators (see list in Table A2.1). The 30 indicators are defined in the NHWA handbook,13 which also provides detailed definitions and metadata for each indicator. Data collection process NHWA is a continuous process with progressive improvement of availability, quality and use of health workforce data. As part of this process, countries were encouraged to set up multistakeholder working groups on all health workforce data-related aspects to conduct internal validation before submitting data; this was done in a substantial number of countries. The preparation of the State of the world’s nursing 2020 report accelerated this global effort of improved monitoring and reporting of standardized data. Countries were asked to nominate focal points, which were provided with access to the NHWA online platform to enter or validate the data. In addition, data for OECD countries resulting from the joint OECD, Eurostat and WHO Regional Office for Europe data collection questionnaire were prepopulated to avoid double reporting to international organizations, and focal points were advised to review and validate the data. The population size for each country and year were extracted from the 2019 revision of the World population prospects of the United Nations Department of Economic and Social Affairs.14 Additional data on indicators assessing the governance and policy environment through binary questions (yes/no) on the existence of related mechanisms and processes, as well as on the duration of education and training, were also gathered from the Sigma and the NCBSN databases15 to complete information for a small number of countries. To support the data collection, WHO conducted regional NHWA workshops in all six regions and provided tools and information in several languages. In total, more than 250 representatives from around 80 countries attended these capacity-building events. Data were submitted between July and November 2019, and data cleaning and analysis were conducted between October and December 2019. The present report is based on the data set from the NHWA online platform as of 17 December 2019. NHWA focal points were advised to involve nursing leaders and other national stakeholders. The WHO country and regional offices supported the NHWA implementation and reporting process, including the collection, reporting and validation of the relevant data. Data reported Of the 194 WHO Member States, 193 reported data (191 reported on stock) either directly via the NHWA platform or through regional offices and other international processes such as OECD, Eurostat and WHO Regional Office for Europe joint data collection on non- monetary health care statistics. Figure A2.1 illustrates that 80% of countries provided data for at least 15 of the 36 selected indicators, and 23% of countries did so for at least 25 indicators. The main data gaps were for the indicators relating to wages, expenditure on nursing education and other education- related issues. For selected indicators, alternative sources were identified to supplement the NHWA data, such as duration of education and training, wages and capacity indicators. For example, the international nursing honours society, Sigma, manages a database on the status of nursing education globally, including indicators on entry- level wages and educational programme duration for around 50 additional countries. For the set of binary indicators relevant to policies and regulations of nursing practice and education, the Global Regulatory Atlas was used to identify where licensure examinations are required and where regulatory bodies exist. 110 State of the world’s nursing 2020 Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% List of 36 indicators used for the State of the world’s nursing 2020 reportTable A2.1 Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 111Annex 2 Of the 191 countries, 83% provided nursing headcount data from 2017 or 2018. Others were able to provide data only from earlier years (from 2013 to 2016). In such cases, the 2018 headcount was estimated by applying the latest available year’s density to the 2018 population. For four countries for which headcount was not reported, the corresponding regional densities were applied to their 2018 populations. The fact that many countries — most notably in west and central Africa and in central Asia — were unable to provide data for several indicators indicates a critical need to continue to strengthen human resources for health information systems in these regions. Not all data collected are presented in this report: only indicators for which a significant number of countries reported statistics were analysed and presented. Additional data will be made available progressively through a public portal for accessing NHWA data. Composite score on education regulation and working conditions in sections 5.4 and 5.6 Whilst most analyses were purely descriptive in nature, focusing mainly on percentages, composite scores were used to summarize regulation of education and working condition indicators. For both scores, a country was awarded 1 point for every indicator for which the answer was “yes”, 0.5 points if the answer was “partially”, and 0 points if the answer was “no”, then the scores were added to determine a composite one. Thus, the maximum possible score was 9, and the minimum was 0. For indicators with missing information, the indicator was considered as “no”, hence 0 points. Multiple correspondence analysis of education regulation and working conditions in sections 5.4 and 5.6 Indicators on regulation of education and practice display a high level of correlation: if one is answered “yes”, it is likely that some others will also be answered “yes”. To better understand such patterns, a multiple correspondence analysis was conducted, which simplifies the correlation between many variables in a single two-dimensional graph (Figure A2.2). The analysis enabled extraction of two dimensions (x and y axis). The first “dimension” (the x axis) can be interpreted as factors associated with the absence of regulation on the right as opposed to presence of regulation on the left. The first Number of indicators reported globally for the State of the world’s nursing 2020 reportFigure A2.1 0 1,000 2,000 3,000 4,000500 km <5 5 to 9 10 to 14 15 to 19 20 to 24 25+ not reportednot applicable Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. 112 State of the world’s nursing 2020 dimension explains 79.7% of the variation between variables. The second dimension (the y axis) can be interpreted as an absence of accreditation mechanisms towards the top of the axis as opposed to an absence of education regulation towards the bottom of the axis. This dimension explains 2.1% of the variation between indicators. The graph also includes regions to highlight to which indicators they are more closely correlated. The analysis confirmed that, with the South-East Asia Region, Eastern Mediterranean Region and Western Pacific Region on the right side of the graph, these regions are more likely to be associated with a lower level of regulation of nursing education. The indicators on working conditions were strongly correlated, as evidenced by multiple correspondence analysis (Figure A2.3). Two indicators showing a strong correlation were measures to prevent attacks and existence of advanced nursing role: this might suggest that in more risky environments nurses may be awarded a greater level of professional autonomy to continue ensuring patient care under challenging circumstances. The European Region displayed a different pattern than other regions, indicating both fewer measures to prevent attacks on workers and fewer advanced nursing roles. Projected stock by 2030 For the assessment of the stock of nurses by 2030, three scenarios were developed, as follows. • Scenario 1: ageing (single effect of ageing of the nursing workforce). A projection used the age distribution per country and a stable age group of less than 35 years, considering a replenishment of one tenth the size of this lowest age category. It considered an ageing workforce with retirement of one tenth of the size of the group of nurses aged 55 years and over. This scenario does not take into account the graduation statistics and considers the proportion of the younger age group as constant for upcoming years. Figure A2.2 Correlation of education indicators with a multiple correspondence analysis SEAR EUR AMR EMR AFR WPR Dimension 1 (79.7%) D im en si on 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fi tness for practice examination; NN3: standards for faculty qualifi cations. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 113Annex 2 • Scenario 2: replenishment. A scenario with similar ageing as scenario 1 but using the most recent graduation rate by region computed in section 5.5 to which a correction factor of 0.6 was applied, assuming that 60% of the new graduates will find a job in the health sector, to mimic the difference between graduation and entry into the active workforce as observed in OECD countries. • Scenario 3: accelerated replenishment. A similar scenario as scenario 2 but considering an acceleration of graduation and absorption rate, with more graduates per year by 2030, assuming a growth of 50% from 2018 to 2030 of the graduation capacity of countries (equivalent to an annual increase of 3.44%). This scenario also assumes a 60% absorption into the health labour market. From these scenarios, estimated projected densities for 2030 were calculated using population estimates from the United Nations population prospect estimates for 2030. To assess the impact of scenario 3, various simulations with variations in the increase in graduates were used: 25% increase, 50% increase and 100% increase (a doubling of production) (Figure A2.4). This shows that the choice of the growth rate of the number of nursing graduates does not drastically impact the estimated stock by 2030, with projected stocks of 38.0 million, 39.7 million and 42.8 million nurses with total growth rates of 25%, 50% and 100%, respectively. Words of caution in interpreting projections Several limitations need to be taken into account when interpreting projections. 1. Regarding the availability of data, not all countries were able to report on age, used in scenario 1, and on graduation rate, used in scenario 2. The analysis showed consistent results for scenarios 1 and 2, therefore providing reassurance on the entry rate into the labour market of new graduates. 2. Several assumptions were used on the attrition rate for personnel aged 55 years and above. This could potentially vary across regions and might be optimistic, considering that the retirement age will be up to 65 years. Similarly, the analysis applied a ratio of 0.6 Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes Dimension 1 (80.1%) D im en si on 2 (2 .6 % ) Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacifi c Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. 114 State of the world’s nursing 2020 for adding graduates who were starting to practise, based on the OECD ratio of practising to licensed nursing workforce. However, this could potentially vary by region. To test the impact of all underlying assumptions for scenarios 1–3 a series of sensitivity analyses were conducted. Results only varied marginally, and the conclusions remained largely unchanged. 3. Projections only reflect recent trends and provide a broad understanding of the trajectory of the stock of the nursing workforce. This would need to be revised in the future as more data become available. Also, these projections do not replace the conclusions derived from national-level modelling, which would take account of a wider range of health workforce and other indicators throughout the health labour market and more detailed economic statistics, including fiscal space. Estimating shortage The estimation of the shortage in nursing personnel followed a method similar to the one described in the Global Strategy on Human Resources for Health. However, because of the updated data, the shortage values cannot be directly compared to those estimated in the Global Strategy. The analysis shows that the estimation in the Global Strategy was based on 102 countries with stock available for the period 2009–2013; older or imputed data were used for the remaining countries. Based on the recent data available for the State of the world’s nursing 2020 report, 174 countries had stock data for 2013 or the previous five years (including 130 countries with 2013 data), and the revised stock for 2013 was estimated at 23.2 million nurses. The stock for 2018 is based on data for 191 countries for the period 2013– 2018, including 89% with data for 2017 and 2018. Therefore, the stock reported in the State of the world’s nursing 2020 report for 2018 can also be considered as a very robust estimate. For estimating the shortage, the 2018 and 2030 densities were compared to a benchmark value used in the Global Strategy on Human Resources for Health. That benchmark of 4.45 medical doctors, Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Figure A2.4 Nursing stock graduation constant 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 N ur si ng p er so nn el s to ck in m ill io ns Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specifi c: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. 115Annex 2 nurses and midwives per 1000 population was then converted into a benchmark value for nursing. • First, the share of nurses and midwives in the Global Strategy was applied to this benchmark: with 20.7 nurses and midwives per 10 000 population and 9.8 medical doctors per 10 000 population in 2013, the benchmark is corrected to 3.02 nurses and midwives per 1000 population (4.45 x (20.7/(9.8+20.7))). • Then, to calculate a benchmark value for nurses only, the share of nurses among nurses and midwives combined (90.7% from most recent year) was applied to this benchmark, giving a benchmark value of 2.74 nurses per 1000 population. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Because densities on the health workforce are expressed per 10 000 population, the value of 27.4 nurses per 10 000 population was used as benchmark. • This benchmark value was then compared to the density observed in 2018 and projected for 2030 under the three scenarios. The estimated shortage by 2030 was estimated for the three projection scenarios described above and showing that the shortages remain high in low- and lower middle- income countries under each scenario (Table A2.2). Cost per graduate Multiple divergent sources of costs per graduate were identified for low- and lower middle-income countries, where the shortages are mostly located. These range from US$ 5180 in Madagascar, US$ 5589 in the World Bank ECSA analysis,16 and US $5656 in Mozambique, to US$ 19 794 in Ghana.17 Therefore, computations of costs were conducted with a lower-cost scenario of US$ 5000 per graduate, an intermediate scenario of US$ 10 000 per graduate, and a higher scenario of US$ 20 000 per graduate. Note that available data on these costs were from African countries and could not be transposed to high-income countries, for which published data show much higher costs per graduate. INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) Table A2.2 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 116 State of the world’s nursing 2020

Investing in education, jobs and leadership STAT E O F T H E 2020 Investing in education, jobs and leadership S T A T E O F T H E W O R L D ’S N U R S IN G 2020 NURSING WORLDʼS In collaboration with:

Влож ение средст в в образование, рабочие м ест а и воспит ание лидеров СО СТО Я Н И Е СЕСТРИ Н СК О ГО Д ЕЛ А В М И РЕ 2020 г. Cотрудничающие организации: Вложение средств в образование, рабочие места и воспитание лидеров СОСТОЯНИЕ СЕСТРИНСКОГО ДЕЛА В МИРЕ 2020 г. b Состояние сестринского дела в мире, 2020 г. Вложение средств в образование, рабочие места и воспитание лидеров СОСТОЯНИЕ СЕСТРИНСКОГО ДЕЛА В МИРЕ 2020 г. Состояние сестринского дела в мире, 2020 г.: вложение средств в образование, рабочие места и воспитание лидеров [State of the world's nursing 2020: investing in education, jobs and leadership] ISBN 978-92-4-000492-4 (Версия онлайн) ISBN 978-92-4-000493-1 (Версия для печати) © Всемирная организация здравоохранения 2020 Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Некоммерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводится библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за его содержание и точность. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интеллектуальной собственности. Образец библиографической ссылки. Состояние сестринского дела в мире, 2020 г.: вложение средств в образование, рабочие места и воспитание лидеров [State of the world's nursing 2020: investing in education, jobs and leadership]. Женева: Всемирная организация здравоохранения; 2020. Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке: http://apps.who.int/iris/. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/about/ licensing/. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминание определенных компаний или продукции определенных производителей не означает, что они одобрены или рекомендованы ВОЗ в отличие от аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет никакой ответственности за ущерб, связанный с использованием материалов. Данный документ был подготовлен при финансовой поддержке со стороны Партнерства по ВОУЗ (Бельгия, Европейский союз, Франция, Ирландия, Япония, Люксембург, Соединенное Королевство и ВОЗ), Германии и Норвегии. Обложка Ряд 1 (слева неправо): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Ряд 2 (слева направо): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Предисловие . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Обращение сопредседателей. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii Составители и выражение благодарности . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Глоссарий . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Резюме 2020 г. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 1ГЛАВА Введение . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2ГЛАВА Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 Роль сестринского дела в достижении всеобщего охвата услугами здравоохранения . . . . . . . . .5 2.2 Кто такая медицинская сестра? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 СОДЕРЖАНИЕ 3ГЛАВА Роль и функции сестринского персонала в системах здравоохранения XXI века . . . . . . 11 3.1 Роль сестринского дела в достижении всеобщего охвата услугами здравоохранения . . . . . . .11 3.2 Роль сестринского дела в контексте чрезвычайных ситуаций, эпидемий и бедствий . . . . . . . . .15 3.3 Роль сестринского дела в обеспечении здоровья и благополучия населения . . . . . . . . . . . . . . . 16 5ГЛАВА Текущее состояние фактических данных о кадровых ресурсах сестринских служб . . . . 35 5.1 Наличие, состав и распределение сестринских кадров . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 5.2 Справедливость по показателям наличия и доступности сестринских кадров . . . . . . . . . . . . . . 43 5.3 Международная миграция и мобильность сестринских кадров . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 5.4 Нормативно-правовое регулирование сестринского образования и практики . . . . . . . . . . . . . 49 5.5 Предложение на рынке трудовых ресурсов в сфере сестринского дела . . . . . . . . . . . . . . . . . . . . . 52 5.6 Регулирование занятости и условий труда . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.7 Стратегическое руководство и лидерство . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 5.8 Оценка современных перспектив для достижения ЦУР к 2030 г. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 4ГЛАВА Стратегические рычаги расширения профессиональных возможностей сестринского персонала . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.1 Базовое образование и профессиональная подготовка . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.2 Приток и отток трудовых ресурсов . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 4.3 Справедливое распределение и экономическая эффективность . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.4 Нормативно-правовое регулирование . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Дальнейшие направления развития кадровой политики в области сестринского дела . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.1 Укрепление базы фактических данных для планирования, мониторинга и подотчетности . . . . .68 6.2 Мобильность и миграция . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.3 Развитие и поддержка сестринского персонала . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 6.4 Укрепление институционального потенциала и лидерских навыков для обеспечения эффективного стратегического руководства . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6.5 Стимулирование инвестиций, направленных на создание рабочих мест для сестринского персонала . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.6 Повестка дня научных исследований и накопления фактических данных . . . . . . . . . . . . . . . . . . . 87 6ГЛАВА Заключение . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Библиография . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Приложение 1. Кто такая медицинская сестра? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Приложение 2. Методы . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Веб-приложение. Роль и функции сестринского персонала в системах здравоохранения XXI века https://apps.who.int/iris/bitstream/handle/10665/332852/9789240009455-rus.pdf 7ГЛАВА iiiСОДЕРЖАНИЕ Таблицы 5.1 Численность сестринского персонала в мире и обеспеченность сестринскими кадрами на 10 000 населения, по регионам ВОЗ, 2018 г.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 5.2 Изменения численности сестринского персонала в связи с улучшением данных и с фактическим ростом кадровых ресурсов в период с 2013 по 2018 г. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 5.3 Сестринский персонал в процентах от общего числа медицинских работников (врачи, сестринский и акушерский персонал, стоматологи и фармацевты), в разбивке по регионам ВОЗ . . . . . . . .39 5.4 Процентная доля женского сестринского персонала в разбивке по регионам ВОЗ. . . . . . . . . . . . . . . . . . . . . . .41 5.5 Обеспеченность населения сестринским персоналом, в разбивке по уровням дохода стран (2018 г.) . . . .46 5.6 Процентная доля работников сестринских служб, родившихся (или прошедших обучение) за рубежом, в разбивке по уровням дохода стран . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 5.7 Процент стран-респондентов, сообщивших о наличии механизмов правового регулирования в сфере образования и профессиональной подготовки сестринских кадров, в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.8 Масштабы подготовки выпускников программ сестринского образования, в разбивке по регионам ВОЗ и группам стран по уровню дохода . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 5.9 Процент стран, сообщивших о наличии у них механизмов нормативно-правового регулирования условий труда, в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.10 Показатели лидерства и стратегического руководства: процент стран с наличием должности главного специалиста по сестринскому делу и программы развития сестринского лидерства, в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 5.11 Моделирование прогнозируемой численности сестринского персонала в период с 2018 по 2030 г. по трем сценариям, в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 A2.1 Перечень 36 показателей, использованных для подготовки настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 A2.2 Расчетные значения дефицита сестринского персонала (в миллионах человек) в странах, где показатель обеспеченности кадрами ниже порогового значения, приведенного в Глобальной стратегии, в разбивке по уровню дохода стран, 2018 и 2030 гг. (три сценария) . . . . . . . . . . . . . . . . . . . . . . . . . .116 Вставки 3.1 Вклад сестринского персонала в обеспечение безопасности пациентов . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 3.2 Модель обеспечения сестринского ухода на общинном уровне за стареющим населением . . . . . . . . . . . . .14 4.1 Австралия: привлечение недопредставленных групп населения к работе в составе сестринских кадров. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 4.2 Стоимость обучения сестринскому делу. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 Решение проблемы нехватки кадров преподавателей сестринского дела . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4.4 Глобальные партнерства по профессиональным навыкам. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.5 Примеры экономического спроса на сестринский персонал в странах с высоким уровнем дохода . . . . . .27 4.6 Расширение доступа населения Польши к услугам медицинской помощи посредством сестринского назначения лекарств . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.7 Пример функций специализированной медицинской сестры в Африканском регионе . . . . . . . . . . . . . . . . . .29 4.8 Руководящие принципы удержания кадров в сельских районах . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 4.9 Примеры гармонизации образовательных стандартов и экзамена на получение лицензии . . . . . . . . . . . . .33 5.1 Справедливость внутри стран . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 6.1 Анализ рынка труда в области здравоохранения в Шотландии . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 6.2 Сообщество здравоохранения стран Восточной, Центральной и Южной Африки: национальное сотрудничество в области представления данных по сестринским кадрам с использованием показателей НСУКЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 6.3 Подход Германии к управлению миграционным процессом . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 6.4 Современные технологии в образовании и практике сестринского дела. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 6.5 Усилия Пакистана по наращиванию потенциала в области подготовки сестринских кадров . . . . . . . . . . . . .75 6.6 Расширение доступа к общинным услугам здравоохранения в Омане . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 6.7 Африканское сотрудничество в области регулирования медицинских профессий. . . . . . . . . . . . . . . . . . . . . . .80 6.8 Забастовки работников здравоохранения . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 iv 6.9 Программа предоставления стипендий для развития лидерских навыков в Регионе Западной части Тихого океана. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 6.10 Вложение средств в развитие человеческого капитала. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 A1.1 Определения МСКЗ, относящиеся к сестринскому персоналу . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Рисунки 1. Обеспеченность сестринским персоналом на 10 000 человек населения в 2018 г. . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. Доля медсестер старше 55 лет и младше 35 лет (по данным из выборки стран) . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv 3. Прогнозируемое увеличение (в период до 2030 г.) численности сестринского персонала в разбивке по регионам ВОЗ и категориям стран по уровню дохода . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv 4. Средняя продолжительность обучения сестринского персонала профессионального уровня в разбивке по регионам ВОЗ (в годах) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi 5. Доля стран, в которых существуют нормативные положения, регламентирующие условия труда. . . . . . . xvii 6. Доля женщин и мужчин среди сестринского персонала в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . .xx 2.1 Глобальная стратегия для развития кадровых ресурсов здравоохранения: стратегические цели и актуальность для сестринского дела . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 Количество отдельных должностных категорий сестринского персонала в каждом регионе ВОЗ. . . . . . . . . . 9 3.1 Вклад сестринского дела в достижение целей «трех миллиардов» . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 4.1 Рычаги государственной политики для воздействия на рынки труда в сфере здравоохранения . . . . . . . . . .20 5.1 Число стран с данными о трудовых ресурсах, имеющимися в НСУКЗ ВОЗ (1990–2018 гг.) . . . . . . . . . . . . . . . . . .36 5.2 Соотношение категорий сестринского персонала в общей численности данной профессиональной группы, в разбивке по регионам ВОЗ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 5.3 Процентная доля сестринского персонала моложе 35 лет и в возрасте 55 лет и старше, в разбивке по регионам ВОЗ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 5.4 Относительная доля работников старше 55 лет и моложе 35 лет в составе сестринского персонала. . . . . .42 5.5 Численность сестринского персонала из расчета на 10 000 населения в 2018 г. . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.6 Региональные различия в значениях показателя обеспеченности населения сестринским персоналом на 10 000 населения (2018 г.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.7 Численность сестринского персонала из расчета на 10 000 населения, в разбивке по уровням дохода стран (2018 г.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 5.8 Процент стран-респондентов, сообщивших о наличии нормативов и стандартов в области сестринского дела. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 5.9 Карта с обозначением суммарных баллов нормативно-правового регулирования в области сестринского образования, по странам . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 5.10 Средняя продолжительность (число лет) обучения сестринских кадров, в разбивке по регионам ВОЗ . . .54 5.11 Процент стран, имеющих нормативные положения об условиях труда. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.12 Карта с обозначением суммарных баллов нормативно-правового регулирования условий труда. . . . . . . . 57 5.13 Процент стран с наличием сестринских кадров с расширенными функциями, в разбивке по численности врачей на 10 000 населения . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 5.14 Связи между ГССД, программой сестринского лидерства и нормативной средой . . . . . . . . . . . . . . . . . . . . . . . . .60 5.15 Прогнозируемая численность сестринского персонала из расчета на 10 000 населения в 2030 г. (глобальное распределение) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 5.16 Прогнозируемое увеличение (в период до 2030 г.) численности сестринского персонала в разбивке по регионам ВОЗ и категориям стран по уровню дохода . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 5.17 Оценка дефицита сестринского персонала по состоянию на 2013 и 2018 гг. и по прогнозу на 2030 г. . . . . . .64 A2.1 Число показателей, по которым страны представили данные для настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 A2.2 Корреляция показателей образования по результатам анализа множественного соответствия . . . . . . . . .113 A2.3 Корреляция показателей условий труда по результатам анализа множественного соответствия . . . . . . . .114 A2.4 Рост мировой численности сестринского персонала (млн) при сохранении прежних масштабов подготовки кадров и трех сценариев роста численности выпускников программ сестринского образования, 2018–2030 гг. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 vСОДЕРЖАНИЕ Вложение средств в сестринское дело будет способствовать достижению ЦУР, касающихся не только здравоохранения, но также образования (ЦУР 4), гендерного равенства (ЦУР 5), достойных условий труда и экономического роста (ЦУР 8). Фотографии на обложке Первый ряд (слева направо): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa Второй ряд (слева направо): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer Элизабет Иро Главный специалист по сестринскому делу, ВОЗ Аннетт Кеннеди Председатель Международного совета медицинских сестер Шила Тлоу Сопредседатель инициативы «Сестринское дело сегодня» Найджел Крисп Сопредседатель инициативы «Сестринское дело сегодня» Тедрос Гебрейесус Генеральный директор ВОЗ ISBN 978-92-4-000337-8 (Версия онлайн) ISBN 978-92-4-000338-5 (Версия для печати) © Всемирная организация здравоохранения 2020 . Некоторые права защищены. Данная работа распространяется на условиях лицензии CC BY-NC-SA 3.0 IGO vi Состояние сестринского дела в мире, 2020 г. ЦУР 3 ЦУР 4 ЦУР 5 ЦУР 8 Тедрос Гебрейесус Генеральный директор ВОЗ Предисловие Доклад «Состояние сестринского дела в мире, 2020 г.: вложение средств в образование, рабочие места и воспитание лидеров» выходит в свет в эпоху беспрецедентной политической приверженности делу обеспечения всеобщего охвата услугами здравоохранения во всем мире. Параллельно с этим, в условиях вспышки новой коронавирусной инфекции COVID-19 и массового перемещения людей в зонах вооруженных конфликтов, проверку на прочность проходят возможности человечества в сфере обеспечения готовности и реагирования на чрезвычайные ситуации. Во всех этих обстоятельствах жизненно важную роль играет сестринский персонал. Сегодня человечество более чем когда бы то ни было нуждается в работниках сестринских служб, для которых должна быть обеспечена возможность трудиться в полном соответствии с их образованием и квалификацией. В первом докладе «Состояние сестринского дела в мире» упоминается множество достижений в области развития сестринских кадров. Создание новых возможностей для получения высшего сестринского образования и расширение полномочий сестринского персонала, в том числе на уровне формирования политики здравоохранения, может способствовать повышению уровня здоровья населения. В то же время в мире по-прежнему сохраняется колоссальное неравенство в обеспеченности населения сестринскими кадрами, и эта проблема требует решения. В 2020 г. пройдет Международный год работников сестринских и акушерских служб. Это даст нам возможность выработать на основе фактических данных и выводов, представленных в докладе Состояние сестринского дела в мире, 2020 г., программу действий в области развития сестринского дела на период до 2030 г. и принять обязательства по ее осуществлению. В связи c этим мы настоятельно призываем правительства стран и все соответствующие заинтересованные стороны: • вкладывать ресурсы в массированное ускорение развития сестринского образования – в преподавательский состав, инфраструктуру и студентов – для удовлетворения глобальных потребностей и национального спроса на сестринские кадры, а также реагирования на научно- технический прогресс и реализации моделей комплексного медицинского и социального обслуживания; • обеспечить создание к 2030 г. по меньшей мере 6 миллионов новых рабочих мест в рамках сестринских служб, прежде всего в странах с низким и средним уровнем дохода, для предупреждения прогнозируемого дефицита сестринских кадров и устранения неравенства в обеспеченности населения сестринскими кадрами во всем мире; • обеспечить укрепление лидерской роли работников сестринских служб – посредством воспитания нынешних и будущих лидеров – для обеспечения значимого участия сестринского персонала в процессах выработки политики здравоохранения и принятия решений, а также содействия повышению эффективности систем здравоохранения и социального обеспечения. Все страны могут принять меры в поддержку осуществления этой программы действий. Большинство стран могут сделать это за счет собственных ресурсов. Тем странам, которым для этого потребуется поддержка со стороны международного сообщества, мы обязаны предоставить дополнительную помощь в интересах повышения объемов инвестиций в развитие человеческого капитала в сферах здравоохранения и социального обеспечения. Эти инвестиции будут также способствовать прогрессу в достижении Целей в области устойчивого развития и улучшению ситуации в области гендерного равенства, расширению экономических возможностей женщин и занятости молодежи. Давайте воспользуемся этой возможностью и примем активное участие в этом десятилетии действий, начав с вложения ресурсов в образование, занятость и повышение лидерской роли сестринского персонала. viiПредисловие Обращение сопредседателей Семьдесят вторая сессия Всемирной ассамблеи здравоохранения провозгласила 2020 г. Международным годом работников сестринских и акушерских служб не только в связи с 200 летней годовщиной со дня рождения Флоренс Найтингейл, но и в качестве выражения признательности медицинским сестрам и акушеркам за их повседневный вклад в укрепление здоровья и благополучия населения во всем мире. Поскольку заслуги медицинских сестер будут в центре внимания мирового сообщества во Всемирный день здоровья 2020 г., мы рады предложить вашему вниманию первый доклад о состоянии сестринского дела в мире. В докладе представлены самые актуальные фактические данные и сформулированы самые современные варианты политики в отношении трудовых сестринских ресурсов во всем мире. В нем также приводятся весомые аргументы в пользу широкомасштабного, но практически осуществимого наращивания инвестиций в образование, трудоустройство и руководство работой медицинских сестер, поскольку это необходимо для развития трудовых ресурсов среднего медицинского персонала в интересах достижения Целей в области устойчивого развития, укрепления здоровья всех людей и совершенствования кадрового обеспечения систем первичной медико- санитарной помощи в процессе обеспечения всеобщего охвата услугами здравоохранения. Доклад о состоянии сестринского дела в мире, 2020 г. стал итогом замечательного сотрудничества на уровне стран. Во многих странах инициативу по сбору отчетности взяли на себя руководители государственных сестринских и акушерских служб при информационной поддержке со стороны министерств образования, труда и финансов. Передача и триангуляция данных обеспечивалась учреждениями системы образования среднего медицинского персонала и регулирующими органами. Важнейшую роль инициаторов сбора информации и обсуждения рассматриваемых в докладе вопросов сыграли национальные ассоциации медицинских сестер и организации, участвующие в кампании «Сестринское дело сегодня». Такое взаимодействие имеет решающее значение для обеспечения регулярного поступления достоверных отчетных данных о состоянии сестринского дела и в будущем должно способствовать подготовке еще более информативных докладов. Наши совместные успехи впечатляют. Однако нам предстоит достичь гораздо более серьезных результатов. Нам необходимо, опираясь на данные национального, регионального и глобального уровня и активно участвуя в мероприятиях Международного года работников сестринских и акушерских служб, активизировать более тесный диалог и сотрудничество между всеми секторами по вопросам укрепления трудовых ресурсов в интересах повышения качества первичной медико- санитарной помощи и продвижения навстречу всеобщему охвату услугами здравоохранения. Мы должны стимулировать и поддерживать стабильный приток инвестиций в подготовку медицинских сестер, создание рабочих мест и совершенствование руководства в этой области. В интересах глобального здравоохранения все страны должны взять на себя обязательство развивать сестринские трудовые ресурсы и направлять на это достаточные ресурсы. Надеемся на то, что вы поддержите наш призыв к действиям. Джеймс Кэмпбелл Директор Департамента трудовых ресурсов здравоохранения Всемирной организации здравоохранения Хауард Каттон Директор-распорядитель Международного совета медицинских сестер Мэри Уоткинс Заместитель сопредседателя кампании «Сестринское дело сегодня» viii Состояние сестринского дела в мире, 2020 г. РУКОВОДЯЩИЙ КОМИТЕТ Сопредседатели: Говард Кэттон, Мэри Уоткинс Члены: Султана Н. Афдхал, Сумайя Мохамед Аль-Блооши, Дэвид Бентон, Шэрон Брауни, Питер Джонсон, Франциска Окафор, Нэнси Рейнольдс, Дебра Томс, Элизабет Иро (по должности), Джеймс Кэмпбелл (по должности) ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ Ведущие авторы: Кэри Маккарти, Матье Бониол, Карен Дэниелс, Джорджо Кометто, Хассум Диалло, Анвар Дин Лоуани, Джеймс Кэмпбелл Административная поддержка: Беатрис Вамуститу, Элизабет Тексон Члены авторского коллектива: Джонатан Абрахамс, Адам Ахмат, Оньема Аджубор, Бенедетта Аллегранци, Авни Амин, Джорджина Арройо, Джеймс Асамани, Ян Аскью, Софониас Гетачью Асрат, Шамсуззоха Бабар Саед, Рейчел Баггалей, Валентина Балтаг, Ана Пилар Бетран Лазага, Мелисса Бингхэм, Мусса Бизо, Нэнси Болан, Кэролин Броуди, Лугемба Будиаки, Ричард Карр, Сильвия Кассини, Алессандро Кассини, Хорхе Кастилья Эченике, Паула Кавальканте, Момоду Сизай, Питер Коули, Вания де ла Фуэнте-Нуньес, Ибадат Дхиллон, Нилам Дхинра-Кумар, Линда Дуаль, Натали Дрю Болд, Тарун Дуа, Джеймс Фицджеральд, Шивон Фицпатрик, Хельга Фогстад, Натан Форд, Пьер Форменти, Донгбо Фу, Клаудия Гарсия-Морено, Фетхие Гулин Гедик, Регина Гутхольд, Индраджит Хазарика, Паскаль Хайльберг, Альберт Мохлакола Хлабана, Лиза Хоффманн, Абубакар Иноуа, Габриэль Якоб, Манодж Джалани, Рита Кабра, Микико Канда, Рут Каньиру, Амината Сахо Келли, Джеймс Киари, Хё Чжон Ким, Теэна Кунджумэн, Этьен Ланглуа, Анаис Леганд, Орнелла Линчетто, Фрэнсис Магомбо, Мэри Манандхар, Карифа Мара, Реджис Антуан Мбари-Даба, Фрэнсис Макконвилл, Мишель МакИсаак, Хеди Мерташ, Набиль Менастрия, Нана Менса- Абрампа, Жан Жак Сальвадор Миллого, Анн-Бет Моллер, Маргарет Монтгомери, Эшли Мур, Манджулаа Нарасимхан, Стефани Нго, Сьюзен Норрис, Ян Нортон, Стефен Нерс-Финдли, Дженнифер Ниони, Асия Одугле-Колев, Алана Оффисер, Ми Окамура, Санни Окорофор, Олуфеми Оладапо, Каролина Омар, Зои Опара, Арва Оуэйс, Моника Падилья, Эдит Перейра, Сильвия Перел Левин, Владимир Позняк, Винаяк Мохан Прасад, Жакки Рейли, Прейанка Релан, Тери Рейнольдс, Пол Роджерс, Давид Росс, Аврора Саарес, Салим Садруддин, Бегонья Сагастюи, Фарба Ламин Салл, Диа Саминарсих, Джулия Самуэльсон, Элисон Шафер, Крис Скоттер, Джастин Аданмавокин Соссу, Сьюзан Спаркс, Симона Мари Сент-Клер, Джулия Сторр, Тигст Тамрат, Ай Танимидзу, Мартин Тейлор, Нурия Тото Поланко, Проспер Тумузиме, Озге Тунчальп, Энтони Твайман, Николь Валентайн, Марк Ван Оммерен, Шериан Варгезе, Джемма Весталь, Марко Витория, Виктория Вилле, Масахиро Закоджи, Томас Запата Лопес. ЭКСПЕРТЫ, ВНЕСШИЕ ВКЛАД В АНАЛИЗ ФАКТИЧЕСКИХ ДАННЫХ Томас Альварез, Сара Аббуд, Нерадж Агравал, Шантель Аллен, Антонио Фернандо Амарал, Бетани Арнольд, Мукул Бахши, Майра Бетрон, Аурелия Блажевичене, Джулия Блустоун, Йо Бут, Дебора Боссемейер, Ирма Брито, Эрика Бертон, Кенрик Като, Шоластика Чибехе, Мари Клариссе, Кей Керри, Шина Керри, Франсуа-Ксавье Даудал, Аннетт де Жонг, Ана де ла Осада, Дженнифер Дорн, Джо-Анн Доннер, Манья Дотсон, Хелен Ду Туа, Кристина Даффилд, Камаль Элдейрави, Лори Эллиот, Мария Энгстрем, Диана Эстевез, Черри Эванс, Бетти Феррелл, Лора Фицджералд, Энн Гардалф, Нэнси Гласс, Клэр Глентон, Патрисия Гомес, Деб Грант, Меган Грили, Дорис Гринспан, Валери A. Грусс, Марк Хатауэй, Карен Хитон, Айша Холлоуэй, Мелисса Хожан, Энн Храдски, Тонда Хьюз, Кэрол Хьюстон, Энн Хайр, Дарлин Ирби, Брижитт Иресон-Валуа, Сьюзан Якоби, Криста Джонс, Розмари Камунья, Джойс Кенкре, Джармила Клишикова, Тамара Кредо, Маргриета Лангинс, Маргрет Лепп, Изабель Лессард, Саймон Левин, Рики Лу, Джилл Мабен, Элизабет Мадиган, Андреа Марелли, Аделаис Маркаки, Мокгади Матлакала, Донна Маккарти Беккет, Сонья Макилфатрик, Сьюзан Мунаби Бабигумира, Доун Мунро, Анжелина Мутенга, Хайн Хаймар Майнт, Маделин А. Негл, Эдгар Некоча, Венди Николсон, Ян Нильссон, Лиза Ногути, Шелли Новлан, Арасели Окампо-Балабаньо, Джохис Ортега, Джейн Отай, Пирет Паал, Анна Пфицер, Лусинэ Погосян, Замира Рахмонова, Амелия Рануци, Вероника Рейс, Джим Рикка, Чандракант Рупарелия, Марла Сэлмон, Джейн Сэлвидж, Диана Шмалькуче, Франклин Шаффер, Джудит Шамиан, Бонги Сибанда, Дженнифер Снайдер, Сюзанна Столлс, Стейси Стендер, Барбара Стиллуэлл, Шерил Стогис, Луиза Страни, Ханна Таппис, Гауденсия Тибайджука, Вики Трейси-Вонг, Эрика Тронкоско, Аннука Туомикоски, Пол Тутилл, Карлос Ван дер Лаат, Тенер Гудвин Веенема, Мегги Верпуттен, Изабель Виоре, Синтия Власич, Джейми Ватеральл, Джин Уайт, Джилл Уайт, Барбара Венкамп-Вебер, Тегбар Йигцав ЛИЦА, ОКАЗАВШИЕ СОДЕЙСТВИЕ В ПРЕДОСТАВЛЕНИИ И АНАЛИЗЕ ДАННЫХ ВОЗ выражает признательность всем координаторам Национальных систем учета кадров здравоохранения, главным государственным специалистам по сестринскому и акушерскому делу, сотрудникам компании Novametrics (Мартин Бойс, Андреа Нове) и другим лицам, которые внесли вклад в процесс предоставления данных для подготовки настоящего доклада. Африканский регион Ханнату Абдуллахи, Соломон Абебе, Медеиле Алакпадонг, Фатимету Али, Баба Амиви, Гислен Арно, Яо Бэди, Эльшейх Бадр, Тамали Банда, Тереза Белай, Ана Белла, Эль-Хадж Бенчерик, Мохамед Берте, Мохамед Бу, Сильвино Н'дафа Браба, Синтия Шасокела, Кит Жан Хризостом, Аханханзон Агонгло Клариссе, Мария да Лус Медина да Круз, Мохамед Фаза Диалло, Демба Мусса Диалло, Бакала Дьедонне, Мамади Дукуре, Халид Эльмарди, Жан-Батист Годуи, Дембо Гуирасси, Фатима Халидани, Симон Хлунгвани, Идрисс Муджиегу Игалас, Мария Нандили Ишепе, Хамза Исмаила, Шакури Айинла Кадири, Чаа Каджанта, Эдна Камайе, Хоссинату Мэри Кану, Селлу Кейфала, Жан Хризостом Кетте, Эмиль Корома, Серафин Куаку, Ханна Ку-Киго, Ферозе Лалл Махомед, Самкелисиве Лукеле, Чиприано Майнга, Мпоэтси Макау, Нонхланхла Махания, Абед Малика, Сатурини Манангва, Мириам Мангея, Фелело Мароле, Ламин Маронг, Джезеле Мартинс, Муребуэйр Мари, Тэмби Мавузо, Джилиан Мейн, Камель Мессар, Джанет К. Майкл, Люси Мкутумула, Хумо Модисаэман, Флавия Моэтсана-Пока, Сисай Момоду, Матапело Мотебе, Джамиру Мпийма, Джейн Мудьяра, Чильвеза Мусонда Музонгве, Лония Мвапе, Вендин Манэгде Фелиситэ Нана, Мариам Ндагидже, Экири Нгуи, Аль Нхома, Нкосинати Р. Нкваньяна, Клодин Дьянго Нобоу, Кассома Педро Норберто, Ольга Новела, Эммануэль Нтавуируша, Тити Нелли Нтабана, Пол Ньячае, Мартиньо Огедже, Франсиска Окафор, Петуа Кибоко Олобо, Якуба Уэдраого, Джейкоб Пуда, Тарло Куивонкпа, Нуджалта Ремаджи, Баньоу Сахия, Давда Саматех, Ригбе Самуэль, Нене Катирона Санка, Экан Нди Сандрин, Мвила Секесеке, Малик Сейди, Мойба Шериф, Тулипока Соко, Репент Хамис Джордж Стивен, Яо Теодор, Джастин Тьендребеого, Франсина Тьитука, Теклу Цегай, Нкала Викторин, Соломон Волдеамануэль, Амброуз Вре, Джекки Йабилли, Исса Йахайя, Назир Йама, Барнабас Йебоа, Рабесата Жюст Йоланде Регион стран Америки Мария Лусия Айкарди, Рамон Абрего, София Ачукарро, Асиф Али, Аугустина Амбросе-Попо, Деннис Исраэль Анас Моралес, Дженнифер Андалл, Элизабет Андерсон, Джон Франциско Ариза Монтойя, Джой Арнелл, Сандра Бэрроу, Лиана Беллисарио, Луис Габриэль Бернал Пулидо, Шеллон Бесс, Ирма Буа, Рафаэль Борда, Дженнифер Бредс, Леонардо Брито, Сильвия Бризуэла, Хейзел Браун, Робин Бакленд, Родриго Кастро, Кертни Карлемань-Сураге, Андрей Челл, Альба Консуэло Флорес, Альберто Косме Лопес де Соуза, Эрнандо Кубидес, Натали Кюппенс, Лериван да Силва, Гайе Дэвис, Каролина де Басс, Джина Дин, Маркос дель Риско дель Рио, Нестер Эдвардс, Фульвия Элисондо Сибаха, Хулиана Феррейра Лима Коста, Эвелин Флорес де Ньето, Джанет Флинн, Мирейе Фуэнтес, Луис Фелипе Гарсия Руано, Роза Джордж, Клаудиа Годой, Кристиан Гонсалес Опельт, Заила Гонсалес Виво, Стейси Горинг, Иветта Каталина Гриалва Саенс, Норка Росио Гильен Понсе, Ясинт Ганнибал, Шэрон Харпер, Карла Гарри, Густаво Хофф, Гейл Хадсон, Бренда Джефферс, Линда Джонсон, Клаудия Лея Эрнандес, Лиза Литтл, Хавьер Сезар Лоайза Тамирано, Ховард Линч, Марсело Маркес, Диана Изабель Мартинес Чангуан, Итиния Мартинес Мора, Жаклин Мэтью-Феврье, Энн Матут, Линн Макнили, Темешвар Мерай, Фернандо Мунар Хименес, Карен Нельсон, Керри Несселер, Мирна Нобрега, Сьюзан Орсега, Бете Паз, Эмилиана Пенья, Хуан Лукас Перейра, Уолтер Перес Лазаро, Полин Питерс, Бетти Энн Пилгрим, Энма Поррас Маррокин, Хорхе Раманьо, Джейсон Роффенбендер, Дезрин Силкотт, Маргарет Смит, Тиаго Суза, Делорес Стейплтон Харрис, Джекурлин Саттон, Алдира Саманта Тейшейра, Сильвия Техада, Руди Термидор, Камилла Томас-Джеральд, Кс Дайанна Торрес Куинтеро, Педро Диас Уртеага, Карлос Валли, Алессандро Васконселос, Ауристела Васкес, Жанет Вега Чавес. Регион Юго-Восточной Азии Лила Адхикари, Кимат Адхикари, Сабина Алам, Алаам Али, Нан Нан Аун, Хла Хла Айе, Рати Балахандран, Алам Ара Бегум, Норберта Белу, К.С. Бхарати, Винай Ботра, Джермиас да Круз, Атул Дахал, Дилип де Сильва, Падмал де Сильва, Априянти Шинта Деви, Мария Долорес Кастелло, Аминат Фариха Мохамед, Орасио Фернандес Рибейро, Хариндаржит Гойял, Налика Гунавардена, Анил Кумар Гупта, Хтай Хтай Хлаинг, Фатимат Худха, Анеега Ибрахим, Сугенг Эко Ирианто, Айшат Ируфа, Урайпорн Джанта-ум-му, Шивангини Кар Дэйв, RADC Карунаратне, До Нве Нве Кхин, Титипат Куха, До Кхин Ма Ма Кьау, Кхин Мар Кьи, Сирима Лилавонг, Буддика Локу Баласурияге, Хуссейн Мааниу, Дилип Майрембам, До Инь Мя, Кавита Нараян, Тхинакорн Нори, Мд Нуруззаман, Чжоу Со Нюнт, Тандин Пемо, Вичави Плойсонгсри, Пуджа Прадхан, г-жа Рахмат, Мариам Рашид, Томасиа Ана Мариоа ду Росарио и Суза, Жоао Норонга Рой, Бхим Прасад Сапкота, Теерапорн Сатира- Ангкура, Тини Сетиван, Мариам Шафик, Мохаммад Шахджаджан, Джайендра Шарма, Мэй Твел Хла Шве Алака Сингх, Сасамон Срисутисак, Раттанапорн Тангтанасет, Рошани Туи Туи, Фикру Тесфайе Туллу, Ливиу Ведраско, Нани Хидаянти Видодо, Панарут Висаватапнимит, Сонам Янгчен Европейский регион Айзат Асанова, Ангел Абад Бассолс, Заза Бохуа, Айше Бойсан, Мэтт Эдвардс, Анастасия Гажева, Шоши Голдберг, Ривка Хазан Хазореф, Жак Хугенин, Наталья Камынина, Кристин Кляйн, Серджиу Отгон, Мария Палибрк, Цецилия Ротим, Васос Скутеллас, Джесмонд Шарплс, Артурас Шимкус Регион Восточного Средиземноморья Анмаль Абу Авад, Алавиа Ахмад, Мохаммад Альгамди, Мохамед Бахади, Камран Байг, Омар Черкауи, Ишрага Эльбашир, Каутер Махмуд, Фузия Муштак, Натали Рича, Анмаль Свайд Салим, Мохаммед Тараунех, Насир Яма, Лубна Якуб Регион Западной части Тихого океана Амелия Афухааманго, Леле Ах Му, Тельма Али, Картер Апаисам, Джасмин Мохамед Ариф, Маргарет Брудкорн, Морален Капелл, Теофила Круз, Эрвина Хь Эмран, Луиза Хельгенбергер, Сынгрюнг Хонг, Мэри Ката, Асена Кауяка, Мэри Килило Самор, Вирья Кой, Хиллия Лангрин, Майкл Ларуй, Маргарет Леонг, Фуатаи Майява, Антоннетт Мерюр, Хелен Мердок, Аманда Нилл, Куок Гуй Нгуен, Джейн О'Мэлли, Лэй Тин Онг, Дафни Ринги, Майкл Роуч, Мишель Рамси, Филояла Сакайо, Юоко Шимада, Бо Йи Шу, Берта Тарилео, Пуасина Татуй, Алайта Таулима, Кхампасонг Тэппаня, Лиза Таунсенд, Учаа Тувшин, Бен Унг, Хан Чжоу РЕДАКЦИОННАЯ КООРДИНАЦИЯ, ДИЗАЙН И ИЗДАНИЕ ПУБЛИКАЦИИ Шарад Агарвал, Прографикс, Инк.; Джон Доусон, службы письменного перевода, публикаций и печати ВОЗ. Приносится благодарность Ее Королевскому Высочеству Принцессе Иордании Муне, а также отдельным работникам сестринских служб и партнерским агентствам, которые оказали содействие в получении фотографий. ВОЗ хотела бы отдать особую дань памяти Саломе Карва, медицинской сестре из Либерии, которая перенесла болезнь, вызванную вирусом Эбола, но впоследствии скончалась в результате послеродовых осложнений, когда ей было отказано в оказании медицинской помощи. JHPIEGO И ШКОЛА СЕСТРИНСКОГО ДЕЛА УНИВЕРСИТЕТА ДЖОНСА ХОПКИНСА – выражается признательность этим организациям за внесенный ими вклад в процессы анализа фактических данных и предоставления сведений, необходимых для подготовки настоящего доклада. Питер Джонсон, Нэнси Рейнолдс, Дженнифер Брэдс, Анна Брайант, Патрика Дэвидсон, Лиза ДиАндрет, Джудит Фуллертон, Лиа Харт, Марк Кубуэ, Семакаленг Пафоли, Тимоти Робертон, Элизабет Томпсон Составители и выражение благодарности Мэри Уоткинс Заместитель сопредседателя кампании «Сестринское дело сегодня» ixСоставители и выражение благодарности Рынок труда (Labour market) – структура, которая определяет возможность поиска рабочей силы (то есть спрос) и ее предоставления (то есть предложение). Уровень оплаты труда и условия найма (например, наличие адекватной инфраструктуры, поддержка со стороны руководства, возможности для профессионального развития и продвижения по служебной лестнице) – все это влияет на выбор, который делают как медицинские работники, так и работодатели (1). Спрос (Demand) относится к рабочим местам, предлагаемым на рынке. Спрос – это число медицинских работников, которых система здравоохранения может трудоустроить исходя из наличия финансируемых должностей или экономического спроса на услуги. Спрос соотносится с объемами государственных расходов на здравоохранение, частного страхования и прямой оплаты населением медицинских услуг (2). Предложение (Supply) обеспечивается контингентом квалифицированных медицинских работников, готовых работать в системе оказания медицинской помощи. Уровень предложения на рынке труде зависит от таких факторов, как масштабы подготовки кадров, миграция, смертность и выход на пенсию работников здравоохранения (2). Потребность (Need) – число медицинских работников, необходимых для достижения целей системы здравоохранения, касающихся предоставления услуг. Ситуация на рынке труда в области здравоохранения определяется главным образом спросом и предложением и лишь косвенным образом – потребностями (1). Поглощающая (абсорбционная) способность рынка труда в области здравоохранения (Absorption capacity for health care workers by the health labour market) – способность системы здравоохранения (включая как государственный, так и частный сектор) полностью и продуктивно использовать имеющийся контингент квалифицированных медицинских работников (формируемый главным образом за счет учебной подготовки и иммиграции кадров). Поглощающая способность зависит от эффективности и своевременности трансформации экономического спроса в создание рабочих мест и заполнение вакансий. Базовое образование (Pre-service education) относится к формальной программе обучения, завершение которой рассматривается в качестве предварительного условия для профессионального трудоустройства (3). Лицензирование (Licensing) означает процедуру присвоения физическому лицу права выполнять функции в рамках определенной сферы практики в соответствии с требуемым стандартом. При этом ему выдается лицензия – юридическое разрешение заниматься определенной профессией на территории данной юрисдикции. Аккредитация (Accreditation) относится к процессу оценки образовательных учреждений на предмет соответствия заранее определенным стандартам, необходимого для получения права на образовательную деятельность. Результатом является удостоверение пригодности учебных программ и компетентности учреждений в отношении предоставления образовательных услуг. Аттестация (Credentialing) – процесс получения, проверки и оценки квалификации медицинского работника, необходимой для оказания медицинской помощи или выполнения других соответствующих видов работы в медицинском учреждении или по его поручению. Аттестационные сертификаты (credentials) – это документированные свидетельства наличия лицензии, полученного образования, профессионального опыта и других квалификаций (4). Профессиональная сертификация (Professional certification) – добровольный процесс, в рамках которого организация предоставляет физическому лицу на определенный срок официальное признание его квалификационных свидетельств и право на их использование после проверки соответствия данного лица заранее определенным и стандартизированным критериям (5). ЛИТЕРАТУРНЫЕ ИСТОЧНИКИ ДЛЯ ГЛОССАРИЯ 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https://www. jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, по состоянию на 5 марта 2020 г.). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty-resources/ research-grants/styles-credentialing-research-grants/credentialing-definitions/, по состоянию на 5 марта 2020 г.) Глоссарий Состояние сестринского дела в мире, 2020 г.x РЕЗЮМЕ 2020 г. Фото наверху: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi Центральная роль работников сестринского персонала в деле обеспечения всеобщего охвата услугами здравоохранения и достижения Целей в области устойчивого развития РЕЗЮМЕ всех кадров здравоохранения. Сестринский персонал – наиболее многочисленная категория в структуре медицинского персонала, на долю которой приходится порядка 59% Сестринский персонал имеет решающее значение для выполнения задачи «никого не оставить без внимания» и успеха глобальных усилий по достижению Целей в области устойчивого развития (ЦУР). Эта категория медицинских работников вносит ценнейший вклад в решение национальных и глобальных задач, касающихся широкого спектра приоритетных проблем здравоохранения, включая всеобщий охват услугами здравоохранения, охрану психического здоровья и борьбу с неинфекционными заболеваниями, обеспечение готовности и реагирование на чрезвычайные ситуации, безопасность пациентов, а также оказание комплексной и ориентированной на потребности людей медицинской помощи. Ни одна глобальная задача в сфере здравоохранения не может быть решена без координированных и систематических усилий по максимальной реализации потенциала сестринского персонала и повышения его роли в рамках междисциплинарных медицинских коллективов. Для этого требуется проведение политики по созданию условий, в которых работники сестринских служб будут достигать максимальной эффективности и результативности, посредством оптимизации круга обязанностей сестринского персонала, повышения значимости их функций, а также увеличения объема ресурсов, вкладываемых в их подготовку, профессиональное развитие и создание соответствующих рабочих мест. Такие инвестиции будут также способствовать выполнению задач ЦУР, касающихся образования, гендерных аспектов, достойного труда и инклюзивного экономического роста. В докладе «Состояние сестринского дела в мире, 2020 г.», подготовленном Всемирной организацией здравоохранения (ВОЗ) в партнерстве с Международным советом медицинских сестер и глобальной кампанией «Сестринское дело сегодня» и при поддержке со стороны ряда государств и широкого круга партнеров, представлено убедительное обоснование ценности сестринского персонала для развития здравоохранения во всем мире. © Shapecharge/Getty Images Данные о положении дел по состоянию на 2020 г. В настоящее время отмечаются как рост численности сестринского персонала, так и расширение круга его должностных обязанностей и функций. Тем не менее эти процессы развиваются неоднородно и недостаточными темпами для удовлетворения растущих потребностей, в результате чего целые группы населения остаются без доступа к сестринской помощи. Данные для доклада были предоставлены 191 страной, что является беспрецедентной цифрой и на 53% превосходит показатели за 2018 г. Около 80% стран предоставили данные по 15 и более индикаторам. Тем не менее по таким аспектам, как потенциал в сфере обучения, уровень финансирования, оплата труда и динамика рынка труда, в имеющейся статистике отмечаются существенные пробелы. Это препятствует надлежащему выполнению анализа рынка труда в сфере здравоохранения, необходимого для принятия решений относительно политики развития сестринских кадров и предоставления соответствующего финансирования. Численность сестринского персонала во всем мире составляет 27,9 миллиона человек, из которых 19,3 миллиона – медсестры профессионального уровня. Это свидетельствует о росте общей численности этой категории работников на 4,7 миллиона за период 2013-2018 гг. и подтверждает, что сестринский персонал – наиболее многочисленная категория в структуре медицинского персонала, на долю которой приходится порядка 59% всех кадров здравоохранения. К 27,9 миллиона работников сестринских служб относятся 19,3 (69%) медсестер профессионального уровня, 6 миллионов (22%) медицинских сестер ассоциированного профессионального уровня и 2,6 миллиона (9%) работников, не относящихся ни к одной из указанных категорий. Общая численность сестринского персонала в мире не соответствует потребностям, возникающим в связи с необходимостью обеспечения всеобщего охвата услугами здравоохранения и достижения задач ЦУР. Более 80% сестринского персонала в мире работает в странах, в которых проживает половина населения планеты. Глобальный дефицит медсестер, который по оценкам составлял 6,6 миллиона в 2016 г., несколько снизился и в 2018 г. составил 5,9 миллиона работников. Порядка 89% этого дефицита (5,3 млн медсестер) приходится на долю стран с низким уровнем дохода и доходом ниже среднего, в которых рост численности сестринского персонала с трудом поспевает за ростом численности населения и где обеспеченность сестринскими кадрами на душу населения растет незначительными темпами. На рисунке 1 показаны значительные различия в показателях обеспеченности сестринским персоналом на душу населения, причем наибольшие пробелы в обеспеченности сестринским персоналом отмечаются в странах Африки, Юго- Восточной Азии и Восточного Средиземноморья, а также в некоторых странах Латинской Америки. Рисунок 1 Обеспеченность сестринским персоналом на 10 000 человек населения в 2018 г. *Включая сестринский персонал профессионального и ассоциированного профессионального уровней. Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Новейшие доступные данные за период 2013-2018 гг. нет данныхне применимо 0 1,000 2,000 3,000 4,000500 km < 10 10-19 20-29 30-39 40-49 50-74 75-99 более 100 3РЕЗЮМЕ xiiiРезюме В некоторых регионах стабильность численности сестринского персонала находится под угрозой ввиду старения кадровых ресурсов. Средний возраст сестринского персонала в мире является относительно низким, однако в этом отношении ситуация является неоднородной в зависимости от региона. Так, в Регионе стран Америки и Европейском регионе средний возраст сестринских кадров значительно превышает их средний возраст в других регионах. Для сохранения доступа населения к услугам здравоохранения на прежнем уровне странам с низким отношением численности начинающих медсестер (т.е. медсестер в возрасте до 35 лет) к численности медсестер предпенсионного возраста (в возрасте более 55 лет) потребуется обеспечить приток молодых специалистов в сфере сестринского дела и укрепить пакет мер по удержанию персонала. Странам с большим числом молодых специалистов в структуре среднего медицинского персонала следует обеспечить их более равномерное географическое распределение. Как показано на рисунке 2, страны, в которых доля медсестер предпенсионного возраста превышает долю молодых медсестер (т.е. страны, находящиеся над зеленой линией), в будущем столкнутся с проблемой поддержания численности сестринского персонала. * Включая сестринский персонал профессионального уровня и ассоциированного профессионального уровня. Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Новейшие доступные данные за период 2013-2018 гг. Рисунок 2 Доля медсестер старше 55 лет и младше 35 лет (по данным из выборки стран) Доля медсестёр в возрасте младше 35 лет 70% 60% 50% 40% 30% 20% 10% 0% До ля м ед се ст ёр в во зр ас те ст ар ш е 5 5 л ет 60%0% 10% 20% 30% 40% 50% 70% 18 стран подвержены риску старения сестринского персонала Каждая точка соответствует отдельной стране На зеленой линии расположены точки, в которых число медсестер предпенсионного возраста равно числу молодых медсестер 4 Доклад о состоянии сестринского дела в мире, 2020 г.xiv Состояние сестринского дела в мире, 2020 г. В некоторых регионах стабильность численности сестринского персонала находится под угрозой ввиду старения кадровых ресурсов. Средний возраст сестринского персонала в мире является относительно низким, однако в этом отношении ситуация является неоднородной в зависимости от региона. Так, в Регионе стран Америки и Европейском регионе средний возраст сестринских кадров значительно превышает их средний возраст в других регионах. Для сохранения доступа населения к услугам здравоохранения на прежнем уровне странам с низким отношением численности начинающих медсестер (т.е. медсестер в возрасте до 35 лет) к численности медсестер предпенсионного возраста (в возрасте более 55 лет) потребуется обеспечить приток молодых специалистов в сфере сестринского дела и укрепить пакет мер по удержанию персонала. Странам с большим числом молодых специалистов в структуре среднего медицинского персонала следует обеспечить их более равномерное географическое распределение. Как показано на рисунке 2, страны, в которых доля медсестер предпенсионного возраста превышает долю молодых медсестер (т.е. страны, находящиеся над зеленой линией), в будущем столкнутся с проблемой поддержания численности сестринского персонала. * Включая сестринский персонал профессионального уровня и ассоциированного профессионального уровня. Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Новейшие доступные данные за период 2013-2018 гг. Рисунок 2 Доля медсестер старше 55 лет и младше 35 лет (по данным из выборки стран) Доля медсестёр в возрасте младше 35 лет 70% 60% 50% 40% 30% 20% 10% 0% До ля м ед се ст ёр в во зр ас те ст ар ш е 5 5 л ет 60%0% 10% 20% 30% 40% 50% 70% 18 стран подвержены риску старения сестринского персонала Каждая точка соответствует отдельной стране На зеленой линии расположены точки, в которых число медсестер предпенсионного возраста равно числу молодых медсестер 4 Доклад о состоянии сестринского дела в мире, 2020 г. Для решения проблемы дефицита сестринского персонала во всех странах к 2030 г. общее число молодых специалистов в области сестринского дела должно расти в среднем на 8% в год одновременно с расширением возможностей трудоустройства и принятием мер по удержанию этой категории персонала. Текущие тенденции указывают на то, что без этих мер к 2030 г. совокупная численность медсестер в мире составит 36 миллионов, а дефицит – 5,7 миллиона работников, главным образом, в регионах Африки, Юго-Восточной Азии и Восточного Средиземноморья. Параллельно с этим дефицит среднего медицинского персонала на национальном уровне будет по-прежнему ощущаться в ряде стран регионов Европы, Америки и Западной части Тихого океана. На рисунке 3 показано прогнозируемое увеличение численности сестринского персонала с разбивкой по регионам ВОЗ и категориям стран по уровню дохода. Рисунок 3 Прогнозируемое увеличение (в период до 2030 г.) численности сестринского персонала в разбивке по регионам ВОЗ и категориям стран по уровню дохода *Включая сестринский персонал профессионального уровня и ассоциированного профессионального уровня. EXECUTIVE SUMMARY В этих условиях проблема равномерного распределения и удержания сестринского персонала становится все более насущной ПРАКТИЧЕСКИ ДЛЯ ВСЕХ СТРАН. © ICAP/Sven Torfi nn RUSSIAN Уровень дохода ниже среднего 27% Уровень дохода выше среднего 61% Высокий уровень дохода 6% Низкий уровень дохода 6% Регион стран Америки 43% Европейский регион 7% Африканский регион 6% Регион Восточного Средиземноморья 4% Регион Западной части Тихого океана 22% Регион Юго- Восточной Азии 18% Уровень дохода Регион 5РЕЗЮМЕ xvРЕЗЮМЕ Большинство стран (152 из 157 ответивших, т.е. 97%) сообщили, что минимальная длительность программы обучения сестринского персонала составляет три года. В подавляющем большинстве стран имеются стандарты, определяющие содержание и продолжительность программы обучения (91%), механизмы аттестации (89%), национальные стандарты квалификации преподавательского состава (77%) и совмещенного (межпрофессионального) обучения (67%). Тем не менее данных об эффективности таких мер и механизмов мало. Кроме того, сохраняется большая неоднородность в том, что касается минимального уровня образования и подготовки медсестер, а также отмечаются нехватка преподавательского состава, инфраструктурные ограничения и дефицит мест для прохождения практики в учреждениях здравоохранения. Как показано на рисунке 4, продолжительность обучения сестринского персонала в мире обычно составляет три-четыре года. О наличии среди сестринского персонала медсестер повышенной квалификации с расширенным кругом функций сообщили 78 стран (53% ответивших). Имеются убедительные данные о том, что наличие сестринского персонала повышенной квалификации (с расширенным кругом должностных обязанностей и полномочий) способствует расширению доступа к первичной медико-санитарной помощи в сельских районах и позволяет устранить неравенство в доступе к услугам, с которым сталкиваются представители уязвимых слоев населения в городских районах. Создание благоприятных условий труда и оказание сестринскому персоналу поддержки в полной реализации его профессионального потенциала в соответствии с уровнем образования и квалификации позволят сестринскому персоналу любого уровня эффективно оказывать первичную медико-санитарную помощь, профилактическую помощь, а также предоставлять многие другие услуги, что в конечном счете является необходимым условием обеспечения всеобщего доступа к услугам здравоохранения. Каждый восьмой работник сестринских служб работает за пределами страны своего рождения или обучения. Процесс международной мобильности сестринских кадров становится все более интенсивным. В этих условиях проблема равномерного распределения и удержания сестринского персонала становится все более насущной практически для всех стран. Неуправляемые миграционные процессы могут усугубить нехватку персонала и привести к отсутствию равноправного доступа к услугам здравоохранения. Как показывают © Nazeer Al-Khatib/AFP via Getty 2 года 3 года 4 года 5 лет 0% 20% 40% 60% 80% 100% Африканский регион Регион стран Америки Регион Юго-Восточной Азии Европейский регион Регион Восточного Средиземноморья Регион Западной части Тихого океана РЕГИОН ВОЗ Все страны мира Источник: Национальные счета кадров здравоохранения за 2019 г. по 99 странам и база данных Sigma по 58 странам. Новейшие данные, предоставленные странами в период с 2013 по 2018 г. Рисунок 4 Средняя продолжительность обучения сестринского персонала профессионального уровня в разбивке по регионам ВОЗ (в годах) 6 Доклад о состоянии сестринского дела в мире, 2020 г. данные, в ряде регионов многие страны с высоким уровнем дохода испытывают чрезмерную зависимость от притока иностранного сестринского персонала ввиду недостаточного числа новых выпускников, дефицита сестринских кадров для заполнения имеющихся вакантных должностей или же, напротив, отсутствия возможностей для трудоустройства молодых специалистов. В большинстве стран (86%) действует государственный орган регулирования в области сестринского дела. Почти две трети стран (64%) сообщили о наличии у них требований в отношении аттестации всех начинающих работников сестринских служб, и почти три четверти стран (73%) сообщили о наличии требований постоянного повышения квалификации сестринского персонала как условия продолжения профессиональной деятельности. Тем не менее регулирование обучения и профессиональной деятельности сестринского персонала не является стандартизированным, за исключением отдельных случаев существования на субрегиональном уровне механизмов взаимного признания дипломов и квалификации. В условиях высокой трудовой мобильности, растущего акцента на междисциплинарной работе и развития цифровых технологий перед надзорными органами встает трудная задача по постоянному обновлению норм регулирования в сфере обучения и профессиональной деятельности сестринского персонала и актуализации реестров сестринских трудовых ресурсов. На рисунке 5 показана доля стран (из числа предоставивших соответствующую информацию), в которых существуют нормативные положения, регламентирующие условия труда. Сестринское дело остается профессией с сильным гендерным дисбалансом со всеми вытекающими последствиями в области трудовых отношений. Порядка 90% членов сестринского персонала – женщины, однако медсестры или женщины крайне редко занимают руководящие должности в системе здравоохранения. Имеются данные о гендерно-обусловленном неравенстве в оплате труда, а также о других формах дискриминации на рабочем месте по гендерному признаку. По результатам опроса, в большинстве стран созданы необходимые правовые механизмы охраны труда, включая нормативы по продолжительности рабочего дня, условиям труда, минимальной оплате труда и социальной защите, однако обеспеченность такими механизмами в разных регионах разная. Немногим более одной трети стран (37%) сообщили о наличии у них мер по предупреждению нападений на работников здравоохранения. Всего 82 из 115 ответивших стран (71%) сообщили о наличии на национальном уровне высокопоставленного должностного лица, ведающего вопросами сестринского дела, в полномочия которого входит участие в выработке политики в областях сестринского дела и здравоохранения. 78 стран (53% ответивших) сообщили о наличии национальной программы, направленной на расширение руководящих функций сестринского персонала. Одновременное наличие национального руководителя сестринских служб (или аналогичной должности) и программы по расширению руководящих функций сестринского персонала ассоциируется с наличием в целом более благоприятных нормативно-правовых условий труда сестринского персонала. Рисунок 5 Доля стран, в которых существуют нормативные положения, регламентирующие условия труда Положения, регламентирующие продолжительность рабочего дня и условия труда (133 из 142) Положения о мерах социальной защиты (125 из 137) Положения о минимальной заработной плате (119 из 134) Совет по сестринскому делу (141 из 164) Наличие сестринского персонала с расширенным кругом функций (50 из 95) Меры по предупреждению нападений на медработников (20 из 55) Доля стран, давших утвердительный ответ 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. 7РЕЗЮМЕ xvi Состояние сестринского дела в мире, 2020 г. данные, в ряде регионов многие страны с высоким уровнем дохода испытывают чрезмерную зависимость от притока иностранного сестринского персонала ввиду недостаточного числа новых выпускников, дефицита сестринских кадров для заполнения имеющихся вакантных должностей или же, напротив, отсутствия возможностей для трудоустройства молодых специалистов. В большинстве стран (86%) действует государственный орган регулирования в области сестринского дела. Почти две трети стран (64%) сообщили о наличии у них требований в отношении аттестации всех начинающих работников сестринских служб, и почти три четверти стран (73%) сообщили о наличии требований постоянного повышения квалификации сестринского персонала как условия продолжения профессиональной деятельности. Тем не менее регулирование обучения и профессиональной деятельности сестринского персонала не является стандартизированным, за исключением отдельных случаев существования на субрегиональном уровне механизмов взаимного признания дипломов и квалификации. В условиях высокой трудовой мобильности, растущего акцента на междисциплинарной работе и развития цифровых технологий перед надзорными органами встает трудная задача по постоянному обновлению норм регулирования в сфере обучения и профессиональной деятельности сестринского персонала и актуализации реестров сестринских трудовых ресурсов. На рисунке 5 показана доля стран (из числа предоставивших соответствующую информацию), в которых существуют нормативные положения, регламентирующие условия труда. Сестринское дело остается профессией с сильным гендерным дисбалансом со всеми вытекающими последствиями в области трудовых отношений. Порядка 90% членов сестринского персонала – женщины, однако медсестры или женщины крайне редко занимают руководящие должности в системе здравоохранения. Имеются данные о гендерно-обусловленном неравенстве в оплате труда, а также о других формах дискриминации на рабочем месте по гендерному признаку. По результатам опроса, в большинстве стран созданы необходимые правовые механизмы охраны труда, включая нормативы по продолжительности рабочего дня, условиям труда, минимальной оплате труда и социальной защите, однако обеспеченность такими механизмами в разных регионах разная. Немногим более одной трети стран (37%) сообщили о наличии у них мер по предупреждению нападений на работников здравоохранения. Всего 82 из 115 ответивших стран (71%) сообщили о наличии на национальном уровне высокопоставленного должностного лица, ведающего вопросами сестринского дела, в полномочия которого входит участие в выработке политики в областях сестринского дела и здравоохранения. 78 стран (53% ответивших) сообщили о наличии национальной программы, направленной на расширение руководящих функций сестринского персонала. Одновременное наличие национального руководителя сестринских служб (или аналогичной должности) и программы по расширению руководящих функций сестринского персонала ассоциируется с наличием в целом более благоприятных нормативно-правовых условий труда сестринского персонала. Рисунок 5 Доля стран, в которых существуют нормативные положения, регламентирующие условия труда Положения, регламентирующие продолжительность рабочего дня и условия труда (133 из 142) Положения о мерах социальной защиты (125 из 137) Положения о минимальной заработной плате (119 из 134) Совет по сестринскому делу (141 из 164) Наличие сестринского персонала с расширенным кругом функций (50 из 95) Меры по предупреждению нападений на медработников (20 из 55) Доля стран, давших утвердительный ответ 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. 7РЕЗЮМЕ xviiРЕЗЮМЕ Странам, испытывающим нехватку сестринского персонала, потребуется повысить объем финансовых вложений в целях обеспечения подготовки и найма по меньшей мере 5,9 миллиона новых работников сестринских служб. В странах с низким и средним уровнем дохода объем дополнительных затрат на обучение сестринского персонала составит порядка 10 долл. США на душу населения. Для создания возможностей трудоустройства молодых специалистов потребуется выделение дополнительных финансовых ресурсов. В большинстве стран эта задача может быть выполнена за счет внутренних источников финансирования. К необходимым действиям относится анализ ситуации и решение проблем, касающихся фонда оплаты труда, а также в некоторых странах снятие квот на сестринский персонал. В случае ограниченности ресурсов в среднесрочной и долгосрочной перспективах, например в странах с низким уровнем дохода и странах, затронутых вооруженными конфликтами или нестабильностью, следует рассмотреть использование таких механизмов, как институциональные договоренности об объединении ресурсов. Партнеры в области развития и международные финансовые учреждения могут оказывать содействие посредством интеграции ресурсов, выделяемых в сферах образования, занятости, гендерного равенства, здравоохранения и повышения квалификации, в рамках осуществления национальных стратегий развития кадров здравоохранения в интересах развития первичной медико-санитарной помощи и достижения всеобщего охвата услугами здравоохранения. Вложение ресурсов в развитие сестринских кадров может также способствовать занятости, гендерному равенству и вовлечению молодежи. Дальнейшие направления политики развития трудовых ресурсов в области сестринского дела ДЕСЯТЬ КЛЮЧЕВЫХ ДЕЙСТВИЙ © John W. Poole/NPR 8 Доклад о состоянии сестринского дела в мире, 2020 г.xviii Состояние сестринского дела в мире, 2020 г. Странам следует укреплять потенциал в области сбора, анализа и использования данных о кадровых ресурсах здравоохранения. К числу необходимых действий в этой сфере относятся ускорение внедрения национальных счетов кадровых ресурсов здравоохранения и использование этих данных для анализа рынка труда в сфере здравоохранения в интересах информационного обеспечения процессов разработки политики и принятия решений относительно бюджетных ассигнований. Обработка статистических данных о сестринском персонале потребует межведомственной работы, а также участия ключевых заинтересованных сторон, таких как надзорные органы, образовательные учреждения, медицинские организации и профессиональные ассоциации. Трудовая мобильность и миграция сестринского персонала должны быть объектом эффективного мониторинга и ответственного и этичного управления. К необходимым действиям в этой области относится обеспечение более последовательного применения странами, нанимающими организациями и международными субъектами Глобального кодекса ВОЗ по практике международного найма персонала здравоохранения. Наличие партнерских отношений и сотрудничества между надзорными органами, системами сбора информации о кадрах здравоохранения, работодателями, руководителями правительственных ведомств и другими заинтересованными сторонами может помочь в повышении эффективности мониторинга, управления и регулирования международной мобильности сестринского персонала. Страны, в слишком большой степени зависимые от притока иностранного сестринского персонала, должны стремиться к более высокому уровню самообеспечения сестринскими кадрами посредством вложения дополнительных ресурсов в подготовку медсестер на национальном уровне. Страны, сталкивающиеся с чрезмерно большой утечкой сестринского персонала в связи с трудовой миграцией, должны рассмотреть вопрос о принятии мер по удержанию кадров, таких как повышение заработной платы (и обеспечение равной оплаты труда) и улучшение условий труда, создание возможностей карьерного роста и обеспечение сестринскому персоналу возможности реализовывать свой потенциал в соответствии с уровнем образования и квалификации. Программы обучения и подготовки сестринского персонала должны готовить медсестер, которые станут движущей силой в деле развития первичной медико-санитарной помощи и обеспечения всеобщего охвата услугами здравоохранения. К необходимым действиям в этой сфере относятся инвестиции в преподавательский состав, обеспечение наличия мест прохождения клинической практики и обеспечение доступности обучения в интересах повышения разнообразия состава слушателей. Сестринское дело должно стать привлекательной профессией, опирающейся на науку, новые технологии, ценности командной работы и принцип справедливости в сфере здравоохранения. Руководители национальных сестринских служб и другие национальные заинтересованные стороны могут инициировать диалог о необходимых требованиях к программам начальной и специализированной подготовки медсестер, которые позволят удовлетворить спрос системы здравоохранения на сестринский персонал. Программы обучения должны соответствовать национальным приоритетам в сфере здравоохранения, а также составляться с учетом новых глобальных тенденций и вызовов, что даст возможность готовить сестринский персонал, способный эффективно работать в рамках междисциплинарных коллективов и хорошо знакомый с новыми медицинскими технологиями. Лидерство и управление являются важнейшим условием укрепления сестринских трудовых ресурсов. К необходимым действиям относятся учреждение на уровне правительства должности руководителя национальной сестринской службы, ответственного за развитие национальных сестринских кадров и принимающего участие в формировании политики в сфере здравоохранения, и оказание этому руководителю необходимой поддержки. Руководители государственных сестринских служб должны активно способствовать повышению эффективности сбора и анализа данных о сестринских трудовых ресурсах и координировать политический диалог, целью которого является основанное на научных данных принятие решений, касающихся финансирования развития сестринского персонала. Должны быть организованы программы укрепления руководящей роли сестринского персонала в интересах развития лидерских качеств у молодых работников сестринских служб. В условиях нестабильности и вооруженных конфликтов потребуется особое внимание к восстановлению институциональных основ и индивидуального управленческого потенциала в области эффективного управления сестринским персоналом и координации его деятельности. 9РЕЗЮМЕ xixРЕЗЮМЕ Лица и органы, ответственные за планирование и регулирование в области сестринского дела, должны принять меры по оптимальному использованию профессионального потенциала сестринских кадров. К необходимым действиям относится обеспечение использования сестринского персонала на уровне первичного звена в полном соответствии с его должностными функциями. В соответствующих случаях целесообразно расширить сферу обязанностей и полномочий сестринского персонала для удовлетворения потребностей населения в услугах здравоохранения и расширения доступа к первичной медико-санитарной помощи, в том числе в условиях растущего спроса на медицинскую помощь в связи с неинфекционными заболеваниями, а также обеспечить интеграцию медицинской и социальной помощи. Для решения типовых проблем, приводящих к текучести сестринских кадров, должны быть приняты соответствующие меры в сфере трудовой политики; к таким мерам относится, в частности, развитие моделей оказания помощи силами сестринского персонала, расширение перечня должностных функций и полномочий медсестер, использование возможностей, открывающихся в связи с новыми технологиями цифрового здравоохранения, а также обеспечение учета возрастной структуры сестринского персонала. Политики, работодатели и органы регулирования должны координировать действия в интересах обеспечения достойных условий труда. Страны обязаны обеспечить благоприятные условия для деятельности среднего медицинского персонала в целях повышения привлекательности профессии, улучшения распределения кадров, удержания персонала и создания у него мотивации. В приоритетном порядке должно быть обеспечено достаточное укомплектование кадрами и приняты меры по охране и гигиене труда с оказанием особого внимания сестринскому персоналу, работающему в условиях нестабильности, конфликтов или в небезопасной обстановке. Оплата труда должна быть достаточной для того, чтобы привлекать, удерживать и мотивировать сестринские кадры. В дополнение к перечисленному страны должны в приоритетном порядке принять меры по предупреждению и пресечению сексуальных домогательств, сексуального насилия и дискриминации по отношению к сестринскому персоналу. Страны должны последовательно обеспечивать учет гендерных аспектов при разработке политики по развитию трудовых ресурсов в области сестринского дела. К необходимым действиям в этой области относится создание справедливой и гендерно-нейтральной системы оплаты труда медицинских работников и обеспечение соблюдения нормативно-правовых положений, касающихся равной оплаты труда, в том числе в частном секторе. Меры политики, касающиеся сестринского дела, должны разрабатываться с учетом гендерных соображений. Это относится к политике в области образования, практической деятельности, надзорной или управленческой функции, учитывая тот факт, что сестринский персонал по-прежнему представлен преимущественно женщинами (рисунок 6). К мерам политики, требующим рассмотрения применительно к данному вопросу, относятся создание благоприятных условий труда для женщин, например посредством введения гибкого и удобного графика работы, позволяющего учитывать особые обстоятельства жизни женщин, а также создание возможностей для развития управленческого потенциала женщин-медсестер. % женщин % мужчин РЕГИОН ВОЗ Африканский регион Регион стран Америки Регион Юго-Восточной Азии Европейский регион Регион Восточного Средиземноморья Регион Западной части Тихого океана 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Рисунок 6 Доля женщин и мужчин среди сестринского персонала в разбивке по регионам ВОЗ Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Новейшие данные, предоставленные в период с 2013 по 2018 г. 10 Доклад о состоянии сестринского дела в мире, 2020 г.xx Состояние сестринского дела в мире, 2020 г. Лица и органы, ответственные за планирование и регулирование в области сестринского дела, должны принять меры по оптимальному использованию профессионального потенциала сестринских кадров. К необходимым действиям относится обеспечение использования сестринского персонала на уровне первичного звена в полном соответствии с его должностными функциями. В соответствующих случаях целесообразно расширить сферу обязанностей и полномочий сестринского персонала для удовлетворения потребностей населения в услугах здравоохранения и расширения доступа к первичной медико-санитарной помощи, в том числе в условиях растущего спроса на медицинскую помощь в связи с неинфекционными заболеваниями, а также обеспечить интеграцию медицинской и социальной помощи. Для решения типовых проблем, приводящих к текучести сестринских кадров, должны быть приняты соответствующие меры в сфере трудовой политики; к таким мерам относится, в частности, развитие моделей оказания помощи силами сестринского персонала, расширение перечня должностных функций и полномочий медсестер, использование возможностей, открывающихся в связи с новыми технологиями цифрового здравоохранения, а также обеспечение учета возрастной структуры сестринского персонала. Политики, работодатели и органы регулирования должны координировать действия в интересах обеспечения достойных условий труда. Страны обязаны обеспечить благоприятные условия для деятельности среднего медицинского персонала в целях повышения привлекательности профессии, улучшения распределения кадров, удержания персонала и создания у него мотивации. В приоритетном порядке должно быть обеспечено достаточное укомплектование кадрами и приняты меры по охране и гигиене труда с оказанием особого внимания сестринскому персоналу, работающему в условиях нестабильности, конфликтов или в небезопасной обстановке. Оплата труда должна быть достаточной для того, чтобы привлекать, удерживать и мотивировать сестринские кадры. В дополнение к перечисленному страны должны в приоритетном порядке принять меры по предупреждению и пресечению сексуальных домогательств, сексуального насилия и дискриминации по отношению к сестринскому персоналу. Страны должны последовательно обеспечивать учет гендерных аспектов при разработке политики по развитию трудовых ресурсов в области сестринского дела. К необходимым действиям в этой области относится создание справедливой и гендерно-нейтральной системы оплаты труда медицинских работников и обеспечение соблюдения нормативно-правовых положений, касающихся равной оплаты труда, в том числе в частном секторе. Меры политики, касающиеся сестринского дела, должны разрабатываться с учетом гендерных соображений. Это относится к политике в области образования, практической деятельности, надзорной или управленческой функции, учитывая тот факт, что сестринский персонал по-прежнему представлен преимущественно женщинами (рисунок 6). К мерам политики, требующим рассмотрения применительно к данному вопросу, относятся создание благоприятных условий труда для женщин, например посредством введения гибкого и удобного графика работы, позволяющего учитывать особые обстоятельства жизни женщин, а также создание возможностей для развития управленческого потенциала женщин-медсестер. % женщин % мужчин РЕГИОН ВОЗ Африканский регион Регион стран Америки Регион Юго-Восточной Азии Европейский регион Регион Восточного Средиземноморья Регион Западной части Тихого океана 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% Рисунок 6 Доля женщин и мужчин среди сестринского персонала в разбивке по регионам ВОЗ Источник: Национальные счета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Новейшие данные, предоставленные в период с 2013 по 2018 г. 10 Доклад о состоянии сестринского дела в мире, 2020 г. © Yoshinobu Oka via Sasakawa Health Foundation Необходимо модернизировать профессиональные стандарты, касающиеся сестринского дела. В частности, следует гармонизировать стандарты в области обучения и аттестации сестринских кадров, включая обеспечение взаимного признания дипломов и квалификации, а также создать совместимые системы, которые позволяли бы надзорным органам просто и быстро выполнять проверку квалификации и информации о возможных дисциплинарных мерах в отношении работников. Меры нормативного регулирования, в том числе касающиеся объема должностных обязанностей, первоначальной аттестации и требований по постоянному повышению квалификации, должны способствовать тому, чтобы сестринский персонал мог в полной мере реализовывать свой профессиональный потенциал в соответствии с уровнем полученного образования в рамках динамичных междисциплинарных коллективов. Ключевым слагаемым успеха является сотрудничество. В данной сфере необходимо наладить межсекторальный диалог под руководством министерств здравоохранения и руководителя национальной сестринской службы с привлечением других соответствующих министерств (образования, иммиграции, финансов, труда) и заинтересованных сторон из государственного и частного секторов. Важнейшим элементом является укрепление потенциала государственного сектора для эффективного выполнения им своей координационной роли, с тем чтобы финансовые решения частного сектора, возможности в сфере профессиональной подготовки и роль медсестер в предоставлении услуг здравоохранения были оптимизированы в соответствии с целями государственной политики. Профессиональные ассоциации работников сестринских служб, образовательные учреждения и преподавательский состав, органы регулирования сестринской деятельности и профессиональные союзы, студенты и молодежные объединения, организации гражданского общества и глобальные кампании, такие как «Сестринское дело сегодня» являются ценными участниками процесса укрепления роли сестринского персонала в рамках медицинских коллективов, занятых удовлетворением приоритетных потребностей населения в услугах здравоохранения. Для решения типовых проблем, приводящих к текучести сестринских кадров, должны быть приняты соответствующие меры в сфере трудовой политики; к таким мерам относятся, в частности, развитие моделей оказания помощи силами сестринского персонала, расширение перечня должностных функций и полномочий медсестер. В данном докладе представлен большой массив убедительных научных данных и статистики, касающихся сестринского персонала. Эти данные необходимы для информационной поддержки диалога по вопросам политики и процесса принятия решений о вложении ресурсов в развитие сестринского дела как инструмента укрепления первичной медико-санитарной помощи, обеспечения всеобщего охвата услугами здравоохранения и дальнейшего движения по направлению к ЦУР. Несмотря на ряд позитивных тенденций, в докладе также отмечено несколько ключевых проблемных областей. Для устранения главных проблем многим странам с низким уровнем дохода и доходом ниже среднего в регионах Африки, Юго-Восточной Азии и Восточного Средиземноморья потребуется ускорить темпы работы. В то же время не следует успокаиваться и странам с доходом выше среднего и высоким уровнем дохода, в которых такие проблемы, как недостаточное предложение на рынке труда, старение сестринского персонала и чрезмерная зависимость от притока иностранных кадров, ставят под угрозу достижение национальных задач в области развития сестринских трудовых ресурсов. ВЫВОД Необходимо вкладывать ресурсы в обучение, создание рабочих мест и развитие лидерских функций сестринского персонала Правительства стран, при необходимости при поддержке внутренних и международных партнеров, должны активизировать и возглавить работу по ускорению деятельности в следующих областях: наращивание лидерского, управленческого и руководящего потенциала сестринского персонала в интересах дальнейшего решения соответствующих задач в области образования, здравоохранения, занятости и гендерного равенства; обеспечение оптимальной отдачи от инвестиций в развитие сестринского дела посредством принятия необходимых мер в таких областях, как обучение, достойный труд, справедливая заработная плата, практическая деятельность, производительность труда, регулирование и удержание сестринского персонала; ускорение и поддержание на достаточном уровне дополнительных инвестиций в обучение сестринского персонала, формирование необходимых навыков и создание рабочих мест. Необходимые вложения потребуют дополнительных финансовых средств. Отдача, которую принесут эти инвестиции для общества и экономики стран, может быть выражена в улучшении здоровья миллиардов людей, создании миллионов квалифицированных рабочих мест, особенно для женщин и молодежи, и укреплении безопасности в сфере здравоохранения во всем мире. Целесообразность вложения ресурсов в обучение сестринского персонала, создание рабочих мест и обеспечение его лидерских позиций в системе здравоохранения не вызывает сомнений, и все соответствующие заинтересованные стороны должны взять на себя обязательства по осуществлению конкретных действий. © St Thomas’ Hospital, London Правительства стран, при необходимости при поддержке внутренних и международных партнеров, должны активизировать и возглавить работу по ускорению деятельности в следующих областях: наращивание лидерского, управленческого и руководящего потенциала сестринского персонала в интересах дальнейшего решения соответствующих задач в области образования, здравоохранения, занятости и гендерного равенства; обеспечение оптимальной отдачи от инвестиций в развитие сестринского дела посредством принятия необходимых мер в таких областях, как обучение, достойный труд, справедливая заработная плата, практическая деятельность, производительность труда, регулирование и удержание сестринского персонала; ускорение и поддержание на достаточном уровне дополнительных инвестиций в обучение сестринского персонала, формирование необходимых навыков и создание рабочих мест. Необходимые вложения потребуют дополнительных финансовых средств. Отдача, которую принесут эти инвестиции для общества и экономики стран, может быть выражена в улучшении здоровья миллиардов людей, создании миллионов квалифицированных рабочих мест, особенно для женщин и молодежи, и укреплении безопасности в сфере здравоохранения во всем мире. Целесообразность вложения ресурсов в обучение сестринского персонала, создание рабочих мест и обеспечение его лидерских позиций в системе здравоохранения не вызывает сомнений, и все соответствующие заинтересованные стороны должны взять на себя обязательства по осуществлению конкретных действий. © St Thomas’ Hospital, London © Carrie Tudor/The Union 1ГЛАВА Введение 1. Сестринские кадры, представленные медицинскими сестрами профессионального и ассоциированного профессионального уровней1, составляют наиболее многочисленную категорию работников здравоохранения в мире и являются основой межпрофессиональных медицинских бригад, труд которых вносит незаменимый вклад в реализацию принципа «Здоровье для всех». 2. Сферы ответственности и функции работников сестринских служб, выступающих в качестве высококвалифицированных практиков, клиницистов, лидеров, разработчиков и проводников политики, исследователей, ученых и педагогов, имеют важнейшее значение для эффективного функционирования систем обучения и практической деятельности работников здравоохранения. Преданность своему делу, готовность к внедрению инноваций и энтузиазм представителей сестринской профессии были и будут залогом успешного улучшения показателей здоровья и благосостояния населения. 3. Уход за больными как отдельный вид занятий существовал на протяжении веков, но значительно эволюционировал за последние 200 лет – эпоху, начало которой ознаменовалось 1 В соответствии с Международной стандартной классификацией занятий Международной организации труда (https://www.ilo.org/public/english/ bureau/stat/ISCO/ISCO08/). рождением Флоренс Найтингейл – признанной основоположницы современного сестринского дела. В 1800-х годах сформировалась структурированная система учебной подготовки, были разработаны клинические стандарты и возникли профессиональные ассоциации медицинских сестер, что способствовало стойкому повышению качества оказываемой помощи, росту профессиональных навыков и улучшению условий труда сестринского персонала. 1900-е годы были ознаменованы ростом специализации и профессиональной автономии медсестер наряду с укреплением механизмов нормативно-правового регулирования, направленного на обеспечение общественной подотчетности и безопасности предоставляемых услуг (1). Основанный в 1899 г. Международный совет медицинских сестер стал первой международной организацией медицинских работников. В настоящее время, в 121-й год своей деятельности, Международный совет медицинских сестер объединяет более 130 национальных сестринских ассоциаций, представляющих свыше 20 миллионов работников сестринских служб по всему миру (2). 4. Всемирная организация здравоохранения (ВОЗ) с первых лет своего существования признает огромную ценность и неизмеримый вклад 1Введение © WHO/NOOR/Sebastian Liste сестринского и акушерского персонала в дело охраны здоровья (3). Труд медсестер и акушерок на протяжении многих лет в значительной степени способствовал достижению важнейших глобальных целей в области здравоохранения, включая искоренение оспы, успешную борьбу с другими инфекционными болезнями, а также резкое сокращение материнской, младенческой и детской смертности и заболеваемости во всем мире (4,5). Выдающаяся роль сестринского персонала нашла свое отражение в беспрецедентном уровне внимания со стороны Всемирной ассамблеи здравоохранения, которая за 70-летний период приняла 10 резолюций, направленных на содействие внедрению международных стандартов в области образования, найма и удержания сестринских и акушерских кадров в рамках более широких приоритетов развития трудовых ресурсов (3,6). 5. В настоящем докладе «Состояние сестринского дела в мире, 2020 г.», подготовленном силами ВОЗ в партнерстве с Международным советом медицинских сестер и глобальной кампанией «Сестринское дело сегодня», подвергнуты всестороннему анализу современные фактические данные в целях выработки концептуального видения и перспективной повестки дня для формирования политики в 2 http://apps.who.int/nhwaportal. области сестринского дела. В соответствии с решением Всемирной ассамблеи здравоохранения (7) 2020 г. объявлен Международным годом работников сестринских и акушерских служб. В этой связи цель настоящего фундаментального доклада – дать обоснование для принятия национальных, региональных и глобальных мер в области сестринского дела в оставшееся десятилетие до установленного срока достижения Целей в области устойчивого развития (ЦУР). 6. В докладе представлены всеобъемлющие обновленные данные о современной численности сестринского персонала во всем мире; проанализированы основные проблемы, вызовы и имеющиеся факты, касающиеся роли сестринской профессии в достижении целей здравоохранения; освещены конкретные варианты политики по развитию сестринской профессии в рамках комплексного подхода к укреплению трудовых ресурсов здравоохранения, первичной медико-санитарной помощи и систем здравоохранения. 7. Онлайновый раздел, размещенный на веб-сайте ВОЗ2, содержит профили отдельных стран, в которых представлены данные, полученные от стран в рамках подготовки настоящего доклада. Темы отдельных глав ГЛАВА 2 Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения Глава посвящена описанию вклада работников сестринских служб в Повестку дня в области устойчивого развития на период до 2030 г. и, в частности, в достижение ЦУР 3 (обеспечение здоровья и благополучия) (8). ГЛАВА 3 Роль и функции сестринских служб в системах здравоохранения XXI века В главе приведен обзор вклада сестринского персонала в осуществление приоритетных вмешательств в области здравоохранения в соответствии с задачами «трех миллиардов» ВОЗ по достижению всеобщего охвата услугами здравоохранения, обеспечению более эффективной защиты при чрезвычайных ситуациях в области здравоохранения и повышению уровня здоровья и благосостояния для всех (9). ГЛАВА 4 Стратегические рычаги расширения профессиональных возможностей сестринского персонала Глава содержит описание более общих рычагов воздействия посредством механизмов рынка труда и кадровой политики в здравоохранении, для того чтобы работники сестринских служб могли полностью реализовывать свой профессиональный потенциал в медицинских учреждениях и в местных сообществах, как в странах, так и на глобальном уровне. ГЛАВА 5 Текущее состояние фактических данных о кадровых ресурсах сестринских служб Глава включает аналитический обзор современного состояния сестринских трудовых ресурсов, включая области, имеющие наибольшее значение для разработки национальной, региональной и глобальной политики, а именно: суммарная численность, состав и распределение; потенциал подготовки кадров; образование, регулирование, практика, политика и управление; лидерство; факторы рынка труда. В этой главе также освещаются прогресс и современные вызовы, связанные с вкладом сестринского персонала в решение проблемы прогнозируемой нехватки 18 миллионов медицинских работников к 2030 г. ГЛАВА 6 Будущие направления кадровой политики сестринского дела В главе кратко охарактеризована повестка дня на перспективу с вариантами политики. В ней также содержится призыв к действиям, адресованный государствам-членам, образовательным учреждениям, регулирующим органам, профессиональным ассоциациям, партнерам в поддержку развития, международным организациям и другим заинтересованным сторонам. 3Введение © Cecilie Arcurs/ Getty Image 4 Состояние сестринского дела в мире, 2020 г. Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения 2ГЛАВА 2.1 Роль трудовых ресурсов здравоохранения в осуществлении Повестки дня на период до 2030 г. 8. В 2015 г. мир приступил к реализации Повестки дня Организации Объединенных Наций в области устойчивого развития на период до 2030 г., встав на путь к достижению 17 амбициозных и взаимосвязанных целей в областях, имеющих решающее значение для человечества и планеты (8). Эти цели, в частности, предусматривают ликвидацию нищеты (ЦУР 1), достижение хорошего здоровья и благополучия для всех (ЦУР 3), обеспечение инклюзивного и социально справедливого образования (ЦУР 4), достижение гендерного равенства (ЦУР 5), а также содействие достойной работе и инклюзивному и устойчивому экономическому росту (ЦУР 8). 9. ВОЗ возглавляет усилия глобального сообщества в области здравоохранения по ускорению прогресса в достижении ЦУР 3 на основе концепции всеобщего охвата услугами здравоохранения. Все государства-члены Организации Объединенных Наций выразили четкую и единодушную приверженность делу 3 Астанинская декларация. Глобальная конференция по первичной медико-санитарной помощи: от Алма-Атинской декларации к всеобщему охвату услугами здравоохранения и Целям в области устойчивого развития. последовательного обеспечения всеобщего охвата услугами здравоохранения, в частности посредством Политической декларации Генеральной Ассамблеи Организации Объединенных Наций, принятой на заседании высокого уровня по вопросу о всеобщем охвате услугами здравоохранения (10), и резолюции Межпарламентского союза (11). 10. Краеугольным камнем всеобщего охвата услугами здравоохранения является первичная медико-санитарная помощь. Мировые лидеры отметили сорокалетие Алма-Атинской декларации 1978 г. о первичной медико- санитарной помощи, приняв Астанинскую декларацию3 (12), в которой прочно закреплена первичная медико-санитарная помощь в качестве основного подхода к достижению всеобщего охвата услугами здравоохранения. Положения ЦУР и логика первичной медико- санитарной помощи нашли свое отражение в Тринадцатой общей программе работы ВОЗ в форме целей «трех миллиардов»: всеобщий охват услугами здравоохранения дополнительно для 1 миллиарда человек; более эффективная защита при чрезвычайных ситуациях в области здравоохранения дополнительно для 1 миллиарда человек; 5Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения повышение уровня здоровья и благополучия дополнительно для 1 миллиарда человек (9). 11. В докладе ВОЗ по итогам глобального мониторинга за 2019 г. «Первичная медико- санитарная помощь на пути к всеобщему охвату услугами здравоохранения» содержатся свидетельства значительного прогресса в деле улучшения охвата медицинскими услугами; при этом страны все чаще закрепляют обязанности по обеспечению всеобщего доступа к медицинским услугам и продукции в национальных нормативно-правовых инструментах (13). Однако темпы прогресса остаются неравномерными как внутри стран, так и между ними, и обеспечение финансовой защиты наиболее уязвимых слоев населения по-прежнему сопряжено со значительными трудностями. Движению вперед препятствуют слабые системы здравоохранения и воздействие социально-экономических факторов; для определения инвестиционных приоритетов и отслеживания прогресса необходимы более точные фактические данные. Существуют возможности для перехода от жестких моделей получения запланированных результатов к более динамичным, доступным и структурированным системам. 12. По оценкам ВОЗ, общий объем инвестиций, необходимых для достижения целевых показателей в области здравоохранения в рамках ЦУР 3 к 2030 г., составляет 3,9 трлн долл. США (10). Из расчета на 12-летний период более 40% вкладываемых средств приходится на должностные оклады, выплаты и вознаграждения для работников здравоохранения в целях решения проблемы прогнозируемой нехватки 18 миллионов медицинских работников к 2030 г. (14–16). Расчетные данные, включающие суммы дополнительных инвестиций для удовлетворения потребностей трудовых ресурсов в образовании и обучении на протяжении всей жизни, показывают, что, в среднем, более 50% инвестиций на нужды здравоохранения должны быть направлены на развитие, оплату труда и поддержание кадров здравоохранения. 13. Такие вложения не следует рассматривать как «издержки». Вопреки давнему – и ошибочному – представлению о том, что расходы на трудовые ресурсы здравоохранения – это издержки, которые необходимо сокращать (17,18), Комиссия высокого уровня Организации Объединенных Наций по вопросам занятости в области здравоохранения и экономического роста (далее «Комиссия») в 2016 г. опубликовала фактические данные, свидетельствующие о том, что рабочие места и занятость в здравоохранении способствуют экономическому росту и повышению производительности в других секторах (17,18). Вложение средств в систему здравоохранения и ее трудовые ресурсы в значительной степени способствуют инклюзивному экономическому росту (ЦУР 8), в частности посредством обеспечения занятости и расширения прав и возможностей женщин (ЦУР 5) и молодежи (19,20). Женщины составляют 70% от общей численности работников социальной сферы и здравоохранения в мире (21) и почти 90% от общей численности сестринского и акушерского персонала (22,23). 14. Комиссия представила веские аргументы в пользу вложения средств в здравоохранение и социальный сектор, а также предложила механизм, с применением которого эти инвестиции позволят нарастить потенциал в сфере образования для обеспечения устойчивого притока кадров медицинских работников и развития их компетенций с учетом имеющихся потребностей. Это станет залогом формирования трудовых ресурсов здравоохранения с наличием у работников надлежащих навыков для заполнения достойных рабочих мест там, где это необходимо для улучшения медицинских услуг, и в достаточном количестве, чтобы предотвратить прогнозируемый дефицит 18 миллионов работников здравоохранения. 15. В 2017 г. государства-члены ВОЗ приняли пятилетний план выполнения рекомендаций Комиссии, который осуществляется в рамках программы «Работа в интересах здоровья» под эгидой Многостороннего целевого фонда с участием ВОЗ, Международной организации труда (МОТ) и Организации экономического сотрудничества и развития (ОЭСР) (15,17). ВОЗ выполняет эти рекомендации в соответствии с подходами к укреплению кадрового потенциала здравоохранения, изложенными в Глобальной стратегии для развития кадровых ресурсов здравоохранения: трудовые ресурсы 2030 г. (рисунок 2.1) (16). 6 Состояние сестринского дела в мире, 2020 г. Важнейшие задачи сестринского дела включают обеспечение максимального вклада сестринского персонала посредством оптимизации сферы практической деятельности и функций работников сестринских служб в оказании профилактической и первичной помощи. Глобальная стратегия для развития кадровых ресурсов здравоохранения: стратегические цели и актуальность для сестринского дела Рисунок 2.1 Важнейшие задачи сестринского дела включают рациональное управление процессами миграции сестринского персонала, обеспечение качества образовательной подготовки работников сестринских служб, инвестирование в удержание работников в сельских, отдаленных или иных недостаточно обслуживаемых сообществах. Важнейшие задачи сестринского дела включают достоверный учет численности сестринских кадров и определение источников необходимой информации для анализа рынка труда в области здравоохранения. Получение данных для мониторинга и подотчетности требует участия не только министерств, но и заинтересованных сторон, представляющих сестринское дело и другие секторы. Важнейшие задачи сестринского дела включают вовлечение лидеров из числа работников сестринских служб в формирование политики в области здравоохранения и развитие сестринского лидерства. Оптимизировать показатели деятельности, качества, эффективности, соотношения компетенций, удержания кадров, а также устранять недостатки в работе и дефекты распределения кадров в целях обеспечения справедливости и всеобщего доступа к услугам здравоохранения. Стимулировать вложение средств в развитие кадровых ресурсов здравоохранения в соответствии с потребностями населения в охране здоровья, с учетом динамики рынка труда, политикой в сфере образования, дефицита кадров и дисбаланса в их распределении. Укреплять данные о кадровых ресурсах здравоохранения для мониторинга и обеспечения подотчетности. Наращивать потенциал учреждений на субнациональном и международном уровнях для эффективного лидерства и руководства деятельностью в области кадровых ресурсов здравоохранения. СТ РА ТЕ ГИ ЧЕ СК АЯ ЦЕ ЛЬ 1 СТРАТЕГИЧЕСКАЯ ЦЕЛЬ 3 СТРАТЕГИЧЕСКАЯ Ц ЕЛЬ 2 СТРА ТЕГ ИЧ ЕС КА Я ЦЕ ЛЬ 4 16. Ускорение прогресса на пути к всеобщему охвату услугами здравоохранения и достижению ЦУР 3 возможно, если перевести фокус внимания на потребности во вложении средств в развитие медицинских кадров. Это требует всестороннего изучения и количественной оценки предложения, спроса и потребностей – показателей, используемых для анализа рынка труда в области здравоохранения, результаты которого служат основой для разработки комплексных стратегий и планов по развитию трудовых ресурсов. 17. Работники сестринских служб сталкиваются с проблемами, общими для всех медицинских профессий, в том числе по таким аспектам, как адекватная численность, справедливое распределение и удержание кадров, качественное образование, эффективное регулирование, благоприятные условия труда, а также качество и эффективность в контексте всеобщего охвата услугами здравоохранения (24–26). Однако существуют и специфические вызовы, характерные для сестринской профессии, включая проблемы 7Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения © AKDN/Christopher Wilton-Steer гендерной предвзятости, лидерства в решении стратегических вопросов, регулирования и различий в уровнях образования и профессиональных функций (25). Четкое понимание этих вопросов и приоритетов может способствовать принятию оптимальных стратегических и инвестиционных решений. 2.2 Кто такие работники сестринских служб? 18. Цель настоящего доклада – представить наилучшие имеющиеся, сопоставимые на международном уровне фактические данные в отношении сестринских кадров. Для этого необходимо четко определить понятие «работник сестринских служб/медсестра» (англ. «nurse»). В главах 3 и 4 на основе фактических данных из опубликованной литературы представлено существующее широкое толкование сестринского дела. В главе 5, где изложены сведения, собранные и проанализированные специально в рамках подготовки настоящего доклада, термин «медицинская сестра» конкретно и однозначно относится к следующим двум профессиональным группам, включенным в Международную стандартную классификацию занятий 2008 г. (МСКЗ-08): «медицинская сестра профессионального уровня» (англ. «professional nurse») (код МСКЗ 2221) и «медицинская сестра ассоциированного профессионального уровня» (англ. «associate professional nurse» (код МСКЗ 3221). 19. Страны представили данные в соответствии с тем, какие национальные категории медицинских работников, по их заключению, соответствуют определениям этих двух профессий; странам не было предложено сообщать о других профессиональных группах (таких как акушерки, помощники медсестер и другие представители вспомогательного медицинского персонала). В некоторых странах среди медицинских работников выделяют «медсестер-акушерок», которые получают гибридное образование и выполняют двойные функции. Поскольку категория «медсестра-акушерка» не включена в перечень профессиональных групп согласно международной классификации, в докладе использованы только данные о медицинских работниках, отнесенных странами к категориям медицинских сестер профессионального или ассоциированного профессионального уровня. Более подробную Количество отдельных должностных категорий сестринского персонала в каждом регионе ВОЗ Рисунок 2.2 Европейский регион Регион Западной части Тихого океана Регион Восточного Средиземноморья Регион стран Америки Регион Юго-Восточной Азии Африканский регион Ч ис ло с ам ос то ят ел ьн ы х до лж но ст ны х ка те го ри й в ст ра на х ка ж до го р ег ио на В О З Регион ВОЗ 0 5 10 15 20 25 30 35 31 19 32 11 20 10 Примечание: цифры означают количество сестринских должностных категорий, требующих сдачи экзамена на уровне страны, суммированы по регионам ВОЗ Источник: Глобальный нормативный атлас NCSBN (29). информацию об этих терминах и о том, какое содействие было оказано странам в подготовке отчетности о своем сестринском персонале, можно найти в описании методов в главе 5, а также в приложении 1 к настоящему докладу. 20. Сестринское дело включает в себя оказание помощи – самостоятельное и в сотрудничестве с другими работниками – гражданам всех возрастов, семьям, конкретным группам населения и сообществам, как больным, так и здоровым индивидуумам и в любых условиях; речь идет о таких видах услуг, как содействие поддержанию и укреплению здоровья, профилактика заболеваний, а также уход за больными, лицами с ограниченными возможностями и людьми, находящимися на конечном отрезке жизни (7,27). Важные дополнительные функции сестринского персонала – это информационно- пропагандистская работа, содействие в обеспечении безопасной окружающей среды, участие в ведении пациентов и организации медицинской помощи, формирование политики в области здравоохранения, преподавательская деятельность и научные исследования (27,28). Работники сестринских служб предоставляют широкий спектр услуг здравоохранения во всех медицинских учреждениях, от специализированных больниц до медицинских пунктов в отдаленных общинах. Название «медицинская сестра» в его различных формах должно обозначать лицо, отвечающее юридическим, образовательным и административным требованиям, предъявляемым к сестринскому персоналу. 21. Существует множество путей получения квалификации, необходимой для практической работы в должности «медицинская сестра». Выпускник курса обучения по базовой программе сестринского дела, как правило, может продолжить учебу в целях получения высшего образования и квалификации специалиста с присвоением различных профессиональных титулов и права на выполнение различных профессиональных функций. Результатом является широкий набор сестринских специальностей, функций и компетенций, даже в пределах одной страны. Такое разнообразие, наблюдаемое в любой отдельно взятой стране, растет при рассмотрении на региональном уровне и еще больше расширяется при оценке в глобальном масштабе (рисунок 2.2). По данным Глобального нормативного атласа (29), в мире существует по меньшей мере 144 различных должностных категорий сестринского персонала, которые требуют сдачи экзамена на получение лицензии, включая специализированных медсестер и практикующих медсестер с расширенными профессиональными функциями. Наблюдается определенный географический разброс в количестве категорий медицинских сестер: от 10 в Регионе Юго-Восточной Азии до более 30 в Регионе стран Америки и в Европейском регионе. 22. Должностные обязанности представителей сестринского персонала с одним и тем же должностным титулом, но работающих в разных странах, могут отличаться друг от друга. В связи с этим особую важность приобретают международные стандартизированные определения терминов для использования в дискуссиях о том, кого можно назвать медсестрой, для анализа функций сестринского персонала и для планирования медицинских услуг, в которых вклад работников сестринских служб оптимизирован в целях достижения целей охраны здоровья населения. 9Сестринское дело в контексте более широких приоритетов в области трудовых ресурсов и здравоохранения © WHO/Atul Loke 10 Состояние сестринского дела в мире, 2020 г. Роль и функции сестринского персонала в системах здравоохранения XXI века 3ГЛАВА 23. В этой главе приведен консолидированный обзор современных фактических данных (детальный синтез – см. в веб-приложении) о функциях и обязанностях работников сестринских служб применительно к их вкладу в достижение ЦУР 3 и, более конкретно, в отношении миссии ВОЗ «укрепление здоровья, поддержание безопасности в мире, охват услугами уязвимых групп населения», а также целей «трех миллиардов», поставленных в Общей программе работы ВОЗ. 3.1 Роль сестринского дела в достижении всеобщего охвата услугами здравоохранения 24. Выводы одного из выполненных Кокрановских обзоров продемонстрировали эффективность сестринского персонала в оказании первичной медико-санитарной помощи по широкому спектру услуг в отношении инфекционных и неинфекционных заболеваний, включая самостоятельное принятие клинических решений при некоторых состояниях, а также в области медицинского образования и профилактических вмешательств (30). Обзор показал, что предоставление услуг первичной медицинской помощи под руководством сестринского персонала может в определенных условиях и при наличии надлежащих обстоятельств приводить к аналогичным или в некоторых случаях даже лучшим результатам в отношении здоровья пациентов и к более высокой степени их удовлетворенности качеством услуг, чем другие модели оказания медицинской помощи; работники сестринских служб, вероятно, также могут уделять больше времени непосредственному консультативному общению с пациентами (30). По данным других Кокрановских обзоров, работники сестринских служб эффективны в инициировании терапии ВИЧ-инфекции и в последующем наблюдении за ходом лечения (31); также есть свидетельства того, что сестринские вмешательства, направленные на помощь в прекращении употребления табака, повышают вероятность успешного отказа от курения (32). Еще один Кокрановский обзор продемонстрировал, что услуги, предоставляемые медицинскими работниками общего профиля, в том числе медсестрами, могут повышать эффективность лечения пациентов при таких состояниях, как общая и перинатальная депрессия, посттравматические стрессовые расстройства, патология, связанная с употреблением алкоголя, а также улучшать состояние здоровья пациентов с деменцией и лиц, ухаживающих за ними (33). Систематический обзор, выполненный под эгидой Кэмпбелловского сотрудничества, 11Роль и функции сестринского персонала в системах здравоохранения XXI века Вставка 3.1 Вклад сестринского персонала в обеспечение безопасности пациентов Ежегодно более 8 миллионов смертей в странах с низким и средним уровнем дохода обусловлены неудовлетворительным качеством медицинской помощи (39). Работники сестринских служб могут способствовать повышению качества медицинской помощи и безопасности пациентов путем предотвращения нежелательных явлений, но для этого требуется, чтобы они работали с оптимальным использованием своих профессиональных возможностей, в составе сильных команд и в благоприятных условиях. Работники сестринских служб играют важную роль в обеспечении безопасности пациентов, наблюдая за пациентами на предмет возможного ухудшения состояния, выявляя ошибки и рискованные ситуации при оказании помощи, демонстрируя понимание клинических процессов и слабых мест, присущих некоторым системам, и выполняя множество других действий, направленных на гарантированное оказание высококачественной медицинской помощи (36). Профессиональное «выгорание» среди медсестер и врачей из-за высокой рабочей нагрузки, длительных поездок и субоптимальных межличностных отношений коррелирует с ухудшением показателей безопасности пациентов (40), в то время как благоприятная рабочая среда, достаточный по численности штат сестринского персонала и взаимное обучение при совместной работе в многопрофильных бригадах коррелируют с сокращением сроков стационарного лечения, снижением частоты осложнений, таких как пневмония, гастрит, кровотечения из верхних отделов желудочно-кишечного тракта, пролежни и катетер- ассоциированные инфекции мочевыводящих путей, а также со снижением общей смертности (41–48). показал, что медицинские сестры, проводящие медицинское обследование жертв сексуального насилия, и медицинские сестры – судебно- медицинские эксперты способны эффективно проводить судебно-медицинскую экспертизу и документирование случаев сексуального насилия. Был также сделан вывод о том, что эти работники могут обеспечивать необходимые меры профилактики инфекций, передаваемых половым путем, и предупреждения беременности и что данный вид помощи характеризуется хорошим соотношением цены и качества (34). 25. Работники сестринских служб играют важную роль в обеспечении качества медицинской помощи и безопасности пациентов, в профилактике инфекций и борьбе с ними, а также в борьбе с устойчивостью к противомикробным препаратам (35). Это достигается за счет выполнения многочисленных функций, включая наблюдение за пациентами на предмет возможного ухудшения состояния, выявление ошибок и рискованных ситуаций при оказании помощи (36), осуществление мероприятий по профилактике инфекции, контрольный мониторинг и наставничество (37), а также обеспечение соблюдения санитарных норм и правил гигиены рук (38). При вспышках инфекционных болезней, таких как COVID-19, когда ключевое значение для сдерживания распространения инфекции имеют гигиена рук, соблюдение социальной дистанции и обеззараживание поверхностей, центральную роль в профилактике инфекции и инфекционном контроле играет сестринский персонал (вставка 3.1). 26. Также хорошо документирован исторический вклад сестринского персонала в профилактику, лечение и борьбу с инфекционными болезнями (4,49). Так, например, сестринские вмешательства могут приводить к увеличению охвата вакцинацией (50). Работники сестринских служб по всему миру активно участвуют в лечении и профилактике туберкулеза и могут успешно вносить вклад в решение как клинических, так и неклинических задач, таких как содействие поддержанию и укреплению здоровья населения, оказание психосоциальной поддержки (51–54), добровольное медицинское мужское обрезание (55–61), разработка и осуществление программ доконтактной профилактики ВИЧ-инфекции (62). Медицинские сестры также активно участвуют в борьбе с забытыми тропическими болезнями посредством таких направлений деятельности, как просветительные мероприятия среди населения, массовая химиопрофилактика, выявление и диагностика случаев и определение распространенности заболеваний, скрининг и подтверждение подозрительных случаев, 12 Состояние сестринского дела в мире, 2020 г. © WHO/Tania Habjouqa выявляемых общинными медико-санитарными работниками, выдача лекарств, выполнение определенных видов хирургических вмешательств (например, при трахоме) и обучение пациентов методам самопомощи при различных заболеваниях, например при лимфедеме (63). В ряде стран Африки работники сестринских служб также вносят вклад в повышение качества медицинской помощи, оказываемой при инфекционных заболеваниях, посредством обучения, наставничества и руководства работой общинных медико- санитарных работников (63–65). 27. Работники сестринских служб играют решающую роль в работе по укреплению здоровья, в повышении уровня грамотности населения в вопросах здоровья, а также в ведении случаев неинфекционных заболеваний (НИЗ) (66–72). При наличии необходимых знаний, навыков, возможностей и финансовой поддержки они располагают уникальной возможностью выступать в качестве эффективных практиков, консультантов по вопросам здоровья, проводников полезных знаний для пациентов и семей на протяжении всей жизни (73). Успех медицинских сестер в лечении и профилактике НИЗ неоднократно демонстрировался (66–72) в связи с решением ряда актуальных задач, включая скрининг и оказание первичной медико-санитарной помощи при различных НИЗ, таких как артериальная гипертензия, сердечно- сосудистые заболевания, диабет, нарушения психического здоровья, неврологические расстройства, респираторные заболевания и рак (70). Работа сестринского персонала в этих областях способствовала улучшению клинических показателей, например снижению артериального давления и уровня депрессии; работники сестринских служб оказывали вполне эффективную помощь пациентам с сердечной недостаточностью и диабетом (30,70). Медицинские сестры также вносят вклад в достижение позитивных поведенческих сдвигов у пациентов, добиваясь, например, более регулярного приема назначенных лекарств и более дисциплинированного отношения амбулаторных пациентов, находящихся под наблюдением работников сестринских служб, к явкам на последующие приемы в медицинском учреждении (30,70). Расширение функций сестринского персонала в медицинских бригадах, обеспечиваемое соответствующей ориентацией сестринского образования и сферы практики, может способствовать интеграции НИЗ в систему первичной медико-санитарной помощи (74,75). Хотя расширение функций медицинских сестер потенциально актуально в самых различных условиях, при нехватке врачей-специалистов оно может способствовать повышению уровня справедливости в отношении здоровья (73,76). 13Роль и функции сестринского персонала в системах здравоохранения XXI века Вставка 3.2 Модель обеспечения сестринского ухода на общинном уровне за стареющим населением Руководствуясь статусом Японии как «сверхстареющего» общества, Мемориальный фонд здравоохранения Сасакавы в 2014 г. приступил к реализации программы, дающей медсестрам возможность создавать общинные центры сестринского ухода на дому и управлять их работой (88). На базе этих центров сестринский персонал оказывает необходимые услуги пожилым людям, что позволяет им достойно жить у себя дома, и тем самым способствует общему повышению качества жизни в местном сообществе. Мемориальный фонд здравоохранения Сасакавы также поддерживает работу сети, обеспечивающей укрепление сотрудничества между центрами, сбор данных и пропаганду создания новых общинных центров сестринского ухода на дому (89). Восьмимесячная образовательная программа по уходу за пожилыми людьми и сестринскому уходу на дому позволяет медицинским сестрам приобретать дополнительные навыки по проведению физикального обследования пожилых пациентов, удовлетворению потребностей местных жителей в услугах первичной медико-санитарной помощи и оказанию помощи семьям в обеспечении паллиативного ухода на дому, в частности за пациентами на конечном отрезке жизни. Дополнительный учебный курс посвящен вопросам предпринимательства, менеджмента и составления бизнес-планов по созданию и эксплуатации центра сестринского ухода на дому (89). К марту 2019 г. обучение по данной программе завершили 67 медсестер, и более 56 из них управляют центрами сестринского ухода на дому в 23 префектурах по всей Японии. Штат центров состоит в среднем на 70% из медицинских сестер и на 30% из работников других специальностей, что обеспечивает межпрофессиональное сотрудничество в удовлетворении потребностей местных сообществ в услугах первичной медико-санитарной помощи – как в самих центрах, так и на дому. В масштабе всей сети центры обслуживают, в среднем, 25 000 обращений в месяц. Оказание поддержки семьям в обеспечении ухода за близкими людьми в конце жизни позволило сократить медицинские расходы, связанные с госпитализацией и клиническими процедурами (90). 28. Сестринский персонал вносит вклад в оказание помощи на всех этапах жизни. Работники сестринских служб, работающие с акушерками, врачами акушерско-гинекологического профиля и другими врачами-специалистами, предоставляют женщинам услуги дородовой помощи, родовспоможения и послеродового ухода (77). Неонатальные медицинские сестры, обладающие специальными навыками ухода за новорожденными, совместно с другими специалистами неонатологического профиля оказывают эффективную специализированную поддержку и своевременную высококачественную стационарную помощь. В большинстве стран работники сестринских служб составляют основу школьных служб здравоохранения, обеспечивающих оказание необходимой помощи детям и подросткам (78–81). Медицинские сестры оказывают полный спектр услуг по охране сексуального и репродуктивного здоровья; например, они предоставляют с соблюдением требований безопасности оральные и инъекционные контрацептивы, имплантаты и внутриматочные противозачаточные устройства (82). Фактические данные также подтверждают эффективность медицинских сестер в проведении скрининга на рак шейки матки и предоставлении услуг в связи с ВИЧ женщинам репродуктивного и более старшего возраста (83,84). Предоставление актуальных сведений и информационно- пропагандистская работа с подростками соответствующего возраста и их родителями или попечителями являются центральными компонентами роли медсестер в расширении охвата вакцинацией против вируса папилломы человека (83,85,86). Работники сестринских служб играют центральную роль в обеспечении ухода за пожилыми людьми и могут выполнять важные функции в оказании комплексной помощи, что позволяет улучшить показатели здоровья пожилого населения (вставка 3.2) (87). В качестве основных поставщиков услуг паллиативной помощи работники сестринских служб способствуют повышению качества жизни пациентов на ее финальном отрезке, позволяя 14 Состояние сестринского дела в мире, 2020 г. © National Health Commission of the People's Republic of China провести его в атмосфере достоинства и сопереживания. 3.2 Роль сестринского персонала в контексте чрезвычайных ситуаций, эпидемий и бедствий 29. Работники сестринских служб участвуют в оказании медицинской помощи при экстренных клинических ситуациях (таких как несчастные случаи или острые кардиологические нарушения), предупреждении и контроле эпидемических вспышек, а также в принятии мер реагирования при бедствиях и гуманитарных кризисах. Медсестра часто является первым медицинским работником, которого пациент видит в медицинском учреждении; функции сестринского персонала могут варьироваться в зависимости от контекста, но часто включают проведение медицинской сортировки, раннее распознавание жизнеугрожающих состояний, назначение лекарств, выполнение реанимационных процедур и неотложное направление на специализированные виды помощи. 30. Сестринский персонал играл ключевую роль в составе групп по борьбе с эпидемиями, угрожающими здоровью во всем мире, включая тяжелый острый респираторный синдром (ТОРС) в 2003 г. (91), вспышку ближневосточного респираторного синдрома, вызванного коронавирусом (БВРС-КоВ), в 2015 г. (92), болезнь, вызванную вирусом Зика, в 2016 г. (93,94), болезнь, вызванную вирусом Эбола, в 2014 г. (95,96), а также начавшуюся в 2019 г. вспышку COVID-19. В рамках Инициативы ВОЗ по созданию чрезвычайных медицинских бригад медсестры и другие медицинские работники проходят учебную подготовку для более эффективного поддержания потенциала своих стран по реагированию на возможные будущие бедствия и чрезвычайные ситуации (97). Это, по- видимому, особенно актуально для повышения устойчивости тех систем здравоохранения, которые стали более уязвимыми в результате бедствий и конфликтов (98). 31. В условиях нестабильности и социальных конфликтов медицинские работники, включая медсестер, сталкиваются с рядом как личных, так и профессиональных вызовов, таких как угроза похищения, переживания в связи со смертью коллег, опасения за собственную жизнь, увеличение рабочей нагрузки и усложнение обязанностей (например, необходимость иметь дело с огнестрельными ранениями), а также размывание этических и профессиональных стандартов (99). Несмотря на эти тяжелые условия, медсестры и другие медицинские работники продемонстрировали стойкость и преданность своему делу, продолжая оказывать необходимые виды помощи (99). При поддержке со стороны работников сестринских служб, действующих в условиях конфликта или помогающих беженцам, удалось добиться успеха в лечении целого ряда различных заболеваний, таких как туберкулез легких (100) и другие инфекции дыхательных путей, кариес зубов и посттравматические стрессовые расстройства (101). 15Роль и функции сестринского персонала в системах здравоохранения XXI века 3.3 Роль сестринского дела в обеспечении здоровья и благополучия населения 32. Для того чтобы добиться улучшения показателей здоровья и благополучия населения, медсестрам и другим работникам здравоохранения необходимо воздействовать на социальные детерминанты здоровья и тем самым вносить свой вклад в достижение ЦУР. Профилактика диарейных болезней путем активной пропаганды частого мытья рук, здорового питания и соблюдения правил санитарии (102,103) – это одно из направлений, в которых появляются новые свидетельства эффективности сестринского дела в воздействии на социальные детерминанты здоровья (4). Представители сестринской профессии могут стать одними из первых, кто будет оказывать помощь людям, страдающим от последствий изменения климата (104–106). Эта работа будет включать усилия по повышению устойчивости малоимущих и уязвимых групп населения к климатическим воздействиям, а также по снижению смертности от таких чувствительных к климату болезней, как диарейные заболевания, малярия, африканский трипаносомоз, лейшманиоз, шистосомоз, кишечный нематодоз и лихорадка денге. 33. Улучшение показателей здоровья населения и поддержание значений этих показателей на высоком уровне зависят как от охраны здоровья подростков и молодежи на основе всеобщего охвата услугами здравоохранения с соблюдением принципов социальной справедливости, так и от предоставления им благоприятных условий для поддержания своего здоровья и готовности продолжать работу по обеспечению устойчивого развития в следующем поколении. Работники сестринских служб осознают и способны принять подходы, необходимые для гибкого реагирования на ожидания молодежи. Для этого сестринский персонал должен вызывать доверие, быть непредвзятым и ориентированным на нужды клиентов, стремиться к удовлетворению их потребностей с соблюдением их интересов и быть всегда доступным для оказания помощи (107–110). 34. Работники сестринских служб достигли позитивных результатов в областях, представляющих особую проблему для женщин, таких как планирование семьи и искусственное прерывание беременности (111,112). Оптимизация сестринских функций в оказании этих видов помощи может привести к улучшению доступа для многих женщин к услугам в области охраны репродуктивного 16 Состояние сестринского дела в мире, 2020 г. © WHO/Yoshi Shimizu Вклад сестринского дела в достижение целей «трех миллиардов»Рисунок 3.1 СЕСТРИНСКИЙ ПЕРСОНАЛ в составе многопрофильных бригад • Оказание помощи в экстренных клинических ситуациях • Реагирование при эпидемиях, бедствиях и гуманитарных кризисах • Распознавание жизнеугрожающих состояний и проведение реанимационных мероприятий ВСЕОБЩИЙ ОХВАТ УСЛУГАМИ ЗДРАВООХРАНЕНИЯ • Работники первичного звена системы здравоохранения • Профилактика и лечение широкого спектра инфекционных и неинфекционных заболеваний • Оказание помощи на всех этапах жизни, от рождения до смерти ЗДОРОВЬЕ И БЛАГОПОЛУЧИЕ • Воздействие на социальные детерминанты здоровья на основе сотрудничества • Учет и принятие мер в связи с воздействием изменения климата • Обеспечение доступа для уязвимых групп, включая женщин и молодежь ЧРЕЗВЫЧАЙНЫЕ СИТУАЦИИ, ЭПИДЕМИИ И БЕДСТВИЯ здоровья. Работники сестринских служб оказывают женщинам социальную поддержку в вопросах охраны материнства во время критических жизненных событий (например, во время пренатального и послеродового периодов (113) и при раке молочной железы) и играют ключевую роль в обеспечении уважительного отношения к женщинам при оказании им помощи в медицинских учреждениях (114,115). Медицинские сестры также играют важную роль в борьбе с гендерным насилием: по данным исследований программ скрининга на предмет насилия со стороны интимных партнеров, медицинские сестры и акушерки – это те категории медицинских работников, которые чаще всего (45% и 24%, соответственно) обеспечивают идентификацию случаев насилия на основе личного контакта с потерпевшей (116). В заключение этой главы на рисунке 3.1 представлен общий вклад сестринского дела в достижение целей «трех миллиардов». 17Роль и функции сестринского персонала в системах здравоохранения XXI века © WHO/ Yoshi Shimizu 18 Состояние сестринского дела в мире, 2020 г. 4ГЛАВА Стратегические рычаги расширения профессиональных возможностей сестринского персонала 35. Оптимизация вклада сестринской профессии, описанной в предыдущей главе, требует наличия благоприятной среды в отношении проводимой политики и условий практической деятельности медсестер. Многие факторы, влияющие на наличие, распределение, профессиональный потенциал, условия труда и эффективность работы сестринских кадров, поддаются анализу с позиций государственной политики с использованием предложенной ВОЗ схемы рынка труда в области здравоохранения (117) (рисунок 4.1). 36. С учетом этой схемы в докладе рассматриваются четыре измерения, характеризующие обсуждения вариантов политики по вопросу сестринских кадров, а также приведен обзор фактических данных из рецензируемой литературы по следующим темам: (а) базовое образование и профессиональная подготовка; (b) приток и отток рабочей силы; (с) справедливое распределение и экономическая эффективность; и (d) нормативное регулирование (включая частный сектор). В рамках этой схемы также обозначены социальные, экономические и демографические факторы, влияющие на рынок труда в сфере здравоохранения. Некоторые из этих факторов (гендерные предубеждения, уровень дохода страны) подробно обсуждаются в настоящем докладе, в то время как другие, такие как демографические тенденции (старение, модели роста) и изменение климата, следует рассматривать более конкретно в национальном контексте в процессе разработки и реализации соответствующих мер политики в области сестринских трудовых ресурсов. 4.1 Базовое образование и профессиональная подготовка 37. Цель сестринского образования состоит в том, чтобы обеспечить приток сестринских кадров в целях удовлетворения потребностей населения по показателям численности, профессиональной квалификации и распределения работников сестринских служб. Таким образом, параметры набора студентов, а также численности и состава выпускников сестринских образовательных организаций должны соответствовать потребностям и кадровой мощности сектора здравоохранения. Для того чтобы избежать нестыковок, следует поддерживать регулярный диалог и координацию между секторами здравоохранения, образования, труда и финансов. 38. На число студентов, поступающих на программы обучения по сестринскому делу и успешно их завершающих, влияют, в первую очередь, 19Стратегические рычаги расширения профессиональных возможностей сестринского персонала уровень базового образования населения, а также образовательные требования, предъявляемые к абитуриентам для поступления на программы сестринского дела (118,119). На зачисление в программы сестринского дела влияют географическая локализация программы, стоимость, количество мест, связи с клиническими учреждениями, а также предлагаемый уровень сестринского образования. Каждый из этих факторов, в свою очередь, зависит от численности квалифицированных преподавателей, обеспечивающих выполнение миссии и целей программы, а также от инфраструктуры и наличия возможностей для клинического обучения (120). По данным, приведенным в работе Squires et al. (121), на интенсивность подготовки сестринских кадров в данной стране также влияют макроуровневые факторы, такие как потенциал системы здравоохранения (число больничных коек на душу населения) и расширение прав и возможностей женщин. 39. На набор студентов и, таким образом, на последующий приток сестринских кадров могут оказывать влияние гендерные факторы. Социальная и экономическая недооценка сестринской работы ограничивает возможности медсестер участвовать в принятии решений и становиться лидерами в рамках систем здравоохранения (22,23,122), что может подрывать усилия по набору достойных кандидатов в программы сестринского образования. Предвзятое представление о том, что женщины лучше справляются с задачами ухода за больными, и наличие других социальных гендерных норм делают постоянной проблемой набор студентов- мужчин. В то время как для женщин получение сестринской профессии может рассматриваться как повышение социального статуса, для мужчин это не всегда так (123–125). Кроме того, возможности женщин в других профессиональных группах могут быть ограничены вследствие наличия культурных Рычаги государственной политики для воздействия на рынки труда в сфере здравоохранения Рисунок 4.1 Сектор образования Динамика рынка труда Средняя школа Медицинская подготовка Обучение в других областях Контингент квалифициро- ванных медицинских работников Миграция За рубежом Трудоустроенные Безработные Покинувшие состав кадровых ресурсов Сектор здравоохранения Кадры здравоохранения с оптимальными показателями численности, доступности и приемлемости, предоставляющие качественные услуги Всеобщий охват услугами здравоохранения Меры политики по вопросам подготовки кадров • по инфраструктуре и материалам • по критериям зачисления • по отбору студентов • по преподавательскому составу Другие секторы Меры политики в отношении притока и оттока кадров • для воздействия на иммиграцию и эмиграцию • для привлечения нетрудоустроенных медицинских работников • для возвращению медицинских работников в сектор здравоохранения Меры политики в отношении дисбаланса в распределении кадров и субоптимальной эффективности работы • для повышения производительности труда и улучшения показателей деятельности • для оптимизации соотношения компетенций • для удержания медицинских работников в недостаточно обслуживаемых районах Меры политики по регулированию частного сектора • для управления вопросами двойной практики • для повышения качества обучения • для повышения качества предоставляемых услуг Источник: адаптировано из Sousa A, Scheˆ er RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 20 Состояние сестринского дела в мире, 2020 г. или системных барьеров, что делает сестринское образование единственным или наиболее привычным путем к карьере в области здравоохранения для женщин, но никак не престижным профессиональным выбором для молодых людей обоего пола, стремящихся стать медицинскими работниками. 40. В некоторых ситуациях в системе сестринского образования могут быть недостаточно представлены определенные расовые, этнические или другие уязвимые группы (126). Это может препятствовать обеспечению культурного соответствия между медсестрами и сообществами, в которых они работают. В настоящее время все большее внимание в контексте сестринской профессии уделяется тому, чтобы образование и профессиональная подготовка включали культурные компетенции, однако необходимы более активные усилия для набора студентов из недопредставленных групп населения (вставка 4.1). 41. На численность квалифицированных абитуриентов также влияет географическое расположение сестринских школ и программ профессиональной подготовки. Программы обучения сестринскому делу осуществляются главным образом в крупных городах с наличием университетов и клинических больниц, в результате чего потенциальные студенты из сельских и отдаленных районов имеют гораздо меньше возможностей для получения образования (129). Поскольку уделяется все больше внимания таким вопросам, как географическое распределение кадров здравоохранения и социальная ответственность учебных заведений, некоторые программы предусматривают создание сельских учебных центров или активный набор и поддержку студентов из сообществ, традиционно недостаточно представленных в системе послешкольного образования. Возможным эффективным вариантом для студентов в сельских районах могут стать онлайновые программы дистанционного обучения в сочетании с соответствующими возможностями клинической практики (130). Этот подход требует постоянного внимания к мониторингу и поддержанию надлежащего качества образования, однако в некоторых условиях он может способствовать расширению разнообразия социального профиля учащихся в программах сестринского дела (131). 42. Расходы (включающие плату как за обучение, так и за проживание) могут повлиять на возможности студента посещать или завершить программу сестринского образования. Хотя стоимость обучения сестринскому делу может варьироваться в широких пределах (вставка 4.2), государственные программы субсидируются в большем объеме и зачастую являются менее дорогостоящими, чем частные программы, которые зависят от студенческих взносов и частных пожертвований. Расходы на проживание в условиях низкого или нулевого заработка при дневном обучении, когда занятия продолжаются полный рабочий день, прибавляются к индивидуальной стоимости обучения. В различных странах практикуются разнообразные схемы финансирования, которые могут включать варианты или стимулы для студентов из недопредставленных групп Вставка 4.1 Австралия: привлечение недопредставленных групп населения к работе в составе сестринских кадров В Австралии представители коренных народов обратились с просьбой о предоставлении большего объема помощи от практикующих врачей той же этнической принадлежности, с тем чтобы получить более полный доступ не просто к услугам, но к медицинской помощи с учетом их культурных особенностей и традиций (127). Однако для удовлетворения этого запроса нельзя было ограничиться простым наращиванием числа студентов – австралийских аборигенов и жителей островов Торресова пролива. Было необходимо обеспечить решение проблем, с которыми сталкиваются эти студенты: создать благоприятные условия среды, привлечь преподавателей сестринского дела из числа коренных этнических групп, включить в учебную программу темы, актуальные для коренных народов, а также удовлетворить финансовые потребности учащихся (127, 128). 21Стратегические рычаги расширения профессиональных возможностей сестринского персонала или для тех, кто готов после окончания учебы работать в недостаточно обслуживаемых регионах. 43. Существует целый ряд образовательных программ базового уровня, предназначенных для подготовки и выпуска медсестер с различной квалификацией и профессиональными компетенциями, но которые соответствуют квалификационным критериям медицинских сестер профессионального и ассоциированного профессионального уровней (МСКЗ-08). Программы базового уровня могут использоваться для подготовки медсестер на уровне сертификата, диплома и академической степени (бакалавра); академические требования для сестринской программы базового уровня могут варьироваться от уровня девятилетнего образования или ниже и возраста 17 лет для программы сертификата до полного среднего образования (12 классов) плюс два года университетского образования для поступления в программу бакалавриата (135,136). Разнообразие программ и требований к абитуриентам позволяет более широкому кругу лиц войти в профессию, однако работодатели часто не дифференцируют практические функции в зависимости от уровня образования, что создает нестыковку между системой подготовки кадров, которая выпускает профессионала широкого профиля, и работодателем, который структурирует предоставляемые услуги в контексте специализированной или дифференцированной помощи. 44. В некоторых странах различных регионов мира обучение значительной части сестринских работников осуществляется на уровне сертификатов и дипломов, часто в автономных учебных заведениях. При этом основное внимание уделяется выработке практических компетенций для выполнения клинических процедур (137). Университетские программы (бакалавриат) обычно включают дополнительные курсы по формированию навыков лидерства, ведения клинических случаев и учета социально-экономических факторов, влияющих на здоровье и результаты оказания помощи пациентам в различных стационарных и амбулаторных условиях; иногда также включается исследовательский компонент. В этих программах также уделяется внимание «навыкам критического мышления», обеспечивающим способность к более глубоким клиническим суждениям, что повышает безопасность предоставляемых услуг медицинской помощи. Результаты исследований свидетельствуют о том, что для пациентов, получающих помощь в медицинских учреждениях с более высокой долей Вставка 4.2 Стоимость обучения сестринскому делу По оценкам специалистов, ежегодно в мире на образование сестринского и акушерского персонала тратится 27,2 млрд долл. США (132). Хотя эти категории составляют более половины глобальных трудовых ресурсов здравоохранения, расходы на сестринское и акушерское образование составляют лишь около четверти глобальных расходов на образование работников здравоохранения. По оценкам, опубликованным в 2010 г., среднемировая стоимость подготовки одного выпускника сестринского училища составила 50 000 долл. США с разбросом от среднего значения около 3000 долл. США в Китае до более 100 000 долл. США в Северной Америке (132). Это различие можно объяснить соотношением государственных и частных фондов в финансировании, владении и управлении учебными заведениями, поскольку модели финансирования сестринского образования различаются как внутри стран, так и между ними (133). Другим фактором, определяющим вариабельность стоимости обучения сестринскому делу, являются параллельно существующие различные уровни квалификации, а также разнообразие продолжительности и предварительной квалификации образовательных программ (134). Для того чтобы направить ресурсы на покрытие прогнозируемого кадрового дефицита к 2030 г., необходимы дополнительные и более качественные данные о выпускниках сестринских и акушерских учебных заведений, а также о стоимости обучения и профессиональной подготовки. 22 Состояние сестринского дела в мире, 2020 г. медицинских сестер-бакалавров, характерны более низкие показатели смертности, более короткие сроки пребывания в стационаре, а также более низкие медицинские расходы (46,138,139). Следует, однако, оговориться, что большинство исследований, которые демонстрировали лучшие результаты для пациентов, получающих помощь от медсестер- бакалавров, проводились в больницах и не были воспроизведены в амбулаторных условиях и на уровне местных сообществ, что ограничивает обобщаемость результатов (140). Дополнительные данные свидетельствуют о том, что медсестры, получившие степень бакалавра, не всегда могут в полной мере использовать свои знания и навыки на рабочем месте (141). 45. Работники сестринских служб также могут получать подготовку по программам пост- бакалавриата или специализации, получать степень магистра по той же специальности или специализированной практике, получать докторскую степень в области сестринского дела – практически ориентированную степень доктора сестринской практики либо научно- ориентированную степень доктора философии (PhD) (142). Повышение квалификации профессиональных медицинских сестер потребует четкого разграничения между различными уровнями программ, которые учитывают ранее полученные знания и навыки (143). В странах с существующим спросом на медсестер-бакалавров образовательные программы, которые «соединяют» или повышают уровень имеющихся дипломов, могут представлять собой важный механизм развития карьеры и генерировать высокие показатели роста индивидуального дохода благодаря полученному образованию. Следует отметить, что получение степени бакалавра необходимо для последующего поступления в магистратуру или докторантуру, что, в свою очередь, может повлиять на численность и качество преподавательского состава для программ сестринского дела базового уровня. 46. Важнейшим, но зачастую сопряженным с трудностями компонентом сестринского образования является обеспечение достаточного времени и возможностей для практических занятий студентов в клинических условиях. В ходе клинической практики студенты применяют и закрепляют навыки критического мышления, клинической оценки и ухода за больными, полученные в классе. Клинические преподаватели должны обеспечивать надлежащее руководство и проведение оценки клинических навыков студентов. Поскольку многие программы сестринского дела базируются в городах, обеспечение надлежащего клинического опыта в сельских или отдаленных учреждениях может быть сопряжено с трудностями. Вместе с тем на основании такого опыта студент может принимать окончательное решение о том, где он хотел бы в дальнейшем практиковать (144). Было показано, что некоторые онлайновые и дистанционные программы расширяют доступ к сельским и отдаленным клиническим учреждениям, ранее не аффилированным с традиционными учебными заведениями (145,146). В качестве альтернативы можно использовать телемедицинские технологии и лаборатории моделирования, которые позволяют получить дополнительный клинический опыт в условиях первичной медико-санитарной помощи (147–150). Программы онлайнового дистанционного обучения должны контролироваться и соответствовать тем же стандартам аккредитации и качества, что и традиционные образовательные учреждения. 47. Во многих странах наблюдается значительный рост числа частных медицинских учебных заведений, как некоммерческих, так и рассчитанных на получение прибыли (151,152). Для последней группы чаще характерна более высокая плата за обучение; к таким учреждениям могут предъявляться различные требования со стороны регулирующих органов, и они должны проходить соответствующую аккредитацию (152). Их деятельность не обязательно направлена на достижение целей государственной политики в области здравоохранения и образования и, таким образом, не всегда увязана с приоритетами охраны здоровья населения, особенно если речь идет о подготовке сестринского персонала для растущего международного рынка труда в области здравоохранения. При отсутствии механизмов обеспечения качества содержание и формы осуществления учебной программы могут не соответствовать национальным стандартам, включая вопросы приобретения студентами необходимого клинического опыта. В результате выпускники не обладают знаниями, навыками и поведенческими характеристиками, необходимыми для предоставления безопасных 23Стратегические рычаги расширения профессиональных возможностей сестринского персонала и качественных услуг медицинской помощи (153). Неконтролируемый рост числа частных школ, не аффилированных с больницами или академическими медицинскими центрами, может оказывать давление на существующие центры клинического обучения и ставить под сомнение качество проводимой там подготовки. 48. Одной из самых больших проблем в образовании сестринских кадров являются наем и удержание в составе кадровых ресурсов достаточного числа квалифицированных преподавателей сестринского дела (19,20,154). Имеющиеся вызовы сопряжены с различиями в условиях труда (в образовательной организации в соотнесении с клиническим учреждением), в том числе по уровню заработной платы и в отношении официально выделенного рабочего времени на преподавательскую деятельность. В докладе Американской ассоциации колледжей сестринского дела предлагалось объединить педагогическую и клиническую работу преподавателей (совместные должностные назначения) для повышения статуса и уровня вознаграждения, а также для вовлечения экспертов-клиницистов в сферу сестринского образования (155). Другие стратегии включают развитие партнерств между академическими и клиническими учреждениями, в рамках которых клиницисты получают академическую подготовку по вопросам обучения студентов в клинических условиях, а также стимулы для дальнейшего повышения квалификации, такие как освобождение от платы за обучение и доступ к дополнительным образовательным возможностям. Успех таких партнерств часто зависит от того, предоставляют ли клинические центры достаточное время опытным клиническим медсестрам для руководства студентами и вовлечения их в клиническую работу. Во вставке 4.3 приведены наглядные примеры из практики стран и регионов. Вставка 4.3 Решение проблемы нехватки кадров преподавателей сестринского дела Остроту проблемы дефицита преподавателей сестринского дела, которая наблюдается во всем мире, можно смягчить путем применения подходов, основанных на сотрудничестве, таких как объединение ресурсов между учреждениями и, возможно, даже между странами (156). В Таиланде таким партнерским подходом к повышению академической квалификации преподавателей сестринского дела стала Программа развития высшего сестринского образования, проводимая в Университете Чиангмая и финансируемая Китайским медицинским советом (157). Эта программа, начатая в 1994 г., изначально была сосредоточена на подготовке преподавателей сестринского дела на уровне магистров и докторов для ведения учебной работы в растущем числе программ бакалавриата по сестринскому делу в различных провинциях Китая. Впоследствии эта программа была распространена на 10 стран Восточной и Юго-Восточной Азии, что позволило расширить масштабы обучения сестринских кадров и обеспечить взаимное признание дипломов медсестер во всем регионе (157). В Соединенных Штатах Программа академического партнерства по сестринскому делу Департамента по делам ветеранов предусматривает выделение фондов на заработную плату и подготовку опытных медсестер в качестве преподавателей в партнерских академических учреждениях в целях увеличения числа выпускников, обладающих необходимыми навыками для удовлетворения специальных потребностей ветеранов в условиях оказания неотложной и первичной помощи (158). В Руанде преподавательский потенциал по сестринскому делу был укреплен за счет мер непрерывного образования, ориентированного, в частности, на передовые методики преподавания и разработку учебных программ (159). Эта инициатива получила поддержку со стороны международного академического партнерства, признавшего, что программа должна принадлежать Руанде и что сотрудничество должно помогать учитывать местные культурные особенности (159). 24 Состояние сестринского дела в мире, 2020 г. 49. Нехватка преподавателей со степенью магистра или доктора является препятствием для создания программ высшего сестринского образования, особенно в тех случаях, когда требования к преподавателям указаны в критериях аккредитации или одобрения программы. Дефицит преподавательского состава, подготовленного на докторском уровне, также влияет на потенциал для проведения научных исследований в сестринском деле, необходимый для генерирования фактических данных в поддержку практики, а также снижает возможности для представителей сестринских служб занимать руководящие позиции в академических и медицинских секторах (20,154,160). 50. По имеющимся данным, в сестринском деле, в наибольшей степени среди всех медицинских дисциплин, находит свое применение межпрофессиональное образование (161). Этот подход ценят и студенты, которые полагают, что он способствует достижению ими компетенций межпрофессионального сотрудничества (149,162). Кроме того, привлечение преподавателей из различных дисциплин в процессы обучения сестринскому делу в потенциале может привносить специализированные знания из других дисциплин в образование сестринских кадров и тем самым повышать их компетенции, необходимые для коллективного оказания помощи пациентам (163). В настоящее время такой подход к обучению в большей мере используется в странах с высоким уровнем дохода, по сравнению со странами с низким и средним уровнем дохода (159), однако все более широкое применение современных технологий, даже в условиях нехватки ресурсов, создает реальную возможность для расширения междисциплинарного обучения (162). 4.2 Приток и отток трудовых ресурсов 51. Численность активного сестринского персонала определяется многими факторами. «Приток» обеспечивается за счет приступающих к работе выпускников отечественных программ сестринского дела, а также медсестер, которые иммигрируют из других стран, и тех, кто возвращается к практической деятельности после перерыва. «Отток» происходит за счет выпускников сестринских учебных заведений, которые теряют работу в отечественном секторе здравоохранения, а также медсестер, предпочитающих работать за пределами сектора здравоохранения, пенсионеров и тех, кто эмигрирует за пределы страны. 52. Одним из основных факторов, определяющих приток медицинских работников на рынок труда в сфере здравоохранения, является экономический потенциал страны в отношении создания финансируемых должностных позиций для работы по найму (в государственном или частном секторе) или возможность получения дохода за счет предоставления медицинских услуг. Таким образом, создание рабочих мест напрямую коррелирует с социально- экономическим уровнем страны и – более конкретно – с уровнем приоритетности, придаваемой государственными директивными органами инвестициям в сектор здравоохранения и, в частности, в развитие трудовых ресурсов. Другими факторами, влияющими на кадровый спрос, являются: демографические изменения, такие как старение населения; изменения структуры заболеваемости, такие как рост хронических заболеваний и множественной патологии; значительная частота ухода медсестер с работы или нехватка других медицинских работников; рост числа медицинских учреждений, например за счет строительства новых больниц, или изменение кадровой политики в стационарных учреждениях; изменения в законодательстве, например применительно к нормам соотношения численности сестринского персонала и пациентов (140,164). К факторам, которые могут снизить спрос на медицинских сестер, относятся новые технологии, влияющие на потребности в медицинских услугах, высокий уровень стабильности кадрового состава, повышение производительности труда (например, за счет использования научно обоснованных методов практики или более широкого применения технологий) и делегирование сестринских функций другим профессиональным группам (164). 53. Растет международная мобильность сестринского персонала, что оказывает значительное влияние на численность медицинских работников в странах. Причины миграции медсестер связаны с такими факторами, как наличие более достойных и хорошо оплачиваемых рабочих мест, условия труда, инфраструктура здравоохранения, 25Стратегические рычаги расширения профессиональных возможностей сестринского персонала ресурсы медицинских учреждений и возможности для повышения квалификации. Кроме того, стимулом для миграции может служить получение визы для въезда в страну на основании запроса на воссоединение семьи. К факторам, определяющим стремление покинуть страну, относятся отсутствие возможностей для трудоустройства, плохие условия труда и найма, а также низкий общий уровень безопасности. В некоторых странах денежные переводы от работников сестринских служб, работающих за рубежом, могут служить существенным источником дохода для семей и значимым вкладом в национальную экономику. Политические решения, например двусторонние соглашения между странами, должны быть выгодными для стран происхождения и стран назначения и соответствовать положениям о поддержке и гарантиях Глобального кодекса ВОЗ по практике международного найма персонала здравоохранения (165) Вставка 4.4 Глобальные партнерства по профессиональным навыкам В декабре 2018 г. 152 государства-члена Организации Объединенных Наций приняли Глобальный договор о безопасной, упорядоченной и легальной миграции, что способствовало выработке всеобъемлющего подхода к решению проблемы международной миграции. Одним из центральных принципов Глобального договора является создание глобальных партнерств по вопросам профессиональных навыков – двусторонних соглашений, направленных на использование возможностей миграции путем согласования спроса и предложения рабочей силы с целевой образовательной поддержкой в странах происхождения (166). Формат партнерств призван направить миграционное давление на достижение ощутимых, взаимных и справедливо распределяемых выгод как для стран происхождения, так и для стран назначения, что соответствует принципам Глобального кодекса практики ВОЗ. В рамках такого соглашения страна назначения обязуется предоставлять технологии и финансовые средства для обучения потенциальных мигрантов с целевыми навыками в стране происхождения до переезда, а страна происхождения соглашается обеспечивать такую учебную подготовку, а также получает поддержку для обучения своих кадров, не планирующих покидать страну (166). В рамках этого партнерства работники сестринских служб могут, например, проходить обучение в «домашнем потоке», где они получают подготовку по навыкам, соответствующим потребностям страны происхождения, или в «выездном потоке», профилированном на потребности страны назначения. В зависимости от нужд каждой стороны, партнерство может не ограничиваться какой-либо одной профессией. Партнерство между действующей под эгидой Национальной службы здравоохранения Соединенного Королевства организацией «Медицинское образование Англии» (Health Education England) и правительством Ямайки направлено на развитие специализированных сестринских кадров в этой стране. Ямайские медсестры в течение двух лет проходят подготовку в отделениях реанимации и интенсивной терапии больниц Соединенного Королевства, а затем возвращаются на родину для перехода на должности специалистов. Параллельно будет осуществляться командирование британских работников сестринских служб в Ямайку для поддержки мероприятий по укреплению системы здравоохранения, включающих предоставление услуг, работу над повышением качества и подготовку кадров. Реализация данной программы обмена была начата в 2019 г. Международная организация по миграции осуществляет аналогичные проекты по всему миру, связывая страны происхождения и страны назначения посредством программ, способствующих эффективному управлению миграцией медицинских работников, укреплению потенциала систем здравоохранения в странах происхождения и передаче навыков и знаний из диаспоры (167). Эта работа проводится в сотрудничестве с национальными правительствами и другими заинтересованными сторонами. В этой области Международная организация по миграции является ключевым партнером ВОЗ, поддерживая Глобальный кодекс практики ВОЗ, а также соответствующую политику и резолюции Всемирной ассамблеи здравоохранения (167). 26 Состояние сестринского дела в мире, 2020 г. (см. вставку 4.4 о глобальных партнерствах по профессиональным навыкам). 54. Число работников сестринских служб, получивших образование за рубежом и работающих в странах ОЭСР, за пятилетний период с 2011 по 2016 г. выросло на 20%, опередив врачей и достигнув почти 550 000 (168). Современные, значительно улучшенные данные указывают на сглаживание различий между традиционно признанными странами «происхождения» и «назначения» (169). Хотя в странах с высоким уровнем дохода по- прежнему сохраняется высокий экономический спрос на медицинских сестер (см. примеры во вставке 4.5), появляются новые модели миграции из Азии, Африки и стран Карибского бассейна в другие регионы и страны (например, страны Персидского залива) (170), а также наблюдается миграция по линии Юг–Юг между странами в пределах одного региона. 4.3 Справедливое распределение и экономическая эффективность 55. Работники сестринских служб трудятся на различных уровнях и по всему спектру учреждений здравоохранения, как государственных, так и частных (175–178). Распределение сестринского персонала по учреждениям различных типов и форм собственности систематически не документируется. Однако медсестры, вероятно, предпочитают работать скорее в больницах и отделениях экстренной помощи, чем в учреждениях первичной медико-санитарной помощи, и в некоторых случаях – в частном секторе из-за более высокого вознаграждения по сравнению с государственными учреждениями (175,177). 56. При разработке моделей оказания помощи необходимо стремиться к оптимальному сочетанию навыков в комплексных бригадах первичной медико-санитарной помощи (179), позволяя медсестрам работать в полном объеме их сестринского образования (180,181). Сестринские работники составляют ключевой компонент комплексных бригад, часто возглавляя процесс оказания медицинской помощи и принимая на себя расширенные практические функции, включая, по мере необходимости, сотрудничество с общинными медицинскими работниками и руководство их деятельностью (182–193). Когда сестринские работники получают возможность в полной мере использовать свою квалификацию и опыт, это повышает уровень их удовлетворенности своей профессиональной деятельностью, а также уровень удовлетворенности пациентов качеством получаемых медицинских услуг (194). Содействующими факторами являются обучение по вопросам первичной медико-санитарной помощи, разработка стандартизированных практических руководств Вставка 4.5 Примеры экономического спроса на сестринский персонал в странах с высоким уровнем дохода Происходящие в странах с высоким уровнем дохода изменения в демографии, эпидемиологии и политике здравоохранения обусловливают растущий спрос на сестринских работников. Можно привести следующие примеры: • По оценкам Фонда здравоохранения Соединенного Королевства, в период до 2024 г. необходимо ежегодно набирать не менее 5000 работников сестринских служб из-за рубежа (171). • В Японии была введена новая визовая программа для привлечения до 245 000 иностранных работников, включая 60 000 помощников медсестер (172). • Правительство Германии сообщило о примерно 36 000 вакантных должностях в учреждениях по уходу за престарелыми и больными (173), отметив, что для заполнения вакансий потребуется набор кадров из-за рубежа (174). 27Стратегические рычаги расширения профессиональных возможностей сестринского персонала или регламентов, а также систем данных для отслеживания результатов оказания помощи пациентам (195,196). 57. Во многих странах в сферу практики профессиональной или зарегистрированной медицинской сестры входит назначение лекарств (197,198). Практика лекарственных назначений может быть ограничена определенными группами препаратов или схемами приема/введения, установленными в законодательстве или профессиональной нормативной базе (199). В других ситуациях эта практика зависит от приоритетов здравоохранения, таких как антиретровирусная терапия препаратами первой линии в странах Африки к югу от Сахары с высоким бременем ВИЧ, устойчивость к противомикробным препаратам или лечение хронических заболеваний (200–202) (см. вставку 4.6 о назначении лекарств в Польше). Работники сестринских служб также выполняют важную функцию оказания помощи пациентам в соблюдении назначенного режима приема лекарств, проводят мониторинг рецептов, содействуют снижению риска ошибок при назначении лекарств (203,204). 58. В целях расширения доступа к услугам медицинской помощи для недостаточно обслуживаемых и удаленных групп населения и решения проблемы нехватки персонала в учреждениях первичной медико-санитарной помощи была введена квалификационная категория зарегистрированной медицинской сестры расширенной практики (192,207). Наиболее распространенной должностью медицинской сестры расширенной практики является практикующая медицинская сестра, в сферу полномочий которой входят самостоятельное назначение диагностических тестов, постановка диагноза, назначение лечебных вмешательств и лекарственных препаратов (207). Для занятия этой должности, как правило, требуется сертификация на уровне профессиональной организации и академическая степень магистра (208). Имеются данные из отдельных стран с высоким уровнем дохода, убедительно свидетельствующие о том, что работа адекватно обученных практикующих медицинских Вставка 4.6 Расширение доступа населения Польши к услугам медицинской помощи посредством сестринского назначения лекарств Одним из национальных приоритетов Польши в области здравоохранения была оптимизация ведения пациентов с хроническими заболеваниями на уровне местных сообществ и повышение доступности услуг лечения и лекарств в учреждениях первичной медико-санитарной помощи. Принятие ряда директивных решений, касающихся сестринского образования и регулирующих механизмов, позволило эффективно расширить функции сестринского персонала в системе здравоохранения и повысить доступ пациентов к медицинским услугам (205). В 2016 г. медсестрам с определенной квалификацией были предоставлены полномочия назначать лекарства в ряде конкретных ситуаций. Для того чтобы подготовить выпускников сестринских училищ к выполнению этих функций, в каждую программу базового обучения сестринскому делу и акушерству были включены вопросы назначения лекарств и были приняты правила, позволяющие всем медсестрам, получившим степень бакалавра сестринского дела, назначать лекарственные препараты, входящие в установленный перечень (206). Параллельно с этим была принята новая национальная стратегия развития сестринского и акушерского дела, в которой были представлены организационные стандарты для различных функций и профессиональных компетенций работников сестринских служб и предусмотрены улучшенные условия труда. За период с 2016 г. 10 287 медсестер и 4799 акушерок прошли обучение, позволяющее им назначать лекарства. К декабрю 2018 г. работники сестринских и акушерских служб самостоятельно выписали 2538 рецептов и продлили 363 288 ранее выписанных рецептов. 28 Состояние сестринского дела в мире, 2020 г. сестер и медицинских сестер расширенной практики эффективно обеспечивает оказание качественной помощи, расширение доступа к медицинскому обслуживанию и повышение удовлетворенности пациентов (208,209). Данные об экономической эффективности носят более ограниченный характер (208–210). Число магистров сестринского дела и практикующих медсестер растет и в других странах (159,211– 214), однако правила, касающиеся обучения, сертификации или лицензирования, существенно варьируются (192). Также между странами имеется широкий разброс в отношении перечня функций медсестры расширенной практики и соответствующих компетенций (192,215). Тем не менее опыт стран показывает, что предоставление расширенных клинических полномочий повышает привлекательность сестринского дела в качестве профессиональной карьеры (211,214). Медсестра, окончившая программу бакалавриата и обладающая навыками и знаниями по оказанию помощи определенным категориям пациентов, может быть также допущена к сертификации в качестве специализированной медицинской сестры несмотря на отсутствие лицензии медицинской сестры расширенной практики (см. пример функций специализированной медсестры во вставке 4.7). 59. Универсальной проблемой является неравномерное географическое распределение кадров здравоохранения между сельскими и городскими районами. Страны предпринимают различные директивные меры по многим направлениям (в сфере образования, нормативного регулирования, финансов и в профессиональной сфере) в попытке Вставка 4.7 Пример функций специализированной медицинской сестры в Африканском регионе В растущем числе стран востока и юга Африки правительства вкладывают средства в подготовку специализированных медицинских сестер для охраны здоровья детей в рамках стратегий по снижению детской смертности. Специалист по детскому здоровью – это зарегистрированная медсестра, прошедшая послебазовую подготовку и получившая дополнительную признанную квалификацию специализированной педиатрической медицинской сестры или медицинской сестры по здоровью детей. Наиболее распространенный путь получения данной квалификации – специализация после завершения базового обучения (диплом или степень бакалавра в области сестринского дела) в форме 12-месячной программы послебазового сестринского образования в области педиатрии. Получаемая квалификационная специальность и выдаваемые свидетельства различаются в зависимости от страны. Типичные формулировки – это «зарегистрированная специализированная педиатрическая медицинская сестра» или «профессиональная медицинская сестра с педиатрической специализацией». В Регионе насчитывается около 3650 зарегистрированных детских медицинских сестер, в том числе около 750 в Замбии, Кении, Малави и Уганде и 2900 в Южной Африке (216). Ежегодно 12 различных образовательных программ (большинство в Южной Африке) выпускают на рынок труда около 205 специализированных детских медицинских сестер. Еще три программы (в Ботсване, Зимбабве и Объединенной Республике Танзания) находятся на стадии разработки (216). В настоящее время в регионе функционируют лишь единичные страновые информационные системы, позволяющие представлять данные в разбивке по специализации медсестер. Обсерватория детского сестринского персонала оказывает поддержку странам в кадровом планировании в целях обеспечения оптимального сочетания профессиональных навыков, которое отвечает конкретным потребностям охраны здоровья детей в регионе. Начиная с 2015 г. развивается сотрудничество исследователей, преподавателей сестринского дела и других заинтересованных сторон, направленное на изучение и документирование роли детского сестринского персонала в странах востока и юга Африки. 29Стратегические рычаги расширения профессиональных возможностей сестринского персонала обеспечить справедливое распределение и удержание медицинских кадров в сельских и отдаленных районах (217) (см. вставку 4.8, посвященную удержанию работников в сельских районах). Для решения этой многогранной проблемы необходим комплексный подход, поэтому ключевым фактором для расширения масштабов и совместного использования таких стратегий в различных условиях практики и географических регионах является тщательный анализ воздействия различных типов вмешательств (144). В одном из страновых исследований было установлено, что для сельских медицинских работников представляют важность дополнительные факторы, прежде всего справедливость, прозрачность и предсказуемость в управлении людскими ресурсами в области здравоохранения со стороны министерства здравоохранения, а также тип трудового контракта (предпочтительно постоянный, а не временный) (218). Исследования, проведенные в странах со средним и высоким уровнем дохода, показали, что эффективность удержания сестринских кадров в сельской практике коррелировала с уровнем организационной приверженности, а также с интенсивностью поддержки со стороны руководителей сестринских служб (219,220). Набор студентов из труднодоступных общин в программы сестринского образования может приводить к повышению уровня удержания кадров, если выпускники вернутся к работе в своей общине (146,221). 60. Обеспечение стабильности сестринских кадров в конкретных условиях практики может представлять собой непростую задачу. Кадровая текучесть среди сестринского персонала является неизбежным следствием рыночных сил, которые могут оказывать как положительное, так и отрицательное воздействие на медицинские учреждения, пациентов и самих медицинских сестер (220,222). Так, умеренная степень сменяемости кадров может быть полезна для развития профессиональных компетенций и оптимизации кадровой структуры организации, например, когда медсестры оставляют свои должности, чтобы продолжить карьерный рост в пределах учреждения или в других звеньях системы здравоохранения (223). С другой стороны, увольнения и текучесть кадров почти всегда сопряжены с организационными издержками и могут оказывать негативное влияние на качество оказания помощи пациентам. 61. Намерение медсестры уйти с занимаемой должности или остаться на прежнем месте работы зависит как от индивидуальных, так и от организационных факторов. Индивидуальные факторы включают изменения в личной или семейной жизни или в состоянии здоровья, желание повысить квалификацию, рабочий стресс, неудовлетворенность условиями труда либо, наоборот, ощущение возросших прав и возможностей для принятия самостоятельных решений (224,225). Организационные факторы, влияющие на удержание персонала, включают рабочую среду, отношения в коллективе, условия труда, заработную плату, стиль управления и эффективность руководящей поддержки (226). В исследованиях, выполненных в таких странах, как Австралия, Египет, Иордания, Исламская Республика Иран и Филиппины, было установлено, что стиль руководства клинических менеджеров и организационная культура непосредственно влияют на удовлетворенность сестринского персонала своей работой и текучесть кадров, а также могут оказывать воздействие на качество медицинской помощи в больницах (227–229) и в сельских районах (219,220). Достойная работа 62. По определению МОТ достойная работа «подразумевает возможность продуктивно трудиться и получать справедливое вознаграждение, работать в безопасных условиях и пользоваться социальной защитой для семьи; более широкие возможности личностного развития и социальной интеграции, право людей выражать свою озабоченность, объединяться в организации и участвовать в принятии решений, которые влияют на их жизнь; равные возможности для всех женщин и мужчин и равное отношение к ним» (230). Типичные препятствия для обеспечения достойной работы в контексте сестринской профессии – это гендерные проблемы, риск насилия, чрезмерная рабочая нагрузка и несправедливое обращение с медсестрами-мигрантами. 63. Женщины-медсестры, так же как и другие женщины, работающие в системе здравоохранения, сталкиваются с различными препятствиями в своей работе чаще, чем их коллеги-мужчины (21,231). Речь идет о таких проблемах, как предвзятое восприятие роли женщин в оказании помощи, социальные гендерные нормы, гендерные предубеждения 30 Состояние сестринского дела в мире, 2020 г. и стереотипы. Все они подрывают возможности медсестер получать хорошие условия труда, справедливую оплату и равное обращение, участвовать в принятии решений и становиться лидерами в сфере здравоохранения (21,22,122). В опубликованном в 2019 г. докладе ВОЗ «Женщины работают, мужчины руководят» (Delivered by women, led by men) констатируется, что в рабочих коллективах, где большинство составляют женщины, часто наблюдается более тяжелое бремя дискриминации: в одном из примеров из практики 36% работников сестринских служб сообщили, что они не чувствуют уважения со стороны руководства, и 32% выразили желание быть услышанными (21). Подобные барьеры оказывают деструктивное воздействие на благополучие и источники средств к существованию женщин – медицинских работников, а также тормозят прогресс в достижении гендерного равенства (21). Гендерная дискриминация также оказывает прямое воздействие на оказание медицинской помощи, поскольку ее качество зависит от институциональной поддержки и уважения к медицинским сестрам (232). Сексуальные домогательства на рабочем месте – это проблема, с которой сталкиваются женщины во всех сферах здравоохранения, включая работников сестринских (25%) (233) и акушерских служб (37%) (21). 64. В некоторых ситуациях медсестры и другие медицинские работники подвергаются 4 Следует отметить, что эти рекомендации в настоящее время находятся в процессе обновления. нападению. В период с 1 января 2019 г. по 1 января 2020 г. в Системе ВОЗ по мониторингу случаев нападений на работников здравоохранения было зарегистрировано 1005 нападений в 11 странах с наличием комплексных чрезвычайных ситуаций; в результате чего 198 медицинских работников и пациентов погибли и 626 получили ранения (234).4 65. Предоставление услуг здравоохранения требует постоянного гибкого реагирования на потребности пациентов, что создает проблемы в связи с длительными и нерегулярными часами работы. Это может иметь негативные последствия как для самих медицинских сестер (включая эмоциональное выгорание), так и для пациентов (в частности, увеличение числа медицинских ошибок) (235). Конвенция МОТ 1977 г. о занятости и условиях труда и жизни сестринского персонала (№ 149) обязывает подписавшие страны обеспечивать, чтобы продолжительность рабочего времени сестринского персонала была эквивалентна рабочему времени других работников и чтобы сверхурочная, неудобная и сменная работа надлежащим образом регулировалась и компенсировалась. 66. Также повышенному риску отсутствия достойных условий труда подвергаются медсестры- мигранты. Работники сестринских служб из числа мигрантов и этнических меньшинств подвергаются более высокому риску травматизма Вставка 4.8 Руководящие принципы удержания кадров в сельских районах Во многих странах трудности, связанные с привлечением, набором и удержанием сестринского персонала в сельских и отдаленных районах, вызывают растущую озабоченность. В 2010 г. ВОЗ выпустила рекомендации по глобальной политике в области расширения доступа к работникам здравоохранения в отдаленных и сельских районах посредством совершенствования системы удержания кадров (217)4 . Рекомендации охватывают четыре основные сферы деятельности: образование, регулирование, финансовое стимулирование, а также персональная и профессиональная поддержка. Хотя масштабы исследований, посвященных сельскому сестринскому делу, растут, они все еще весьма ограниченны. Фактические данные поступают в основном из стран с высоким уровнем дохода (в частности, из Австралии, Канады и Соединенных Штатов); они свидетельствуют о том, что на эффективность удержания сестринских кадров в сельских районах влияют такие факторы, как финансовое стимулирование, предоставление персональной и профессиональной поддержки и возможности для ускоренного карьерного роста в области здравоохранения. 31Стратегические рычаги расширения профессиональных возможностей сестринского персонала и дискриминации на рабочем месте, чем работники сестринских служб из страны назначения или из этнического большинства (236). По имеющимся данным, дискриминация является основной причиной ухудшения здоровья среди медсестер из числа мигрантов и меньшинств (236). Тем не менее, несмотря на эти факторы, отсутствие достойной работы в своей стране подталкивает медсестер к эмиграции (237–240). 4.4 Нормативно-правовое регулирование 67. Регулирование обеспечивает защиту интересов общества посредством установления и контроля за соблюдением стандартов профессионального поведения, образования и практики. Меры регулирования также могут приносить пользу поставщикам услуг и способствовать повышению качества образования (241,242) и практики в области сестринского дела в государственном и частном секторах. Регулирующие органы также все активнее генерируют и систематически обновляют фактические данные о кадрах здравоохранения (243): за последние 15 лет произошел заметный рост научных данных, генерируемых регулирующими органами, по различным дисциплинам, в наиболее выраженной степени – в области сестринского дела (244,245). 68. Регулирование образования может включать установление национальных стандартов подготовки по сестринскому делу, утверждение учебных программ соответствующими регулирующими органами, а также аккредитацию учреждений внешними агентствами. Аккредитация, при которой учреждения оцениваются на соответствие образовательным стандартам, является для этих учреждений стимулом в отношении подготовки выпускников, способных улучшить показатели качества, справедливости, адекватности и эффективности медицинских услуг для населения (246). Однако стандарты и циклы аккредитации должны идти в ногу с развитием медицинской науки и моделей оказания медицинской помощи и быть финансово доступными для учреждений. Обеспечение соблюдения стандартов необходимо для устранения недостатков программ или, в качестве крайней, но иногда необходимой меры, закрытия программ, которые не могут быть доведены до приемлемых стандартов. Результаты проведенного в 2013 г. исследования в 17 странах Африки к югу от Сахары продемонстрировали наличие прочного юридического мандата на аккредитацию сестринского образования; вместе с тем уровни аккредитации программ, готовящих большинство работников сестринских служб в регионе, были низкими, хотя в государственных программах они были выше, чем в частных (247). В некоторых случаях частный сектор оспаривал результаты аккредитации на том основании, что у лиц, принимающих решения, имеется конфликт интересов; в этой связи правительства меняют состав директивных органов, расширяя участие представителей общественности (248). 69. В пределах отдельных стран практика аккредитации может варьироваться в зависимости от типа программы (249). В некоторых странах публичные университеты создаются и контролируются государством, и поэтому аккредитации подлежат только частные учреждения; в других странах, где отсутствуют государственные требования, порой не осуществляется аккредитация и частных учреждений. Необходимость аккредитации может быть предусмотрена непосредственно законом или косвенно, когда от выпускников, подающих заявку на зачисление в штат или регистрацию в совете по сестринскому делу либо сдающих экзамен на получение лицензии, требуется, чтобы учебная программа, которую они прошли, была одобрена советом или аккредитована соответствующей организацией. 70. В большинстве стандартов сестринского образования в целях обеспечения полноценности и необходимого тематического спектра учебных программ установлены минимально необходимое количество клинических часов и минимальный набор компетенций. Стандарты сестринского образования нередко относятся к конкретной юрисдикции (например, к стране, штату или к другой территории, где должен соблюдаться определенный свод законов или правил), что может повлиять на мобильность выпускников программ сестринского образования. Соглашения о взаимном признании квалификации и гармонизированные требования к образованию способствуют повышению уровня стандартизации и безопасной и эффективной мобильности практических работников. Примеры включают Договор о лицензировании работников сестринских служб в Соединенных Штатах (250,251), Карибский региональный экзамен для регистрации работников сестринских служб (252), 32 Состояние сестринского дела в мире, 2020 г. Профессиональную директиву Европейского союза (253,254), Соглашение Ассоциации государств Юго-Восточной Азии (255) и Транстасманское соглашение (256). Во вставке 4.9 представлены примеры гармонизации образовательных стандартов и экзаменов на получение лицензии. 71. Кроме того, профессиональное регулирование включает следующие аспекты, относящиеся собственно к сестринскому персоналу: (а) установление требований к изначальному присвоению профессионального звания «медицинская сестра» (зарегистрированная или зарегистрированная и лицензированная), что может предусматривать сдачу экзамена на получение лицензии; (b) требования к повторному зачислению, регистрации или лицензированию, которые могут включать требования в отношении непрерывного профессионального развития; (с) установление сферы практики для работников сестринских служб и кодекса поведения и этики; (d) проведение расследований и потенциальная возможность применения к сестринским работникам дисциплинарных санкций (259). Регулирующие органы также все чаще наделяются полномочиями и отвечают за формирование и систематическое обновление реестра активных сестринских кадров. 72. Более 60% стран используют экзамен на получение лицензии для оценки и обеспечения минимального уровня профессиональных знаний или «готовности к практике» выпускников программ сестринского дела перед выдачей им официального разрешения на занятия сестринской практикой (29). Другим методом оценки начальной пригодности к практике является объективный структурированный клинический экзамен, в ходе которого осуществляется оценка компетенций путем прямого наблюдения за действиями экзаменуемого в моделируемой клинической ситуации; однако этот метод может быть сопряжен со значительными расходами и характеризуется значительной трудоемкостью (260–262). Ведутся дискуссии о том, следует ли использовать экзамен на готовность к практике для повторного лицензирования, для возвращения в профессию или для работников сестринских служб, получивших образование за рубежом. Вставка 4.9 Примеры гармонизации образовательных стандартов и экзамена на получение лицензии В 1972 г. территории Карибского сообщества учредили Региональный орган сестринского дела, первоначальной задачей которого было формирование общего корпуса квалифицированных преподавателей в целях решения проблемы нехватки кадров для проведения оценки компетенций выпускников программ сестринского образования (252). Когда результаты анализа показали, что цели, содержание и методика учебных программ сестринского дела во всем субрегионе одинаковы, страны приняли решение о проведении единого и общего экзамена для работников сестринских служб, который был введен в практику в 1990 г. Региональный орган сестринского дела координирует проведение экзамена, в ходе которого оцениваются взаимно согласованные компетенции, необходимые для практики зарегистрированной медсестры; проведением экзамена совместно руководят главные специалисты по сестринскому делу, наставники работников сестринских служб и совет по сестринскому делу каждой страны, а также преподаватели из университетов субрегиона (257). Экзамен позволяет стандартизировать и оптимизировать сестринское образование, а также обеспечить взаимную совместимость и легкость перемещения зарегистрированных медсестер между странами субрегиона. В Европейском союзе усилия по гармонизации разнообразных и сложных структур дипломов и учебных программ по сестринскому делу начались с принятия в конце 1970-х годов секторальных директив. Эта работа ускорилась после пересмотра данной темы в 2005 г. (Директива 36) с последующими обновлениями, в которых был установлен стандартный набор компетенций (Директива 55) (253, 254). Эти изменения в сочетании с Болонским соглашением (1999 г.) привели к формированию трехступенчатой образовательной структуры бакалавриата, магистратуры и докторантуры с согласованными академическими квалификациями по всем дисциплинам (258). 33Стратегические рычаги расширения профессиональных возможностей сестринского персонала © WHO/Sergey Volkov 34 Состояние сестринского дела в мире, 2020 г. 73. В этой главе впервые в практике ВОЗ приводятся данные о численности сестринского персонала более чем в 190 странах, систематизированные с использованием набора стандартизированных показателей и собранные в рамках единого процесса на основе применения Национальной системы учета кадровых ресурсов здравоохранения (НСУКЗ). 74. Были собраны данные о наличии, составе, распределении, образовании и профессиональной подготовке, навыках, управлении, регулировании, финансировании и лидерских функциях сестринских кадров5. В общей сложности были собраны и проанализированы данные по более чем 30 показателям. В работу по сбору и предоставлению данных были вовлечены различные заинтересованные стороны, такие как министерства здравоохранения, другие министерства, в частности труда и образования, обсерватории по трудовым ресурсам для здравоохранения, национальные институты общественного здравоохранения, профессиональные организации сестринского персонала, главные государственные специалисты по сестринскому и акушерскому делу, другие национальные, региональные и 5 С использованием определения сестринских кадровых ресурсов, предложенного МОТ, см. приложение 1. международные организации. Сбор данных осуществлялся с помощью платформы НСУКЗ – единой системы определений данных и их представления, а также онлайнового хранилища информации, которое используется государствами-членами для ввода, мониторинга и использования данных, относящихся к кадровым ресурсам здравоохранения. Детальная методика описана в приложении 2. 75. Основное внимание в ходе анализа было уделено текущему состоянию сестринского персонала, однако в последней части этой главы рассматриваются возможные сценарии будущего развития сестринских кадровых ресурсов при различных вариантах оценки прогресса в достижении целей, поставленных в Глобальной стратегии для развития кадровых ресурсов здравоохранения: трудовые ресурсы 2030 г., а также в контексте Целей в области устойчивого развития на период до 2030 г. (ЦУР) и повестки дня всеобщего охвата услугами здравоохранения (16). 76. Проведенный процесс сбора данных о сестринском персонале стал беспрецедентным по числу стран, предоставивших сведения. Текущее состояние фактических данных о кадровых ресурсах сестринских служб 5ГЛАВА 35Текущее состояние фактических данных о кадровых ресурсах сестринских служб В результате был сформирован наиболее полный и обновленный набор данных о сестринских кадровых ресурсах из когда-либо собранных (рисунок 5.1). Особенно возрос объем информации о сестринском деле за период 2013–2018 гг.; стимулом для этого стало объявление 2020 г. Международным годом работников сестринских и акушерских служб. Данные о состоянии кадров здравоохранения в последние годы увеличились не только в плане объема информации, но и в плане своевременности представления отчетности. При этом большинство стран представили данные за последние пять лет по пяти профессиям, включенным в показатель ЦУР 3.c.1 (врачи, медицинские сестры и акушерки, стоматологи, фармацевты). Наличие текущих и ретроспективных данных позволило обновить предыдущие оценки, а также устранить ограничения, связанные с данными предшествующих анализов и отчетов. 77. Из 36 показателей состояния сестринского персонала, использованных в настоящем докладе (см. табл. A2.1 в приложении 2), почти все государства-члены ВОЗ смогли представить данные о численном составе сестринского персонала, большинство стран – также о других ключевых показателях, таких как распределение по возрасту, гендерный состав и продолжительность обучения. Около 80% стран представили данные не менее чем по 15 показателям, 23% стран – не менее чем по 25 показателям. В настоящей главе представлены сведения по отдельным показателям, которые поступили от большого числа государств-членов (полный перечень приведен в приложении 2). Страны с наличием данных по стоматологическому персоналу Страны с наличием данных по сестринскому и акушерскому персоналу Страны с наличием данных по фармацевтическому персоналу Страны с наличием данных по врачам Чи сл о ст ра н 160 140 120 100 80 60 40 20 0 191 страна с данными за последние годы 83% – за 2017 г. или 2018 г. 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Примечания: (а) С охватом последних пяти лет были собраны данные по численности сестринских кадров из 191 страны. Последние данные могут относиться к разным годам; большинство стран (83%) представили сведения о численности работающего персонала за 2017 г. или 2018 г. (b) Задержка в получении данных и представлении отчетности демонстрирует в последние годы явную тенденцию к сокращению; ожидается появление дополнительных данных за период 2014–2018 гг., что будет способствовать сохранению позитивной тенденции к росту сведений о численности сестринского персонала. Источник: НСУКЗ, 2019 г. Число стран с данными о трудовых ресурсах, имеющимися в НСУКЗ ВОЗ (1990–2018 гг.) Рисунок 5.1 36 Состояние сестринского дела в мире, 2020 г. 5.1 Наличие, состав и распределение сестринских кадров 5.1.2 Численность сестринских кадров в мире и по регионам 78. Данные по 191 стране свидетельствуют о том, что в мире насчитывается почти 28 миллионов работников сестринских служб, которые трудятся как в государственном, так и в частном секторах (табл. 5.1). Это соответствует значению обеспеченности населения сестринскими кадрами, составляющему 36,9 медсестер на 10 000 населения. Однако за этой глобальной цифрой скрываются резкие различия внутри регионов и между ними6. 79. Хотя в Регионе стран Америки и в Африканском регионе численность населения примерно 6 См. раздел 5.2, посвященный вопросам справедливости. одинакова, в Америке работников сестринских служб почти в 10 раз больше, чем в Африке: показатель обеспеченности составляет соответственно 83,4 и 8,7 на 10 000 населения. Регионы Восточного Средиземноморья и Юго- Восточной Азии занимают вторую и третью позиции от минимума по данному показателю (15,6 и 16,5 на 10 000 населения), однако эти значения почти вдвое превышают цифры для Африканского региона. 80. Около 81% работников сестринских служб в мире работают в трех регионах (стран Америки, Европейском и Западной части Тихого океана), где проживает 51% мирового населения. 5.1.1 Основные результаты Данные из 191 страны указывают на то, что в 2018 г. в мире насчитывалось около 28 миллионов работников сестринских служб, преимущественно (69%) медицинских сестер профессионального уровня. В период с 2013 по 2018 г. в мире произошел реальный прирост численности сестринского персонала на 4,7 миллиона человек, даже с учетом поправки на улучшение доступности и качества данных. В 172 странах с наличием соответствующих данных примерно 59% от общего числа медицинских работников (включая врачей, сестринский и акушерский персонал, стоматологов и фармацевтов) составляют медицинские сестры профессионального и ассоциированного профессионального уровня. На глобальном уровне 9 из 10 работников сестринских служб – женщины, однако имеются существенные региональные различия: так, в Африканском регионе соотношение женщин и мужчин составляет 3:1. В 13 странах в составе сестринского персонала мужчины представляют более многочисленную категорию по сравнению с женщинами. Также наблюдаются выраженные различия в распределении кадров в пределах регионов. В Регионе стран Америки более 8 из каждых 10 работников сестринских служб трудятся в трех странах (Бразилии, Канаде и Соединенных Штатах), где проживает 57% населения. В Африканском регионе и в Регионе Восточного Средиземноморья наблюдается стократный разброс значений показателя обеспеченности населения сестринскими кадрами. В ближайшие 10 лет каждая шестая медсестра в мире выйдет на пенсию; эта доля значительно выше в Регионе стран Америки (24%), что создает дополнительную проблему пополнения кадровых ресурсов. 37Текущее состояние фактических данных о кадровых ресурсах сестринских служб 81. Следует соблюдать осторожность при сравнении этой общей оценки в 27,9 миллиона работников сестринских служб на 2018 г. с положениями Глобальной стратегии для развития кадровых ресурсов здравоохранения, в которой численность работников сестринских и акушерских служб, по данным за 2013 г., оценивается на уровне 20,7 миллиона человек (из которых 18,8 – медсестры). Рост численности сестринского персонала в период с 2013 по 2018 г. отчасти обусловлен улучшением доступности данных (чем объясняется увеличение этого показателя на 4,4 миллиона человек), при этом реальное увеличение численности оценивается в 4,7 миллиона (таблица 5.2), из которых 3,6 миллиона составляют медицинские сестры профессионального уровня (при условии РЕГИОН ВОЗ Количество стран, представивших численность работающего персонала / общую численность кадров Численность сестринского персоналаа (млн чел.) (%) Показатель обеспеченности на 10 000 населения Африканский регион 44/47 0,9 (3%) 8,7 Регион стран Америки 35/35 8,4 (30%) 83,4 Регион Юго-Восточной Азии 11/11 3,3 (12%) 16,5 Европейский регион 53/53 7,3 (26%) 79,3 Регион Восточного Средиземноморья 21/21 1,1 (4%) 15,6 Регион Западной части Тихого океана 27/27 6,9 (25%) 36,0 Всего в мире 191/194 27,9 (100%) 36,9 a Медицинские сестры профессионального и ассоциированного профессионального уровня. Примечание: по таким странам, как Камерун, Коморские острова и Южный Судан, данные отсутствовали. Источник: НСУКЗ, 2019 г. Последние значения показателя обеспеченности, представленные странами за период с 2013 по 2018 г. Для стран, представивших сведения о численности работающего персонала за период с 2013 по 2017 г., в целях приведения значений к 2018 г. это количество было пересчитано из расчета последнего доступного значения обеспеченности применительно к численности населения в 2018 г. Данные о численности населения по каждой стране и по каждому году, использованные для расчета обеспеченности населения сестринскими кадрами, были взяты из «Мировых демографических перспектив» пересмотра 2019 г., опубликованных Департаментом по экономическим и социальным вопросам Организации Объединенных Наций (263). Численность сестринского персонала в мире и обеспеченность сестринскими кадрами на 10 000 населения, по регионам ВОЗ, 2018 г. Таблица 5.1 Численность сестринского персонала в 2013 г. Численность сестринского персонала в 2018 г. Изменение в связи с фактическим ростом численности (млн чел.)ИСТОЧНИК Число стран с данными за 2009–2013 гг. Численность персонала (млн чел.) Число стран с данными за 2013–2018 гг. Численность персонала (млн чел.) Оценки, приведенные в Глобальной стратегии для развития кадровых ресурсов здравоохранения, 2016 г. 102 18,8a Оценки «Доклада о состоянии сестринского дела в мире, 2020 г.» 174 23,2 191 27,9 4,7 Изменение в связи с улучшением данных (млн чел.) 4,4 a Оригинальная публикация приводит данные, включающие количество акушерок: 20,7 миллиона медсестер и акушерок. Это соответствует 18,8 миллиона медсестер с поправкой на их долю в совокупной численности медсестер и акушерок. Источник: НСУКЗ, 2019 г. Изменения численности сестринского персонала в связи с улучшением данных и с фактическим ростом кадровых ресурсов в период с 2013 по 2018 г. Таблица 5.2 38 Состояние сестринского дела в мире, 2020 г. постоянства соотношения профессиональных и ассоциированных профессиональных медсестер (рисунок 5.2). 82. Таким образом, общая численность сестринского персонала на уровне 27,9 миллиона человек на 2018 г. указывает на две отдельные позитивные тенденции: • улучшение доступности данных о сестринских кадрах, что позволяет лучше интерпретировать и пересмотреть результаты предыдущих анализов; • фактический рост численности сестринских кадров во всем мире, отражающий растущий спрос на рынке труда и инвестиции государств-членов в эту профессиональную группу. 83. При сопоставлении численности сестринского персонала с совокупной численностью врачей, акушерок, стоматологов и фармацевтов в 172 странах, представивших сведения, медсестры составляют в среднем 59% от общего числа медицинских работников, с разбросом от 49% в Регионе Восточного Средиземноморья до 68% в Регионе Западной части Тихого океана (таблица 5.3). РЕГИОН ВОЗ Численность сестринского персоналаа в соотнесении с численностью медицинских работников по показателю ЦУР 3.с.1 Число стран, представивших сведения / всего Средняя доля сестринского персонала Африканский регион 45/47 66% Регион стран Америки 24/35 56% Регион Юго-Восточной Азии 11/11 53% Европейский регион 50/53 57% Регион Восточного Средиземноморья 20/21 49% Регион Западной части Тихого океана 22/27 68% Всего в мире 172/194 59% a Медицинские сестры профессионального и ассоциированного профессионального уровня. Примечание: ЦУР 3.c.1 – это показатель, используемый для оценки прогресса в решении задачи ЦУР 3.c. Источник: НСУКЗ, 2019 г. Сестринский персонал в процентах от общего числа медицинских работников (врачи, сестринский и акушерский персонал, стоматологи и фармацевты), в разбивке по регионам ВОЗ Таблица 5.3 84. Обновленные сведения о численности кадров здравоохранения не менее чем по 10 профессиям смогли представить 66 стран. Доля сестринского персонала от общей численности всех возможных категорий медицинских работников составила от 40% до 50%. 5.1.3 Состав 85. Из 27,9 миллиона медсестер в мире 19,3 миллиона (69%) относятся к категории медицинских сестер профессионального уровня (код МСКЗ 2221), 6,0 миллиона (22%) – к категории медицинских сестер ассоциированного профессионального уровня (код МСКЗ 3221). В результате 2,6 миллиона (9%) медсестер оказываются не отнесенными ни к одной из вышеуказанных категорий, что свидетельствует о возможных нестыковках между национальными системами данных и МСКЗ. Эти работники могут фактически являться медицинскими сестрами профессионального или ассоциированного профессионального уровня, но в эту категорию не входят помощники медицинских сестер. Как показано на рисунке 5.2, относительная представленность различных категорий сестринского персонала существенно различается в зависимости от региона. 39Текущее состояние фактических данных о кадровых ресурсах сестринских служб 5.1.4 Демографические характеристики сестринского персонала: распределение по полу и возрасту РАСПРЕДЕЛЕНИЕ ПО ПОЛУ 86. Чтобы при планировании и управлении кадровыми ресурсами здравоохранения применялись основанные на фактических данных гендерно-чувствительные подходы, необходимо обеспечивать учет гендерных факторов в стратегиях развития кадровых ресурсов. Половой состав и возрастные аспекты сестринской профессии долгое время игнорировались по различным причинам, включая отсутствие высококачественных данных для национального планирования и региональных и глобальных сопоставлений. Из 194 государств-членов ВОЗ 132 представили данные в разбивке по полу, 106 – по возрасту. В вышеуказанных 132 странах около 9 из каждых 10 работников сестринских служб (89%) – это женщины, при этом имеет место значительный разброс между регионами. Самая высокая доля женщин (95%) в составе сестринского персонала характерна для Региона Западной части Тихого океана, самая низкая (76%) – для Африканского региона. В 13 странах среди работников сестринских служб мужчин больше, чем женщин (таблица 5.4). 7 Эта возрастная группа здесь обозначается как «молодые работники сестринских служб». РАСПРЕДЕЛЕНИЕ ПО ВОЗРАСТУ 87. Глобальные тенденции старения населения и трудовых ресурсов обусловливают необходимость учета возрастной структуры кадров при составлении различных прогнозов. Во многих странах разработчики планов полагаются на стандартный пенсионный возраст, но этот подход имеет ограничения, поскольку имеются существенные различия в фактическом возрасте выхода на пенсию в зависимости от профессии, пола и должностного уровня работников. Для иллюстрации современной демографической динамики кадровых ресурсов сестринского дела были использованы данные по возрастному профилю кадров, полученные из 106 стран. Имеющаяся информация в целом указывает на относительную молодость работников сестринских служб: 38% медсестер моложе 35 лет,7 и лишь 17% – в возрасте 55 лет и старше (эта группа считается уходящей на пенсию в течение следующего десятилетия) (рисунок 5.3). Однако представляют важность региональные различия: в Регионе Восточного Средиземноморья на каждого выходящего на пенсию приходится 14 молодых работников сестринских служб; напротив, в Регионе стран Америки это соотношение составляет 1 к 1,2, а в Европе и Африке – 1 к 1,9, что указывает на гораздо меньший резерв замещения. Африканский регион Регион стран Америки Регион Юго- Восточной Азии Европейский регион Регион Восточного Средиземноморья Регион Западной части Тихого океана Всего в мире Процент от общей численности работающего сестринского персонала Медицинские сестры профессионального уровняРЕГИОН ВОЗ 0% 20% 40% 60% 80% 100% Медицинские сестры ассоциированного профессионального уровня Сестринский персонал, без дальнейшего уточнения Соотношение категорий сестринского персонала в общей численности данной профессиональной группы, в разбивке по регионам ВОЗ Рисунок 5.2 40 Состояние сестринского дела в мире, 2020 г. РЕГИОН ВОЗ Число стран, представивших сведения / всего % женщин % мужчин Африканский регион 30/47 76% 24% Регион стран Америки 26/35 87% 13% Регион Юго-Восточной Азии 9/11 89% 11% Европейский регион 32/53 89% 11% Регион Восточного Средиземноморья 11/21 78% 22% Регион Западной части Тихого океана 24/27 95% 5% Всего в мире 132/194 89% 11% Примечание: «сестринский персонал» персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Источник: НСУКЗ, 2019 г. Последние данные о численности работающего персонала, представленные странами за период с 2013 по 2018 г. Процентная доля женского сестринского персонала в разбивке по регионам ВОЗТаблица 5.4 Африканский регион (n=20) Регион стран Америки (n=25) Регион Юго-Восточной Азии (n=8) Европейский регион (n=30) Регион Восточного Средиземноморья (n=5) Регион Западной части Тихого океана (n=18) <35 лет ≥55 лет 0 20% 40%80% 60% 40% 20% РЕГИОН ВОЗ Всего в мире (n=106) Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Процентная доля сестринского персонала моложе 35 лет и в возрасте 55 лет и старше, в разбивке по регионам ВОЗ Рисунок 5.3 41Текущее состояние фактических данных о кадровых ресурсах сестринских служб 88. Поскольку 17% сестринского персонала в мире – это люди в возрасте 55 лет и старше, которые, как ожидается, в течение следующих 10 лет выйдут на пенсию, только для поддержания статус-кво будет необходимо за эти 10 лет подготовить и трудоустроить 4,7 миллиона новых медицинских сестер. При этом, чтобы идти в ногу с ростом населения и ликвидировать дефицит сестринского персонала, потребуется обеспечить еще более значительное увеличение численности кадровых ресурсов (см. раздел 5.8). 89. На рисунке 5.4 показано соотношение более молодых и более пожилых возрастных групп в составе сестринского персонала, которое иллюстрирует феномен старения сестринских кадров. В ряде стран доля молодых работников сестринских служб высока, в ряде других ситуация близка к равновесию (одинаковая доля работников сестринских служб в возрасте до 35 лет и старше 55 лет, что соответствует зеленой линии на рисунке 5.4), а в 18 странах (то есть в каждой шестой из тех, что представили данные) численность молодых работников сестринских служб ниже, по сравнению с медсестрами предпенсионного возраста, что указывает на тяжелое положение в связи со старением кадров. Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня из 106 стран, представивших данные в разбивке по возрастным группам. Источник: НСУКЗ, 2019 г. Последние данные о численности работающего персонала, представленные странами за период с 2013 по 2018 г. Доля работников сестринских служб в возрасте младше 35 лет 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ра бо тн ик ов с ес тр ин ск их с лу ж б в во зр ас те с та рш е 55 л ет 60%0% 10% 20% 30% 40% 50% 70% 18 стран подвержены риску старения сестринского персонала Каждая точка обозначает конкретную страну Зеленая линия соответствует ситуации, когда число работников сестринских служб предпенсионного возраста равно числу молодых работников сестринских служб Рисунок 5.4 Относительная доля работников старше 55 лет и моложе 35 лет в составе сестринского персонала 42 Состояние сестринского дела в мире, 2020 г. 5.2 Справедливость по показателям наличия и доступности сестринских кадров 5.2.1 Основные результаты Около 81% численности мирового сестринского персонала приходится на регионы стран Америки, Европы и Западной части Тихого океана, в которых проживает 51% населения планеты. Страны с низкими показателями обеспеченности населения сестринскими кадрами находятся в основном в регионах Африки, Юго-Восточной Азии и Восточного Средиземноморья, а также в некоторых частях Латинской Америки. Глобальное неравенство в наличии сестринского персонала в значительной степени обусловлено доходами стран: обеспеченность сестринскими кадрами в странах с низким уровнем дохода составляет 9,1 на 10 000 населения, в то время как в странах с высоким уровнем дохода этот показатель составляет 107,7 на 10 000. Существует значительный дисбаланс и внутри стран: в 35 странах с данными, дезагрегированными по городским и сельским районам, 36% медицинских сестер работают в сельских районах, где проживает 49% населения. В 76 странах, представивших соответствующие данные, 75% медицинских сестер работают в государственном секторе, остальные 25% – в частном. 90. Путь к всеобщему охвату услугами здравоохранения требует устранения демографических, географических и квалификационных различий в наличии и доступности медицинских кадров. 5.2.2 Справедливость на межрегиональном уровне 91. На рисунке 5.5 показаны глобальные различия в численности сестринского персонала на 10 000 населения: наименьшие значения характерны для регионов Африки, Юго-Восточной Азии и Восточного Средиземноморья, а также для некоторых стран Латинской Америки. 5.2.3 Справедливость в наличии сестринских кадров в пределах регионов 92. Рисунок 5.6 иллюстрирует разброс значений показателя обеспеченности населения сестринскими кадрами в пределах регионов: каждая точка соответствует конкретной стране. Во всех регионах наблюдаются значительные различия по данному показателю, при этом наибольший разброс характерен для Региона Восточного Средиземноморья с соотношением максимального и минимального значения 121:1 и в Африканском регионе с соотношением 100:1. Также в Регионе стран Америки несколько крупных стран имеют высокую обеспеченность сестринскими кадрами, в то время как в большинстве других стран этот показатель находится на низком уровне: 87% работников сестринских служб в этом регионе работают в Бразилии, Канаде и Соединенных Штатах, где проживает около 57% населения. В Европейском регионе наблюдаются менее значительные диспропорции – 10:1. Страны Африканского региона сгруппированы в нижней части колонки; это указывает на то, что лишь в единичных африканских странах обеспеченность населения сестринским персоналом превышает 25 на 10 000. Аналогичная картина наблюдается в регионах Юго-Восточной Азии и Восточного Средиземноморья. Разброс по показателям обеспеченности в значительной степени обусловлен доходами стран: в странах с низким уровнем дохода этот показатель составляет 9,1 43Текущее состояние фактических данных о кадровых ресурсах сестринских служб Рисунок 5.5 Численность сестринского персонала из расчета на 10 000 населения в 2018 г. Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Источник: Национальная система учета кадров здравоохранения, Всемирная организация здравоохранения, 2019 г. Последние имеющиеся данные за период 2013–2018 г. неприменимо нет данных 0 1,000 2,000 3,000 4,000500 km < 10 10–19 20–29 30–39 40–49 50–74 75–99 100 + 0 50 100 150 200 Соотношение показателей обеспеченности – максимум: минимум 100:1 22:1 18:1 10:1 12:1 33:1 Регионы ВОЗ Африканский регион Регион Восточного Средиземноморья Европейский регион Регион стран Америки Регион Юго- ВосточнойАзии Регион Западной части Тихого океана Чи сл ен но ст ь се ст ри нс ко го п ер со на ла на 1 0 00 0 на се ле ни я Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Источник: НСУКЗ, 2019 г. Последние имеющиеся данные о численности работающего персонала, представленные странами за период с 2013 по 2018 г. Рисунок 5.6 Региональные различия в значениях показателя обеспеченности населения сестринским персоналом на 10 000 населения (2018 г.) 44 Состояние сестринского дела в мире, 2020 г. на 10 000 населения, в то время как в странах с высоким уровнем дохода он достигает 107,7 на 10 000 (таблица 5.5 и рисунок 5.7). 93. Что касается 46 стран, отнесенных Комитетом ООН по политике в области развития по состоянию на декабрь 2018 г. к категории наименее развитых, то в них значение показателя обеспеченности населения сестринскими кадрами составляет 6,4 на 10 000, что в шесть раз меньше, чем в среднем по 8 Страны со значениями Индекса нестабильности 80+. Источник: https://fragilestatesindex.org/. всем остальным странам, и существенно ниже, чем в среднем по странам с низким уровнем дохода. Подавляющее большинство этих стран также считаются уязвимыми – относящимися к категории «высокоприоритетного предупреждения» (high warning) или «тревожного оповещения» (alert) в соответствии с Индексом нестабильности государств8. Во вставке 5.1 представлена дополнительная информация по вопросам справедливости внутри стран. Уровень дохода Низкий уровень дохода Уровень дохода ниже среднего Уровень дохода выше среднего Высокий уровень дохода 0 50 100 150 200 Чи сл ен но ст ь се ст ри нс ко го п ер со на ла на 1 0 00 0 на се ле ни я Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Источник: НСУКЗ, 2019 г. Последние имеющиеся данные о численности работающего персонала, представленные странами за период с 2013 по 2018 г. Распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. Рисунок 5.7 Численность сестринского персонала из расчета на 10 000 населения, в разбивке по уровням дохода стран (2018 г.) 45Текущее состояние фактических данных о кадровых ресурсах сестринских служб Вставка 5.1 Справедливость внутри стран Наличие сестринского персонала в сельской местности Не менее важным в обеспечении справедливого доступа к услугам сестринской помощи является распределение сестринских кадров внутри стран. В общей сложности 35 стран (главным образом в Латинской Америке и Африке)9 представили данные о доле сестринского персонала, работающего в сельских районах. В среднем, в этих странах около 36% медсестер трудятся в сельской местности, в то время как проживает там 50% населения. Наличие сестринских кадров в государственном и частном секторах Еще одним потенциальным источником несправедливых внутристрановых различий является распределение кадров между государственным и частным секторами. В 76 странах, представивших данные, в среднем, 75% медсестер работали в государственном секторе, причем различия между регионами были относительно низкими. ГРУППЫ СТРАН ПО УРОВНЯМ ДОХОДА Число стран, представивших сведения / всего Показатель обеспеченности на 10 000 населения Отношение максимального значения к минимальномуВ целом Низкая Высокая Низкий уровень дохода 30/31 9,1 0,6 42,0 68:1 Уровень дохода ниже среднего 44/46 16,7 1,8 104,6 57:1 Уровень дохода выше среднего 60/60 35,6 5,0 124,2 25:1 Высокий уровень дохода 57/57 107,7 19,4 196,1 10:1 Всего в мире 191/194 36,9 0,6 196,1 319:1 Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Источник: НСУКЗ, 2019 г. Последние сведения, представленные странами за период с 2013 по 2018 г. Для Островов Кука и Ниуэ сведений о принадлежности к той или иной группе стран по уровню дохода не было получено. Поэтому по аналогии с другими странами той же географической области они были включены в группу с доходом выше среднего уровня. Распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. Обеспеченность населения сестринским персоналом, в разбивке по уровням дохода стран (2018 г.) Таблица 5.5 Антигуа и Барбуда, Белиз, Бразилия, Бруней-Даруссалам, Венесуэла (Боливарианская Республика), Гамбия, Гана, Гвинея-Бисау, Гайана, Гондурас, Египет, Исландия, Камбоджа, Кения, Лаосская Народно-Демократическая Республика, Мадагаскар, Маршалловы Острова, Монголия, Мьянма, Объединенная Республика Танзания, Пакистан, Парагвай, Перу, Сальвадор, Самоа, Сербия, Сьерра-Леоне, Таджикистан, Таиланд, Тимор-Лешти, Уганда, Уругвай, Шри-Ланка, Эквадор, Эсватини. 9 46 Состояние сестринского дела в мире, 2020 г. 5.3 Международная миграция и мобильность сестринских кадров 5.3.2 Проблемы количественной оценки международной мобильности сестринского персонала 94. В последние десятилетия тенденции в области демографии, эпидемиологии, финансов и политики здравоохранения способствуют повышению уровня международной мобильности медицинских работников, и ожидается, что эта мобильность будет и далее возрастать (18). Принятый Всемирной ассамблеей здравоохранения в 2010 г. Глобальный кодекс ВОЗ по практике международного найма персонала здравоохранения является ключевым инструментом международного права, направленным на совершенствование механизмов управления международной мобильностью медицинских работников при соблюдении принципов этики. 95. Перемещение работников здравоохранения из стран с низким уровнем дохода в страны с более высоким уровнем, а также связанные с этим проблемы уже давно являются предметом активного обсуждения. Однако данные, необходимые для принятия стратегических решений, в основном ограничены лишь отдельными странами с высоким уровнем дохода. Недавно достигнутые улучшения доступности данных, особенно благодаря системе НСУКЗ, свидетельствуют о менее четком различии между странами происхождения (на глобальном Юге) и странами назначения (на глобальном Севере), чем считалось ранее. 96. По состоянию на 2018 г. в системы отчетности НСУКЗ, ОЭСР, Евростат и Европейского регионального бюро ВОЗ поступили данные об относительной численности работников сестринских служб, родившихся или прошедших обучение за рубежом, в общей сложности из 86 стран. Эти данные могут служить косвенным показателем масштабов миграционных процессов (таблица 5.6). Согласно полученным сведениям, каждая восьмая медсестра (13%) родилась или получила профессию в стране, отличной от той, в которой она в настоящее время работает. Применение этой пропорции к общемировой численности сестринского персонала дает приблизительно 3,7 миллиона работников сестринских служб, родившихся или прошедших обучение за рубежом. Работники сестринских служб, входящие в эту категорию, находятся в основном в странах с высоким уровнем дохода: их доля в этих странах составляет 15,2%, по сравнению с менее чем 2% в странах, входящих в другие группы по уровню дохода. 5.3.1 Основные результаты По данным из 86 стран, каждая восьмая медсестра (13%) родилась или получила профессию в стране, отличной от той, в которой она в настоящее время работает. В странах с высоким уровнем дохода из числа представивших данные сестринские службы в значительной степени опирались на кадры работников сестринских служб иностранного происхождения: по полученным сведениям, доля работников сестринских служб, родившихся или обучавшихся за рубежом, составила 15,2%. Хотя появляется все больше данных по вопросам миграции и мобильности, их по-прежнему недостаточно для всеобъемлющей оценки всей совокупности сложных характеристик миграционных процессов. 47Текущее состояние фактических данных о кадровых ресурсах сестринских служб ГРУППЫ СТРАН ПО УРОВНЮ ДОХОДА Число стран, представивших сведения / всего % медицинских сестер, родившихся или обучавшихся за рубежом Низкий уровень дохода 3/31 Н/Д Уровень дохода ниже среднего 18/46 0,4% Уровень дохода выше среднего 27/60 0,7% Высокий уровень дохода 38/57 15,2% Всего 86/194 13,2% Примечание: : включены только медицинские сестры профессионального и ассоциированного профессионального уровня. Категория «обучавшиеся за рубежом» использовалась в качестве косвенного показателя для 30 стран, которые не смогли представить данные о проценте лиц, родившихся за рубежом. Источник: НСУКЗ, 2019 г. Последние сведения, представленные странами за период с 2013 по 2018 г. Распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. Н/Д – данные не представлены по причине малого числа стран. Процентная доля работников сестринских служб, родившихся (или прошедших обучение) за рубежом, в разбивке по уровням дохода стран Таблица 5.6 © Ian Miles-Flashpoint Pictures/Alamy 48 Состояние сестринского дела в мире, 2020 г. 5.4 Нормативно-правовое регулирование сестринского образования и практики 5.4.2 Анализ результатов 97. Глобальная стратегия для развития кадровых ресурсов здравоохранения: трудовые ресурсы 2030 г. включает этапный целевой ориентир, в соответствии с которым страны должны к 2020 г. иметь механизмы регулирования и аккредитации в сфере образования работников здравоохранения. В настоящем разделе приводится обобщенный обзор результатов самостоятельной страновой оценки по девяти показателям, которые относятся к нормативно- правовому регулированию образования и профессиональной подготовки сестринского персонала (рисунок 5.8). 98. Подавляющее большинство стран сообщили о наличии стандартов продолжительности и содержания сестринского образования, механизмов аккредитации, а также сводного перечня аккредитованных образовательных учреждений (соответственно 91%, 89% и 81% стран-респондентов). Из числа ответивших стран 77% сообщили о наличии стандартных требований к квалификации преподавателей и 73% – о наличии систем непрерывного профессионального развития. Около двух третей стран-респондентов применяют стандарты межпрофессионального образования, проводят экзамен на готовность к практике, а также имеют национальную ассоциацию студентов программ базового сестринского образования (до получения лицензии) (соответственно 67%, 64% и 62%). Из 95 стран, представивших ответы, 53% сообщили о наличии расширенных сестринских функций. Однако само по себе наличие этих регулирующих процессов или систем не гарантирует их адекватного функционирования. 99. В таблице 5.7 представлены данные о наличии регулирующих механизмов и систем в области образования и профессиональной подготовки в различных регионах ВОЗ. Страны Африканского региона, Региона стран Америки и Европейского региона чаще, чем страны других регионов, сообщали о наличии нормативов в области образования. Страны Региона Восточного Средиземноморья сообщили о более широком доступе к экзаменам на готовность к практике и о наличии расширенных сестринских функций. В Регионе Юго-Восточной Азии меньшее число стран, чем в других регионах, 5.4.1 Основные результаты Почти все страны представили сведения о показателях регулирования сестринского образования, и более 50% стран утвердительно ответили на вопросы по всем девяти соответствующим показателям. По поступившим данным, отмечается высокий уровень регуляторных механизмов и процессов в Африканском регионе, Регионе стран Америки и в Европейском регионе. При этом больше внимания уделяется регулированию содержания образования (например, стандартам продолжительности и тематики обучения или механизмам аккредитации учебных заведений), а не руководству и управлению образовательными процессами. Системы сестринского образования, по-видимому, являются предметом более детального регулирования в Европейском регионе и в меньшей степени – в регионах Юго-Восточной Азии, Восточного Средиземноморья и Западной части Тихого океана, особенно в отношении экзаменов на готовность к практике и стандартных требований к квалификации преподавательского состава. 49Текущее состояние фактических данных о кадровых ресурсах сестринских служб Карта с обозначением суммарных баллов нормативно-правового регулирования в области сестринского образования, по странам Рисунок 5.9 4 и менее 5 6 7 8 9 нет данныхнеприменимо Примечание: *сочетание вопросов по потенциалу в сфере образования, сумма баллов от 0 до 9. Источник: НСУКЗ, 2019 г. РЕГИОН ВОЗ Сводный перечень аккредитованных образовательных учреждений Стандарты продолжительности обучения и содержания учебных программ Механизмы аккредитации учебных заведений Стандарты межпрофессионального образования Непрерывное профессиональное развитие Наличие расширенных сестринских функций Экзамен на готовность к практике Стандартные требования к квалификации преподавательского состава Национальная ассоциация студентов программ базового сестринского образования (до получения лицензии) Африканский регион 91% 100% 90% 81% 68% 74% 68% 78% 66% Регион стран Америки 77% 91% 94% 49% 71% 55% 57% 75% 91% Регион Юго- Восточной Азии 69% 85% 78% 60% 61% 75% 72% 64% 38% Европейский регион 85% 94% 98% 87% 91% 30% 64% 94% 67% Регион Восточного Средиземноморья 80% 80% 70% 20% 50% 50% 70% 80% 30% Регион Западной части Тихого океана 70% 77% 78% 52% 63% 52% 56% 71% 35% Всего в мире 81% 91% 89% 67% 73% 53% 64% 77% 62% Источник: НСУКЗ, 2019 г.; по последним трем показателям – данные настоящего доклада «Состояние сестринского дела в мире, 2020 г.» Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. Процент стран-респондентов, сообщивших о наличии механизмов правового регулирования в сфере образования и профессиональной подготовки сестринских кадров, в разбивке по регионам ВОЗ Таблица 5.7 0 % 20% 40% 60% 80% 100% Стандарты продолжительности обучения и содержания учебных программ (да – 154 из 169) Механизмы аккредитации учебных заведений (да – 147 из 165) Сводный перечень аккредитованных учебных заведений (да – 118 из 146) Стандартные требования к квалификации преподавателей (да – 76 из 99) Непрерывное профессиональное развитие (да – 96 из 132) Стандарты межпрофессионального образования (да – 66 из 99) Экзамен на готовность к практике (да – 73 из 114) Национальная ассоциация студентов программ базового сестринского образования (до получения лицензии) (да – 55 из 89) Наличие расширенных сестринских функций (да – 50 из 95) Число стран, давших утвердительный ответ 91% 53% 62% 64% 6 % 73% 77% 81% 89% Рисунок 5.8 Процент стран-респондентов, сообщивших о наличии нормативов и стандартов в области сестринского дела 50 Состояние сестринского дела в мире, 2020 г. сообщили о наличии систем непрерывного профессионального развития, национальных ассоциаций студентов программ базового сестринского образования или стандартов межпрофессионального образования. Эти региональные различия могут в определенной степени отражать различия в интерпретации данных показателей. 100. Данные по девяти показателям были использованы для расчета для каждой страны сводной балльной оценки «Регулирование образования и практики» (см. приложение 2). При этом каждый показатель оценивали в баллах от 0 (отсутствие) до 1 (наличие); промежуточная ситуация (неполное наличие) оценивалась как 0,5, отсутствие ответа – как 0. Таким образом, максимальная сумма баллов составляла 9. Поскольку в соответствии с методикой анализа пропущенный ответ для показателя дает оценку 0, был проведен анализ чувствительности для определения последствий иной оценки пропущенных значений, и это не изменило интерпретацию результатов. Рисунок 5.9 иллюстрирует вывод о том, что, судя по наличию механизмов регулирования, рассмотренных в настоящем докладе, относительно более сильная регулирующая среда в области образования характерна для Северной Америки, Западной Европы и стран Африки к югу от Сахары. Карта с обозначением суммарных баллов нормативно-правового регулирования в области сестринского образования, по странам Рисунок 5.9 4 и менее 5 6 7 8 9 нет данныхнеприменимо Примечание: *сочетание вопросов по потенциалу в сфере образования, сумма баллов от 0 до 9. Источник: НСУКЗ, 2019 г. 51Текущее состояние фактических данных о кадровых ресурсах сестринских служб 5.5 Предложение на рынке трудовых ресурсов в сфере сестринского дела 5.5.2 Масштабы образования 101. Для удовлетворения текущих и прогнозируемых потребностей систем здравоохранения на национальном и субнациональном уровне требуются вложения значительных средств в образование и профессиональную подготовку кадров. 102. Для оценки адекватности «образовательного конвейера» странам было предложено представить сведения о числе выпускников программ сестринского образования за последний год, по которому имелись данные. Всего по этому показателю отчитались 88 стран, из которых почти половина (41) – в Европе. В связи с этим следует с предельной осторожностью интерпретировать значения «Итого» в таблице 5.8, поскольку они смещены под влиянием данных из Юго-Восточной Азии и Европы и неточно отражают ситуацию в других регионах. 103. Как и в отношении показателя обеспеченности сестринскими кадрами, уровень дохода стран служил фактором, коррелирующим с более значительным числом выпускников на 100 000 населения. 104. Моделирование, основанное на имеющихся данных применительно к мировому населению и суммарному значению численности выпускников – 22,6 на 100 000 населения, позволяет получить оценочную величину – 1,72 миллиона выпускников программ сестринского образования в год. Этот анализ следует рассматривать исключительно как иллюстрацию, поскольку он базируется на небольшом числе стран в каждом регионе, за исключением Европейского. Тем не менее эти данные, хотя и ограниченные по охвату, не выявили значительных различий в численности выпускников относительно общей численности сестринских кадров. Результаты сравнения с общей численностью кадров были дополнительно сопоставлены с численностью возрастной группы моложе 35 лет, то есть примерно с численностью персонала, начавшего трудовую деятельность в течение предшествующих 10 лет. При использовании одной десятой части этой младшей категории в качестве косвенного показателя численности ежегодного кадрового прироста соответствующее значение составит 1,06 миллиона, что можно сравнить с вышеприведенной оценкой в 1,7 миллиона выпускников. Поскольку не все работники 5.5.1 Основные результаты В общей сложности 88 стран, главным образом из Юго-Восточной Азии и Европы, представили данные о ежегодной численности выпускников программ сестринского образования. Регионы с самыми низкими значениями обеспеченности населения сестринскими кадрами (Африканский регион, регионы Восточного Средиземноморья и Юго-Восточной Азии) также характеризовались самой низкой численностью выпускников (соответственно 7,7, 7,1 и 12,2 на 100 000 населения). В Регионе стран Америки численность выпускников по отношению к общему населению в 10 раз превышала значения этого показателя в регионах Африки и Восточного Средиземноморья. Среди стран, представивших данные, средняя продолжительность профессионального образования в области сестринского дела примерно в 75% стран Африканского региона и Региона Западной части Тихого океана составляла от двух до трех лет; более чем в половине стран регионов стран Америки, Юго-Восточной Азии и Восточного Средиземноморья – от четырех до пяти лет. 52 Состояние сестринского дела в мире, 2020 г. Число стран, представивших сведения / всего Средняя численность выпускников программ сестринского образования на 100 активных работников сестринских служб Численность выпускников на 100 000 населенияПО РЕГИОНАМ ВОЗ Всего Низкая Высокая Африканский регион 14/47 8,8 2,8 23,7 7,7 Регион стран Америки 14/35 9,8 0,8 30,8 81,2 Регион Юго-Восточной Азии 8/11 7,5 3,9 13,8 12,2 Европейский регион 41/53 4,0 1,0 31,9 31,9 Регион Восточного Средиземноморья 5/21 4,6 0,6 16,5 7,1 Регион Западной части Тихого океана 6/27 5,7 3,4 12,0 20,6 ПО УРОВНЯМ ДОХОДА СТРАН Низкий уровень дохода 8/31 13,8 4,1 31,9 10,4 Уровень дохода ниже среднего 15/46 7,7 2,8 13,8 12,8 Уровень дохода выше среднего 26/60 6,4 0,6 30,8 22,7 Высокий уровень дохода 40/57 3,6 1,5 7,6 38,7 Итого 88/194 6,2 0,6 31,9 22,6 Источник: НСУКЗ, 2019 г. Распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. Масштабы подготовки выпускников программ сестринского образования, в разбивке по регионам ВОЗ и группам стран по уровню дохода Таблица 5.8 © WHO/Yoshi Shimizu 53Текущее состояние фактических данных о кадровых ресурсах сестринских служб Средняя продолжительность (число лет) обучения сестринских кадров, в разбивке по регионам ВОЗ Рисунок 5.10 2 года 3 года 4 года 5 года 0% 20% 40% 60% 80% 100% Африканский регион Регион стран Америки Регион Юго-Восточной Азии Европейский регион Регион Восточного Средиземноморья Регион Западной части Тихого океана РЕГИОН ВОЗ Всего в мире Источник: для 99 стран – НСУКЗ, 2019 г.; для 58 стран – база данных некоммерческой организации «Сигма». Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. трудоустроены, порядок величин выглядит достаточно реалистично. 5.5.3 Продолжительность базового образования 105. Данные о продолжительности программ базового образования по сестринскому делу были получены из различных источников в отношении 157 стран. В нескольких странах, главным образом в Африканском регионе и в регионах Восточного Средиземноморья и Западной части Тихого океана, действуют двухгодичные программы, в большинстве стран во всех регионах – трех- или четырехлетние программы. Пятилетние программы являются редкостью во всех регионах (рис. 5.10). В Африканском регионе и в Регионе Западной части Тихого океана около трех четвертей стран имеют трехлетние программы, в Регионе Юго-Восточной Азии почти три четверти стран практикуют программы, рассчитанные на четыре года. 106. В эпоху расширения сферы сестринской практики важно уделять внимание послебазовому образованию работников сестринских служб, а также различным возможностям прямого входа в профессию (при соблюдении установленных требований). Внутренние ограничения влияют на предоставление данных о продолжительности программ базового образования, в результате чего эти данные не полностью отражают широкое разнообразие путей учебной подготовки сестринского персонала в глобальном масштабе, особенно относительно функций расширенной практики. 54 Состояние сестринского дела в мире, 2020 г. 5.6 Регулирование занятости и условий труда 5.6.2 Анализ результатов 107. Условия найма и труда – это основные факторы, влияющие на привлекательность рабочих мест, на показатели профессиональной деятельности и производительности труда, а также на кадровую стабильность. В Глобальной стратегии для развития кадровых ресурсов здравоохранения: трудовые ресурсы 2030 г. содержится призыв поддерживать «личные, связанные с занятостью и профессиональные права всех работников здравоохранения, включая безопасные и достойные условия работы и свободу от всех видов дискриминации, принуждения и насилия». Для оценки ситуации в этом отношении были рассмотрены шесть показателей, связанных с регулированием условий найма и труда (рис. 5.11). Следует отметить, что непосредственно к работе сестринского персонала относятся только три показателя (регулирование рабочего времени и условий труда, наличие сестринского совета, наличие расширенных сестринских функций); остальные применимы к медицинскому персоналу в целом, включая сестринских работников. 108. Из числа стран-респондентов более 80% сообщили, что в них осуществляется регулирование рабочего времени и условий труда, обеспечивается социальная защита и минимальная заработная плата, а также имеется сестринский совет или его эквивалент. О расширенных сестринских функциях сообщили лишь 53% стран. В общей сложности 55 стран представили сведения в отношении мер профилактики нападений на работников здравоохранения, из которых чуть более трети (37%) сообщили, что такие меры принимаются. 109. Данные, приведенные в таблице 5.9, свидетельствуют о том, что страны Региона Восточного Средиземноморья сообщили о более высоких уровнях регулирования условий найма сестринского персонала, проанализированных для целей настоящего доклада: более 70% стран дали положительные ответы в отношении всех шести показателей. 5.6.1 Основные результаты Страны Африки, Америки, Европы и Восточного Средиземноморья сообщили о высоком уровне развития в них механизмов регулирования условий труда сестринского персонала. Некоторые страны, главным образом в регионах Юго-Восточной Азии и Западной части Тихого океана, но также в Африканском регионе и в Южной Америке, сообщили о более низких масштабах функционирования таких механизмов. Немногим более одной трети стран (37%), преимущественно в регионах Юго-Восточной Азии и Восточного Средиземноморья, сообщили о наличии у них мер по предупреждению нападений на работников здравоохранения. Наличие расширенных сестринских функций (о чем сообщили 53% из 95 стран-респондентов) чаще отмечается в странах с низким показателем обеспеченности населения врачебными кадрами; это позволяет предположить, что повышение профессиональной самостоятельности работников сестринских служб может являться мерой, направленной на смягчение негативных последствий нехватки врачей. 55Текущее состояние фактических данных о кадровых ресурсах сестринских служб РЕГИОН ВОЗ Регламентация рабочего времени и условий труда Положение о минимальной заработной плате Положение по вопросам социальной защиты Меры предотвращения нападений на медицинских работников Наличие расширенных сестринских функций Совет по сестринскому делу Африканский регион 90% 90% 85% 41% 74% 78% Регион стран Америки 97% 85% 94% 37% 55% 91% Регион Юго-Восточной Азии 75% 50% 50% 67% 50% 80% Европейский регион 98% 92% 100% 26% 30% 96% Регион Восточного Средиземноморья 85% 100% 92% 73% 75% 85% Регион Западной части Тихого океана 100% 86% 57% 30% 52% 78% Всего в мире 94% 89% 91% 37% 53% 86% Источник: НСУКЗ, 2019 г.; по последнему показателю – данные настоящего доклада «Состояние сестринского дела в мире, 2020 г.» Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. Процент стран, сообщивших о наличии у них механизмов нормативно- правового регулирования условий труда, в разбивке по регионам ВОЗ Таблица 5.9 Положения, регламентирующие продолжительность рабочего дня и условия труда (да – 133 из 42) Положения о мерах социальной защиты (да – 125 из 37) Положения о минимальной заработной плате (да – 119 из 134) Совет по сестринскому делу (да – 141 из 164) Наличие сестринского персонала с расширенным кругом функций (да – 50 из 95) Меры по предупреждению нападений на медработников (да – 20 из 55) Доля стран, давших утвердительный ответ 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% Источник: НСУКЗ, 2019 г. Рисунок 5.11 Процент стран, имеющих нормативные положения об условиях труда 56 Состояние сестринского дела в мире, 2020 г. Регионы Юго-Восточной Азии и Восточного Средиземноморья были единственными регионами, в которых большинство стран сообщили о принятии мер по предотвращению нападений на медицинских работников, что, вероятно, отражает относительно высокую распространенность таких нападений в этих регионах10. Африканский регион, Регион стран Америки и Европейский регион также дали утвердительные ответы в отношении большинства отслеживаемых показателей; однако лишь 30% европейских стран, представивших данные, сообщили о наличии расширенных сестринских функций и 26% – о принятии мер по предотвращению нападений на медицинских работников. 110. Значительная часть стран Региона Западной части Тихого океана сообщили о наличии регламентов рабочего времени и условий труда, норм минимальной заработной платы и сестринского совета или его эквивалента. 10 Система ВОЗ по мониторингу случаев нападений на работников здравоохранения: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard. aspx. Вместе с тем для них характерны более низкие уровни трех других механизмов регулирования. Страны Региона Юго-Восточной Азии дали наименьшее количество утвердительных ответов по показателям, характеризующим нормативную среду, хотя половина стран Региона утвердительно ответили по всем шести показателям. Как отмечалось в разделе 5.4, эти межрегиональные различия могут в определенной степени отражать различные представления о значении этих показателей, а также различия в полноте отчетности между регионами. Собранные данные не содержат информации об адекватности нормативных актов или об уровне фактического соблюдения соответствующих положений. 111. Данные по шести показателям были использованы для расчета для каждой страны сводной балльной оценки «Регулирование условий труда». При этом был применен тот же принцип, что и в разделе 5.4, по методике, Карта с обозначением суммарных баллов нормативно-правового регулирования условий труда Рисунок 5.12 1 или 0 2 3 4 5 6 нет данныхнеприменимо Примечание: сочетание вопросов по потенциалу в отношении условий труда, сумма баллов от 0 до 6. Источник: НСУКЗ, 2019 г. 57Текущее состояние фактических данных о кадровых ресурсах сестринских служб изложенной в приложении 2. Рисунок 5.12 иллюстрирует вывод о том, что так же, как и в отношении системы образования, проанализированной в разделе 5.4, нормативная среда выглядит относительно более развитой в Северной Америке, странах Африки к югу от Сахары и в Европейском регионе. 112. Как показано на рисунке 5.13, в странах с более низкими уровнями обеспеченности населения врачебными кадрами работники сестринских служб чаще наделяются расширенными профессиональными полномочиями. Рисунок 5.13 Процент стран с наличием сестринских кадров с расширенными функциями, в разбивке по численности врачей на 10 000 населения Показатель обеспеченности врачебными кадрами на 10 000 населения П ро це нт с тр ан с н ал ич ие м р ас ш ир ен ны х се ст ри нс ки х ф ун кц ий 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% Источник: НСУКЗ, 2019 г. © AKDN/Christopher Wilton-Steer 58 Состояние сестринского дела в мире, 2020 г. 5.7 Стратегическое руководство и лидерство 5.7.2 Анализ результатов 113. Будущее развитие сестринской профессии требует, чтобы работники сестринских служб занимали лидерские позиции и активно участвовали в процессах стратегического руководства в своей области (264,265). Для оценки глобального состояния сестринского лидерства и руководства в настоящем докладе «Состояние сестринского дела в мире, 2020 г.» использованы два показателя: наличие должности ГССД в национальном правительстве и наличие поддерживаемых на национальном уровне программ развития навыков лидерства, научных исследований или грамотности в вопросах формирования политики (ответили соответственно 115 и 76 стран). 114. Из 115 стран, представивших ответы, 71% сообщили о том, что в них имеется должность ГССД. Разброс составил от 54% в Регионе Восточного Средиземноморья до 86% в Европейском регионе (таблица 5.10). Меньшее число стран (53% из 76) сообщили о наличии программы развития сестринского лидерства: от 40% в Регионе Юго-Восточной Азии до 64% в Африканском регионе. 115. Существует прочная взаимозависимость между развитой нормативно-правовой средой и уровнем сестринского лидерства и стратегического руководства. На рисунке 5.14 показано, что страны с наличием ГССД и программой сестринского лидерства достигли, в среднем, более высоких показателей по регулированию условий труда работников сестринских служб и процессов сестринского образования. 116. При этом данная корреляция выражена несколько сильнее в отношении программ лидерства, чем в отношении наличия должности ГССД. Установлено также, что наличие сестринской должности высокого уровня в национальном правительстве не обязательно приводит к таким действиям, как внедрение программ лидерства: эти программы отсутствовали в 37% стран с наличием должности ГССД. 117. Чтобы проверить гипотезу о том, что сестринское лидерство и стратегическое руководство также приводят к росту инвестиций, о чем свидетельствует увеличение масштабов подготовки работников сестринских служб и последующего набора персонала для 5.7.1 Основные результаты Из 115 стран, представивших данные, 71% сообщили о наличии на государственном уровне должности главного специалиста по сестринскому или акушерскому делу, соответственно из 76 стран 53% сообщили о наличии программы развития сестринского лидерства. Одновременное наличие должности главного специалиста по сестринскому делу (ГССД) и программы развития сестринского лидерства коррелирует с более благоприятными условиями для регулирования сестринского дела. Однако ни наличие должности ГССД, ни существование программ развития лидерства не коррелирует с повышенными масштабами подготовки сестринских кадров. 59Текущее состояние фактических данных о кадровых ресурсах сестринских служб Главный специалист по сестринскому делу Программа развития лидерства РЕГИОН ВОЗ Число стран, представивших сведения / всего % да Число стран, представивших сведения / всего % да Африканский регион 26/47 60% 28/47 64% Регион стран Америки 26/35 79% 16/35 46% Регион Юго-Восточной Азии 6/11 60% 4/11 40% Европейский регион 30/53 86% 10/53 56% Регион Восточного Средиземноморья 7/21 54% 8/21 62% Регион Западной части Тихого океана 20/27 74% 10/27 43% Всего в мире 115/194 71% 76/194 53% Источник: данные настоящего доклада «Состояние сестринского дела в мире, 2020 г.» по конкретным показателям, 2019 г. Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. Показатели лидерства и стратегического руководства: процент стран с наличием должности главного специалиста по сестринскому делу и программы развития сестринского лидерства, в разбивке по регионам ВОЗ Таблица 5.10 0 2 4 6 ГССД нет ГССД 0 2 4 6 8 10 Программы развития лидерства нет Программа развития лидерства 0 2 4 6 8 10 ГССД нет ГССД 0 2 4 6 8 10 Программы развития лидерства нет Программа развития лидерства ГССД Су мм а ба лл ов п о ус ло ви ям тр уд а се ст ри нс ко го п ер со на ла Программа развития лидерства Су мм а ба лл ов п о ре гу ли ро ва ни ю у че бн ой по дг от ов ки с ес тр ин ск ог о пе рс он ал а Су мм а ба лл ов п о ус ло ви ям тр уд а се ст ри нс ко го п ер со на ла Су мм а ба лл ов п о ре гу ли ро ва ни ю у че бн ой по дг от ов ки с ес тр ин ск ог о пе рс он ал а Условия труда Регулирование учебной подготовки P=0,008 (тест Крускала–Уоллиса) P<0,001 (тест Крускала–Уоллиса) P=0,007 (тест Крускала–Уоллиса) P<0,001 (тест Крускала–Уоллиса) ГССД Программа развития лидерства Источник: данные настоящего доклада «Состояние сестринского дела в мире, 2020 г.» по конкретным показателям, 2019 г. Рисунок 5.14 Связи между ГССД, программой сестринского лидерства и нормативной средой решения проблемы нехватки кадров, было проведено сравнение стран с наличием и с отсутствием мер, направленных на развитие лидерства и стратегического руководства, по показателям подготовки сестринских кадров. Статистически значимых различий выявлено не было; это говорит о том, что сильное сестринское лидерство и стратегическое руководство не обязательно приводят к росту масштабов подготовки сестринских кадров. 60 Состояние сестринского дела в мире, 2020 г. 5.8 Оценка современных перспектив для достижения ЦУР к 2030 г. 118. Для достижения ЦУР, связанных со здоровьем, государствам-членам ВОЗ будет необходимо обучить достаточное число работников сестринских служб, для того чтобы: (а) компенсировать убыль профессиональных кадров (например, в связи со смертью, миграцией или выходом на пенсию); (b) удовлетворить возросшие потребности во многих регионах мира в связи с ростом численности и старением населения, а также с изменением потребностей в медицинской помощи; (с) восполнить существующий глобальный дефицит. 5.8.2 Прогноз численности сестринских кадров и обеспеченности населения сестринским персоналом к 2030 г. 119. Для каждой страны была разработана базовая модель «общей численности и динамики», учитывающая текущую численность работающих сестринских кадров, расчетный уровень выхода на пенсию (основанный на возрастном распределении кадровых ресурсов), рост населения и прогнозируемые параметры притока на рынок труда (см. описание сценариев в приложении 2). При сохранении нынешних тенденций численность сестринского персонала, по прогнозам, увеличится с 27,9 миллиона в 2018 г. до 35,9 миллиона в 2030 г. 120. Увеличение численности сестринского персонала к 2030 г. будет сосредоточено в странах с высоким уровнем дохода и будет весьма ограниченным в странах с низким уровнем дохода (рисунок 5.15). Диспропорции, зафиксированные в 2018 г. (см. раздел 5.2), по прогнозам, сохранятся в значительной степени неизменными до 2030 г. 5.8.1 Основные результаты Сравнение данных за 2018 г. с целевыми показателями, установленными в Глобальной стратегии для развития кадровых ресурсов здравоохранения, показывает дефицит в размере 5,9 миллиона работников сестринских служб; этот пробел в основном (89%) сосредоточен в странах с низким уровнем дохода и с доходом ниже среднего. Если все страны сохранят свой нынешний уровень подготовки дипломированных работников сестринских служб, их общая численность, по прогнозам, увеличится с почти 28 миллионов в 2018 г. до приблизительно 36 миллионов в 2030 г.; однако 70% этого прогнозируемого увеличения, как ожидается, произойдет в странах c высоким уровнем дохода и с доходом выше среднего, а не там, где кадровый дефицит выражен в наибольшей степени. С учетом прогнозируемого роста численности населения и старения сестринских кадров, обеспеченность населения сестринским персоналом в регионах Африки, Юго-Восточной Азии и Восточного Средиземноморья сохранится в 2030 г. на уровне ниже 25 на 10 000 населения. При этом в Африканском регионе этот показатель, по прогнозам, лишь незначительно вырастет. Восполнение нехватки сестринского персонала в странах с низкими показателями обеспеченности потребует среднего увеличения ежегодного числа выпускников на 8,8% в период с 2018 по 2030 г. (диапазон: 0,2–13,4%) и повышения абсорбционной способности системы здравоохранения по меньшей мере до 70%. Расширение масштабов подготовки сестринского персонала для устранения пробелов в затронутых странах с низким уровнем дохода и с доходом ниже среднего может обойтись приблизительно в 10 долл. США на душу населения в период с 2018 по 2030 г. 61Текущее состояние фактических данных о кадровых ресурсах сестринских служб Прогнозируемая численность сестринского персонала из расчета на 10 000 населения в 2030 г. (глобальное распределение) Рисунок 5.15 0 1,100 2,200 3,300 4,400550 km нет данныхнеприменимо < 10 10–19 20–29 30–39 40–49 50–74 75–99 100 и более Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. 121. Прогнозируемый рост численности кадров недостаточен для полного удовлетворения потребностей, особенно в Африканском регионе, где ожидается рост населения на 34%. Также в Регионе Восточного Средиземноморья прогнозируется лишь незначительное увеличение численности сестринского персонала (таблица 5.11). 122. Прогнозирование проводилось с использованием различных допущений и сценариев с учетом наличия и качества данных для факторов, используемых в анализе. Потенциальные ограничения рассмотрены в приложении 2. 123. В регионах стран Америки, Юго-Восточной Азии и Западной части Тихого океана численность сестринских кадров, по прогнозам, значительно вырастет. Что касается прогнозируемого распределения в зависимости от уровня дохода стран, то 88% роста численности кадров придется на страны со средним уровнем дохода (рисунок 5.16). 5.8.3 Дефицит сестринских кадров 124. По оценкам, приведенным в принятой ВОЗ в 2016 г. Глобальной стратегии для развития кадровых ресурсов здравоохранения, к 2030 г. в странах с показателем обеспеченности населения кадрами врачей, медсестер и акушерок ниже порогового значения 4,45 на 1000 населения будет иметь место суммарный дефицит сестринских и акушерских кадров на уровне 7,6 миллиона работников; вышеуказанный порог исключает большинство стран с высоким уровнем дохода. При использовании той же методики расчетов и пороговых значений, но применительно к более поздним данным, уровень дефицита сестринских кадров по ситуации на 2018 г. оценивается в 5,9 миллиона человек, а к 2030 г. – 5,7 миллиона. Наибольший дефицит (в абсолютных цифрах) по состоянию на 2018 г. отмечен в таких странах, как Бангладеш, Индия, Индонезия, Нигерия и Пакистан. Дефицит кадровых ресурсов тесно коррелирует с уровнем дохода стран (приложение 2, таблица A2.2): 89% от общего объема дефицита по 62 Состояние сестринского дела в мире, 2020 г. Прогнозируемая численность сестринского персонала из расчета на 10 000 населения в 2030 г. (глобальное распределение) Рисунок 5.15 0 1,100 2,200 3,300 4,400550 km нет данныхнеприменимо < 10 10–19 20–29 30–39 40–49 50–74 75–99 100 и более Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. ENGLISH Уровень дохода ниже среднего 27% Уровень дохода выше среднего 61% Высокий уровень дохода 6% Низкий уровень дохода 6% Регион стран Америки 43% Европейский Регион 7% Африканский Регион 6% Регион Восточного Средиземноморья 4% Регион Западной части Тихого океана 22% Регион стран Юго-Восточной Азии 18% Примечание: распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. Рисунок 5.16 Прогнозируемое увеличение (в период до 2030 г.) численности сестринского персонала в разбивке по регионам ВОЗ и категориям стран по уровню дохода УРОВЕНЬ ДОХОДАРЕГИОН Численность по состоянию на 2018 г. (млн чел.) Прогнозируемая численность на 2030 г. (млн чел.) РЕГИОН ВОЗ СЦЕНАРИЙ 1: старение кадров и стабильная доля молодой возрастной группы СЦЕНАРИЙ 2: старение кадров и сохранение масштабов подготовки новых работников на уровне последних лет СЦЕНАРИЙ 3: старение кадров и рост масштабов подготовки новых работников на 50% к 2030 г. Африканский регион 0,9 1,2 1,5 2,0 Регион стран Америки 8,4 9,2 12,4 17,7 Регион Юго-Восточной Азии 3,3 4,7 5,0 6,1 Европейский регион 7,3 8,6 8,0 10,4 Регион Восточного Средиземноморья 1,1 1,9 1,5 1,7 Регион Западной части Тихого океана 6,9 10,3 9,0 11,2 Всего в мире 27,9 35,9 37,4 49,3 Моделирование прогнозируемой численности сестринского персонала в период с 2018 по 2030 г. по трем сценариям, в разбивке по регионам ВОЗ Таблица 5.11 63Текущее состояние фактических данных о кадровых ресурсах сестринских служб Примечание: уровень дефицита определяется путем сравнения численности сестринского персонала в каждой стране в каждом году с пороговым значением показателя обеспеченности населения сестринским персоналом. Источник: Глобальная стратегия для развития кадровых ресурсов здравоохранения, 2016 г. и настоящий «Доклад о состоянии сестринского дела в мире, 2020 г.» (данные для глобального уровня). Оценка степени дефицита сестринского персонала к 2030 г., по данным настоящего доклада «Состояние сестринского дела в мире, 2020 г.», при сохранении нынешних тенденций в основном соответствует значениям, приведенным в Глобальной стратегии (соответственно 5,7 миллиона и 5,6 миллиона человек). Рисунок 5.17 Оценка дефицита сестринского персонала по состоянию на 2013 и 2018 гг. и по прогнозу на 2030 г. Глобальная стратегия для развития кадровых ресурсов здравоохранения, 2016 г. Состояние сестринского дела в мире, 2020 г. Примененные поправочные факторы: 1 Исключение доли акушерских кадров из численности сестринского и акушерского персонала (как дано в Глобальной стратегии) с использованием более недавних значений (90% работников сестринских служб в общем контингенте медсестер и акушерок). 2 Поправка для учета улучшения данных, при которой повышается значение численности и снижается уровень дефицита: 4,4 млн работников сестринских служб из 27,8 млн в 2018 г., что представляет собой улучшенные данные в сравнении с Глобальной стратегией. 9,0 млн работников сестринских и акушерских служб 8,2 млн работников сестринских служб 7,6 млн работников сестринских и акушерских служб 6,9 млн работников сестринских служб Последовательная оценка дефицита к 2030 г. 1 С поправкой для учета только сестринского персонала 2 С поправкой на улучшение данных 5,7 млн работников сестринских служб 5,9 млн работников сестринских служб 6,6 млн работников сестринских служб 2013 г. 2018 г. 2030 г. 5,6 млн работников сестринских служб состоянию на 2018 г. сосредоточены в странах с низким уровнем дохода и с доходом ниже среднего. 125. Эту оценку можно сопоставить с данными Глобальной стратегии на 2016 г., скорректировав ее таким образом, чтобы показать только дефицит работников сестринских служб (то есть исключив компонент акушерок), а также учесть улучшение данных (рисунок 5.17). 126. Дефицит был оценен с учетом порогового значения, использованного в Глобальной стратегии. Таким образом, из этой оценки исключаются все страны, где пороговый показатель превышен. Однако это не означает, что страны, находящиеся выше порогового уровня, не испытывают нехватки сестринского персонала. В большинстве из них на практике имеется значительный дефицит, определяемый в соответствии с установленными на национальном уровне целями предоставления услуг и структурой системы здравоохранения. Для этих стран следует проводить индивидуальную оценку. При этом необходимо применять методики, учитывающие старение населения и кадров, изменение эпидемиологической ситуации, осуществление стратегий удержания кадров и другие факторы, влияющие на динамику рынка труда. Так, по результатам анализа ситуации, основанного на учете потребностей населения на национальном уровне и требований системы здравоохранения, в 31 стране ОЭСР с высоким уровнем дохода к 2030 г. прогнозируется нехватка сестринского персонала вплоть до 3,2 миллиона работников (266). Аналогичные оценки будущего дефицита сестринских кадров были получены, в частности, в Японии (270 000 работников сестринских служб к 2025 г.) (267), в Германии (примерно 500 000 медицинских работников к 2030 г., особенно в отношении 64 Состояние сестринского дела в мире, 2020 г. персонала, осуществляющего уход за пожилыми людьми, и работников сестринских служб) (268) и в Соединенном Королевстве (нехватка более 108 000 работников сестринских служб к 2030 г.) (269). 5.8.4 Подготовка кадров и затраты, необходимые для восполнения недостающей численности сестринского персонала к 2030 г. 127. Необходимое увеличение числа выпускников и рабочих мест для полного решения проблемы нехватки кадров к 2030 г. было рассчитано с использованием различных гипотез. • При сохранении текущих тенденций потребуется, в среднем, увеличить ежегодное число выпускников примерно на 10% (разброс значений от 1,5% до 14,9%). • Если степень обеспечения трудоустройства выпускников программ сестринского образования (абсорбционная способность рынка труда) повысится до 70%, то для восполнения дефицита потребуется средний ежегодный прирост относительной численности выпускников на уровне 8,8% (разброс значений от 0,2% до 13,4%). • В сценарии с дальнейшим повышением абсорбционной способности рынка 11 Эти цифры соответствуют единовременному вложению средств, покрывающих учебную подготовку всех выпускников в странах с наличием дефицита. труда (до 80% выпускников) для решения проблемы дефицита к 2030 г. потребуется среднее увеличение относительной численности выпускников на 8,1% в год (разброс значений от 0,03% до 12,2%). 128. Для расчета объема вкладываемых средств, необходимых для восполнения дефицита к 2030 г., дополнительное число сестринских кадров (прогнозируемое по сценарию трудоустройства 80% выпускников), подготавливаемых в период с 2018 по 2030 г., было умножено для каждой страны на среднюю стоимость обучения одного работника сестринских служб (270). На основе опубликованной и «серой» литературы о расходах на образование в странах с низким уровнем дохода и с доходом ниже среднего были использованы три различных варианта средней стоимости обучения одной медсестры: 5000, 10 000 и 20 000 долл. США (271). Необходимые инвестиции в подготовку дополнительных медицинских сестер для ликвидации дефицита в среднем составили соответственно 5,2, 10,5 и 21 долл. США на душу населения11. Учитывая чувствительность анализа к сделанным допущениям и скудость фактических данных, для разработки наглядной модели, вероятно, будет разумным принять средний вариант – примерно 10 долл. США на душу населения. 65Текущее состояние фактических данных о кадровых ресурсах сестринских служб © WHO/Yoshi Shimizu 66 Состояние сестринского дела в мире, 2020 г. 129. Представленные в настоящем докладе фактические данные, полученные как из имеющихся источников, так и на основе изучения опубликованной литературы (главы 2, 3 и 4), а также анализ текущего состояния сестринских кадров (глава 5) убедительно доказывают необходимость радикального изменения механизмов подготовки, трудоустройства, управления и поддержки сестринского персонала в рамках более широкой политики в области кадров и систем здравоохранения. 130. Для решения этой задачи потребуются значительные средства, однако еще более значительной станет отдача, которую дадут эти инвестиции для общества и экономики стран в плане улучшения здоровья сотен миллионов людей, создания миллионов квалифицированных рабочих мест, особенно для женщин и молодежи, и повышения уровня глобальной безопасности в сфере общественного здоровья. 131. Использование этого потенциала требует согласованных усилий, охватывающих различные секторы на местном, национальном и глобальном уровне. В этой главе обсуждаются основные выводы из глобального дискурса и конкретных данных, собранных для настоящего доклада; на этой основе предлагаются меры, необходимые для стимулирования устойчивых инвестиций, наращивания институционального потенциала и активизации действий в сфере политики в поддержку адекватно обученных и готовых к практике сестринских кадров. 132. Формулируемые варианты политики адресованы как государствам-членам, так и, в соответствующих случаях, другим заинтересованным сторонам. Их применимость и актуальность должны рассматриваться странами на индивидуальной основе, в зависимости от целей их систем здравоохранения, существующих условий и потенциала для практической реализации. Дальнейшие направления развития кадровой политики в области сестринского дела 6ГЛАВА 67Дальнейшие направления развития кадровой политики в области сестринского дела 6.1 Укрепление базы фактических данных для планирования, мониторинга и подотчетности Синтез результатов 133. Настоящий доклад «Состояние сестринского дела в мире, 2020 г.» содержит наиболее полные фактические данные, непосредственно относящиеся к состоянию сестринского дела в мире. Хотя 80% стран представили сведения не менее чем по 15 показателям, обнаруженные пробелы в данных отражают неодинаковый потенциал информационных систем по кадрам здравоохранения стран, что открывает широкие возможности для целенаправленного улучшения ситуации. 134. Наибольший объем данных был получен по таким показателям, как численность и возрастной состав работающих медицинских сестер (соответственно 191 и 132 страны). Гораздо хуже были освещены показатели, касающиеся образования, финансирования, а также притока и оттока кадров, и это затруднило проведение всеобъемлющего анализа рынка труда в области здравоохранения. Например, наличие сведений только о численности персонала без количественных данных о потенциале систем образования, о численности вакансий, об уровне безработицы и естественной убыли кадров не дает возможности руководителям, определяющим политику, принимать взвешенные решения относительно необходимости наращивания подготовки кадров. Должностные лица, формирующие политику и планы, должны знать, соответствуют ли масштабы учебной подготовки возможностям рынка труда для обеспечения занятости выпускников или имеет место дисбаланс (дефицит кадров или, напротив, безработица) (см. вставку 6.1 о рынке труда в сфере здравоохранения в Шотландии). 135. Факторы, влияющие на наличие данных и способность стран отчитываться по установленным показателям, включают уровень координации между министерствами здравоохранения, труда, образования и финансов, а также взаимодействие с другими заинтересованными сторонами, такими как Вставка 6.1 Анализ рынка труда в области здравоохранения в Шотландии В декабре 2019 г. шотландское правительство опубликовало комплексный план развития кадровых ресурсов здравоохранения и социального обеспечения для Шотландии (272). Одним из положений плана является стимулирование помощи на дому как альтернатива госпитализации. Однако для его осуществления необходимо увеличить число районных медицинских сестер. Правительство Шотландии использовало данные Отдела информационных услуг Шотландского филиала Национальной службы здравоохранения для моделирования различных сценариев определения масштабов дополнительной подготовки сестринских кадров. Правительство также рассмотрело уровни кадровой обеспеченности и дефицит кадров по другим медицинским профессиям, последствия нехватки, потребности в оказании помощи и возможные пути решения существующих проблем. Собранные данные и результаты их анализа были переданы в Референтную группу по приему студентов в программы обучения сестринского и акушерского персонала, а также другим заинтересованным сторонам. Состоявшийся диалог привел к принятию решений об использовании проактивного подхода и увеличении объема средств, вкладываемых в образование и профессиональную подготовку районных медсестер, а также о создании механизмов, которые позволят уже работающим медсестрам повышать свою квалификацию в данной области. Эта программа стала первой попыткой правительства комплексно решать кадровые вопросы здравоохранения и социального обеспечения на национальном уровне и перейти от планирования в рамках одной профессии к планированию многопрофильной бригадной помощи. 68 Состояние сестринского дела в мире, 2020 г. профессиональные ассоциации, советы и учебные заведения. Варианты политики 136. Странам следует ускорить внедрение своих национальных систем учета кадровых ресурсов здравоохранения (НСУКЗ), включая дезагрегированную отчетность по сестринским кадрам. В наиболее неотложном порядке следует устранить пробелы в основных элементах данных для проведения национального анализа рынка труда в области здравоохранения. Эта задача должна быть решена путем всеобъемлющих усилий по укреплению и наращиванию потенциала информационной системы по кадровым ресурсам здравоохранения (273). Описание глобального состояния трудовых ресурсов в области сестринского дела стало возможным благодаря общемировым усилиям по внедрению НСУКЗ и приверженности принципу диверсификации источников данных. Наращивание институционального потенциала информационных систем по кадровым ресурсам здравоохранения может включать такие меры, как систематическое проведение форумов заинтересованных сторон, в том числе руководителей сестринского дела, создание четких механизмов сбора и обмена данными, анализ доступности и качества данных и связанных с ними проблем, а также внедрение взаимно совместимых систем данных. Координация между различными секторами и заинтересованными сторонами может также открывать возможности для формализации политического мандата на сбор данных и обмен ими, а также для межсекторального диалога в целях преобразования данных в значимые изменения политики. Странам следует использовать надежные данные по сестринскому делу и кадрам здравоохранения для включения в анализ рынка труда в области здравоохранения в качестве ориентира для принятия решений в сфере политики и инвестиций на национальном уровне (см. вставку 6.2 о группах сестринского лидерства, использующих показатели НСУКЗ при проведении анализа рынка труда применительно к сестринским кадрам). 6.2 Мобильность и миграция Синтез результатов 137. Примерно 3,7 миллиона медсестер (или каждая восьмая) работают в стране, отличной от той, в которой они родились или получили профессию. Эти данные свидетельствуют о высокой международной мобильности сестринского персонала, обусловленной сильной зависимостью стран с недостаточными масштабами подготовки собственных кадров от притока медсестер- мигрантов. Повышенный спрос в странах с высоким уровнем дохода (где более 15% работников сестринских служб, как сообщается, родились или прошли обучение за рубежом) может привлекать наиболее квалифицированных работников сестринских служб из стран с низким уровнем дохода, что приводит к углублению разрыва по показателям качества и распределения, которое наносит ущерб здоровью населения (см. вставку 6.3 о подходе Германии к управлению миграционным процессом). 138. Крайне высокий уровень эмиграции (когда он не является результатом целенаправленной политики по экспорту сестринских кадров) может расцениваться как признак непривлекательных условий труда на родине. Поэтому рациональная политика должна быть направлена на глубинные причины (в плане улучшения условий труда, систем профессиональной поддержки и вознаграждения), а не на попытки изолированного решения проблемы миграции. Аналогичным образом, при подготовке работников сестринских служб необходимо соблюдать надлежащий баланс между навыками и компетенциями, требуемыми для работы в местных условиях и в системе первичной медико-санитарной помощи, и интересами студентов к приобретению навыков, которые позволят им максимально повысить свои возможности для получения дохода и мигрировать для трудоустройства в более специализированной или глобальной профессиональной среде. 139. На фоне резкого увеличения числа медицинских сестер-мигрантов типичный подход к решению проблемы защиты населения усилиями лишь одной из задействованных стран (происхождения или назначения) становится неэффективным; на основе реформирования существующих систем необходимо разрабатывать и внедрять региональные и глобальные решения (245,278,279). Кроме того, поскольку многие страны одновременно являются странами как происхождения, так и назначения, крайне важно лучше понимать закономерности перемещения людей, с тем чтобы эффективно управлять мобильностью и планировать будущие потребности в кадрах 69Дальнейшие направления развития кадровой политики в области сестринского дела Вставка 6.2 Сообщество здравоохранения стран Восточной, Центральной и Южной Африки: национальное сотрудничество в области представления данных по сестринским кадрам с использованием показателей НСУКЗ Сообщество здравоохранения стран Восточной, Центральной и Южной Африки (ECSA-HC) – это межправительственная организация, деятельность которой направлена на развитие и укрепление регионального сотрудничества в области здравоохранения (274). Общей проблемой стран этого субрегиона является нехватка сестринского персонала. Плохие условия труда и тяжелая рабочая нагрузка обусловливают отсутствие стимулов для притока медсестер в состав работающих кадров, а также высокий уровень эмиграции. Системы образования, которые нередко носят фрагментированный характер, страдают от дефицита компетентных преподавателей и отсутствия необходимой нормативно-правовой базы, что приводит к ограничению возможностей для подготовки достаточно квалифицированных сестринских кадров. Под эгидой Группы Всемирного банка в сотрудничестве с такими организациями, как «Jhpiego», Международный совет медицинских сестер и Коллегия сестринского дела ECSA, было проведено исследование по оценке состояния рынка труда и системы учебной подготовки сестринских кадров. Цель состояла в том, чтобы оценить масштабы проблем, имеющихся в этих областях, и наметить меры политики, направленные на расширение масштабов сестринского образования в регионе за счет целевых государственных и частных инвестиций. В исследовании были подвергнуты анализу взаимодействия между системами образования и здравоохранения, опосредованные рынком труда применительно к сестринским кадрам с учетом проблем стратегического руководства и нормативно-правового регулирования. В ходе исследования были рассчитаны показатели разработанной ВОЗ НСУКЗ (273), а также использованы дополнительные качественные данные, собранные путем проведения региональных консультаций. Координацию сбора и представления данных для исследования осуществляли страновые команды, так называемые «четверки» (quads) лидеров в области сестринского дела; обзор полученных сведений проводился при дополнительной поддержке со стороны ВОЗ (см. также подраздел 6.3.3). Результаты этой работы выявили несбалансированность рынка и критическое несоответствие спроса и предложения применительно к сестринским кадрам в субрегионе. В течение последних 10 лет рост численности сестринского персонала на рынке труда опережал увеличение численности населения, однако во многих странах это происходило на фоне низких показателей обеспеченности медсестер рабочими местами в государственном секторе (часто из-за неэффективности процессов привлечения и найма работников или неблагоприятных условий труда) и сохранения значительного кадрового дефицита в сопоставлении с имеющимися потребностями. Прогностический анализ показал, что в период с 2019 по 2039 г. эффективный спрос на сестринский персонал вырастет на 33%, но все равно сохранится кадровый избыток на уровне 220 000 медсестер, которые не смогут найти работу в результате неспособности или нежелания государственного и частного секторов обеспечить их трудоустройство. Между тем дефицит медицинских сестер, основанный на анализе потребностей, по оценкам, к 2030 г. достигнет 841 000 человек, что приведет к углублению нынешних диспропорций на рынке труда сестринского персонала. В исследовании был сделан вывод о том, что рост численности подготавливаемых сестринских кадров, необходимый для достижения ЦУР в странах ECSA, потребует расширения масштабов сестринского образования, повышения качества сестринских учебных заведений (в частности, в отношении контроля за соблюдением механизмов обеспечения качества) и увеличения объемов ресурсов, вкладываемых в усилия по обеспечению трудоустройства медицинских сестер на местном и региональном уровне. Этому может способствовать вложение адекватных объемов средств в развитие физических и людских ресурсов, в повышение уровня участия сестринского персонала в процессах стратегического руководства, нормативно- правовое регулирование и наращивание информационно-аналитического потенциала для расширения возможностей осуществлять мониторинг полезной отдачи от инвестиций. 70 Состояние сестринского дела в мире, 2020 г. здравоохранения. Однако лишь 86 государств- членов сообщили о процентной доле работников сестринских служб, родившихся или прошедших обучение за рубежом, в составе своих кадровых ресурсов, несмотря на то что это является одним из основных требований к отчетности, предусмотренных Глобальным кодексом ВОЗ по практике международного найма персонала здравоохранения. Варианты политики 140. Правительствам и регулирующим органам стран следует активизировать осуществление положений, регламентирующих международную мобильность медицинского, в том числе сестринского персонала. Регулирующие органы в странах назначения в целях защиты интересов общества должны постановить, чтобы уровень подготовки, квалификация и послужной список работников соответствовали требуемым лицензиям, образовательным и этическим стандартам и кодексам профессионального поведения. Усовершенствованные модели регулирования могут стимулировать мобильность за счет гармонизации требований для поступления на курс обучения сестринскому делу, а также содержания образовательных программ, необходимого для получения и поддержания сестринской квалификации. Региональный опыт соглашений о взаимном признании профессиональных квалификаций работников сестринских служб создает потенциальную основу для более развернутых соглашений в будущем. 141. Страны и международные заинтересованные стороны должны обеспечить более строгое соблюдение положений Глобального кодекса практики ВОЗ. Эффективное осуществление мониторинга, стратегического руководства и регулирования применительно к процессам международной мобильности сестринского персонала может потребовать наращивания потенциала, развития партнерств и сотрудничества между регулирующими органами, информационными системами по кадровым ресурсам здравоохранения, работодателями, министерствами и другими заинтересованными сторонами, такими как профессиональные ассоциации. Страны, сталкивающиеся с чрезмерным оттоком сестринского персонала в связи с эмиграцией, Вставка 6.3 Подход Германии к управлению миграционным процессом Парламент Германии принял 9 ноября 2018 г. «Закон о совершенствовании системы оказания помощи», который направлен на повышение привлекательности рабочих мест для сотрудников больниц и стационарных учреждений длительного ухода (275). Улучшение кадровой обеспеченности этих учреждений полностью соответствовало основным целям новой государственной политики в области здравоохранения. В течение многих лет службы оказания медицинской помощи и длительного ухода страдали от острой нехватки сестринского персонала с широко распространенной недоукомплектованностью штатов больниц и домов- интернатов. Число квалифицированных работников, увольняющихся из системы здравоохранения в связи с выходом на пенсию или неудовлетворенностью своей работой, превышало число тех, кто поступал на работу, получив соответствующую профессиональную подготовку. Кроме того, сложилось представление о том, что нехватка персонала ведет к ухудшению условий труда и снижению качества оказываемой помощи. В 2012 г. прогнозировалось, что к 2030 г. Германия будет испытывать дефицит сестринских кадров в размере от 263 000 до 500 000 работников (276). Стремясь сократить нехватку кадров, Германия приняла многоплановую стратегию, предусматривающую расширение масштабов образования, создание новых рабочих мест для сестринского персонала и оптимизацию международного набора медицинских работников-мигрантов, в частности сестринского персонала из стран Центральной и Юго-Восточной Европы (277). В отношении этого последнего элемента Германия как страна назначения предприняла шаги, направленные на получение взаимной выгоды вместе со странами происхождения в условиях международной мобильности работников здравоохранения, в том числе посредством технического сотрудничества и двусторонних соглашений, которые создают возможности для профессиональной подготовки и инвестиций в стране происхождения (168). 71Дальнейшие направления развития кадровой политики в области сестринского дела должны предусматривать принятие мер по удержанию кадров, таких как повышение заработной платы (и обеспечение справедливой оплаты труда), улучшение условий труда, создание достойных рабочих мест, а также, по мере необходимости, предоставление целевых пакетов мер по обеспечению кадровой стабильности. 6.3 Развитие и поддержка сестринского персонала 6.3.1 ОБРАЗОВАНИЕ Синтез результатов 142. Объективные сведения, изложенные в настоящем докладе, иллюстрируют сложную ситуацию в отношении подготовки выпускников программ сестринского образования. Самая низкая доля выпускников по сравнению с численностью существующих кадров характерна для стран Европейского региона и Региона Восточного Средиземноморья, а также для стран с высоким уровнем дохода. По имеющимся данным, если страны со средним и высоким уровнем дохода не смогут увеличить масштабы подготовки работников сестринских служб, это в потенциале приведет к сохранению зависимости этих стран от международного найма, что может вызвать усугубление существующего общего дефицита и обострение связанных с этим проблем доступа и справедливости. 143. В регионах мира существуют значительные различия в продолжительности обучения и профессиональной подготовки сестринского персонала. При этом подавляющее большинство стран (154 из 169 представивших сведения) сообщили о наличии у них стандартов содержания и продолжительности базового обучения и профессиональной подготовки. Важнейшие требования, рассматриваемые при разработке таких стандартов, заключаются в том, чтобы они помогали преподавателям обеспечивать студентов компетенциями, необходимыми для удовлетворения потребностей населения в области здравоохранения, включая подготовку к оказанию первичной и профилактической медицинской помощи, навыки оказания помощи при бедствиях, чрезвычайных ситуациях и конфликтах, лидерские качества и умение использовать современные технологии (см. вставку 6.4 о современных технологиях в образовании и практике сестринского дела). 144. Большинство стран (89%) также сообщили о наличии механизмов аккредитации учебных заведений и ведении общего перечня аккредитованных учреждений. Это означает возможность сосредоточить внимание в этих странах на укреплении ключевых аспектов аккредитации, включая экономически эффективные и финансово доступные модели, а также на обеспечении социальной подотчетности и соответствия программ приоритетам в области охраны здоровья населения. Хорошо развитые механизмы аккредитации могут охватывать такие вопросы, как содержание программ, учебные планы, клиническая практика студентов, квалификация преподавателей и межпрофессиональное обучение. Данные настоящего доклада свидетельствуют о том, что 67% стран-респондентов имеют стандарты для межпрофессионального обучения, однако есть регионы, где эта доля составляет менее 50% и даже всего 20%. 145. Формирование кадровых ресурсов здравоохранения, состав которых полноценно отражает характеристики обслуживаемого населения, требует обеспечения демографического и географического разнообразия применительно к контингенту абитуриентов и выпускников программ сестринского образования. Объективные данные, собранные для настоящего доклада, свидетельствуют о том, что сестринский персонал по-прежнему в основном представлен женщинами, что особенно характерно для регионов стран Америки и Западной части Тихого океана. Содействие формированию надлежащего состава сестринских кадров потребует не только расширения набора представителей различных социальных групп; это также потребует устранения ряда структурных и организационных ограничений, которые либо лишают определенные категории молодежи возможности поступать на программы обучения сестринскому делу (например, отсутствие среднего образования), либо препятствуют завершению учебы (например, по причине чрезмерных расходов на обучение) (126). Спрос на поступление в программы сестринского образования может также зависеть от гендерной профессиональной сегрегации и низкого статуса сестринского 72 Состояние сестринского дела в мире, 2020 г. дела в некоторых странах. Эти проблемы необходимо решать, для того чтобы сестринское дело стало привлекательной профессией, особенно в таких регионах, как страны Америки, где выпускников меньше всего по сравнению с численностью населения. Варианты политики 146. Страны должны обеспечить, чтобы программы сестринского образования и профессиональной подготовки формировали у студентов необходимые компетенции для предоставления высококачественных, комплексных Вставка 6.4 Современные технологии в образовании и практике сестринского дела Новые технологии играют все более важную роль как в образовании, так и в практической деятельности сестринского персонала. Современные технические средства могут использоваться для доступа к источникам поддержки клинических решений, применения методов телемедицины (связь от поставщика услуг к пациенту) и проведения учебных мероприятий и консультаций (связь между поставщиками услуг) (280). Это позволяет улучшить доступ к услугам, обеспечить дистанционное оказание помощи, повысить уровень первичной медико-санитарной помощи и расширить права и возможности пациентов. Работники сестринских служб должны быть адекватно оснащены цифровыми средствами и владеть навыками их использования: речь идет о достаточном уровне цифровой грамотности, доступе к необходимому оборудованию и инфраструктуре интернета, включая, при наличии возможностей, широкополосное соединение (281). Технологии цифрового здравоохранения, будь то искусственный интеллект или другие форматы, такие как дополненная реальность и использование робототехники, уже сегодня преобразуют сестринское дело и оказание помощи пациентам (282). Потенциальные возможности для совершенствования оказания помощи пациентам открываются благодаря внедрению методов персонализированной медицины и геномики (283). Одно из выдающихся достоинств цифрового здравоохранения заключается в том, что эти методы открывают новые возможности для непрерывного повышения квалификации на протяжении всей жизни. Такие технологии, как искусственный интеллект, позволяют сделать обучение персонализированным, соответствующим актуальным потребностям и передающим самые современные знания. По результатам одного из Кокрановских систематических обзоров, посвященных изучению опыта применения методов мобильного здравоохранения в первичной медико-санитарной помощи, медицинские работники, включая медсестер, высоко оценили преимущества использования мобильных технологий при оказании услуг, но также столкнулись с рядом проблем (284). Отмеченные преимущества включали более тесную связь работников друг с другом, освоение новых функций, улучшение координации и качества медицинской помощи, совершенствование коммуникации с пациентами и обеспечение связи с жителями труднодоступных районов (284). В то же время медицинские работники описывали многочисленные сложные проблемы: личного порядка (например, низкая цифровая грамотность), относящиеся к взаимоотношениям с другими (предпочтение личных контактов с пациентами и коллегами), профессиональные (опасения того, что доступ к цифровым инструментам клинической поддержки создает угрозу для профессионального престижа, обусловленного наличием индивидуальных клинических навыков), контекстуальные (пациенты не могут позволить себе иметь мобильные телефоны по финансовым соображениям) или инфраструктурные (отсутствие электроснабжения) (284). Хотя технический прогресс дает множество преимуществ, сообщения медицинских работников, включенные в этот систематический обзор, свидетельствуют о том, что должностные лица, принимающие решения в системе здравоохранения, должны тщательно продумывать пути внедрения новых технических средств с учетом имеющегося контекста, так чтобы свести к минимуму проблемы, с которыми сталкиваются медицинские работники, включая сестринский персонал. 73Дальнейшие направления развития кадровой политики в области сестринского дела услуг, ориентированных на нужды людей. Одним из приоритетных аспектов является критическая оценка набора профессиональных навыков для работы в сестринской профессии и принятие решений о том, соответствуют ли квалификационные уровни и типы специализации сестринского персонала задачам системы здравоохранения. Также крайне важно обеспечить наличие достаточного количества учебных мест с учетом потребностей системы здравоохранения и возможностей для трудоустройства выпускников. Создание или увеличение числа высших уровней сестринского образования – например, программ бакалавриата, магистратуры или докторантуры – имеет структурные последствия, такие как разработка новых образовательных программ, укомплектование их соответствующим преподавательским составом и обеспечение того, чтобы выпускники таких программ имели возможность выполнять строго определенные функции в системе здравоохранения. 147. Странам следует разрабатывать механизмы расширения демографического и географического разнообразия контингентов учащихся в школах сестринского дела. Это может означать борьбу с предубеждениями, которые негативно влияют на выбор сестринской профессии мужчинами, молодежью или представителями конкретных этнических групп, и удовлетворение потребностей тех, кто выбирает сестринское дело в качестве второй, новой для себя профессии. В некоторых случаях для обеспечения гендерного баланса и надлежащей численности студентов из сельских, отдаленных и других недостаточно обслуживаемых районов и сообществ может потребоваться создание облегченных условий для приема таких категорий абитуриентов. В целях расширения возможностей получения формального образования для меньшинств, уязвимых групп и малообеспеченных групп населения, а также для привлечения преподавателей из числа представителей соответствующих сообществ могут также использоваться адресная финансовая поддержка и другие механизмы стимулирования. Одним из таких механизмов являются критерии аккредитации, которые усиливают меры социальной подотчетности. 148. Медицинские учебные заведения и регулирующие органы должны внедрять образовательные программы, основанные на формировании компетенций, и использовать соответствующие технологии. Все учебные программы должны быть направлены на обеспечение надлежащего качества оказания сестринской помощи. В дополнение к техническим знаниям и навыкам проведения конкретных клинических процедур работники сестринских служб должны получить надлежащую подготовку в следующих областях: работа в составе межпрофессиональных команд; проявление отзывчивости и участия по отношению к пациентам; принятие решений в экстренной ситуации; использование инструментов для непрерывного продолжения образования в течение десятилетий на своем трудовом пути. Учебные программы должны соответствовать как кругу предстоящих профессиональных обязанностей выпускников, так и потребностям охраны здоровья населения. Традиционные методы обучения могут с успехом дополняться применением цифровых средств предоставления учебного контента. Успех таких усилий по «распределенному обучению» потребует, чтобы студенты в процессе учебы приобретали минимально необходимый уровень грамотности в вопросах цифрового здравоохранения, чтобы при разработке учебных программ использовались соответствующие цифровые и телемедицинские технологии обучения для формирования необходимых компетенций наряду с обеспечением надлежащей клинической практики (285) и чтобы были предоставлены институциональные и инфраструктурные ресурсы, необходимые для преодоления цифрового разрыва (286). 149. Правительствам и заинтересованным сторонам в целях активного продвижения повестки дня сестринского образования следует развивать и использовать межсекторальные партнерства и сотрудничество. Сотрудничество с регулирующими органами может способствовать пересмотру вступительных требований для программ сестринского дела и минимальных образовательных стандартов для сестринского персонала (с учетом текущих и будущих профессиональных функций в системе здравоохранения), а также содействовать гармонизации стандартов на региональном уровне. Межсекторальный диалог с органами, ответственными за аккредитацию, может помочь 74 Состояние сестринского дела в мире, 2020 г. в определении механизмов для дальнейшего повышения уровня социальной ответственности, например путем обеспечения того, чтобы учреждения сестринского образования уделяли приоритетное внимание не наращиванию своего дохода и статуса за счет взимания платы за обучение и получения государственных субсидий, а подготовке выпускников, способных предоставлять высококачественные медицинские услуги. Профильным министерствам (образования, здравоохранения) было бы целесообразно усилить формальную координацию для продвижения науки и техники как основы сестринской профессии. Следует популяризировать сестринское дело как вид профессиональной деятельности в сфере науки и высоких технологий в целях привлечения в эту профессию широких слоев выпускников средней школы. Государственно- частные партнерства могут помочь в создании площадок для клинического обучения в учреждениях первичной медико-санитарной помощи; развитие взаимодействий с другими программами медицинского профессионального образования может обеспечить межпрофессиональный характер клинической практики. 150. Сестринские учебные заведения должны укреплять свой потенциал, в этих целях необходимо устранять дисбаланс, связанный с дефицитом преподавателей, в том числе обладающих необходимыми компетенциями, а также решать проблемы инфраструктурных ограничений и отсутствия соответствующих центров клинической практики (см. вставку 6.5 об обязательствах Пакистана по увеличению масштаба подготовки сестринских кадров). Для увеличения числа учебных мест при сохранении качества обучения может потребоваться вложение средств в программы наращивания потенциала преподавательского состава. Страны с высоким уровнем дохода и страны, полагающиеся на международный набор персонала, должны увеличить масштабы подготовки собственных сестринских кадров. 151. В целях решения проблем, связанных с рынком труда в области здравоохранения, странам рекомендуется применять надлежащие финансовые рычаги для расширения масштабов (там, где это необходимо) или повышения качества сестринского образования. Финансовые механизмы обладают значительным потенциалом для повышения уровня социального разнообразия контингента студентов и преподавателей, для увеличения числа мест в программах сестринского дела, а также для устранения некоторых из имеющихся ограничений в клинической подготовке. Финансовое субсидирование программ послебазового образования иногда используется для стимулирования роста числа выпускников на более высоких уровнях сестринской практики. Вставка 6.5 Усилия Пакистана по наращиванию потенциала в области подготовки сестринских кадров Пакистан пытается решить проблему нехватки 1 миллиона медицинских работников. В 2018 г. страна приступила к реализации национальной Стратегической концепции развития кадровых ресурсов здравоохранения на период до 2030 г., направленной на повышение уровня обеспеченности населения медицинскими кадрами с необходимым сочетанием навыков, в том числе сестринским персоналом. Сестринское дело, которое рассматривается в качестве основы сектора здравоохранения, занимает в этой концепции центральное место; в ознаменование вклада работников сестринских служб в охрану здоровья населения 2019 г. был объявлен в Пакистане годом сестринского дела (287). Выступая на его открытии, президент Пакистана Ариф Алви объявил, что в Исламабаде будет создан университет сестринского дела, призванный обеспечить ежегодный прием 25 000 студентов (287). В целях преодоления национального дефицита сестринских кадров страна планирует в течение двух лет удвоить численность работников сестринских служб. Д-р Наушин Хамид, парламентский секретарь по национальным службам здравоохранения, охарактеризовал нехватку работников сестринских служб как препятствие для достижения всеобщего охвата услугами здравоохранения, поскольку эффективная работа системы здравоохранения требует наличия достаточной численности адекватно функционирующего сестринского персонала (288). 75Дальнейшие направления развития кадровой политики в области сестринского дела Однако правительства должны быть в состоянии принимать обоснованные решения о том, является ли субсидирование сестринского образования экономически эффективным вложением средств, и если да, то при каких обстоятельствах и какими способами, отдавая приоритет использованию ограниченных ресурсов на инвестиции, которые могут непосредственно способствовать достижению целей справедливости и эффективности (289). Например, с помощью анализа рынка труда в здравоохранении следует выявлять ситуации подготовки недостаточного или, напротив, избыточного числа работников сестринских служб в сопоставлении с потребностями системы здравоохранения. В тех случаях, когда документируется систематический дефицит в области подготовки кадров, это дает правительству основания для смягчения избыточных требований к абитуриентам и, при необходимости, для субсидирования базового образования, особенно если приоритет отдается группе малообеспеченных студентов. Такие меры направлены в первую очередь на стимулирование подготовки кадров для системы первичной медико-санитарной помощи, когда выпускники обязуются отработать минимальный гарантированный период в учреждениях государственного сектора (140). 6.3.2 ПРАКТИЧЕСКАЯ ДЕЯТЕЛЬНОСТЬ СЕСТРИНСКОГО ПЕРСОНАЛА Синтез результатов 152. Объективные данные, приведенные в настоящем докладе, свидетельствуют о том, что численность сестринского персонала превышает результаты более ранних оценок, составив в 2018 г. почти 28 миллионов человек, куда входят как минимум 69% медицинских сестер профессионального и не менее 22% – ассоциированного профессионального уровня. Рост, по сравнению с оценочными данными 2016 г., приведенными в Глобальной стратегии для развития кадровых ресурсов здравоохранения, обусловлен, примерно в равной степени, значительным улучшением доступности и качества данных о сестринских кадрах, а также фактическим увеличением численности сестринского персонала. 153. Суммарный рост численности не привел к решению такой глобальной проблемы, как несправедливое географическое распределение медицинских работников, включая медсестер. В настоящем докладе выявлены существенные различия в распределении сестринских кадров между странами и регионами и внутри них. Данные, приведенные в докладе, также указывают на то, что в 53% стран-респондентов работает сестринский персонал с расширенными профессиональными функциями. Такая практика более характерна для стран с низкими показателями обеспеченности населения врачебными кадрами. Это свидетельствует о способности гибкого реагирования сестринского персонала на имеющуюся в стране общую кадровую ситуацию в области здравоохранения. Такие медицинские сестры могут оказывать необходимую помощь населению в сельских и отдаленных районах, если набор профессиональных навыков, которыми располагают эти работники, позволяет повысить экономическую эффективность предоставления услуг. 154. Внутристрановые данные указывают на сохраняющуюся необходимость сосредоточить внимание на решении проблемы неравномерного распределения медицинских сестер между сельскими и городскими районами в целях повышения уровня справедливости. Удержание кадров медицинских работников связано с целым рядом сложных и взаимосвязанных факторов, таких как условия труда и их безопасность, уровень заработной оплаты и неденежные стимулы. Стабильный успех в более эффективном удержании на рабочих местах медсестер, вероятно, будет результатом запланированных, последовательных, многоплановых мероприятий, адаптированных к местному контексту. Эти меры следует осуществлять с обязательным учетом всех условий труда и жизни работников сестринских служб. Варианты политики 155. Страны должны предоставить медсестрам возможность работать с полным использованием потенциала полученного образования и профессиональной подготовки (180). Решение этой задачи должно стать частью более широких национальных усилий по внедрению моделей оказания медицинской помощи, направленных на оптимизацию распределения функций в 76 Состояние сестринского дела в мире, 2020 г. многопрофильных бригадах первичной медико- санитарной помощи (179). Это, в частности, предполагает максимальное увеличение вклада медицинских сестер в укрепление первичной медико-санитарной помощи в приоритетных областях (см. вставку 6.6 о расширении доступа к общинным медицинским услугам в Омане). Возможные подходы могли бы включать в себя расширение круга профессиональных функций, увеличение числа медицинских учреждений, возглавляемых медсестрами, делегирование или расширение полномочий сестринского персонала по назначению лекарств с соответствующим повышением требуемого уровня образования и профессиональной подготовки. Для работников сестринских служб с расширенным кругом клинических функций должны быть созданы условия, которые оптимизируют их деятельность по оказанию помощи пациентам или руководству работой других сотрудников клинического профиля. Медицинские сестры с расширенным кругом клинических функций или возглавляющие медицинские учреждения должны получать необходимую поддержку в форме наставничества или партнерского сотрудничества, быть обеспечены надлежащими расходными материалами и лекарствами, иметь четкие клинические и административные руководства и инструкции, а также иметь доступ к необходимым ресурсам, включая онлайновые справочные материалы и соответствующие технические средства. Осуществление необходимых реформ, предусмотренных в проводимой политике в области образования, здравоохранения, труда и других сферах, требует наличия следующих факторов: институциональный потенциал для эффективного сотрудничества и координации; поддерживающие институциональные структуры и целевые ресурсы; лидерство и политическая воля; эффективный управленческий надзор; эффективная организационная культура. Также важно, чтобы функции работников сестринских служб, вытекающие из сферы их практической деятельности и имеющихся компетенций, точно доводились до сведения других медицинских работников и населения. 156. Странам следует оптимизировать формы и механизмы эффективного распределения сестринских кадров и управления ими. Вставка 6.6 Расширение доступа к общинным услугам здравоохранения в Омане Государство Оман является примером переориентации сестринского и акушерского образования с особым вниманием к компетенциям по оказанию первичной медико-санитарной помощи. Эти шаги были предприняты в ответ на призыв к действиям по укреплению потенциала сестринских кадров, прозвучавший на 66-й сессии Регионального комитета ВОЗ для Восточного Средиземноморья (октябрь 2019 г.) (290). В Омане наблюдается быстрый рост численности и ожидаемой продолжительности жизни населения. Однако улучшение социально-экономического положения сопровождается увеличением бремени хронических заболеваний. Для решения возникшей проблемы в области общественного здоровья правительство решило инвестировать средства в развитие контингента общинных медицинских сестер (291). Департамент сестринского дела и акушерства Министерства здравоохранения учредил 16-недельную программу обучения на рабочем месте, которая сначала была опробована в столице, Маскате, а затем распространена на другие провинции (мухафазы). Общинные сестринские службы были интегрированы в структуру услуг, предоставляемых в центрах первичной медико-санитарной помощи (292). В последующем вышеуказанная 16-недельная программа была преобразована в программу для получения степени бакалавра в области сестринского дела с акцентом на общинное здравоохранение, а затем-в послебазовый курс для получения диплома по специальности общинного сестринского дела (291). Введение этого курса способствовало поддержанию притока квалифицированных общинных медицинских сестер для удовлетворения потребностей страны в первичной медико-санитарной помощи. 77Дальнейшие направления развития кадровой политики в области сестринского дела Эффективность, справедливость и прозрачность в вопросах найма и распределения персонала являются ключевыми элементами усилий по обеспечению достойных рабочих мест (16). Руководители и организаторы здравоохранения должны иметь доступ к надежным количественным показателям эффективности и быстроты процесса трудоустройства. В число таких показателей входят процент выпускников, нанятых через три месяца, через шесть месяцев и через один год после получения лицензии, а также средние интервалы времени между завершением учебы и получением лицензии и между получением лицензии и трудоустройством. Низкий уровень трудоустройства выпускников может быть симптомом насыщения рынка труда, но, если он сочетается с чрезмерно длительными задержками между выпуском, лицензированием и трудоустройством, это может указывать на отсутствие гибкости и наличие бюрократических барьеров в административной системе. Также имеют значение формы кадрового распределения: если государственный сектор не может гарантировать трудоустройство всех квалифицированных кандидатов, то методом выбора остается конкурсный набор после публикации вакансий и оценки компетенций соискателей (289). Возможности карьерного роста и продвижения по службе также должны быть увязаны главным образом не с накопленным стажем работы, а с профессиональными достоинствами и потенциалом работников. Как и применительно к другим профессиональным © Kieran Dodds группам, при использовании таких схем следует учитывать предельные требования в отношении обязательной работы по распределению и кадровой ротации. Везде, где это возможно, кадровое распределение сестринского персонала должно основываться на добровольном выборе пути последующего развития карьеры и предпочтениях в отношении конкретного места работы. Однако достижение рационального баланса между предпочтениями работников и потребностями системы здравоохранения, в частности с позиций справедливого географического распределения кадров, может оказаться непростой задачей. В таких ситуациях, для того чтобы обеспечить эффективность использования кадров и соблюдение прав работников, необходимо разработать целый ряд взаимодополняющих стратегий привлечения выпускников к работе в сельской местности и удержания персонала (289). 157. Страны должны четко прогнозировать проблемы, связанные с удержанием сестринского персонала, и активно принимать необходимые стратегические меры, направленные на их решение. Объективно обоснованные подходы к более эффективному удержанию кадров включают предоставление возможностей для развития лидерских качеств, наставничество (293,294), гибкое планирование рабочего времени, неденежные стимулы и повышение квалификации на протяжении всей профессиональной карьеры. Формализованное кураторство выпускников, поступающих на работу, может облегчать их вхождение в практику, повышать уровни клинической компетентности, удовлетворенности работой и профессиональной социализации – все эти факторы могут способствовать удержанию новых работников сестринских служб в составе кадровых ресурсов (295). Влияние кураторства на развитие компетентности и удержание работников аналогично для новых медсестер в сельских и городских условиях (296). Необходимо разрабатывать конкретные стратегии для повышения лидирующей роли женщин в руководстве, активизации борьбы с гендерной дискриминацией и предотвращения сексуальных домогательств. Эти негативные проявления не только свидетельствуют о нарушении достоинства и прав работников, но и коррелируют с повышенным оттоком кадров (122,297,298). 78 Состояние сестринского дела в мире, 2020 г. 6.3.3 НОРМАТИВНО-ПРАВОВОЕ РЕГУЛИРОВАНИЕ Синтез результатов 158. Нормативно-правовое регулирование сестринского дела играет важную роль в охране здоровья и в расширении возможностей систем здравоохранения реагировать на меняющиеся потребности пациентов и населения в целом. Регулирование также может служить основой для повышения значимости и престижа этой профессии (243,299). По данным настоящего доклада, в 164 государствах-членах (86%) имеется орган, ответственный за регулирование образования и практики в области сестринского дела. Вместе с тем силу и эффективность принимаемых норм следует оценивать на уровне отдельных стран. Например, 73% стран указали на наличие в них нормативных требований в отношении непрерывного образования в течение всей профессиональной жизни, однако лишь 64% сообщили об обязательной сдаче экзамена на получение лицензии или на готовность к практике. 159. Профессиональные нормы и правила также важны для поддержания надлежащего качества медицинской помощи в контексте растущей международной профессиональной мобильности, так чтобы прибывающие в страну медицинские работники обладали компетенциями, соответствующими потребностям населения, и были способны практиковать без ущерба для общественной безопасности. В качестве новых полезных инструментов для применения на региональном и потенциально на глобальном уровне рассматриваются работающие в реальном времени онлайновые системы, позволяющие в ускоренном порядке обеспечивать подтверждение дипломов и предоставлять систематизированную информацию о текущем статусе лицензии и профессионального послужного списка практикующего работника (168,300–302). Варианты политики 160. Странам следует развивать и совершенствовать нормативно-правовую базу в области сестринского дела в целях обеспечения безопасных, стабильных и высококачественных процессов образования и практики сестринского персонала. Следует учреждать органы, отвечающие за регулирование сестринского дела. Эта задача решается путем принятия новых законов или обновления существующего законодательства с установлением роли и функций таких органов, а также ключевых положений и стандартов в отношении сестринского образования и практики. Одна из частых проблем заключается в необходимости достижения рационального баланса: нормативные акты должны быть наименее ограничительными, но при этом обеспечивать надлежащий уровень защиты общественных интересов (303–306). Странам следует рассмотреть вопрос об установлении требований в отношении непрерывного повышения квалификации на протяжении всей жизни, так чтобы медсестры различного профессионального уровня имели возможности для непрерывного образования в соответствии с их функциями. Находит все большее распространение практика экзамена на получение лицензии для оценки минимального уровня начальных знаний, позволяющих медицинской сестре начать свою профессиональную деятельность (255,307). Сохраняется потребность в более убедительных доказательствах сравнительной эффективности различных подходов, однако существует широкий консенсус в отношении того, что оценка компетентности должна быть достоверной, справедливой, независимой и основываться на определении уровней знаний и навыков, которые потребуются медсестрам в различных условиях практики. 161. В целях укрепления и повышения качества сестринского образования и практики странам следует вкладывать средства в развитие потенциала систем нормативно- правового регулирования. Крайне важно обеспечить, чтобы регулирующие органы вели в режиме реального времени реестры, которые были бы совместимы с другими базами данных в системе здравоохранения и в других сферах регулирования. Одним из способов поддержания реестров в обновленном состоянии является требование обязательной перерегистрации или периодического подтверждения лицензии, что также может стимулировать непрерывное образование и, кроме того, генерировать доход для регулирующего органа. Также требует укрепления индивидуальный потенциал должностных лиц, отвечающих за процессы нормативного регулирования работы 79Дальнейшие направления развития кадровой политики в области сестринского дела сестринского персонала. Такие должностные лица, как это характерно для аналогичных работников применительно к другим медицинским профессиям, скорее всего, не получают формальной подготовки в области профессионального регулирования до принятия на себя этой роли. Регулирующие органы могут извлекать полезные уроки из успешного опыта других стран и усилий на региональном уровне в деле укрепления нормативно-правовой базы (см. вставку 6.7 об Африканском сотрудничестве в области регулирования медицинских профессий). 6.3.4 ДОСТОЙНАЯ РАБОТА Синтез результатов 162. Обеспечение достойных условий труда актуально и необходимо для всех медицинских профессий, однако работники сестринских служб сталкиваются с особыми проблемами. Поскольку сестринские кадры представлены преимущественно женщинами, которым в определенных контекстах в силу традиций отводится подчиненная роль, медицинские сестры чаще сталкиваются с гендерной предвзятостью и дискриминацией на рабочем месте. Они также вынуждены проводить больше часов на работе, иногда подвергаются риску нападения и сексуальным домогательствам. Имеют место случаи несправедливого отношения к медицинским сестрам из числа мигрантов. О наличии норм продолжительности рабочего времени и условий труда сообщили 94% стран, о мерах социальной защиты – 91%, об установленной минимальной заработной плате – 89%. Об адекватности и фактическом уровне реализации этих норм известно меньше. В общей сложности 55 стран (36%), главным образом в регионах Юго-Восточной Азии и Восточного Средиземноморья, сообщили о принимаемых мерах по предотвращению нападений на работников здравоохранения. Вставка 6.7 Африканское сотрудничество в области регулирования медицинских профессий Африканское сотрудничество в области регулирования медицинских профессий (ARC) было создано для того, чтобы помочь странам в обновлении нормативно-правовой базы сестринского и акушерского дела в целях содействия разработке безопасных и стабильных моделей оказания сестринской помощи и лечения для пациентов с ВИЧ-инфекцией. В программе сотрудничества приняли участие 17 стран, в том числе большинство членов Коллегии сестринского дела Восточной, Центральной и Южной Африки (ECSACON) (308). Под эгидой ARC состоялось совещание с участием главной государственной медицинской сестры, президента национальной ассоциации медсестер, одного из лидеров научного сообщества и секретаря национального совета медсестер и акушерок от каждой страны. Совещание поддержало идею развития сотрудничества в решении выявленных на национальном уровне приоритетных проблем в области регулирования. Страновые руководящие группы, состоящие из четырех членов («четверки»), проводили совместную работу по приоритетным аспектам регулирования (например, таким как сфера практики, включая задачи оказания помощи при ВИЧ-инфекции, требования к непрерывному профессиональному развитию по тематике ВИЧ) в формате годичных циклов. «Четверки» проводили частые встречи в стране, а также с региональными коллегами, работающими над аналогичными приоритетными задачами. Прогресс измерялся регулярно и с использованием различных индикаторов (309). В течение пяти лет (2011–2016 гг.) была укреплена нормативно-правовая база в области сестринского и акушерского дела, «четверки» сообщили о значительном росте лидерских навыков, организационного потенциала и сотрудничества между национальными сестринскими и акушерскими организациями (310). Инициатива ARC получала финансирование из донорских фондов, однако практика сотрудничества «четверок» была институционализирована в странах ECSACON и теперь служит постоянным механизмом для привлечения лидеров в области сестринского и акушерского дела к решению приоритетных национальных задач в области здравоохранения. 80 Состояние сестринского дела в мире, 2020 г. Варианты политики 163. Странам следует продолжать осуществление повестки дня «Достойная работа» и вкладывать средства в создание благоприятных условий труда для сестринского персонала. Основные элементы этой деятельности включают адекватное вознаграждение, социальную защиту, справедливые условия труда, рациональную продолжительность рабочего времени, безопасность труда, неденежные стимулы и прозрачные и основанные на индивидуальных успехах возможности для карьерного роста. Эти условия тесно коррелируют с удержанием сестринских кадров и должны быть применимы к работникам сестринских служб вне зависимости от пола, принадлежности к той или иной социальной или этнической группе, родного языка, страны или региона происхождения и неуклонно обеспечиваться с использованием четких механизмов подотчетности. Несоблюдение прав работников здравоохранения, в том числе на надлежащую заработную плату и благоприятные условия труда, является одной из наиболее распространенных причин трудовых споров и забастовок (см. вставку 6.8 о забастовках работников здравоохранения). 164. Страны должны защищать и поддерживать работников сестринских служб, находящихся под прямым воздействием гуманитарных кризисов. Министерствам здравоохранения, профессиональным сестринским и неправительственным организациям необходимо взаимодействовать с соответствующими органами власти и заинтересованными сторонами для обеспечения защиты и поддержки медсестер, которые оказывают помощь в крайне стесненных или тяжелых условиях (например, в лагерях беженцев) или сами являются частью трансгранично перемещенного населения и работают в стране, где они не имеют официального разрешения на медицинскую практику. Такие меры помогут обеспечить в любых условиях безопасность всех медицинских учреждений и работников, особенно женщин, которые подвергаются более высокому риску нападений или притеснений во время кризисов. Вставка 6.8 Забастовки работников здравоохранения Во многих странах мира работники имеют законное право на забастовки, широко признанное в качестве одного из гражданских прав (311). Однако для работников здравоохранения осуществление этого права затруднено, поскольку это создает конфликт с правами пациентов на получение медицинской помощи и правами граждан на всеобщий охват услугами здравоохранения. Одним из возможных последствий такого конфликта является повышение смертности (311–314). Тем не менее забастовки работников здравоохранения, в том числе сестринского персонала, периодически проходят в мире повсеместно – в странах с высоким, средним и низким уровнем дохода (313,314). По данным одного из аналитических исследований, в 23 странах с низким уровнем дохода в период с 2009 по 2018 г. работники здравоохранения бастовали в течение 875 рабочих дней (311). В исследовании было показано, что забастовки могут длиться дни и месяцы, а также могут повторяться в течение месяцев или лет (311). Основными поводами для забастовок были претензии работников в отношении размеров вознаграждения и задержек с выплатами, за которыми следовали протесты против неудовлетворительного выполнения ранее достигнутых договоренностей или против руководства и политики сектора здравоохранения, а также жалобы на условия труда и проблемы безопасности. Сокращение масштабов забастовок работников здравоохранения потребует применения многосторонних, многоплановых и многоотраслевых подходов (311,314,315). Для анализа причинно-следственных факторов в отдельных случаях, изучения типовых характеристик, наблюдаемых в разных регионах, а также для определения круга субъектов, которые должны быть задействованы для позитивного разрешения трудовых конфликтов, необходимы дополнительные исследования (311). Однако очевидно, что для решения коренных проблем, связанных с забастовками работников здравоохранения, необходимы многоотраслевые действия с участием сектора здравоохранения и других секторов и при поддержке со стороны политического руководства (314). Вложение средств в создание достойных условий труда для работников здравоохранения с гарантированным обеспечением безопасной и способствующей максимальной эффективности рабочей среды имеет жизненно важное значение для полной реализации прав людей на всеобщий охват услугами здравоохранения (314). 81Дальнейшие направления развития кадровой политики в области сестринского дела 6.3.5 ГЕНДЕРНЫЕ АСПЕКТЫ И ПРАВА ЖЕНЩИН Синтез результатов 165. Примерно 90% сестринского персонала в мире составляют женщины. Высокий уровень гендерной сегрегации в сестринском деле обусловливает наличие сложной картины в области оплаты труда: во многих странах отмечается гендерный разрыв в размере заработной платы, хотя этот феномен базируется в основном на данных из стран с высоким уровнем дохода (21). Для целенаправленного продвижения принципов гендерной справедливости в решении кадровых вопросов здравоохранения и преодоления устаревших традиций, связанных с недооценкой работы медсестер, в частности из-за гендерных предубеждений, необходимо эффективное осуществление и мониторинг политики, направленной на устранение гендерного разрыва в оплате труда (121,232). Анализ, проведенный ВОЗ, показал, что в руководстве здравоохранением по-прежнему доминируют мужчины: на долю женщин приходится лишь 25% руководящих должностей в этой области (21). В исследовании препятствий и стимулов для развития лидерства в сестринском деле, проведенном в рамках кампании «Сестринское дело сейчас» (Nursing Now), был описан не только «стеклянный потолок» для женщин, но и «стеклянный лифт» для мужчин, которые занимают непропорционально большое число руководящих сестринских должностей (122). Это лишь наиболее заметное проявление глубоко укоренившихся гендерных диспропорций, которые пронизывают системы здравоохранения на всех уровнях и затрагивают все аспекты управления в сфере сестринского дела. Варианты политики 166. Странам следует устранять гендерный разрыв в оплате труда женщин-медсестер. В некоторых странах несправедливые различия в размерах оплаты труда между мужчинами и женщинами могут быть обусловлены высоким уровнем профессиональной сегрегации в сестринском деле по сравнению с другими профессиями. Решение этой проблемы можно начать с анализа национальных шкал заработной платы и принятия мер, направленных на постепенное внедрение более справедливой и гендерно-нейтральной системы оплаты труда работников здравоохранения. Процесс должен включать в себя продуманную политику и пересмотр бюджетных механизмов вознаграждения медицинских работников. Несмотря на объективную реальность влияния рыночных сил на уровень оплаты труда, политика и законы, направленные на устранение разрыва в оплате труда мужчин и женщин, должны соответствующим образом применяться также и к частному сектору. В оценке уровней справедливости в вопросах оплаты труда и в разработке надлежащих мер политики должны принимать участие лидеры в сфере сестринского дела. 167. Странам следует уделять приоритетное внимание разработке и активному проведению в жизнь политики, направленной на борьбу с сексуальными домогательствами и дискриминацией в отношении сестринского персонала и кадров здравоохранения в целом. Речь идет о принципе абсолютной нетерпимости к насилию, равно как и к проявлениям вербального, физического и сексуального харассмента. Проводимая политика должна быть направлена на создание достойных условий труда для женщин, включая гибкий и управляемый рабочий график, учитывающий меняющиеся потребности женщин-медсестер. Женщинам должны быть предоставлены возможности развивать лидерские качества с учетом гендерных аспектов в составе сестринского персонала. 6.4 Укрепление институционального потенциала и лидерских навыков для обеспечения эффективного стратегического руководства Синтез результатов 168. Более 80 стран сообщили о наличии на национальном уровне должности руководителя сестринского дела, который вносит вклад в принятие стратегических решений, касающихся здравоохранения и оказания сестринской помощи. Главные государственные медицинские сестры (главные специалисты по сестринскому делу) должны сотрудничать в качестве полноправных партнеров с другими руководителями системы здравоохранения в принятии стратегических решений, влияющих на планирование медицинских услуг, оказание медицинской помощи и формирование условий 82 Состояние сестринского дела в мире, 2020 г. труда (316). Для определения приоритетов и разработки объективно обоснованных решений по укреплению потенциала в области образования, созданию рабочих мест и удержанию сестринских кадров необходимо проводить анализ состояния рынка труда и бюджетных возможностей, реализовывать соответствующую кадровую политику, предпринимать меры планирования и стратегического руководства. По данным настоящего доклада, из 76 стран-респондентов 53% сообщили о наличии национальных программ развития сестринского лидерства. Распределение было неравномерным: такие страны составляли большинство в Африканском регионе и в Регионе Восточного Средиземноморья. 169. Потенциал в области стратегического руководства для рациональной разработки и осуществления политики в области сестринского дела и здравоохранения также требует наличия институтов, механизмов, стратегий и процедур, обеспечивающих учет сестринских кадровых приоритетов и их включение в более широкие государственные меры в секторе здравоохранения и за его пределами. По данным настоящего доклада, наличие должности главной государственной медицинской сестры и наличие программ развития сестринского лидерства коррелируют с более прочной нормативно-правовой средой в сестринском деле. Однако наличие должности главного специалиста по сестринскому делу не всегда коррелирует с наличием программ лидерства. Это может быть связано с тем, что такие программы нередко осуществляются профессиональными ассоциациями в качестве услуги, предоставляемой своим членам, либо как возможность получения дохода. Варианты политики 170. Сестринское лидерство следует развивать на страновом, региональном и глобальном уровне. Работники сестринских служб должны иметь возможность развивать свой лидерский потенциал и участвовать в форумах по принятию решений. Работники сестринских служб должны рассматриваться наравне с представителями других медицинских профессий в качестве кандидатов для назначения на руководящие должности в органах государственного управления на национальном и региональном уровне, а также в местных и других организационных структурах. Эти усилия потребуют выделения бюджетных средств специально для развития сестринского лидерства. В целях достойного признания вклада работников сестринских служб в дело обеспечения всеобщего охвата услугами здравоохранения можно создавать страновые механизмы присуждения денежных премий и других наград. Отмеченные работники смогут служить примером для молодых медсестер (см. вставку 6.9 о программе предоставления стипендий для развития лидерских навыков в Регионе Западной части Тихого океана). 171. Национальные форумы по выработке политики должны учитывать перспективы сестринского дела в процессе принятия © Janice Mullings-George 83Дальнейшие направления развития кадровой политики в области сестринского дела решений относительно деятельности системы здравоохранения. Политика должна обеспечивать, чтобы работники сестринских служб были представлены на всех уровнях принятия решений и могли оказывать влияние на ключевые решения системы здравоохранения и на стратегии в сфере охраны общественного здоровья. Работники сестринских служб также должны участвовать в принятии клинических решений на популяционном уровне, что предполагает, например, их включение в состав рабочих групп по составлению или пересмотру руководств в целях учета мнений представителей сестринской профессии относительно практической осуществимости и приемлемости клинических рекомендаций. 6.5 Стимулирование инвестиций, направленных на создание рабочих мест для сестринского персонала Синтез результатов 172. В настоящем докладе приведены новые факты, подтверждающие необходимость повышенного внимания к сестринскому делу в рамках более широкого подхода к вложению средств в развитие кадров здравоохранения как важнейшему условию для достижения всеобщего охвата услугами здравоохранения. Если не добиться существенного роста масштабов подготовки и трудоустройства сестринских кадров, то даже при позитивной тенденции, отмеченной в течение нескольких последних Вставка 6.9 Программа предоставления стипендий для развития лидерских навыков в Регионе Западной части Тихого океана Системы здравоохранения в Регионе Западной части Тихого океана вынуждены справляться с двойным бременем неинфекционных и инфекционных заболеваний, а также сталкиваются со значительными экономическими, социальными и экологическими проблемами. В этом регионе примерно 78% услуг медицинской помощи предоставляют медицинские сестры (317), поэтому крайне важно, чтобы они располагали соответствующими правами и возможностями, а также получали надлежащее образование, что обеспечит им тот уровень влияния, который необходим для улучшения показателей здоровья населения. Вместе с тем в Регионе традиционно отмечается нехватка программ развития лидерства (318,319), в том числе мало программ для медицинских работников (320–322), а существующие программы не приведены в соответствие с культурным контекстом (317,323,324). В период с 2009 по 2017 г. Технологический университет Сиднея в партнерстве с Южнотихоокеанским альянсом главных ответственных специалистов по сестринскому и акушерскому делу проводил программу Австралийских призовых стипендий по развитию лидерства и наставничества (318). Эта программа была сосредоточена на таких темах, как развитие кадровых ресурсов здравоохранения, коллективная культура, наставничество, осуществление политики и связь с всеобщим охватом услугами здравоохранения. В проведении оценки полезного эффекта приняли участие более 300 представителей заинтересованных сторон и участников программы из 14 стран (318). Предварительные результаты показывают, что 85% участников модуля развития лидерства добились существенных успехов в карьере и заняли руководящие должности в сестринском деле и акушерстве. Они также осуществляли проекты в своих странах в таких областях, как планирование преемственности кадров, профессиональное развитие, регулирование и проведение курсов повышения квалификации (319). Еще один значимый результат: представители этих профессий начали принимать участие в глобальных саммитах, оказывая влияние на политику на общемировом, региональном и национальном уровне (325). На Семьдесят второй сессии Всемирной ассамблеи здравоохранения присутствовали девять специалистов по сестринскому и акушерскому делу – участников программы развития лидерства. Шесть из них стали главными государственными специалистами по сестринскому делу в своих странах, а двое – министрами здравоохранения. 84 Состояние сестринского дела в мире, 2020 г. лет, показатели обеспеченности населения сестринским персоналом в большинстве регионов в течение предстоящего десятилетия улучшатся лишь ненамного, причем сохранится существенный дефицит применительно к имеющимся потребностям в странах с низким и средним уровнем дохода, особенно в Африканском регионе и в регионах Юго- Восточной Азии и Восточного Средиземноморья. 173. Понадобится организация межсекторального диалога по вопросам политики для определения размеров и ассигнования адекватных бюджетных ресурсов на нужды образования, профессиональной подготовки и создания рабочих мест, укрепления механизмов набора, распределения и удержания кадров, а также для наращивания потенциала соответствующих национальных институтов, таких как органы лицензирования и аккредитации. Расширение рынков труда в сфере здравоохранения создает возможности для трудоустройства, особенно для женщин. Увеличение числа рабочих мест в сфере сестринского дела может способствовать расширению участия женщин в общем объеме трудовых ресурсов – которое составляет в глобальном масштабе лишь 48%, по сравнению с 75% для мужчин – а также позволит повысить уровень трудовой занятости женщин (326,327). Полезный эффект инвестиций в создание рабочих мест для медсестер подтверждается бесспорными доказательствами «тройных дивидендов» – для здоровья, гендерного равенства и общего развития (21). Варианты политики 174. Страны должны координировать межсекторальные действия и обеспечивать стабильное финансирование, для того чтобы распространить общий экономический спрос на создание рабочих мест для сестринского персонала. Необходимые 5,9 миллиона новых рабочих мест для сестринского персонала (только тех, которые требуются для заполнения текущего дефицита) в большинстве стран могут быть созданы за счет имеющихся внутренних фондов путем эффективного регулирования роста заработной платы. В процессе национального планирования следует учитывать рентабельность инвестиций в сестринское дело по сравнению с другими профессиональными группами и оптимизировать производительность труда ныне работающих сестринских кадров и © WHO/Yoshi Shimizu приходящих им на смену с помощью надлежащих стимулов и систем управления. В большинстве стран с высоким и средним уровнем дохода текущие расходы на содержание кадровых ресурсов здравоохранения могут покрываться за счет государственных средств (при условии нормальных показателей бюджетного роста и приоритетного внимания к вопросам здравоохранения) (328). Некоторые страны с высоким и средним уровнем дохода могут решить проблему дефицита и повысить спрос, сняв ограничения на подготовку кадров медицинских работников и одновременно сократив чрезмерную зависимость от международной мобильности рабочей силы и иммиграции. 85Дальнейшие направления развития кадровой политики в области сестринского дела 175. Партнерские организации должны согласовывать официальную помощь в поддержку развития в области сестринского образования и занятости с национальными стратегиями в области здравоохранения, в том числе относящимися к развитию кадров. Некоторые страны с низким уровнем дохода и с доходом ниже среднего столкнутся с трудностями в увеличении числа рабочих мест для медсестер из-за недостаточных бюджетных возможностей. Гармонизация и согласованность мер поддержки со стороны доноров и партнеров по развитию могут способствовать наращиванию объемов стабильного финансирования для укрепления кадрового потенциала в области здравоохранения и социального обеспечения. При этом необходимо расширять и поддерживать фонды оплаты труда в целях ускорения прогресса в достижении всеобщего охвата услугами здравоохранения (см. вставку 6.10 об инвестировании в человеческий капитал). В случае ограниченности ресурсов в среднесрочной и долгосрочной перспективе, например в странах с низким уровнем дохода и в условиях нестабильности государства, при наличии конфликтов и других факторов уязвимости, следует, если это позволяют действующие механизмы стратегического руководства, рассмотреть использование таких подходов, как институциональные договоренности об объединении ресурсов. 176. Странам следует рассмотреть вопрос о размерах оплаты труда сестринского персонала с учетом преобладающих местных, национальных и международных условий на рынке труда. Директивные и регулирующие органы, регламентирующие труд государственных служащих или работников здравоохранения, должны осознанно избегать некоторых типичных подводных камней. Речь может идти о таких просчетах, как сохранение слишком низкого уровня оплаты труда (что может привести к демотивации, чрезмерной текучести кадров и незаконным путям приобретения дохода), чрезмерное повышение уровней вознаграждения (что может порождать инфляцию и нарушения стабильности фондов Вставка 6.10 Вложение средств в развитие человеческого капитала Для расширения доступа к качественным услугам первичной медико-санитарной помощи, которая является основой достижения всеобщего охвата услугами здравоохранения, необходимы значительные инвестиции в инфраструктуру (например, больницы и медицинские центры) и в связанный с ней человеческий капитал (кадровые ресурсы здравоохранения, в том числе знания и навыки работников) (14,328). Ряд инициатив в области развития человеческого капитала нацелен на то, чтобы помочь странам инвестировать больше – и более эффективно – в своих граждан для улучшения показателей здоровья, питания, качественного образования и приобретения профессиональных навыков. • Всемирный банк выразил готовность инвестировать 15 млрд долл. США в поддержку реформ, направленных на развитие человеческого капитала в странах с низким уровнем дохода и с доходом ниже среднего, уделив особое внимание Африке; участниками проекта по развитию человеческого капитала стали 63 страны. • Международный валютный фонд укрепляет все программы, выдвигая в качестве основной задачи инициативу по наращиванию социальных расходов. Фонд будет оказывать дополнительную техническую помощь в таких областях, как социальные расходы, социальная защита, образование и здравоохранение. • В контексте всеобщего охвата услугами здравоохранения Европейский инвестиционный банк и ВОЗ сотрудничают в рамках повестки дня развития человеческого капитала в деле разработки финансового инструмента, который свяжет инвестиции Банка с целевой поддержкой образования, приобретения профессиональных навыков и создания рабочих мест в секторе здравоохранения. • ОЭСР, ВОЗ и МОТ учредили Многосторонний партнерский целевой фонд Организации Объединенных Наций для консолидации ресурсов в целях осуществления рекомендаций Комиссии высокого уровня Организации Объединенных Наций по вопросам занятости в области здравоохранения и экономического роста, касающихся преобразующего обучения, приобретения профессиональных навыков и создания рабочих мест. 86 Состояние сестринского дела в мире, 2020 г. оплаты труда) или стойкие неравенства в оплате труда мужчин и женщин. Кроме того, важен формат оплаты труда: в большинстве случаев работники сестринских служб получают фиксированную заработную плату, а доход от двойной практики (в государственном и частном секторе) менее распространен, чем в других медицинских профессиях. Следует избегать мер изолированного финансового стимулирования применительно к отдельным программам или конкретным видам патологии, поскольку они приводят к искажению национальных приоритетов и, как правило, не являются устойчивыми. Директивные органы должны также обеспечивать сбалансированность размеров оплаты труда в разных медицинских профессиях, чтобы не допустить, например, снижения интереса молодых людей к выбору карьеры в области сестринского дела. В конечном счете работники сестринских служб должны получать вознаграждение на уровне, который привлекает, удерживает и мотивирует их в достаточной степени для удовлетворения потребностей населения страны в услугах сестринской помощи. 6.6 Повестка дня научных исследований и накопления фактических данных 177. В настоящем докладе содержатся беспрецедентный объем данных и обзор результатов исследований, касающихся сестринского персонала, что позволяет разработать варианты политики и представить их на рассмотрение государств-членов и других заинтересованных сторон. Вместе с тем на эту работу повлиял ряд ограничений в отношении как самих данных, так и объективных доказательств эффективности. Основные выявленные нами пробелы представлены ниже и могут рассматриваться как часть повестки дня дальнейших научных исследований. 178. Количественные и полуколичественные фактические данные в отношении сестринского дела. Один из самых важных выводов настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» относится не к содержанию данных, а к ситуации с их сбором. Налицо масштабные пробелы в получении важной информации, необходимой для всестороннего анализа состояния сестринских кадров и рынка труда в области здравоохранения, особенно в отношении потенциала для подготовки новых кадров, убыли персонала, уровня заработной платы и возможностей для трудоустройства медицинских работников. Необходимо укрепить вспомогательные системы, лежащие в основе сбора, анализа и применения фактических данных по этим вопросам. Использование системы НСУКЗ, которая базируется на активном межсекторальном взаимодействии, может способствовать поддержанию стратегического диалога и принятию решений относительно плановых, стабильных инвестиций, направленных на стимулирование прогресса по ключевым направлениям развития сестринского дела. 179. Фактические данные об эффективности работы сестринского персонала в сфере первичной медико-санитарной помощи и обеспечения всеобщего охвата услугами здравоохранения. В настоящем докладе обобщены фактические данные об участии работников сестринских служб в осуществлении различных клинических вмешательств и принятии мер в области общественного здравоохранения. Наиболее убедительные сведения получены из выводов систематического обзора, охватившего 18 рандомизированных контролируемых испытаний, продемонстрировавших эффективность проводимых под руководством работников сестринских служб вмешательств по целому ряду функций первичной медико- санитарной помощи (30). Однако 17 из этих 18 исследований были проведены в странах с высоким уровнем дохода, одно – в стране со средним уровнем дохода и ни одного-в странах с низким уровнем дохода. Были также проведены обзоры под эгидой Кокрановского и Кэмпбелловского сотрудничеств по конкретным клиническим и программным областям, в том числе по таким темам, как антиретровирусная терапия, отказ от табака, психическое здоровье и медицинское обследование жертв сексуального насилия. Один из обзоров включал только рандомизированные контролируемые испытания, в то время как другие охватывали как экспериментальные, так и квазиэкспериментальные исследования, в том числе контролируемые испытания (рандомизированные или нерандомизированные), контролируемые 87Дальнейшие направления развития кадровой политики в области сестринского дела исследования «до и после», когортные исследования (проспективные и ретроспективные), а также работы по анализу прерванных временных рядов, что позволяло проводить сравнения между вмешательством и контролем (31,33,34). Кэмпбелловский обзор был сосредоточен на вопросах практики в Соединенных Штатах и Соединенном Королевстве и поэтому охватывал только исследования, проведенные в этих странах. Обзор по антиретровирусной терапии включал только исследования из Африки. Все исследования, включенные в обзор по вопросу об отказе от употребления табака, были проведены в странах с высоким уровнем дохода, главным образом в Соединенных Штатах. Обзор по психическому здоровью был сосредоточен только на странах с низким и средним уровнем дохода, включая семь исследований из стран с низким уровнем дохода и 15 – с низким и средним уровнем дохода (31,33,34). Суммарные обобщенные сведения отражают также конкретные пробелы в фактических данных об эффективности – например, о результативности сестринских вмешательств в отношении социальных детерминант здоровья, включая изменение климата, а также об эффективности работы сестринского персонала в условиях комплексных чрезвычайных ситуаций. 180. Влияние различных условий и методик, использованных в научных исследованиях. Хотя вышеперечисленные систематические обзоры имеют большое значение для оценки эффективности сестринских вмешательств, условия проведения включенных исследований ограничивают обобщаемость и глобальную применимость сформулированных результатов. Кроме того, в экспериментальных и квазиэкспериментальных исследованиях чаще всего проводилось сравнение сестринского персонала с другими медицинскими работниками. Данный метод хотя и позволяет получить полезную информацию, но плохо подходит для иллюстрирования и всестороннего анализа коллективного характера усилий и © WHO/Yoshi Shimizu 88 Состояние сестринского дела в мире, 2020 г. взаимосвязанных процессов, необходимых для успешного оказания качественной медицинской помощи. Более широкий спектр работ, включающий количественные (экспериментальные и неэкспериментальные) и первичные качественные исследования, обзоры смешанных методов и описания на местах, обеспечивает более полный охват вопросов политики сестринского дела по всему миру (см. веб-приложение). Однако преобладающая часть этих данных, а также формирование научно- исследовательских приоритетов (330) относится к странам с высоким уровнем дохода (30,329). 181. Необходимы дополнительные усилия, направленные на документирование сестринских вмешательств в странах с низким и средним уровнем дохода и на поддержку в этих странах сестринской научно-исследовательской работы, с тем чтобы сами работники сестринских служб развивали свои исследовательские программы, опираясь на собственный опыт работы в сфере предоставления услуг здравоохранения. Медицинские сестры уже сегодня вносят весьма существенный вклад в медицинскую науку, сюда относится и разработка инновационных методов научных исследований, и их использование для изучения вопросов, имеющих важное значение для совершенствования глобального здравоохранения (331). Результаты проведенных исследований указывают на низкое качество фактических данных в поддержку эффективных стратегий улучшения практики работы медицинских работников в странах с низким и средним уровнем дохода (332). Поэтому вложение средств в исследования в области сестринского дела должны быть направлены не только на увеличение объема получаемых данных, но и на повышение их научного качества – это будет способствовать углублению наших знаний о кадрах здравоохранения в целом. 182. Фактические данные об эффективной политике и системной поддержке для оптимизации функций сестринского дела. В настоящем докладе подчеркнуты наглядные фактические данные об эффективности вариантов политики, направленной на оптимизацию полезного вклада сестринского дела в различных областях, включая образование, нормативно- правовое регулирование, распределение, практику и удержание персонала. В то же время данные по другим областям были менее убедительными. Например, нуждается в более тщательном изучении вопрос полезной отдачи от инвестиций в развитие сестринских кадров и трудовых ресурсов здравоохранения в целом. Эта тема заслуживает изучения в различных условиях и контекстах политики, в том числе посредством оценки экономической эффективности сестринских услуг, особенно на уровне первичной медико-санитарной помощи в странах с низким и средним уровнем дохода. Имеются также неиспользованные возможности для улучшения фактических данных об эффективности стратегических вмешательств по удержанию работников сестринских служб в условиях практики, подходов к регулированию и управлению, позволяющих медсестрам в полной мере использовать свой профессиональный потенциал в сфере оказания первичной медико- санитарной помощи, а также действенных механизмов регулирования образования и практики в частном секторе. Более тщательная оценка политики, направленной на устранение негативных аспектов миграции, позволит оптимизировать планирование и более реалистично нацеливать соответствующие стратегические меры. Во всех этих областях анализ следует проводить с тщательным учетом гендерных факторов. Поскольку большинство рассмотренных исследований обычно охватывали короткий временной интервал, нужны более долгосрочные, лонгитюдные исследования, которые позволят повысить уровень уверенности в релевантности полученных результатов применительно к условиям реальной жизни. 89Дальнейшие направления развития кадровой политики в области сестринского дела © AKDN/Christopher Wilton-Steer 90 Состояние сестринского дела в мире, 2020 г. 183. В настоящем «Докладе о состоянии сестринского дела в мире, 2020 г.» подчеркивается центральное место работников сестринских служб в составе комплексных бригад, деятельность которых вносит решающий вклад в обеспечение всеобщего охвата услугами здравоохранения и достижение других национальных и глобальных целей в области здравоохранения. Сестринский персонал представляет собой самую крупную профессиональную группу, общая численность которой по состоянию на 2018 г. оценивается примерно в 28 миллионов человек. Медицинские сестры составляют центральный компонент первичной медико-санитарной помощи и систем здравоохранения в странах всех уровней социально-экономического развития. 184. Собранные в процессе подготовки настоящего доклада фактические данные являются более убедительными, чем когда-либо ранее. Сведения о численности кадров поступили, в общей сложности, из 191 страны – рекордно высокий показатель, демонстрирующий 53%-ный рост объема сведений по сравнению с данными по кадрам здравоохранения, полученными в 2018 г. Впервые 80% стран представили ВОЗ данные по не менее 15 показателям сестринского дела, характеризующим различные аспекты кадровой политики. Анализ динамики численности кадров указывает, по состоянию на 2018 г., на нехватку 5,9 миллиона работников сестринских служб, преимущественно в регионах Африки, Юго-Восточной Азии и Восточного Средиземноморья. Это, однако, свидетельствует об улучшении состояния сестринских кадров в странах, затронутых дефицитом, по сравнению с исходной ситуацией, описанной в Глобальной стратегии. 185. Наряду с фактами, подтверждающими прогресс, в докладе также указан ряд ключевых проблемных областей. В соответствии с прогнозами, приведенными в Глобальной стратегии в 2016 г., для устранения ключевых пробелов необходимо ускорить прогресс в странах с низким уровнем дохода и с доходом ниже среднего, а также в регионах Африки и Восточного Средиземноморья. Самый большой дефицит в абсолютных цифрах сохраняется в Регионе Юго-Восточной Азии. Дополнительную угрозу для Региона стран Америки и Европейского региона несет проблема старения сестринских кадров. Некоторые страны с высоким уровнем дохода в регионах стран Америки, Европы и Восточного Средиземноморья, как представляется, ЗАКЛЮЧЕНИЕ 7ГЛАВА 91Заключение чрезмерно зависят от международной мобильности работников сестринских служб. 186. Правительства стран при поддержке, в случае необходимости, со стороны отечественных и международных партнеров должны стимулировать и возглавить усилия по активизации деятельности в следующих областях: • наращивание лидерского, руководящего и управленческого потенциала работников сестринских служб в интересах дальнейшего развития программ в сфере образования, здравоохранения, трудовой занятости и учета гендерных аспектов; • обеспечение оптимальной отдачи от инвестиций в развитие сестринского дела посредством принятия необходимых стратегических мер в таких областях, как подготовка кадров, достойная работа, справедливая заработная плата, практика, производительность труда, нормативно- правовое регулирование и удержание сестринского персонала; • масштабное вложение ресурсов в укрепление кадров здравоохранения, в том числе сестринского персонала, и использование этих средств для достижения различных целей в области развития, включая создание рабочих мест, решение гендерных проблем и расширение прав и возможностей молодежи. 187. Преобразование фактических данных настоящего доклада, рекомендованных вариантов политики и вышеописанных стратегических направлений в конкретные решения в сфере политики и инвестиций потребует координации усилий различных государственных секторов и сотрудничества с наиболее важными заинтересованными сторонами. Представленные выводы и данные следует использовать для реализации возможностей стратегического диалога в странах с участием ключевых заинтересованных сторон. Такой диалог следует использовать для выработки необходимых решений в плане принятия рациональной и объективно обоснованной политики, а также при определении соответствующих уровней инвестиций. © WHO/Yoshi Shimizu 92 State of the world’s nursing 2020 Не упустим эту возможность, чтобы посвятить силы десятилетию действий, первейшее из которых – вложение РЕСУРСОВ в СЕСТРИНСКОЕ ДЕЛО – в образование, рабочие места и лидерство работников сестринских служб. Библиография 1. 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Кто такие работники сестринских служб? 12 Международная стандартная классификация занятий МОТ (https://www.ilo.org/public/english/bureau/stat/isco/) Работники сестринских служб предоставляют широкий спектр медицинских услуг в различных условиях – от специализированных больниц до периферических медпунктов и на дому у пациентов. Сестринский персонал характеризуется широким набором должностных категорий, профессиональных функций и различными уровнями образовательной подготовки. Шесть наиболее распространенных названий сестринских должностей – дипломированная медицинская сестра; медицинская сестра; лицензированная практикующая медицинская сестра, зарегистрированная медицинская сестра расширенной практики; практикующая медсестра; ассистент медицинской сестры. Функции работников сестринских служб с одним и тем же должностным титулом, но работающих в разных странах, могут различаться. Это делает нецелесообразным использование названия должности в качестве метода классификации и анализа на международном уровне. Цель настоящего доклада – представить наилучшие имеющиеся, сопоставимые на международном уровне данные о сестринских кадрах в соответствии с определением, приведенным в Международной стандартной классификации профессий МОТ 2008 г. (МСКЗ-08). Эти данные были получены от государств-членов ВОЗ, которые подтвердили их достоверность. Содействие в достижении этой цели оказала Национальная система учета кадров здравоохранения (НСУКЗ), в которой используется МСКЗ- 08 для классификации трудовых ресурсов. Странам было предложено классифицировать свои сестринские кадры по одному из двух основных кодов МСКЗ-08: медицинская сестра профессионального уровня (код МСКЗ 2221) и медицинская сестра ассоциированного профессионального уровня (код МСКЗ 3221). Следует уточнить, что в настоящем разделе говорится о сестринском персонале как о профессиональной группе, определенной выше, но «сестринская помощь», в рамках оказания которой сестринский персонал является частью мультидисциплинарной системы здравоохранения, включает в себя ряд других профессий, не описанных в настоящем разделе. Например, в соответствии с МСКЗ в странах, использующих данную классификацию, выделяют категорию «помощников медицинских сестер» (nursing aids) для обозначения более широкой профессиональной группы12. Руководство МСКЗ содержит подробное описание того, какие медицинские работники должны учитываться в каждой категории (вставка А1.1). Медицинские сестры профессионального уровня отвечают за планирование и организацию сестринской помощи пациентам, работая самостоятельно или совместно с врачами и другими сотрудниками. Медицинские сестры ассоциированного профессионального уровня предоставляют пациентам основные услуги сестринской помощи и индивидуального ухода, работая, как правило, под руководством и при поддержке со стороны врачей, медицинских сестер или других медицинских работников. Однако в некоторых странах различия между медицинскими сестрами профессионального и ассоциированного профессионального уровня выглядят размытыми. Аналогичным образом, не всегда четкий характер носят различия между медицинскими сестрами ассоциированного профессионального уровня и помощниками медсестер. В таких случаях было необходимо получить определенные разъяснения от национальных заинтересованных сторон. Странам было рекомендовано учитывать как функции и обязанности, так и продолжительность базового образования при принятии решения о том, следует ли относить ту или иную профессиональную группу к категории медсестер профессионального или ассоциированного профессионального уровня либо вообще не включать этих работников в состав сестринского персонала. Например, в качестве общего правила, срок базового обучения медицинской сестры профессионального уровня должен составлять не менее трех лет. Для тех случаев, когда страна не может решить, какую категорию использовать, в НСУКЗ предусмотрена категория «медицинские сестры: без дальнейшего уточнения», и некоторые страны решили отнести к этой категории определенную часть или всех работников сестринских служб. Данная категория может охватывать медицинских сестер профессионального или ассоциированного профессионального уровня, но не включает помощников медсестер, которые относятся к профессиональной группе помощников по оказанию медицинской помощи, не анализируемой в настоящем докладе. 108 Состояние сестринского дела в мире, 2020 г. ФУНКЦИИ МЕДИЦИНСКОЙ СЕСТРЫ ПРОФЕССИОНАЛЬНОГО УРОВНЯ: ФУНКЦИИ МЕДИЦИНСКОЙ СЕСТРЫ АССОЦИИРОВАННОГО ПРОФЕССИОНАЛЬНОГО УРОВНЯ: • Планирование и предоставление услуг сестринской помощи пациентам, а также оценка качества услуг • Координация оказываемой помощи в консультации с другими медицинскими работниками • Разработка и осуществление, в сотрудничестве с другими медицинскими работниками, планов предоставления услуг в контексте лечения пациентов • Планирование и предоставление услуг индивидуального ухода и лечения, включая введение (контроль за приемом) лекарственных препаратов и мониторинг динамики состояния пациента в ответ на проводимое лечение • Обработка ран и наложение повязок • Мониторинг болевого синдрома и дискомфорта у пациентов и облегчение боли с помощью лечебных вмешательств, включая назначение обезболивающих препаратов • Планирование и участие в просветительных программах по вопросам здоровья, в программах содействия поддержанию и укреплению здоровья и в мероприятиях по повышению квалификации сестринского персонала • Ответы на вопросы пациентов и членов их семей и предоставление информации о профилактике заболеваний, лечении и уходе за заболевшими • Руководство и координация деятельности других медицинских работников • Проведение исследований по проблемам • Предоставление услуг сестринской помощи и индивидуального ухода, осуществление лечебных процедур и медицинских консультаций для пациентов в соответствии с планами оказания помощи, установленными медицинскими работниками профессионального уровня • Введение (контроль за приемом) лекарственных препаратов и выполнение других лечебных процедур, мониторинг состояния пациента, включая реагирование на проводимое лечение, а также, при необходимости, направление пациентов и их семей для получения специализированной помощи • Обработка ран и наложение повязок • Документирование информации о состоянии пациентов и проводимых лечебных вмешательствах в системах клинического учета • Помощь в планировании и организации медицинских услуг, предоставляемых индивидуальным пациентам • Участие в оказании первой медицинской помощи в чрезвычайных ситуациях Определения МСКЗ, относящиеся к сестринскому персоналуВставка A1.1 Примечание: различие между медсестрами профессионального и ассоциированного профессионального уровня должно устанавливаться на основе характера выполняемой работы применительно к вышеперечисленным функциям. Квалификация, которой обладают отдельные работники или которая преобладает в стране, не является определяющим фактором для проведения этого различия, поскольку механизмы подготовки медицинских сестер широко варьируются между странами и периодически меняются и внутри стран. Источник: адаптировано из МСКЗ-08. 109Приложение 1 Приложение 2. Методы 13 Национальная система учета кадровых ресурсов здравоохранения: руководство. Женева: Всемирная организация здравоохранения; 2018 г. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York: United Nations; 2019. 15 Данные организации «Сигма» были взяты из следующего источника: https://www.sigmanursing.org/advance-elevate/research/research-resources. Данные NCSBN были взяты из следующего источника: https://www.ncsbn.org/national-nursing-database.htm. Показатели, использованные в настоящем «Докладе о состоянии сестринского дела в мире, 2020 г.» Государствам-членам ВОЗ было предложено представить в период с июля по ноябрь 2019 г. самые последние имеющиеся у них данные о сестринских кадрах по 36 показателям: 30 – из НСУКЗ плюс шесть дополнительных специальных показателей (см. перечень в таблице A2.1). Вышеупомянутые 30 показателей приведены в руководстве НСУКЗ13, которое также содержит подробные определения и метаданные для каждого показателя. Процесс сбора данных Использование НСУКЗ предусматривает непрерывный процесс, характеризующийся постоянным улучшением доступности, качества и практического применения данных о кадрах здравоохранения. В рамках этого процесса странам было рекомендовано создать многопрофильные рабочие группы по всем аспектам, связанным с данными о кадрах здравоохранения, с задачей проведения внутренней проверки этих данных перед их представлением; это было сделано в значительном числе стран. Подготовка настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» ускорила эти глобальные усилия по совершенствованию мониторинга и представления стандартизированных данных. Странам было также предложено назначить координаторов, которым был предоставлен доступ к онлайн- платформе НСУКЗ для ввода и верификации данных. Кроме того, чтобы избежать двойного представления отчетности, были предварительно внесены данные по странам ОЭСР, полученные в результате заполнения совместного вопросника ОЭСР, Евростат и Европейского регионального бюро ВОЗ, и координаторам было рекомендовано провести обзор и проверку этих данных. Цифры численности населения по каждой стране и по каждому году были взяты из «Мировых демографических перспектив» пересмотра 2019 г., опубликованных Департаментом по экономическим и социальным вопросам Организации Объединенных Наций14. Дополнительные данные по показателям оценки условий стратегического руководства и политики, полученные с помощью ответов на закрытые вопросы (да/ нет) о наличии соответствующих механизмов и процессов, а также данные о продолжительности образования и профессиональной подготовки были также взяты из баз данных организаций «Сигма» и NCBSN15 для получения полной информации по небольшому числу стран. В целях поддержки процесса сбора данных ВОЗ провела региональные семинары по НСУКЗ во всех шести регионах и предоставила инструменты и информацию на нескольких языках. В общей сложности в этих мероприятиях по наращиванию потенциала приняли участие более 250 представителей примерно 80 стран. Данные поступали в период с июля по ноябрь 2019 г., а их очистка и анализ были проведены в период с октября по декабрь 2019 г. Настоящий доклад базируется на наборе данных, полученных с онлайн-платформы НСУКЗ по состоянию на 17 декабря 2019 г. Координаторам НСУКЗ было рекомендовано привлечь к этой работе руководителей сестринского дела и представителей других национальных заинтересованных сторон. Страновые офисы и региональные бюро ВОЗ оказали поддержку процессу внедрения НСУКЗ, включая сбор, представление и валидацию соответствующих данных. Представленные данные Из 194 государств-членов ВОЗ 193 представили данные (191 – о численности кадров) либо непосредственно через платформу НСУКЗ, либо через региональные бюро и посредством других международных процессов, таких как совместный сбор нефинансовых статистических данных по здравоохранению, осуществляемый под эгидой ОЭСР, Евростат и Европейского регионального бюро ВОЗ. Как показано на рисунке А2.1, 80% стран представили данные не менее чем по 15 из 36 показателей, а 23% – не менее чем по 25 показателям. Основные пробелы в данных были связаны с показателями, касающимися оплаты труда, а также расходов и других характеристик, которые относятся к учебной подготовке сестринского персонала. Для отдельных показателей, таких как продолжительность базового образования и профессиональной подготовки, заработная плата и параметры потенциала, были использованы альтернативные источники, дополняющие данные НСУКЗ. Например, международное общество поддержки сестринского дела «Сигма» ведет базу данных о состоянии сестринского образования во всем мире, включая показатели заработной платы начального уровня и продолжительности образовательных программ примерно для 50 стран. Для получения сведений по показателям, имеющим отношение к политике и регулированию 110 Состояние сестринского дела в мире, 2020 г. Тридцать показателей были взяты из Руководства по НСУКЗ, а шесть были специально разработаны для настоящего доклада. Название индикатора (по НСУКЗ, сокращенное) Номер в НСУКЗ Процент ответивших стран, по состоянию на 17 декабря 2019 г. ОБЩАЯ ЧИСЛЕННОСТЬ И РАСПРЕДЕЛЕНИЕ СЕСТРИНСКИХ КАДРОВ Обеспеченность сестринским персоналом по типам / профессиональным уровням 1-01 98% Обеспеченность сестринским персоналом на субнациональном уровне 1-02 31% Распределение сестринского персонала по возрастным группам 1-03 55% Работники сестринских служб – женщины 1-04 68% Распределение сестринского персонала между учреждениями различной формы собственности 1-05 47% Распределение сестринского персонала между учреждениями различного типа 1-06 34% Доля работников сестринских служб, родившихся за границей 1-07 35% Доля работников сестринских служб, получивших образование за границей 1-08 46% ОБУЧЕНИЕ И ПРОФЕССИОНАЛЬНАЯ ПОДГОТОВКА Сводный перечень аккредитованных образовательных учреждений 2-01 88% Продолжительность образования и профессиональной подготовки 2-02 56% Количество заявлений на получение образования и профессиональной подготовки 2-03 12% Отношение числа студентов в программах сестринского образования к числу квалифицированных преподавателей 2-05 10% РЕГУЛИРОВАНИЕ И АККРЕДИТАЦИЯ ОБРАЗОВАНИЯ И ПРОФЕССИОНАЛЬНОЙ ПОДГОТОВКИ Стандарты продолжительности обучения и содержания учебных программ 3-01 87% Механизмы аккредитации учебных заведений 3-02 84% Стандарты межпрофессионального образования 3-06 80% Непрерывное профессиональное развитие 3-08 82% ФИНАНСИРОВАНИЕ ОБРАЗОВАНИЯ Расходы на одного выпускника программы сестринского образования 4-05 7% ДВИЖЕНИЕ КАДРОВ НА РЫНКЕ ТРУДА Выпускники, приступающие к практической работе в течение одного года 5-01 14% Доля пополнения кадров в результате внутригосударственных усилий 5-02 45% Доля иностранных медицинских сестер, вступающих на рынок труда 5-03 11% Уровень добровольного оттока кадров с рынка труда 5-04 9% Уровень безработицы 5-06 8% ПАРАМЕТРЫ ЗАНЯТОСТИ И УСЛОВИЯ ТРУДА Работники здравоохранения, занятые неполный рабочий день 6-02 6% Положение о продолжительности рабочего времени и условиях труда 6-03 86% Положение о минимальном размере оплаты труда 6-04 86% Положение о социальной защите 6-05 86% Меры по предотвращению нападений на работников здравоохранения 6-09 80% РАСХОДЫ НА СЕСТРИНСКИЙ ПЕРСОНАЛ И ОПЛАТА ТРУДА РАБОТНИКОВ СЕСТРИНСКИХ СЛУЖБ Начальный уровень заработной платы и окладов 7-05 42% Гендерный разрыв в заработной плате 7-07 3% СОЧЕТАНИЯ КВАЛИФИКАЦИЙ ДЛЯ РАЗЛИЧНЫХ МОДЕЛЕЙ ОКАЗАНИЯ ПОМОЩИ Наличие расширенных сестринских функций 8-06 79% ДОПОЛНИТЕЛЬНЫЕ СПЕЦИАЛЬНЫЕ ПОКАЗАТЕЛИ, ИСПОЛЬЗОВАННЫЕ В НАСТОЯЩЕМ «ДОКЛАДЕ О СОСТОЯНИИ СЕСТРИНСКОГО ДЕЛА В МИРЕ, 2020 Г.» Должность главного государственного специалиста по сестринскому и/или акушерскому делу (главной государственной медицинской сестры и/или акушерки) – 84% Программы развития сестринского лидерства – 76% Национальная ассоциация молодых и начинающих работников сестринских служб – 76% Сестринский совет – 98% Стандартные требования к квалификации преподавателей – 68% Экзамен на готовность к практике – 92% Перечень 36 показателей, использованных для подготовки настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» Таблица A2.1 Примечание: дополнительная информация о показателях НСУКЗ, включая детальное описание метаданных, содержится в руководстве по НСУКЗ: https:// apps.who.int/iris/handle/10665/311615 Для получения метаданных по дополнительным шести показателям, не относящимся к НСУКЗ, просьба направить запрос по адресу: SOWN2020@who.int. 111Приложение 2 сестринской практики и образования, был использован Глобальный нормативный атлас NCSBN. Из этого источника были взяты сведения о том, в каких странах проводится экзамен на получение лицензии и в каких имеются регулирующие органы. Из 191 страны 83% представили данные о численности работающего сестринского персонала по состоянию на 2017 или 2018 г. Другие смогли представить данные только за более ранние годы (с 2013 по 2016 г.). В таких случаях численность персонала на 2018 г. оценивалась путем применения последнего имеющегося значения показателя обеспеченности кадрами к численности населения в 2018 г. Для четырех стран, по которым численность работающего персонала не была указана, использовались соответствующие региональные значения обеспеченности применительно к численности населения в 2018 г. Тот факт, что многие страны – особенно в Западной и Центральной Африке, а также в Центральной Азии – не смогли представить данные по ряду показателей, свидетельствует о настоятельной необходимости дальнейшего укрепления информационных систем по кадрам здравоохранения в этих регионах. В настоящем докладе приведены не все собранные данные: проанализированы и представлены только те показатели, по которым были получены статистические данные от значительного числа стран. Дополнительные данные будут по мере их поступления размещаться на открытом информационном портале НСУКЗ. Сводные баллы оценки состояния нормативно- правового регулирования образования и условий труда, приведенные в разделах 5.4 и 5.6 В то время как большинство аналитических заключений носили чисто описательный характер с приведением главным образом процентных отношений, для обобщения оценок показателей регулирования в сфере образования и условий труда были рассчитаны сводные баллы. Страна получала 1 балл за каждый показатель, по которому был получен ответ «да», 0,5 балла, если ответ был «отчасти», и 0 баллов при ответе «нет». Затем баллы суммировались для определения сводного показателя. Таким образом, максимально возможная сумма баллов составляла 9, минимальная – 0. Показатели с отсутствием сведений расценивались как «нет», следовательно получали 0 баллов. Анализ множественного соответствия применительно к оценке нормативно-правового регулирования образования и условий труда в разделах 5.4 и 5.6 Показатели регулирования образования и практики демонстрируют высокий уровень корреляции: если на один вопрос дан ответ «да», существует высокая вероятность утвердительного ответа и на некоторые другие вопросы. Для лучшего понимания таких закономерностей был проведен анализ множественного соответствия, который позволяет представить корреляцию между многими переменными в одном двумерном графике (рисунок А2.2). Этот анализ позволил построить два измерения (оси Х и Y). Первое измерение (ось Х) Число показателей, по которым страны представили данные для настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.» Рисунок A2.1 0 1,000 2,000 3,000 4,000500 km <5 5–9 10–14 15–19 20–24 25 и более нет данныхнеприменимо Примечание: включают 30 показателей НСУКЗ и шесть показателей потенциала. Источник: НСУКЗ, 2019 г. 112 Состояние сестринского дела в мире, 2020 г. может быть интерпретировано как совокупность факторов, коррелирующих с отсутствием регулирования (справа на графике) или с его наличием (слева на графике). Это измерение объясняет 79,7% вариабельности между переменными. Второе измерение (ось Y) может быть интерпретировано как отсутствие механизмов аккредитации (в верхней части оси) в противоположность отсутствию регулирования образования (в нижней части оси). Это измерение объясняет 2,1% вариабельности между показателями. На графике также обозначены регионы, чтобы выделить, с какими показателями они более тесно коррелируют. Анализ подтвердил, что поскольку регионы Юго-Восточной Азии, Восточного Средиземноморья и Западной части Тихого океана попали в правую часть графика, для них выше вероятность наличия корреляции с более низким уровнем регулирования сестринского образования. По результатам анализа множественного соответствия (рис. А2.3) выявлена тесная корреляция между показателями условий труда. Два таких показателя – это принятие мер по предотвращению нападений на персонал и наличие расширенных сестринских функций. Данный феномен может свидетельствовать о том, что в более рискованных условиях медсестрам предоставляют более высокий уровень профессиональной автономии для поддержания необходимого уровня помощи пациентам в сложных обстоятельствах. В этом отношении Европейский регион продемонстрировал иную картину, чем другие регионы: в нем в меньшей степени применялись меры по предотвращению нападений на работников и реже практиковались расширенные сестринские функции. Прогнозируемая численность кадров к 2030 г. Для расчета прогнозируемой численности сестринского персонала к 2030 г. были разработаны следующие три сценария. • Сценарий 1: старение (изолированный эффект старения сестринских кадров). В прогнозе использовалось возрастное распределение в разбивке по странам при сохранении стабильной численности возрастной группы до 35 лет с учетом пополнения на одну десятую от размера этой самой младшей возрастной категории. При этом считалось, что численность выходящих на пенсию работников составит одну десятую от численности группы сестринского персонала в возрасте 55 лет и старше. Данный сценарий не учитывает Рисунок A2.2 Корреляция показателей образования по результатам анализа множественного соответствия SEAR EUR AMR EMR AFR WPR Измерение 1 (79,7%) И зм ер ен ие 2 (2 ,1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 Нет-M2-01 Нет-M3-02 Нет-M3-01Нет-NN2 Нет-NN3 Нет-M3-08 Нет-M3-06Да Да Да Да Да Да Да Тип анализа: анализ множественного соответствия переменных по регулированию системы сестринского образования; регионы отображены как независимые переменные. Переменные, суммированные в настоящем графике: М2-01 – сводный перечень аккредитованных образовательных учреждений; М3-01 – стандарты продолжительности и содержания образования; М3 02 – механизмы аккредитации образовательных учреждений; М3-06 – стандарты межпрофессионального образования; М3-08 – непрерывное профессиональное развитие; NN2 – экзамен на готовность к практике; NN3 – стандарты квалификации преподавателей. AFR – Африканский регион; AMR – Регион стран Америки; SEAR – Регион Юго-Восточной Азии; EUR – Европейский регион; EMR – Регион Восточного Средиземноморья; WPR – Регион Западной части Тихого океана. Источник: НСУКЗ, 2019 г. Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. 113Приложение 2 статистику подготовки выпускников и предполагает сохранение постоянной доли младшей возрастной группы на предстоящие годы. • Сценарий 2: пополнение. В этом сценарии предполагаются такие же масштабы старения, как и в сценарии 1, но используются рассчитанные в разделе 5.5 самые последние показатели подготовки выпускников по регионам с применением поправочного коэффициента 0,6 с учетом того, что лишь 60% новых выпускников найдут работу в секторе здравоохранения. Таким образом воспроизводится разница между выпуском и вступлением в состав трудоустроенных кадров, которая наблюдается в странах ОЭСР. • Сценарий 3: ускоренное пополнение. Данный сценарий аналогичен сценарию 2, но предусматривает повышение масштабов подготовки и трудоустройства выпускников. Предполагается, что за период с 2018 по 2030 г. потенциал подготовки выпускников в странах повысится на 50%, что эквивалентно ежегодному росту на 3,44%. При этом сценарии также считается, что поглощающая способность рынка труда в сфере здравоохранения составляет 60%. Исходя из этих сценариев были рассчитаны прогнозируемые значения обеспеченности населения сестринскими кадрами на 2030 r. с использованием оценок из демографических перспектив Организации Объединенных Наций на 2030 г. Для оценки влияния сценария 3 были использованы различные модели с вариантами прироста численности выпускников: 25%-ный прирост, 50%-ный прирост и 100%-ный прирост (удвоение масштабов подготовки новых кадров) (рис. А2.4). При этом видно, что выбор темпа роста числа выпускников программ сестринского дела не оказывает радикального влияния на прогнозируемую численность к 2030 г.: при уровнях прироста 25%, 50% и 100% эта численность составляет соответственно 38,0 млн, 39,7 млн и 42,8 млн человек. Следует соблюдать осторожность при трактовке прогнозов При интерпретации прогнозов необходимо учитывать ряд ограничений. 1. Имеет место неполнота данных: не все страны смогли представить сведения о возрастных группах, используемые в сценарии 1, и о масштабах подготовки выпускников для сценария 2. Проведенный анализ показал аналогичные результаты для сценариев 1 и 2, что, таким образом, обеспечивает Рисунок A2.3 Корреляция показателей условий труда по результатам анализа множественного соответствия 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR Нет-M6-03 Нет-M6-04 Нет-NN1 Нет-M6-09 Нет-M8-06 Да-M6-09 Да-M8-06 Да Да Да Измерение 1 (80,1%) И зм ер ен и е 2 (2 ,6 % ) Тип анализа: анализ множественного соответствия переменных по регулированию условий труда; регионы отображены как независимые переменные. Переменные, суммированные в настоящем графике: М6-03 – наличие положения о рабочем времени и условиях труда; М6-04 – положение о минимальной заработной плате; М6-09 – наличие мер по предотвращению нападений; М8-06 – наличие расширенных сестринских функций; NN1 – наличие сестринского совета. AFR – Африканский регион; AMR – Регион стран Америки; SEAR – Регион Юго-Восточной Азии; EUR Европейский регион; EMR – Регион Восточного Средиземноморья; WPR – Регион Западной части Тихого океана. Источник: НСУКЗ, 2019 г. Последние имеющиеся данные, представленные странами за период с 2013 по 2018 г. 114 Состояние сестринского дела в мире, 2020 г. уверенность в уровнях вступления новых выпускников в рынок труда. 2. Был использован ряд предположительных значений сокращения численности кадров за счет лиц в возрасте 55 лет и старше. Эти значения варьировались в зависимости от региона и, вероятно, являются оптимистичными, поскольку возраст выхода на пенсию будет составлять вплоть до 65 лет. Аналогичным образом при анализе применялось соотношение 0,6 для расчета численности выпускников, приступающих к практической деятельности, основанное на принятой в ОЭСР пропорции практикующих медсестер по отношению ко всем получившим лицензию. Это значение, однако, в потенциале может варьироваться по регионам. Для оценки влияния всех базовых допущений на сценарии 1–3 была проведена серия анализов чувствительности. Результаты менялись лишь незначительно, и выводы оставались в основном неизменными. 3. Прогнозы отражают только недавние тенденции и дают широкое представление о динамике численности сестринских кадров. Их будет необходимо пересматривать по мере поступления новых данных. Кроме того, эти прогнозы не заменяют выводов, сделанных на основе моделирования на национальном уровне, которое учитывает более широкий спектр трудовых ресурсов здравоохранения и другие показатели по всем аспектам рынка труда в области здравоохранения, а также более детальную экономическую статистику, включая бюджетные возможности. Оценка дефицита Оценка уровня дефицита сестринского персонала проводилась по методу, аналогичному тому, что был приведен в Глобальной стратегии для развития кадровых ресурсов здравоохранения. Однако, поскольку появились обновленные данные, значения дефицита нельзя непосредственно сопоставить с оценками Глобальной стратегии. Анализ показывает, что расчеты, содержащиеся в Глобальной стратегии, базировались на сведениях из 102 стран о численности кадров по состоянию на период 2009-2013 гг.; для остальных стран были использованы более ранние или смоделированные данные. На основе последних данных, представленных для подготовки настоящего «Доклада о состоянии сестринского дела в мире, 2020 г.», 174 страны имели данные о численности сестринских кадров за 2013 г. или за предыдущие пять лет (включая 130 стран с данными за 2013 г.), и пересмотренное значение численности по состоянию за 2013 г. оценивалось в 23,2 миллиона работников. Оценка численности по состоянию на 2018 г. основана на данных по 191 стране за период 2013–2018 гг. При этом 89% стран Рост мировой численности сестринского персонала (млн) при сохранении прежних масштабов подготовки кадров и трех сценариев роста численности выпускников программ сестринского образования, 2018–2030 гг. Рисунок A2.4 Численность выпускников программ сестринского обучения постоянна 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 Чи сл ен но ст ь се ст ри нс ко го п ер со на ла в м ил ли он ах ч ел ов ек Численность сестринского персонала – 25%-ный рост числа выпускников Численность сестринского персонала – 50%-ный рост числа выпускников Численность сестринского персонала – 100%-ный рост числа выпускников Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Используемые поправочные факторы, специальные по каждому региону: фактор старения (ежегодно выходит на пенсию одна десятая от численности возрастной группы в возрасте 55 лет и старше по состоянию на 2018 г.); поправочный коэффициент 0,6, применяемый к значениям численности выпускников, рассчитанным в разделе 5.5 (пропорция ОЭСР «практика / наличие лицензии»), для учета работы выпускников вне сестринской практики. 115Приложение 2 представили данные за 2017 и 2018 гг. Таким образом, значение этого показателя за 2018 г., приведенное в настоящем «Докладе о состоянии сестринского дела в мире, 2020 г.», можно рассматривать как весьма надежное. Для оценки кадрового дефицита показатели обеспеченности населения сестринскими кадрами на 2018 и 2030 гг. были сопоставлены с пороговым значением, использованным в Глобальной стратегии для развития кадровых ресурсов здравоохранения. Этот показатель в размере 4,45 врачей, медсестер и акушерок на 1000 населения был затем преобразован в пороговое значение для сестринского дела. • Сначала доля медсестер и акушерок, приведенная в Глобальной стратегии, была применена к этому пороговому показателю: с 20,7 медсестер и акушерок на 10 000 населения и 9,8 врачей на 10 000 населения в 2013 г. пороговое значение было скорректировано до 3,02 медсестер и акушерок на 1000 населения (4,45 х (20,7/(9,8+20,7))). 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. • Затем, чтобы рассчитать пороговое значение только для сестринского персонала, была учтена доля медсестер среди медсестер и акушерок, вместе взятых (90,7% за последний год с наличием данных), что дает базовое значение обеспеченности сестринскими кадрами 2,74 на 1000 населения. • Поскольку показатель обеспеченности выражается в расчете на 10 000 населения, в качестве ориентира для обеспеченности сестринскими кадрами было использовано значение 27,4 на 10 000 населения. • Затем это базовое значение было сопоставлено с обеспеченностью по состоянию на 2018 г. и экстраполировано на 2030 г. в соответствии с тремя сценариями. Предполагаемый дефицит к 2030 г. был рассчитан для трех прогнозируемых сценариев, описанных выше. Было установлено, что при всех сценариях дефицит остается высоким в странах с низким уровнем дохода и с доходом ниже среднего (таблица А2.2). Затраты на подготовку одного выпускника Был выявлен ряд различных источников, приводящих данные о стоимости подготовки сестринских кадров из расчета на одного выпускника в странах с низким уровнем дохода и с доходом ниже среднего, где в основном имеет место дефицит. Данные варьируются от 5180 долл. США на Мадагаскаре, 5589 долл. США в анализе ECSA Всемирного банка16 и 5656 долл. США в Мозамбике до 19 794 долл. США в Гане17. Поэтому расчеты затрат были проведены с использованием трех следующих сценариев: более низкий уровень – 5000 долл. США, промежуточный уровень – 10 000 долл. США и более высокий уровень – 20 000 долл. США на подготовку одного выпускника. Следует оговориться, что имеющиеся значения по уровням затрат были получены из африканских стран и неприменимы к странам с высоким уровнем дохода, в которых, по опубликованным данным, затраты на подготовку одного выпускника намного выше. ГРУППЫ СТРАН ПО УРОВНЮ ДОХОДА 2018 г. 2030 г. Старение кадров и стабильная доля молодой возрастной группы Старение кадров и сохранение масштабов подготовки новых работников на уровне последних лет Старение кадров и рост масштабов подготовки новых работников на 50% к 2030 г. Низкий уровень дохода 1,34 1,80 1,54 1,26 Уровень дохода ниже среднего 3,91 3,44 2,81 1,54 Уровень дохода выше среднего 0,67 0,45 0,25 0,12 Высокий уровень дохода (используется для сравнения, все страны – с показателем обеспеченности выше порогового значения) – – – – Всего в мире 5,91 5,69 4,60 2,92 Расчетные значения дефицита сестринского персонала (в миллионах человек) в странах, где показатель обеспеченности кадрами ниже порогового значения, приведенного в Глобальной стратегии, в разбивке по уровню дохода стран, 2018 и 2030 гг. (три сценария) Таблица A2.2 Примечание: «сестринский персонал» включает только медицинских сестер профессионального и ассоциированного профессионального уровня. Распределение стран по уровням дохода выполнено в соответствии с классификацией Всемирного банка по состоянию на 2018 г. 116 Состояние сестринского дела в мире, 2020 г. 117Section title Влож ение средст в в образование, рабочие м ест а и воспит ание лидеров СО СТО Я Н И Е СЕСТРИ Н СК О ГО Д ЕЛ А В М И РЕ 2020 г. Cотрудничающие организации: Вложение средств в образование, рабочие места и воспитание лидеров СОСТОЯНИЕ СЕСТРИНСКОГО ДЕЛА В МИРЕ 2020 г.

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الاستثمار في التعليم والوظائف والمهارات القيادية حالة التمريض 0202 في العالم حالة التمريض في العالم 0202: الاستثمار في التعليم والوظائف والمهارات القيادية [pihsredael dna sboj ,noitacude ni gnitsevni :0202 gnisrun s’dlrow eht fo etatS] 3-684000-4-29-879 NBSI (نسخة الإلكترونية) 0-784000-4-29-879 NBSI (نسخة مطبوعة) © منظمة الصحة العالمية 0202 بعض الحقوق محفوظة. هذا المصنف متاح بمقتضى ترخيص المشاع الإبداعي "نسب المصنف – غير تجاري – المشاركة بالمثل 0.3 لفائدة المنظمات الحكومية الدولية" (ra.deed/ogi/0.3/as-cn-yb/sesnecil/gro.snommocevitaerc//:sptth ;OGI 0.3 AS-CN-YB CC) وبمقتضى هذا الترخيص يجوز أن تنسخوا المصنف وتعيدوا توزيعه وتحوروه للأغراض غير التجارية، وذلك شريطة أن يتم اقتباس المصنف على النحو الملائم كما هو مبين أدناه. ولا ينبغي في أي استخدام لهذا المصنف الإيحاء بأن المنظمة (OHW) تعتمد أي منظمة أو منتجات أو خدمات محددة. ولا ُيسمح باستخدام شعار المنظمة (OHW). وإذا قمتم بتعديل المصنف فيجب عندئٍذ أن تحصلوا على ترخيص لمصنفكم بمقتضى نفس ترخيص المشاع الإبداعي (ecnecil snommoC evitaerC) أو ترخيص يعادله. وإذا قمتم بترجمة المصنف فينبغي أن تدرجوا بيان إخلاء المسؤولية التالي مع الاقتباس المقترح: "هذه الترجمة ليست من إعداد منظمة الصحة العالمية (المنظمة (OHW)). والمنظمة (OHW) غير مسؤولة عن محتوى هذه الترجمة أو دقتها. ويجب أن يكون إصدار الأصل الإنكليزي هو الإصدار الملزم وذو الحجية." ويجب أن تتم أية وساطة فيما يتعلق بالمنازعات التي تنشأ في إطار هذا الترخيص وفقًا لقواعد الوساطة للمنظمة العالمية للملكية الفكرية .(/selur/noitaidem/ne/cma/tni.opiw.www//:ptth) الاقتباس المقترح حالة التمريض في العالم 0202: الاستثمار في التعليم والوظائف والمهارات القيادية [pihsredael dna sboj ,noitacude ni gnitsevni :0202 gnisrun s’dlrow eht fo etatS] جنيف: منظمة الصحة العالمية: 0202. الترخيص: OGI 0.3 AS-CN-YB CC. بيانات الفهرسة أثناء النشر. بيانات الفهرسة أثناء النشر متاحة في الرابط /siri/tni.ohw.sppa//:ptth. المبيعات والحقوق والترخيص. لشراء مطبوعات المنظمة (OHW) انظر الرابط sredrokoob/tni.ohw.sppa//:ptth. ولتقديم طلبات الاستخدام التجاري والاستفسارات الخاصة بالحقوق والترخيص انظر الرابط gnisnecil/tuoba/tni.ohw.www//:ptth. مواد الطرف الثالث. إذا كنتم ترغبون في إعادة استخدام مواد واردة في هذا المصنف ومنسوبة إلى طرف ثالث، مثل الجداول أو الأشكال أو الصور فإنكم تتحملون مسؤولية تحديد ما إذا كان يلزم الحصول على إذن لإعادة الاستخدام هذه أم لا، وعن الحصول على الإذن من صاحب حقوق المؤلف. ويتحمل المستخدم وحده أية مخاطر لحدوث مطالبات نتيجة انتهاك أي عنصر يملكه طرف ثالث في المصنف. بيانات عامة لإخلاء المسؤولية. التسميات المستعملة في هذا المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر ضمنًا عن أي رأي كان من جانب المنظمة (OHW) بشأن الوضع القانوني لأي بلد أو أرض أو مدينة أو منطقة أو لسلطات أي منها أو بشأن تحديد حدودها أو تخومها. وتشكل الخطوط المنقوطة على الخرائط خطوطًا حدودية تقريبية قد لا يوجد بعد اتفاق كامل بشأنها. كما أن ذكر شركات محددة أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة أو موصى بها من جانب المنظمة (OHW)، تفضيًلا لها على سواها مما يماثلها في الطابع ولم يرد ذكره. وفيما عدا الخطأ والسهو، تميز أسماء المنتجات المسجلة الملكية بالأحرف الاستهلالية (في النص الإنكليزي). وقد اتخذت المنظمة (OHW) كل الاحتياطات المعقولة للتحقق من المعلومات الواردة في هذا المطبوع. ومع ذلك فإن المواد المنشورة ُتوزع دون أي ضمان من أي نوع، سواء أكان بشكل صريح أم بشكل ضمني. والقارئ هو المسؤول عن تفسير واستعمال المواد. والمنظمة (OHW) ليست مسؤولة بأي حال عن الأضرار التي قد تترتب على استعمالها. “ لقد تسّنى إعداد هذه الوثيقة بفضل الدعم المالي المقدم من شراكة التغطية الصحية الشاملة (بلجيكا والاتحاد الأوروبي وفرنسا وأيرلندا واليابان ولوكسمبورغ والمملكة المتحدة ومنظمة الصحة العالمية) وألمانيا والنرويج”. صور الغلاف: الصف 1 (من اليسار إلى اليمين): © aquojbaH aynaT © ,moC VI’L/iugneL .R enerI © ,ytteG aiv SSAT/odreG rimidalV الصف 2 (من اليسار إلى اليمين): © reetS-notliW rehpotsirhC/NDKA © ,erahsotohP/rodalgniS .S emiaJ حالة التمريض في العالم عام 0202ii المحتويات التمهيد . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiv رسالة من الرئيسين المشاركين . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiv المساهمون وكلمة شكر وتقدير . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi المسرد. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x موجز تنفيذي . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix المقدمة 1 التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقا ً 5 2.1 دور التمريض في تحقيق خطة عام 0302 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 ما تعريف الممرض؟ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 أدوار التمريض في النظم الصحية في القرن الحادي والعشرين 11 3.1 دور التمريض في تحقيق التغطية الصحية الشاملة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3.2 دور التمريض في التعامل مع الطوارئ والأوبئة والكوارث. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 3.3 دور التمريض في تحقيق تمتع السكان بأنماط العيش الصحية وبالرفاهية. . . . . . . . . . . . . . . . . . . . . 61 الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض 91 4.1 التعليم والتدريب السابقان للخدمة. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 4.2 تدفقات القوى العاملة إلى الداخل وإلى الخارج . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 4.3 التوزيع المنصف والكفاءة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.4 الأحكام التنظيمية . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 53 5.1 توفر القوى العاملة في مجال التمريض وتكوينها وتوزيعها . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 5.2 الإنصاف في توافر القوى العاملة في مجال التمريض وإتاحتها . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.3 هجرة أفراد كادر التمريض وتنقلهم على المستوى الدولي. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 5.4 تنظيم تعليم التمريض وممارسته. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 5.5 المعروض من القوى العاملة في مجالي التعليم والتمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 5.6 الممارسة: تنظيم الوظيفة وشروط العمل . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.7 تصريف الشؤون والقيادة. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 5.8 تقييم المسار المتجه حاليًا صوب تحقيق حصائل أهداف التنمية المستدامة لعام . . . . . . . . . . . . . . . . . 16 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض 76 6.1 تعزيز قاعدة البينات من أجل التخطيط والرصد والمساءلة . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 6.2 التنقل والهجرة. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 6.3 تطوير القوى العاملة في مجال التمريض ودعمها . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 6.4 بناء القدرات المؤسسية والمهارات القيادية من أجل تحقيق الفعالية في تصريف الشؤون . . . . . . . . . . . . 28 6.5 تحفيز الاستثمار لإيجاد وظائف في مجال التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 6.6 برنامج عمل البحوث والبينات . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 الخلاصة 19 المراجع . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 الملحق -1 ما تعريف الممرض؟ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801 الملحق -2 الأساليب . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 011 المحتويات الفصل 1 الفصل الفصل الفصل الفصل الفصل الفصل 2 3 5 6 7 4 ملحق لنشره على الويب. أدوار التمريض في نظم القرن الحادي والعشرين الصحية fdp.ara/258233/-615900042987956601/eldnah/maertstib/siri/tni.ohw.sppa//:sptth iii الإطار 3.1 مساهمة التمريض في تحقيق سلامة المرضى . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 الإطار 3.2 نموذج الرعاية المجتمعية للفئات السكانية في مرحلة الشيخوخة الذي يقوده كادر التمريض. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 الإطار 4.1 أستراليا: إشراك الفئات السكانية الناقصة التمثيل في القوى العاملة في مجال التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 الإطار 4.2 تكلفة تعليم التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 الإطار 4.3 معالجة النقص في معلمي كادر التمريض. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 الإطار 4.4 الشراكات المتعلقة بالمهارات العالمية . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 الإطار 4.5 أمثلة على الطلب الاقتصادي على كادر التمريض في البلدان المرتفعة الدخل . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 الإطار 4.6 توسيع نطاق الإتاحة من خلال وصف كادر التمريض الأدوية والعلاجات في بولندا . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 الإطار 4.7 مثال على دور فرد كادر التمريض المتخصص في الإقليم الأفريقي . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 الإطار 4.8 المبادئ التوجيهية لاستبقاء كادر التمريض في المناطق الريفية . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 الإطار 4.9 أمثلة على المواءمة بين معايير التعليم وامتحانات منح التراخيص. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 الإطار 5.1 الإنصاف داخل البلدان . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 الإطار 6.1 تحليل سوق العمالة الصحية في اسكتلندا . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 الإطار 6.2 الجماعة الصحية لشرق أفريقيا ووسطها وجنوبها: التعاون الوطني في الإبلاغ ببيانات التمريض باستخدام مؤشرات حسابات القوى العاملة الصحية الوطنية . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07 الإطار 6.3 نهج ألمانيا في إدارة الهجرة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 الإطار 6.4 استخدام التكنولوجيا في تعليم التمريض وممارسته . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 الإطار 6.5 جهود باكستان لزيادة القدرات في مجال تعليم التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 الإطار 6.6 توسيع نطاق إتاحة الخدمات الصحية المجتمعية في ُعمان . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 الإطار 6.7 الجمعية التعاونية التنظيمية الأفريقية لمهنة الصحة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08 الإطار 6.8 إضرابات العاملين الصحيين . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 الإطار 6.9 برنامج الزمالة في مجال القيادة في إقليم غرب المحيط الهادئ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 الإطار 6.01 الاستثمار في رأس المال البشري . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 الإطار (أ)1-1 تعريفات التصنيف الدولي الموحد للمهن لأفراد كادر التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901 الشكل 2.1 الاستراتيجية العالمية بشأن الموارد البشرية الصحية: الأغراض الاستراتيجية والأهمية لمجال التمريض . . . . . . . . . . . . . . . . . . . . . . . . . 7 الشكل 2.2 عدد المسميات الوظيفية المتفردة في مجال التمريض داخل كل إقليم من أقاليم المنظمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 الشكل 3.1 مساهمة التمريض في تحقيق الغايات المليارية الثلاثية . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 الشكل 4.1 الأدوات السياساتية اللازمة لتشكيل أسواق العمالة الصحية. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 الشكل 5.1 عدد البلدان التي تتوافر بشأنها بيانات القوى العاملة في حسابات القوى العاملة الصحية الوطنية لدى المنظمة (0991-8102). . . . . . . . . . . . 63 الشكل 5.2 نسبة عدد العاملين في مجال التمريض داخل كل فئة مهنية، حسب إقليم المنظمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 الشكل 5.3 النسبة المئوية لأفراد كادر التمريض الذين تقل أعمارهم عن 53 عامًا والذين تبلغ أعمارهم 55 عامًا أو أكثر، حسب إقليم المنظمة . . . . . . . . . 14 الشكل 5.4 النسب التقريبية لكادر التمريض الذين تزيد أعمارهم على 55 عامًا والذين تقل أعمارهم عن 53 عامًا . . . . . . . . . . . . . . . . . . . . . . . . . 24 الشكل 5.5 كثافة أفراد كادر التمريض لكل 000 01 نسمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 الشكل 5.6 التفاوتات الإقليمية في كثافة أفراد كادر التمريض لكل 000 01 نسمة (8102) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 الشكل 5.7 كثافة أفراد كادر التمريض لكل 000 01 نسمة حسب فئة الدخل (8102) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 الشكل 5.8 النسبة المئوية للبلدان المجيبة التي أشارت إلى وجود نظم ومعايير في مجال التمريض . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05 الشكل 5.9 خريطة درجات تنظيم تعليم التمريض، حسب البلد . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 الشكل 5.01 متوسط مدة (سنوات) تعليم أخصائيي التمريض، حسب إقليم المنظمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 الأطر الأشكال حالة التمريض في العالم عام 0202vi الشكل 5.11 النسبة المئوية للبلدان التي لديها أحكام تنظيمية بشأن شروط العمل . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 الشكل 5.21 خريطة درجات تنظيم شروط العمل . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 الشكل 5.31 النسبة المئوية للبلدان ذات الدور التمريضي المتقدم حسب مستوى كثافة الأطباء لكل 000 01 نسمة . . . . . . . . . . . . . . . . . . . . . . . . . 85 الشكل 5.41 الارتباط بين منصب رئيس التمريض في الحكومة وبرنامج تطوير المهارات القيادية في مجال التمريض من جهة والبيئة التنظيمية من الجهة الأخرى. . . 06 الشكل 5.51 توقعات كثافة أفراد كادر التمريض لكل 000 01 نسمة في عام 0302 (التوزيع العالمي) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 الشكل 5.61 الزيادة المتوقعة (حتى عام 0302) في رصيد كادر التمريض، حسب إقليم المنظمة وفئة الدخل القطرية . . . . . . . . . . . . . . . . . . . . . . . 36 الشكل 5.71 تقدير النقص في القوى العاملة في مجال التمريض في الأعوام 3102 و8102 و0302 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 الشكل (أ)2.1 عدد المؤشرات المبلغ وفقا لهًا عالميًا في سبيل إعداد تقرير حالة التمريض في العالم لعام 0202. . . . . . . . . . . . . . . . . . . . . . . . . . 211 الشكل (أ)2.2 ارتباط مؤشرات التعليم بتحليل التناظر المتعدد. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 الشكل (أ)2.3 ارتباط مؤشرات شروط العمل بتحليل التناظر المتعدد. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 الشكل (أ)2.4 تطور رصيد كادر التمريض عالميًا (بالملايين) في إطار سيناريو «العمل كالمعتاد» وثلاثة سيناريوهات «زيادة في إنتاج أفراد كادر التمريض الخريجين»، من عام 8102 إلى عام 0302 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 الجدول 5.1 عدد كادر التمريض على مستوى العالم وكثافته لكل 000 01 نسمة، حسب إقليم المنظمة، 8102 . . . . . . . . . . . . . . . . . . . . . . . . . . 83 الجدول 5.2 التغييرات في رصيد كادر التمريض بسبب تحسين البيانات والزيادة الفعلية المحققة بين عامي 3102 و8102 . . . . . . . . . . . . . . . . . . . 83 الجدول 5.3: نسبة كادر التمريض إلى المهنيين الصحيين (الأطباء وكادر التمريض وكادر القبالة وأطباء الأسنان والصيادلة) حسب إقليم المنظمة. . . . . . . . 93 الجدول 5-4 النسبة المئوية للعاملات في مجال التمريض، حسب إقليم المنظمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 الجدول 5-5 كثافة أفراد كادر التمريض حسب كل فئة دخل (8002) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 الجدول 5-6 النسبة المئوية لأفراد كادر التمريض المولودين (أو المدربين) في الخارج حسب كل فئة دخل. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 الجدول 5-7 النسبة المئوية للبلدان المجيبة التي أبلغت بوجود أحكام تنظيمية تتعلق بالتعليم والتدريب في مجال التمريض، حسب إقليم المنظمة . . . . . . . . . . 05 الجدول 5-8 الإنتاج من خريجي التمريض، حسب إقليم المنظمة وفئة الدخل . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 الجدول 5-9 النسبة المئوية للبلدان المجيبة التي أبلغت بوجود أحكام تنظيمية تتعلق بالتمريض من حيث شروط العمل، حسب إقليم المنظمة. . . . . . . . . . . . 65 الجدول 5-01 مؤشرا القيادة وتصريف الشؤون: النسبة المئوية للبلدان التي لديها منصب لرئيس التمريض وبرنامج لتطوير المهارات القيادية في مجال التمريض، حسب إقليم المنظمة . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 الجدول 5-11 محاكة الرصيد المتوقع لأفراد كادر التمريض من عام 8102 إلى عام 0302 وفقًا لثلاثة سيناريوهات، حسب إقليم المنظمة . . . . . . . . . . . 36 الجدول (أ)2-1 قائمة تضم 63 مؤشرًا مستخدمًا لإعداد تقرير حالة التمريض في العالم لعام 0202 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 الجدول (أ)2-2 تقديرات النقص في أفراد كادر التمريض (بالملايين) في البلدان التي تقل عن العتبة المحددة في الاستراتيجية العالمية حسب مستوى الدخل: 8102 و0302 (ثلاث سيناريوهات) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 الجداول vالمحتويات إليزابيث إيرو كبيرة الممرضات، منظمة الصحة العالمية أنيت كنيدي رئيسة المجلس الدولي للممرضات شيلا تلو الرئيسة المشاركة، منظمة التمريض الآن نيجل كريسب الرئيس المشارك، منظمة التمريض الآن تيدروس أدحانوم غيبريسوس المدير العام، منظمة الصحة العالمية الاستثمار في كادر التمريض لن يسهم في أهداف التنمية المستدامة المتعلقة بالصحة فحسب، بل كذلك في التعليم (الهدف 4) والمساواة بين الجنسين (الهدف 5) والعمل اللائق والنمو الاقتصادي (الهدف 8). التمهيد يأتي صدور تقرير حالة التمريض لعام 0202 في العالم: الاستثمار في التعليم والوظائف والمهارات القيادية في وقت يشهد فيه العالم التزامًا سياسيًا غير مسبوق بتحقيق التغطية الصحية الشاملة. وفي الوقت نفسه، تضع فاشية كوفيد91- المندلعة حاليًا وكذلك النزوح الجماعي للسكان الناجم عن النزاعات قدرتنا على التأهُّب لحالات الطوارئ والاستجابة تحت الاختبار. ويقدم كادر التمريض الرعاية الحيوية في هذين الظرفين على حد سواء. والآن يحتاج العالم، أكثر من أي وقت مضى، إلى أن يعمل أفراد كادر التمريض بما يحقق أقصى استفادة من تعليمهم وتدريبهم. ويكشف أول تقرير عن حالة التمريض في العالم الكثير مما يوجب الاحتفاء بالقوى العاملة في مجال التمريض. ويمكن أن تؤدي إتاحة فرص الحصول على تعليم متقدم في مجال التمريض وشغل خريجيه أدوارًا مهنية محسنة، ومنها أدوار رسم السياسات، إلى تحسين صحة السكان. إلا أننا ما زلنا نشهد حالة من عدم الإنصاف الواسع النطاق في توزيع أفراد كادر التمريض حول العالم، وهي حالة لا بد لنا من معالجتها. وسنة 0202 هي السنة الدولية لكادر التمريض والقبالة. وهذه فرصة للاستفادة من البينات الواردة في تقرير حالة التمريض في العالم لعام 0202 والالتزام ببرنامج عمل من شأنه أن يدفع عجلة التقدم ويواصل دفعها حتى عام 0302. وتحقيقا لهذه الغاية، نحث الحكومات وجميع أصحاب المصلحة المعنيين على ما يلي: الاستثمار في إعطاء دفعة عاجلة وقوية لتعليم التمريض -أعضاء هيئة التدريس والبنية التحتية والطلاب- لتلبية الاحتياجات العالمية والطلب المحلي ومواكبة التكنولوجيات المتغيرة والنماذج المتقدمة للرعاية الصحية والاجتماعية المتكاملة؛ إيجاد ما لا يقل عن 6 ملايين وظيفة جديدة في مجال التمريض بحلول عام 0302، على أن تتركز في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل، لتعويض النقص المتوقع ومعالجة التوزيع غير العادل للممرضات في جميع أنحاء العالم؛ تعزيز المهارات القيادية التمريضية -لدى القادة الحاليين والمستقبليين على السواء- لضمان أن يكون لكادر التمريض دورا مؤثرا في صياغة السياسات الصحية واتخاذ القرارات في ذلك المجال، والمساهمة في تحقيق فعالية أنظمة الرعاية الصحية والاجتماعية. ويمكن لجميع البلدان اتخاذ إجراءات لدعم برنامج العمل هذا. ويمكن لمعظم البلدان إنجاز هذه الإجراءات بمواردها الخاصة. وفيما يخص البلدان التي تحتاج إلى مساعدة من المجتمع الدولي، يجب علينا توجيه حصة متزايدة من استثمارات رأس المال البشري إلى اقتصاد الرعاية الصحية والاجتماعية. ومن شأن تلك الاستثمارات أن تؤدي أيضًا إلى دفع عجلة التقدم عبر أهداف التنمية المستدامة، مع تحقيق عوائد في ميادين المساواة بين الجنسين، والتمكين الاقتصادي للمرأة، وتوظيف الشباب. دعونا نغتنم هذه الفرصة لقطع الالتزام بجعل هذا العقد عقد عمل يبدأ بالاستثمار في التمريض من حيث التعليم والوظائف والمهارات القيادية. iiv أطلقت جمعية الصحة العالمية الثانية والسبعون على سنة 0202 السنة الدولية لكادر التمريض والقبالة لا للاحتفاء بالذكرى المائتين لميلاد فلورنس نايتنغيل، بل للإعراب كذلك عن تقديرها للمساهمات اليومية لكادر التمريض والقبالة في تحقيق صحة السكان وعافيتهم في جميع أنحاء العالم. ومع تسليط الضوء عالميًا على كادر التمريض في سياق جائحة كوفيد-91، يشرفنا أن نطلق أول تقرير يصدر على الإطلاق في هذا الموضوع، ألا وهو تقرير حالة التمريض في العالم في يوم الصحة العالمي. ويقدم هذا التقرير أحدث البينات المحدثة والخيارات السياساتية التي تعكس آخر التطورات المتعلقة بالقوى العاملة في مجال التمريض. ويعرض أيضا حجة دامغة على ضرورة تخصيص استثمارات كبيرة -لكنها ممكنة- لمجال لتمريض من حيث التعليم والوظائف والمهارات القيادية، وهو أمر لازم لتعزيز القوى العاملة في مجال التمريض تحقيقا لأهداف التنمية المستدامة، وتحسين صحة الجميع، وتعزيز القوى العاملة في مجال الرعاية الصحية الأولية على طول طريق رحلتنا صوب تحقيق التغطية الصحية الشاملة. وكان تقرير حالة التمريض في العالم لعام 0202 ثمرًة لتعاون ملحوظ على المستوى الوطني. ففي العديد من البلدان، قاد حملة الإبلاغ بالبيانات المسؤولون الحكوميون عن التمريض والقبالة، الذين دعمتهم وزارات التعليم والعمل والمالية بتقديم البيانات اللازمة. وتبادل المعلمون في مجال التمريض والجهات التنظيمية المعنية به البيانات وجمعوها بأكثر من طريقة. وأدت رابطات التمريض الوطنية وجماعات حملة التمريض الآن أدوارًا دعوية رئيسية في إعداد التقارير والتفاعل بشأن القضايا التي تناولها. ولهذه العلاقات أهمية حاسمة في إعداد التقارير الدقيقة والروتينية عن التمريض، ومن شأنها أن تسهل إعداد تقارير أقوى في المستقبل. لقد حققناه معًا عمًلا مثيرًا للإعجاب. ولكن ما لم نحققه بعد أهم كثيرًا. إذ لا بد من أن نستخدم البيانات الوطنية والإقليمية والعالمية، وأن نستفيد من السنة الدولية لكادر التمريض والقبالة لمواصلة تعزيز الحوار والتعاون بين جميع القطاعات في تعزيز القوى العاملة من أجل تقديم الرعاية الأولية بشكل أفضل وإحراز تقدم نحو تحقيق التغطية الصحية الشاملة. ويجب علينا التحفيز على ضخ استثمارات في مجال التمريض من حيث التعليم والوظائف والمهارات القيادة ومواصلة ضخها. إن تحقيق صحة العالم تتطلب التزام جميع البلدان بدعم القوى العاملة في التمريض والاستثمار فيها. ويحدونا الأول في أن تلبوا هذه الدعوة إلى العمل. رسالة من الرئيسين المشاركين ماري واتكينز رئيس حملة التمريض الآن المشارك بالإنابة هوارد كاتون الرئيس التنفيذي للمجلس الدولي للممرضين والممرضات جيمس كامبل مدير إدارة القوى العاملة الصحية بمنظمة الصحة العالمية حالة التمريض في العالم عام 0202iiiv اللجنة التوجيهية الرئيسان المشاركان: هوارد كاتون، ماري واتكينز الأعضاء: سلطانة ن. أفضل، سمية محمد البلوشي، ديفيد بنتون، شارون براوني، بيتر جونسون، فرانسيسكا أوكافور، نانسي رينولدز، ديبرا تومس، إليزابيث إيرو (بحكم المنصب)، جيمس كامبل (بحكم المنصب) منظمـة الصحـة العالميـة المؤلفون الرئيسيون: كاري مكارثي، ماتيو بونيول، كارين دانيلز، جورجيو كوميتو، خاصوم ديالو، أنور الدين لواني، جيمس كامبل الدعم الإداري: بياتريس واموتيتو، إليزابيث تيسون المساهمون: جوناثان أبراهامز، آدم أحمد، أونيما أجبور، بينيديتا أليغرانزي، أفني أمين، جورجينا أرويو، جيمس أسماني، إيان أسكيو، سوفونياس أسكرات، شمسوزوها بابر سيد، راشيل بغالي، فالنتينا بالتاغ، أنا بيلر بيتران لازاغا، ميليسا بينغام، موسى بيزو، نانسي بولنان، كارولين برودي، لوغيمبا بودياك، ريتشارد كار، سيلفيا كاسياني، أليساندرو كاسيني، جورج كاستيلا إشينيق، بولا كافالاكتي، مومودو سيساي، بيتر كاولي، فانيا دي لا فوينتي نونيز، إيبادات ديلون، نيلام دينغرا كومار، ليندا دول، ناتالي درو بولد، تارون دوا، جيمس فيتزجيرالد، سيوبان فيتزباتريك، هيلغا فوجستاد، ناثان فورد، بيير فورمينتي، دونغبو فو، كلوديا جارسيا-مورينو، فتحية غولين جيديك، ريجينا جوثولد، إندراجيت هازاريكا، باسكال هيلبرغ، ألبرت موهلاكولا هلابانا، ليزا هوفمان، أبو بكر، إنوا، غابرييل جاكوب، مانوج جالاني، ريتا كابرا، ميكيكو كاندا، روث كانيرو، أميناتا ساخو كيلي، جيمس كياري، هيو جيونج كيم، تينا كونجومن، إتيان لانغلويس، أنيس ليغاند، أورنيلا لينسيتو، فرانسي ماغومبا، ماري ماناندهار، كاريفا مارا، ريجيس أنطوان مباري دابا، فرانسيس ماكونفيل، ميشيل مكيساك، هدية مهرطاش، نبيل ميناصريا، نانا منساه-أبرامبا، جان جاك سلفادور ميلوغو، آن بيت مولر، مارجريت مونتغومري، أشلي مور، مانجولا ناراسيمهان، ستيفاني نغو، سوزان نوريس، إيان نورتون، ستيفن نورسي فيندلي، جينيفر نيوني، آسيا أودوغليه-كوليف، ألانا أوفيسر، مي أوكامورا، صني أوكوروافور، أولوفيمي أولادابو، كارولينا عمر، زوي أوباراه، أروى عويس، مونيكا باديلا، إديث بيريرا، سيلفيا بيريل ليفين، فلاديمير بوزنيك، فيناياك موهان براساد، جاكوي رايلي، بريانكا ريلان، تيري رينولدز، بول روجرز، ديفيد روس، أورورا سارس، سليم صدر الدين، بيغونا ساغاستوي، فاربا لامين سال، ديا سامينارسيه، جوليا سامويلسون، أليسون شافر، كريس سكوتير، جاستين أدانمافوكين سوسو، سوزان سباركس، سيمون ماري سانت كلير، جولي ستور، تيجست تامرات، آي تانيميزو، مارتن تايلور، نوريا توتو بولانكو، بروسبر توموسيمي، أوزج تونكالب، أنتوني تويمان، نيكول فالنتين، مارك فان أومرين، شيريان فارغيز، جيما فيستال، ماركو فيتوريا، فيكتوريا ويليت، ماساهيرو زاكوجي، توماس زاباتا لوبيز المساهمين في استعراض البينات توماس ألفاريز، سارة عبود، نيراج أغراوال، شانتيل ألين، أنطونيو فرناندو أمارال، بيثاني أرنولد، موكول بخشي، ميرا بيترون، أوريليا بلاسيفيتش، جوليا بلوستون، جو بوث، ديبورا بوسميير، إيرما بريتو، إيريكا بيرتون، كينريك كاتو، سكولاستيكا شيبهي، ماري كلاريس، كاي كوري، شينا كوري، فرانسوا-كزافييه داودال، أنيت دي جونغ، أنا دي لا أوسادا، جنيفر دوهرن، جو-آن دونر، مانيا دوتسون، هيلين دو توا، كريستين دوفيلد، كمال الديراوي، لوري إليوت، ماريا إنغستروم، ديانا استيفيز، شيري إيفانز، بيتي فيريل، لورا فيتزجيرالد، آن جاردولف، نانسي غلاس، كلير غلينتون، باتريشيا غوميز، ديب غرانت، ميغان غريلي، دوريس غرينسبون، فاليري أ. غروس، مارك هاثاواي، كارين هيتون، عائشة هولواي، ميليسا هوزجان، آن هرادسكي، توندا هيوز، كارول هيوستن، آن هيري، دارلين إيربي، وبريغيت إيريسون-فالوا، سوزان جاكوبي، كريستا جونز، وروزماري كامونيا، جويس كينكر، جارميلا كليشيكوفا، تمارا كريدو، مارجريتا لانجينز، مارجريت ليب، إيزابيل ليسارد، سايمون لوين، ريكي لو، مارغريت ليبون، جيل مابان، إليزابث ماديغان، أندرو ماريلي، أديلايس ماركاكي، موكادي ماتلاكالا، دونا مكارثي بيكيت، سونيا مكالفاتريك، سوزان مونابي-بابيجوميرا، دون مونرو، أنجيلين موتينغا، خين هايمار مينت، مادلين أ. نايغل، إدغار نيكوتشول، ويندي نيلسون، جان نيلسون، ليزا نوغوتشي، شيلي نيولان، أراسيلي أوكامبو بالاباغنو، جوهيس أورتيغا، جين أوتاي، بيريت بال، آن فيتزر، لوزين بوغوسيان، زاميرا رحمونوفا، أميليا رانوتسي، فيرونيكا ريس، جيم ريكا، تشاندراكانت روباريليا، مارلا سالمون، جين سالفاج، ديانا شمالكوتش، فرانكلين شافر، جوديث شاميان، بونغي سيباندا، جينيفر سنايدر، سوزان ستالز، ستايسي ستندر، باربارا ستيلويل، شيريل ستوغيس، لويزا ستراني، هانا تابيس، غودينشيا تيبايجوكا، فيكي تريسي-وونغ، إيريكا ترونكوسكو، أنوكا توميكوسكي، بول توثيل، كارلوس فان دير لات، تينر غودوين فينيما، ميغي فيربوتن، إيزابيل فيوريه، سينثيا فلاسيتش، جيمي ووترال، جان وايت، جيل وايت، باربرا وينكامب-فيبر، تيغبار ييغزو المساهمون في الإبلاغ بالبيانات وتحليلها تود منظمة الصحة العالمية أن تشكر جميع مراكز الاتصال المعنية بحسابات القوى العاملة الصحية الوطنية، وكبار مسؤولي التمريض والقبالة في الحكومة، ومؤسسة نوفامتركس (مارتن برويس وأندريا نوف) وغيرهم ممن ساهموا في عملية الإبلاغ بالبيانات في سبيل إعداد هذا التقرير. الإقليم الأفريقي هناتو عبد الله، سليمان أببي، ميديلي الإكادبونغ، فاطميتو علي، بابا أميفي، غيسلين أرنود، ياو بادي، الشيخ بدر، تمالي باندا، تيريزا بيلاي، أنا بيلا، الحاج بن بشريك، محمد برتي، محمد بوه، سيلفينو ندافا براب، سينثيا تشسوكيلا، كيتي جان كريسوستوم، أهانهانزون أغونغلو كلاريس، ماريا دا لوز مدينا دا كروز، محمد فظا ديالو، ديمبا موسى دياللو، باكالا ديودوني، مامادي داكوري، خالد المرضي، جان بابتيست جودوي، ديمبو غويراسي، فاطمة هاليداني، سيمون هلونغواني، إدريس مودجييغو إيغالاس، ماري نانديلي إيشيب، حمزة إسماعيل، شاكوري أيينا كاديري، تاشا كادجانتا، إيدنا كامايو، حسيناتو ماري كانو، سيلو كيفالا، جان كريزوتومي كيتي، إيميل كوروما، سيرفاني كاواكو، هانا كو-كيغو، فيروز لال محمد، سامكيليسيو لوخيل، سيبريانو ماينغا، موبيتيسي ماكاو، نونهالا ماجانيا، عابد مليكة، ساتوريني مانانغوا، ميريام مانغيا، فيليلو مارولي، لامين ماروغ، جيسيلي مارتينز، موريبوار ماري، ثيبي مافو، جيليان مين، كامل ميسر، جانيت ك. ميشيل، لوسي ماكوتومولا، خومو موديسمان، فلافيا موتسانا-بوكا، سيساي مومودو، ماثابيلو موتيب، جاميرو مبيما، جين موديارا، تشيلويزا موسوندا موزونجوي، لونيا موابي، ويندين مانيغدي فيليديت نانا، مريم نداجي، إيكيا نوماغو، أل خوما، نكوسيناثي ر. نكوانيانا، كلودين ديانغو نوبو، كاسوما بيدرو نوربرتو، أولغا نوفيلا، إيمانويل نتاوويريوشا، تيتي نيللي نتابانا، بول نياشاي، مارتينو أوجدج، فرانسيسكا أوكافور، بيتوا كيكوبوكو أولوبو، يعقوبا أويدراغو بودا، يعقوب بودا، تارلو كويونكبا، نودجالتا ريمادجي، باغنو ساهي.داودا ساماته، ريجب صموئيل، نيني كاتيرونا سانكا، إكان ندي ساندرين، مويلا سيكيسيكي، ماليك سيدي، مويبا شريف، توليبوكا سوكو، ريبنت خميس جورج ستيفن، ياو ثيودور، جوستين تيندريبوغو، فرانسينا تيتوكا، تيكلو تسيغاي، نكالا فيكتورين، سولومون ولدمانويل، أمبروز وريه، جاكي يابيلي، عيسى يحيى، ناصر ياما، برنابا يبوا، رابيساتا جوست يولاند إقليم الأمريكتين ماريا لوسيا أيكاردي، رامون أبريغو، صوفيا أكوكارو، آصف علي، أوغسطينا أمبروز-بوبو، دنيس إسرائيل أنس موراليس، جينيفر أندال، إليزابيث أندرسون، جون فرانسيسكو أريزا مونتويا، جوي أرنيل، ساندرا بارو، ليان بيليساريو، لويس غابرييل بيرنال بوليدو، شيلون بيس، إيرما بواس، رافائيل بوردا، جينيفر بريدز، ليوناردو بريتو، سيلفيا بريزويلا، هيزيل براون، روبن بوكلاند، رودريغو كاسترو، كيرثني شارلمان-سوراج، أندري تشيل، ألبا كونسويلو فلوريس، ألبرتو كوزمي لوبيز دي سوزا، هيرناندو كوبيديس، ناتالي كويبينز، ليريفان دا سيلفا، غاي ديفيز، كارولينا دي باس، جينا دين، ماركوس ديل ريسكو ديل ريو، نستر إدواردز، فولفيا إليزوندو سيباجا، جوليانا فيريرا ليما كوستا، إيفلين فلوريس دي نييتو، جانيت فلين، ميري فوينتس، لويس فيليبي غارسيا روانو، روزا جورج، كلوديا غودوي، كريستيان غونزاليس أوبلت، زيلا غونزاليس فيفو، ستاسي غورينغ، إيفي كاتالين جريجالفا ساينز، نوركا روشيو غويلين بونس، جاسثنت هانيبال، شارون هاربر، كارلا هاري، غوستافو هوف، غيل هودسون، بريندا جيفرز، ليندا جونسون، كلوديا ليجا هيرنانديز، ليزا ليتل، خافيير سيزار لوايزا تاميرانو، هوارد لينش، مارسيلو ماركيز، ديانا إيزابيل مارتينيز تشانغوان، إيثينيا مارتينيز مورا، جاكلين-ماثيو فيفيرير، آن ماتوتي، لين ماكنيلي، ثامشوار ميراي، فرناندو مونارنيز، كيري نيسيلر، ميرنا نوبريجا، سوزان أورسيغا، بيت باز، إميليانا بينيا، خوان لوكاس بيريرا، والتر بيريز لازارو، بولين بيترز، بيتي آن بيلغريم، إنما بوراس ماروكين، خورخي رامانهو، جايسون روفينبندر، ديسين سيلكوت، مارغريت سميث، تياغو سوزة، ديلوريس ستابليتون هاريس، جاكورلين ستون، ألديرا سامانثا تساكسيرا، سيلفيا تيخادا، رودي ثيرميدور، كاميل توماس-جيرالد، كي سي ديان توريس كوينتيرو، بيدرو دياز أورتيغا، كارلوس فالي، أليساندرو فاسكونسيلوس، أريستيلا فاسكيز، جينيث فيغا شافيز إقليم جنوب شرق آسيا ليلا أدهيكاري، كيميت أدهيكاري، سانينا ألام، أحلام علي، نان نان أونغ، هلا هلا أيي، راثي بالاشاندران، ألام أرا بيغان، نوربيترا بيلو، ك. س. بهاراتي، فيناي بوثرا، جيرمياس دا كروز، أتول داهال، ديليب دي سيلفا، بادمال دي سيلفا، أبريانتي شينتا ديوي، ماريا دولوريس كاستيلو، أمينت فريحة محمد، هوراسيو فرنانديس ريبيرو، هاريندارجيت جويال، ناليكا جوناواردينا، أنيل كومار جوبتا، هتاي هتاي هلاينج، فاطمة هدى، أنيجا إبراهيم، سوغينغ إيكو إيريانتو، عائشة إيروفا، أورايبورن جانتا-أم مو، شيفانجيني كار ديف، رادك كاروناراتني، داو نوي نوي خين، ثيبات كوا ما، دا خين ما ما كياو، جين مار كيي، سيريما ليلاوانغ، بودهيكا لوكو بالاسورينجا، حسين ماني، ديليب مايمبان، داو ين ميا، كافيتا نارايان، ثيناكورن نوري، مد نور الزمان، كياو سو نيونت، تاندين بيمو، ويشافي بوليسونغريسي، بوجا برادان، مز راجمت، مريم رشيد، توماسيا، أنا ماريوا دو روزاريو إي سوزا، جواو نورونها روي، بهيم براساد سابكوتا، تيرابورن ساتيرا أنغكورا، تيني سيتياوان، مريم شفيق، محمد شاهجاجان، جايندرا شارما، ماي ثويل هلا شوي ألاكا سينغ، ساسامون سريسوثيساك، راتانابورن تانجثانسيز، روشيني توي توي، فيكور تيسفايي تولو، ليفيو فيدراسكوس، ماني هندياتاني ويدو، باناروت ويساوتابندميت، سونام يانغشين الإقليم الأوروبي أيزت أسانوفا، أنجيل أبد باسولس، زازا بوخوا، أيشي بويسان، مات إدواردز، أناستازيا غازيفا، شوشي غولدبرغ، ريفكا هازان هازوريف، جاك هوجوينين، ناتاليا كامينينا، كريستين كلاين، سيرجيو أوتغون، ماريجا باليبرك، سيسيليا روتيم، فاسوس سكوتيلاس، جيسموند شارلز، آرت راس شيمكوس إقليم شرق المتوسط أنمال أبو عوض، علوية أحمد، محمد الغامدي، محمد بهادي، كمران بيغ، عمر الشرقاوي، إشراقة البشير، كوثر محمود، فوزية مشتاق، ناتالي ريشا، أنمال سويد سالم، محمد الطراونة، ناصر ياما، لبنى يعقوب إقليم غرب المحيط الهادئ أميليا أفوهامانجو، ليلي آه مو، ثيلما علي، كارتر أبيسيم، جاسمين محمد عارف، مارغريت برودكورن، مورالين كابيل، تيوفيلا كروز، إرفينا إتش عمران، لويزا هيلجينبرجر، وسونغريونغ هونغ، وماري كاتا، أسينا كاوياكا، وماري كيليلو سامور، فيريا كوي، وهيلي لانجرين، ومايكل لاروي، مارغريت ليونغ، فواتاي مايافا، أنطونيت ميرور، هيلين مردوخ، أماندا نيل، وكوك هوي نغوين، جين أومالي، لاي تين أونغ، دافني رينجي، مايكل روش، ميشيل رمزي، فيلويالا ساكايو، يوكو شيمادا، بو يي شو، بيرثا تاريليو، بواسينا تاتوي، أليتا تاوليما، خامباسونغ ثيبانيا، ليزا تاونسند، أوشا توفشين، بن أونغ هانغ تشو تنسيق التحرير والتصميم والإنتاج شاراد أغاروال، شركة بروجرافيكس أي إن سي، جون داوسون، إدارات منظمة الصحة العالمية المعنية بالترجمة والمطبوعات والطباعة. ونود أن نعرب على تقديرنا لصاحبة السمو الملكي الأميرة منى، من الأردن، وفرادى الممرضين والممرضات والوكالات الشريكة على دعم التقرير بالصور. تود منظمة الصحة العالمية أن تشيد إشادة خاصة بسالومي كاروا، وهي ممرضة من ليبيريا نجت من فيروس الإيبولا، لكنها استسلمت لمضاعفات الولادة عندما ُرفض تقديم الرعاية إليها. ونود أن نعرب على تقديرنا لكلية التمريض بجامعة جابيغو التابعة لجامعة جون هوبكنز على مساهمتها في عمليتي استعراض البينات والمساهمة بالبيانات في سبيل إعداد هذا التقرير. بيتر جونسون، نانسي رينولدز، جينيفر بريدز، آنا براينت، باتريكا ديفيدسون، ليزا دي أندريت، جوديث فوليرتون، ليا هارت، مارك كوبو، سيماكالينغ فافولي، تيموثي روبرتون، إليزابيث طومسون المساهمون وكلمة شكر وتقدير xiالمساهمون وكلمة شكر وتقدير ?rettam secrof tekram ruobal htlaeh od yhW .G ottemoC ,A ybarhgaM lE ,C ereimeL ,CE ojuarA ,A adeaM ,B ekaPcM .1 .497811.31.TLB/1742.01:iod .6–148:19;3102 .noitazinagrO htlaeH dlroW eht fo nitelluB htlaeh labolg eht ni secnalabmi gnitsaceroF .la te AT renkcurB ,J uiL ,A adeaM ,G ottemoC ,J llebpmaC ,MR relffehcS .2 .6-4620-710-06921s/6811.01:iod .5:61;8102 .htlaeH rof secruoseR namuH .sesnopser ycilop gnisived dna tekram robal :aveneG .gniniart ecivres-erp gnitaulave dna gnitnemelpmi ,gninnalp :)ICMI( ssenllI doohdlihC fo tnemeganaM detargetnI .3 .1002 ;noitazinagrO htlaeH dlroW //:sptth( noissimmoC tnioJ .gnigelivirp dna gnilaitnederc fo s’erehw dna ,nehw ,tahw ,ohw eht :margorP eraC yrotalubmA .4 dessecca ,fdp.telkoob_gnilaitnederc_erehw_dna_nehw_tahw_ohw_CHA/6/1/stessa/gro.noissimmoctnioj.www .)0202 hcraM 5 -ytlucaf/stneve-noitacude/gro.dlrowgnisrun.www//:sptth( retneC gnilaitnederC sesruN naciremA .snoitinifed gnilaitnederC .5 .)0202 hcraM 5 dessecca ,/snoitinifed-gnilaitnederc/stnarg-hcraeser-gnilaitnederc-selyts/stnarg-hcraeser/secruoser سوق العمل هي الهيكل الذي يسمح بالبحث عن خدمات العمل (أي الطلب) وطرح الفرص (أي العرض/ المعروض). وتؤدي الأجور وشروط العمل (مثل البنية التحتية الوافية، والإدارة الداعمة، وفرص التطوير المهني والتقدم في المسار الوظيفي) دورًا في تحديد ما يختاره العاملون الصحيون وأرباب العمل من ضمن الخيارات المتاحة أمامهم (1). الطلب يشير إلى الوظائف المطروحة في السوق. والطلب هو عدد العاملين الصحيين الذين يمكن للنظام الصحي دعمهم من حيث الوظائف الممولة أو الطلب الاقتصادي على الخدمات. وهو مرتبط بالإنفاق على الصحة من الحكومة والتأمين الخاص والدفع المباشر من الأموال الشخصية (2). العرض/ المعروض من العاملين الصحيين يشير إلى الرصيد المتاح من العاملين الصحيين المؤهلين الراغبين في العمل في قطاع الرعاية الصحية. وهو دالة إحصائية للقدرات التدريبية وصافي هجرة العاملين الصحيين ووفياتهم وتقاعدهم (2). الحاجة هي عدد العاملين الصحيين المطلوب لتحقيق أغراض تقديم الخدمات في أي نظام صحي. وتتشكل أسواق العمالة الصحية في المقام الأول من خلال العرض والطلب، وكذلك من خلال الحاجة لكن بصورة غير مباشرة (1). قدرة القوى العاملة الصحية على استيعاب العاملين في مجال الرعاية الصحية تشير إلى قدرة النظام الصحي (الذي يشمل القطاعين العام والخاص على حد سواء) على توظيف الرصيد المتاح من العاملين الصحيين المؤهلين (الذين ينتجهم التعليم والهجرة بصفة أساسية) توظيفًا كامًلا ومنتجًا. وتتأثر قدرة الاستيعاب بالكفاءة وحسن توقيت ترجمة الطلب الاقتصادي إلى إيجاد فرص عمل وشغلها. التعليم السابق للخدمة يشير إلى البرنامج التعليمي الرسمي الذي يسبق العمل في بيئة خدمية ويشكل شرطًا مسبقًا لها (3). ترخيص مزاولة المهنة يشير إلى عملية التصديق على قدرة الفرد على أداء الأدوار والمهام ضمن نطاق محدد من الممارسة وفقًا للمعايير المطلوبة ومنحه ترخيصًا يسمح له قانونًا بممارسة مهنة معينة في دائرة اختصاص معينة. الاعتماد التعليمي يشير إلى عملية تقييم المؤسسات التعليمية وفقًا للمعايير المحددة قبل تقديم خدمة التعليم. وتتمثل حصيلة هذه العملية في منح شهادة تفيد مدى ملاءمة البرامج التعليمية وكفاءة المؤسسات التعليمية في تقديم التعليم. الاعتماد المهني هو عملية حصول الشخص على مؤهلات الممارس والتحقق منها وتقييمها قبل تقديمه الرعاية أو الخدمات في مؤسسة الرعاية الصحية أو لصالحها. أمَّ ا مؤهلات الاعتماد، فهي دليل موثق على الحصول على ترخيص مزاولة المهنة أو التعليم أو التدريب أو الخبرة أو غيرها من المؤهلات (4). الشهادة المهنية هي العملية الطوعية التي يمنح بموجبها الكيان اعترافًا محدودًا زمنيًا وهي منح مؤهلات الاعتماد لفرد بعد التحقق من أنه قد استوفى معايير محددة سلفًا وموحدة معياريًا (5). مراجع المسرد المسرد حالة التمريض في العالم عام 0202x يذيفنت زجوم2020 :هلاعأ روصلا © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh :)نيميلا ىلإ راسيلا نم( الدور المحوري لكادر التمريض في تحقيق التغطية الصحية الشاملة وأهداف التنمية المستدامة موجز تنفيذي من العاملين في مجال الصحة تضطلع كوادر التمريض بدور حاسم الأهمية في الوفاء بوعد "عدم ترك أي أحد خلف الركب" والجهد العالمي المبذول في سبيل تحقيق أهداف التنمية المستدامة. كما أنها تسهم إسهامًا محوريًا في تحقيق الغايات الوطنية والعالمية المتعلقة بمجموعة واسعة من الأولويات الصحية، ومن بينها التغطية الصحية الشاملة والأمراض غير السارية، والتأهب والاستجابة للطوارئ، وسلامة المرضى، وتقديم الرعاية المتكاملة التي تركز على الناس. ولا يمكن تنفيذ أي برنامج عمل عالمي للصحة دون بذل جهود متضافرة ومستدامة في سبيل تعظيم إسهام القوى العاملة في التمريض ودورها في الأفرقة الصحية المهنية المشتركة. ويتطلب ذلك تدخلات سياساتية تمكنها من إحداث أعظم الأثر والفّعالية بتحقيق نطاق العمل الأمثل والقيادة المثلى لكادر التمريض، إلى جانب تسريع الاستثمار الموّجه إلى تعليمهم ومهاراتهم ووظائفهم. وستسهم هذه الاستثمارات أيضًا في تحقيق أهداف التنمية المستدامة المتعلقة بالتعليم ونوع الجنس والعمل اللائق والنمو الاقتصادي الشامل للجميع. ويقدم التقرير عن حالة التمريض في العالم 0202 الذي أعدته منظمة الصحة العالمية (المنظمة) بالشراكة مع المجلس الدولي للممرضين والممرضات وحملة التمريض الآن، وبفضل الدعم المقدم من الحكومات والشركاء على نطاق أوسع، حجة دامغة على ما للقوى العاملة في مجال التمريض من قيمة على الصعيد العالمي. segamI ytteG/egrahcepahS © يشكل كادر التمريض أكبر فئة مهنية في قطاع الصحة، بنسبة تقارب 95 في المائة البّينات المتاحة في عام 0202 إن القوى العاملة في مجال التمريض آخذة في الاتساع من حيث حجمها ونطاقها المهني. ومع ذلك، فإن هذا التوّسع يحدث على نحو غير متساو وغير كاف لتلبية الطلب المتنامي، كما أنه يترك بعض المجموعات السكانية خلف الركب. بلغ عدد البلدان التي قدمت بيانات لإعداد هذا التقرير 191 بلدا ًوهو عدد غير مسبوق، ويشكل زيادة بنسبة 35% على البيانات المقدمة في عام 8102 وقدم نحو 08 % من البلدان تقارير عن 51 مؤشرًا أو أكثر. ومع ذلك، فما زالت هناك ثغرات لا ُيستهان بها في البيانات الخاصة بالقدرات التعليمية، والتمويل، والمرتبات والأجور، وتدفقات سوق العمالة الصحية، ويعوق ذلك القدرة على إجراء تحليلات لسوق العمالة الصحية للاسترشاد بها عند اتخاذ القرارات بشأن السياسات والاستثمارات الخاصة بالقوى العاملة في مجال التمريض. تتضمن القوى العالمية العاملة في مجال التمريض 9 72 مليون شخص، من بينهم 3 91 مليون شخص يمتهنون التمريض. ويشير ذلك إلى زيادة قدرها 7.4 مليون في عددهم الإجمالي في الفترة 3102-8102، ويؤكد أن التمريض هو الفئة المهنية الأكبر في قطاع الصحة، حيث إنه يشكل نحو 95 % من المهن الصحية. ويشمل أفراد التمريض البالغ عددهم 9.72 مليون فرد 3.91 مليون (96 % ) ممرض مهني، و0.6 ملايين (22 % ) ممرض مهني معاون، و6.2 مليون (9 % ) من غير المصنفين في أي من الفئتين. يفتقر العالم إلى القوى العالمية العاملة في التمريض التي تتناسب مع تحقيق التغطية الصحية الشاملة والغايات الخاصة بأهداف التنمية المستدامة. يتواجد 08 % من الممرضين والممرضات على صعيد العالم في بلدان تضم نصف سكان العالم. وقد تراجع النقص العالمي في كادر التمريض الذي كان يقدر بنحو 6.6 مليون في عام 6102، تراجعًا طفيفًا ليصبح 9.5 مليون في عام 8102. ويتركز ما يقدر بنحو 3.5 مليون (98 % ) من هذا النقص في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط، التي تكاد زيادة عدد الممرضين والممرضات فيها لا تكفي لمواكبة النمو السكاني، فلا تتحسن نسبتهم إلى السكان إلا تحسنًا هامشيًا. ويوضح الشكل 1 التفاوت الواسع في كثافة كادر التمريض بالنسبة إلى السكان، حيث تتركز الفجوات الأكبر في أقاليم أفريقيا وجنوب شرق آسيا وشرق المتوسط وبعض بلدان أمريكا اللاتينية. كثافة كادر التمريض لكل 000 01 نسمة في عام 8102الشكل 1: *يشمل العاملين الأخصائيين والمبتدئين في مجال التمريض. المصدر: حسابات القوى العاملة الصحية الوطنية، منظمة الصحة العالمية، 9102. آخر البيانات المتاحة للفترة 3102-8102. 005 000,4000,3000,2000,10 mk لا ینطبق لم یُبلغ عنھا + 00157 إلى 9905 إلى 4704 إلى 9403 إلى 9302 إلى 9201 إلى 91> 01 iiix تهدد أنماط شيخوخة القوى العاملة الصحية في بعض الأقاليم استقرار أعداد الممرضين المتوفرة. ُتعد القوى العالمية العاملة في التمريض شابة نسبيًا، ولكن هناك تفاوتات على نطاق الأقاليم، حيث تزداد الفئات العمرية الأكبر سنًا بقدر كبير في إقليم الأمريكتين والإقليم الأوروبي. وسيتعين على البلدان التي لا تقل فيها أعداد الممرضين والممرضات الذين مازالوا في مرحلة مبكرة من مسارهم المهني (تقل أعمارهم عن 53 عامًا) مقارنة بأولئك الذين يقتربون من سن التقاعد (تبلغ أعمارهم 55 عامًا أو أكثر)، زيادة عدد الخريجين وتعزيز الحزم الخاصة باستبقاء الممرضين والممرضات من أجل الحفاظ على إتاحة الخدمات الصحية. وينبغي للبلدان التي لديها قوى شابة عاملة في التمريض أن تعزز توزيع هذه القوى على نحو منصف على نطاق البلاد. وكما يظهر في الشكل 2، فإن البلدان التي ترتفع لديها نسبة الممرضين والممرضات في سن قريب من التقاعد مقارنًة بالفئة الشابة في كادر التمريض (البلدان فوق الخط الأخضر) ستواجه تحديات أكبر في الحفاظ على القوى العاملة في مجال التمريض. *يتضمن العاملين في مجال التمريض الأخصائيين والمبتدئين. المصدر: حسابات القوى العاملة الصحية الوطنية، منظمة الصحة العالمية، 9102. آخر البيانات المتاحة المبلغ عنها في الفترة بين عامي 3102 و8102. الشكل 2: نسب الممرضين والممرضات فوق سن 55 عاما ًودون سن 53 عاما ً نسبة الممرضین/ الممرضات دون سن 53 عاما ً 07% 06% 05% 04% 03% 02% 01% %0 ما ً عا 5 5 سن ق فو ت ضا مر لم / ا ین ض مر لم ة ا سب ن %07 %05 %04 %03 %02 %01 %0%06 81 بلدا ًمعرضا ًلشیخوخة القوى العاملة یشیر الخط الأخضر إلى تساوي عدد الممرضینكل نقطة تمثل بلداً الممرضات قرب سن التقاعد مع عدد الیافعین منھم في القوى العاملة حالة التمريض في العالم عام 0202vix %72 16% 34% 6% 6% 7% 6% 4% 22% 81% CIBARA الدخل المتوسط %72 16% 34% 6% 6% 7% 6% 4% 22% 81% CIBARA الدخل المتوسط %72 16% 34% 6% 6% 7% 6% 4% 22% 81% CIB RA دخل المتوسط يلزم زيادة العدد الإجمالي لخريجي التمريض بنسبة 8 % سنويا ًفي المتوسط، إلى جانب تحسين القدرة على توظيف هؤلاء الخريجين واستبقائهم، من أجل معالجة النقص في كادر التمريض بحلول عام 0302 في جميع البلدان. وفي غياب هذه الزيادة، تشير الاتجاهات الحالية إلى أن عدد الممرضين والممرضات سيبلغ 63 مليون شخص بحلول عام 0302، وسيبلغ بذلك النقص المتوقع مقارنة بالاحتياجات 7.5 مليون ممرض وممرضة، وسيتركز هذا النقص في المقام الأول في الإقليم الأفريقي وإقليم جنوب شرق آسيا وإقليم شرق المتوسط. وفي المقابل، سيظل عدد من البلدان في إقليم الأمريكتين والإقليم الأوروبي وإقليم غرب المحيط الهادئ يواجه التحديات التي تطرحها أوجه النقص المحددة على الصعيد الوطني. وُيظهر الشكل 3 الزيادات المتوقعة في عدد الممرضين والممرضات بحسب أقاليم المنظمة وفئات الدخل في البلدان. الشكل 3: الزيادة المتوقعة (حتى عام 0302) في عدد العاملين في مجال التمريض، بحسب أقاليم المنظمة وفئات الدخل في البلدان مع تطور الاتجاهات، يطرح التوزيع المنصف للممرضين والممرضات واستبقاؤهم تحديا ًشبه عالمي. nnifroT nevS/PACI © * يشمل العاملين في مجال التمريض الأخصائيين والمبتدئين. حسب فئة الدخلحسب الإقليم vx أفاد معظم البلدان (251 بلدا ًمن أصل 751 بلدا ًمجيباً؛ 79 % ) بأن الحد الأدنى للفترة التي يستغرقها التعليم في مجال التمريض هي برنامج يمتد ثلاث سنوات. وأفادت غالبية واسعة من البلدان بوجود معايير للمحتوى التعليمي ومدة التعليم (19 % )، وآليات للاعتماد (98 % )، ومعايير وطنية لمؤهلات هيئة التدريس (77 % ) والتعليم المهني المشترك (76 % ). ومع ذلك فإننا لا نعرف الكثير عن فّعالية هذه السياسات والآليات. وفضًلا عن ذلك، فما زال هناك قدر كبير من التفاوت بين المستويات الدنيا للتعليم والتدريب في مجال التمريض، إلى جانب القدرات المحدودة من قبيل نقص هيئات التدريس وقصور البنية التحتية والافتقار إلى أماكن التوظيف في المجال السريري. وكما يظهر في الشكل 4، فإن مدة التعليم لنيل شهادة التمريض تتراوح بشكل أساسي بين ثلاث وأربع سنوات على الصعيد العالمي. أفاد 87 بلدا ً(35 % من البلدان المجيبة) بوجود أدوار متقدمة في ممارسات التمريض. وهناك بّينات قوية تدل على أن توافر كادر التمريض المشارك في الممارسات المتقدمة من شأنه أن يزيد من إتاحة الرعاية الصحية الأولية في المجتمعات الريفية وأن يعالج الإجحاف في إتاحة الرعاية أمام المجموعات السكانية المستضعفة في البيئات الحضرية. فالممرضون والممرضات على جميع المستويات عند تمكينهم ودعم عملهم على نحو شامل لكامل نطاق تعليمهم وتدريبهم، بإمكانهم أن يقدموا الرعاية الصحية الأولية والوقائية الفّعالة، إلى جانب الخدمات الصحية العديدة الأخرى التي تكتسي أهمية جوهرية لتحقيق التغطية الصحية الشاملة. ytteG aiv PFA/bitahK-lA reezaN © 001% 08% 06% 04% 02% 0% 5 سنوات 4 سنوات3 سنوات سنتان أفریقیا الأمریكتان شرق المتوسط أوروبا جنوب شرق آسیا غرب المحیط الھادئ أقالیم المنظمة عالمیاً المصدر: حسابات القوى العاملة الصحية الوطنية، 9102 فيما يخص 99 بلدًا وقاعدة بيانات سيغما فيما يخص 85 بلدًا. آخر البيانات المتاحة التي أبلغت عنها البلدان في الفترة بين عامي 3102 و8102. الشكل 4: متوسط مدة (سنوات) التعليم للعاملين في مجال التمريض، بحسب أقليم المنظمة حالة التمريض في العالم عام 0202ivx يعمل ممرض واحد من كل ثمانية ممرضين في بلد آخر غير البلد الذي ُولد أو تدرب فيه. يتزايد الحراك الدولي للقوى العاملة في مجال التمريض. وفي حين أن أنماط التنقل تتطور، فإن التوزيع المنصف للممرضين والممرضات واستبقاءهم يطرح تحديًا شبه عالمي. وقد تؤدي الهجرة الخارجة عن نطاق السيطرة إلى تفاقم أوجه النقص وتسهم في الإتاحة غير المنصفة للخدمات الصحية. ويبدو أن العديد من البلدان المرتفعة الدخل في مختلف الأقاليم تعتمد اعتمادًا مفرطًا على التنقل العالمي لكوادر التمريض، نظرًا إلى انخفاض أعداد خريجيها في مجال التمريض أو أوجه النقص القائمة في عدد وظائف التمريض المتاحة والقدرة على توظيف الخريجين الجدد في النظام الصحي. معظم البلدان (68 % ) لديها هيئة مسؤولة عن تنظيم التمريض في ثلثي البلدان تقريبًا (46 % ) يلزم الخضوع لتقييم مبدئي للكفاءة للالتحاق بممارسة التمريض، وفي ثلاثة أرباع البلدان تقريبًا (37 % ) يلزم خضوع الممرضين والممرضات للتطوير المهني المستمر من أجل مواصلة الممارسة. ومع ذلك، فإن تنظيم تعليم التمريض وممارسته لا ينسق إلا من خلال عدد قليل من ترتيبات الاعتراف المتبادل دون الإقليمية. وتواجه الهيئات التنظيمية تحديًا في إبقاء اللوائح المتعلقة بتعليم التمريض وممارسته والسجلات الخاصة بالقوى العاملة في مجال التمريض محدثة في عصر يتسم بمعدلات التنقل المرتفعة وبالاعتماد على الأفرقة والتكنولوجيات الرقمية. وُيظهر الشكل 5 نسبة البلدان المبلغة التي تطبق أحكامًا تنظيمية بشأن أوضاع العمل. مازال التمريض مهنة تتسم بغلبة أحد الجنسين إلى حد بعيد وبوجود أوجه التحيز المرتبطة بذلك في أماكن العمل. وتشّكل الإناث 09 % تقريبًا من القوى العاملة في مجال التمريض، ولكن المناصب القيادية في مجال الصحة نادرًا ما تحتلها الممرضات أو النساء. وتشير بعض البّينات إلى وجود فجوة في الأجور قائمة على أساس نوع الجنس، وأشكال أخرى من أوجه التمييز القائمة على نوع الجنس في بيئة العمل. وأفاد معظم البلدان بتوافر الحماية القانونية، بما في ذلك فيما يتعلق بساعات وظروف العمل والحد الأدنى للأجور والحماية الاجتماعية، ومع ذلك فهي غير موزعة توزيعًا منصفًا على نطاق الأقاليم. وأفاد عدد من البلدان يزيد على الُثلث بقليل (73 % ) بوجود تدابير للوقاية من الاعتداء على العاملين الصحيين. أفاد 28 بلداً من أصل 511 بلداً مجيبا ً(17 % ) بوجود منصب قيادي في مجال التمريض على الصعيد الوطني، مسؤول عن الإسهام في سياسات التمريض والصحة. ويوجد برنامج وطني لتنمية القدرات القيادية في مجال التمريض في 87 بلدًا (35 % من البلدان المجيبة). ويرتبط وجود منصب مسؤول حكومي في مجال التمريض (أو ما يعادله) ووجود برنامج للقيادة في مجال التمريض كلاهما بقوة البيئة التنظيمية للتمريض. الشكل 5: نسبة البلدان التي لديها أحكام تنظيمية لشروط العمل تنظیم ساعات وشروط العمل )331 نعم من أصل 241( تنظیم الحمایة الاجتماعیة )521 نعم من أصل 731( تنظیم الحد الأدنى للأجور )911 نعم من أصل 431( إنشاء مجلس لمھنة التمریض )141 نعم من أصل 461( إتاحة أدوار متقدمة في مھنة التمریض )05 نعم من أصل 59( تطبیق تدابیر لحمایة العاملین الصحیین من الاعتداءات )02 نعم من أصل 55( نسبة البلدان التي أبلغت نعم 001% 08% 06% 04% 02% 0% 49% 35% 68% 73% 98% 19% المصدر: حسابات القوى العاملة الصحية الوطنية، منظمة الصحة العالمية 9102 iivx يلزم على البلدان المتأثرة زيادة التمويل لتعليم وتوظيف 9 5 مليون ممرض وممرضة إضافيين على الأقل. تقدر الاستثمارات الإضافية الموّجهة لتعليم التمريض في البلدان المنخفضة والمتوسطة الدخل بنحو 01 دولارات أمريكية للفرد. وسيلزم تخصيص المزيد من الاستثمارات لتوظيف الممرضين والممرضات بعد تخرجهم. وفي معظم البلدان يمكن تحقيق ذلك باستخدام التمويل المحلي. وتشمل الإجراءات اللازمة استعراض وإدارة الأجور الوطنية، وفي بعض البلدان إلغاء القيود المفروضة على أعداد الممرضين والممرضات. وحيثما كانت الموارد المحلية المتاحة على المدى المتوسط والبعيد محدودة، في البلدان المنخفضة الدخل والبيئات الضعيفة أو المنكوبة بالنزاعات مثًلا، ينبغي النظر في وضع آليات من قبيل الترتيبات المؤسسية لتجميع الأموال. ويمكن أن يساعد شركاء التنمية ومؤسسات التمويل الدولية في هذا المسعى من خلال تحويل استثمارات رأس المال البشري في مجالات التعليم والتوظيف ونوع الجنس والصحة وتطوير المهارات إلى استراتيجيات وطنية بشأن القوى العاملة الصحية من أجل النهوض بالرعاية الصحية الأولية وتحقيق التغطية الصحية الشاملة. ومن شأن الاستثمارات في القوى العاملة في مجال التمريض أن تساعد أيضًا في تسريع وتيرة التقدم في خلق الوظائف وتحقيق المساواة بين الجنسين وإشراك فئة الشباب. التوجيهات المستقبلية للسياسات بشأن القوى العاملة في مجال التمريض الإجراءات الرئيسية العشرة 1 RPN/elooP .W nhoJ © حالة التمريض في العالم عام 0202iiivx ينبغي للبلدان أن تعزز قدراتها في مجال جمع البيانات عن القوى العاملة الصحية وتحليلها واستخدامها. وتتضمن الإجراءات المنشودة تسريع وتيرة تنفيذ حسابات القوى العاملة الصحية الوطنية وتحليلات سوق العمل في قطاع الصحة لُيسترشد بها في وضع السياسات واتخاذ القرارات الاستثمارية. وسيتطلب تجميع البيانات عن التمريض مشاركة مختلف الهيئات الحكومية فضًلا عن إشراك الجهات صاحبة المصلحة الرئيسية، كالمجالس التنظيمية ومؤسسات تعليم التمريض ومقدمي الخدمات الصحية والرابطات المهنية. يجب رصد حراك كادر التمريض وهجرته رصدا ًفاعلا ًوإدارته على نحو أخلاقي ومسؤول. وتشمل الإجراءات اللازمة في هذا المجال: التزام البلدان وأرباب العمل والجهات الدولية صاحبة المصلحة بتعزيز تنفيذ أحكام "المدونة العالمية للمنظمة بشأن قواعد الممارسة المتعلقة بتوظيف العاملين الصحيين على المستوى الدولي". ومن شأن إقامة الشراكات والتعاون بين الهيئات التنظيمية وُنظم المعلومات عن القوى العاملة الصحية وأرباب العمل والوزارات الحكومية والجهات الأخرى صاحبة المصلحة أن تحّسن من القدرة على رصد التنقل الدولي لكادر التمريض وضبطه وتنظيمه. وينبغي للبلدان التي تّتكل بشدة على كوادر التمريض المهاجرة أن تسعى إلى تحقيق المزيد من الاكتفاء الذاتي من خلال استثمار المزيد في تأهيل كادر تمريض محلي. أما البلدان التي تعاني من خسائر مفرطة في قواها العاملة في مجال التمريض بسبب الهجرة، فعليها أن تنظر في تطبيق تدابير للتخفيف من حدة هذه المشكلة ووضع حوافز لاستبقاء العاملين في هذا المجال، من قبيل تحسين الرواتب (وتكافؤ الأجور) وظروف العمل، واستحداث فرص للتطور المهني، والسماح لكادر التمريض بالعمل على نحو يستغل كامل نطاق تعليمهم وتدريبهم. يجب أن تخّرج برامج تعليم وتأهيل الممرضين والممرضات كادر تمريض قادرا ًعلى النهوض بأهداف الرعاية الصحية الأولية والتغطية الصحية الشاملة. تتضمن الإجراءات في هذا المجال الاستثمار في كليات التمريض وتوفير فرص التدريب السريري وإتاحة البرامج التدريبية لاجتذاب شريحة متنوعة من الطلبة. وينبغي أن يبرز التمريض كخيار مهني قائم على العلم والتكنولوجيا وفريق العمل والإنصاف الصحي. وبإمكان المسؤولين الحكوميين في مجال التمريض وغيرهم من أصحاب المصلحة الوطنيين قيادة الحوار الوطني عن برامج التدريب الأولي والتخصصي المناسبة في مجال التمريض، لضمان توفر عرٍض كاٍف لتلبية طلب النظام الصحي على خريجي هذه البرامج. كما يتعين مواءمة المناهج الدراسية مع أولويات الصحة الوطنية فضًلا عن القضايا العالمية الناشئة من أجل إعداد كادر التمريض للعمل بفعالية ضمن أفرقة مهنية متعددة التخصصات والاستفادة إلى أقصى حد من كفاءات الخريجين في مجال التكنولوجيا الصحية. تكتسي القيادة والحوكمة في مجال التمريض بأهمية حاسمة لتوطيد مهارات القوى العاملة في مجال التمريض. وتشمل الإجراءات في هذا المجال استحداث ودعم دور المسؤول الحكومي في مجال التمريض ليتولى مسؤولية تدعيم القوى العاملة الوطنية في هذا المجال والمساهمة في تقرير السياسات الصحية الوطنية. وينبغي أن يتولى المسؤولون الحكوميون عن التمريض ريادة الجهود الرامية إلى تعزيز البيانات عن القوى العاملة في مجال التمريض وقيادة الحوار السياسي الذي يفرز قرارات قائمة على الأدلة لبذل الاستثمارات اللازمة في القوى العاملة في مجال التمريض. وينبغي تطبيق أو استحداث برامج المهارات القيادية لتنمية روح القيادة لدى كوادر التمريض اليافعة. وعادًة ما تتطلب الظروف في الأوضاع الهشة أو المنكوبة بالنزاعات تركيزًا خاصًا من أجل بناء أو إعادة بناء الركائز المؤسسية والقدرات الفردية لترسيخ القدرات القيادية والإشرافية الفعالة للقوى العاملة في مجال التمريض. 2 3 4 5 xix ينبغي أن تسعى الجهات القائمة على التخطيط والتنظيم إلى ترشيد مساهمات كوادر التمريض. وتشمل الإجراءات في هذا المجال ضمان عمل كادر التمريض في أفرقة الرعاية الصحية على مستوى يغطي كامل نطاق ممارستهم. وينبغي توسيع نطاق نماذج الرعاية القائمة على التمريض كلما كان ذلك مناسبًا لتلبية الاحتياجات الصحية لمختلف الشرائح السكانية وتحسين الحصول على خدمات الرعاية الصحية الأولية، بما في ذلك تلبية الطلب المتزايد الناشئ عن الأمراض غير السارية وتكامل الرعايتين الصحية والاجتماعية. ويجب أن تتصدى سياسات مكان العمل للشواغل التي ُتعرف بتأثيرها على فرص استبقاء العاملين في مجال التمريض، بما يشمل دعم نماذج الرعاية القائمة على كادر التمريض وفرص الممارسة المتقدمة، وتعزيز الفرص المنبثقة من تكنولوجيا الصحة الرقمية مع مراعاة أنماط الشيخوخة في صفوف القوى العاملة في مجال التمريض. ينبغي أن ينسق واضعو السياسات وأرباب العمل والجهات التنظيمية إجراءاتهم دعما ًللعمل اللائق. ويجب أن تهيئ البلدان بيئة عمل تمكينية لكادر التمريض من أجل تحسين فرص اجتذاب القوى العاملة في مجال التمريض وتوظيفها واستبقائها وحفزها. ويتعين إعطاء الأولوية لتوفير مستويات توظيف كافية وتعزيز السلامة والصحة المهنيتين، مع بذل عناية خاصة بكوادر التمريض العاملة في أوضاع هشة أو مهددة أو منكوبة بالنزاعات. وينبغي أن تكون الأجور منصفة وكافية لاجتذاب كوادر التمريض واستبقائها وحفزها. كما ينبغي أن تعطي البلدان الأولوية لتطبيق وتعزيز السياسات التي تتصدى لممارسات التحرش الجنسي والعنف والتمييز في مجال التمريض وتستجيب لها على النحو اللازم. ينبغي للبلدان أن تضع خططا ًمدروسة لتطبيق سياسات مراعية لنوع الجنس في مجال التمريض. وتشمل هذه الإجراءات تنفيذ نظام منصف ومحايد جنسانيًا فيما يتعلق بأجور العاملين الصحيين، وضمان انطباق السياسات والقوانين التي تتصدى لفجوة الأجور بين الجنسين على القطاع الخاص أيضًا. وينبغي أن تسترشد سياسات التمريض باعتبارات نوع الجنس في مجالات التعليم والممارسة والتنظيم والقيادة، على نحو يضع في الاعتبار حقيقة أن النساء ما زلن يشّكلن النسبة الأكبر من القوى العاملة في مجال التمريض (الشكل 6). وينبغي أن تشمل الاعتبارات السياساتية في هذا الصدد تهيئة بيئة عمل تمكينية للمرأة، مثًلا من خلال ساعات عمل مرنة تتكيف مع الاحتياجات المتغيرة للممرضات، وإتاحة الفرص لتطوير المهارات القيادية القائمة على نوع الجنس للنساء العاملات في مجال التمريض. ذكورإناث أقالیم المنظمة أفریقیا الأمریكتان شرق المتوسط أوروبا جنوب شرق آسیا غرب المحیط الھادئ 001% 08% 06% 04% 02% 0% 67% 98% 98% 59% 78% 42% 11% 22% 87% 11% 5% 31% الشكل 6: نسبة العاملات والعاملين في مجال التمريض، بحسب إقليم المنظمة المصدر: حسابات القوى العاملة الصحية الوطنية، منظمة الصحة العالمية 9102. آخر البيانات المتاحة المبلغ عنها في الفترة بين عامي 3102 و8102. 6 7 8 حالة التمريض في العالم عام 0202xx noitadnuoF htlaeH awakasaS aiv akO ubonihsoY © يجب تحديث تنظيم مهنة التمريض. تشمل الإجراءات في هذا المجال مواءمة تعليم التمريض ومعايير التأهيل وإرساء الاعتراف المتبادل بمؤهلات التمريض والشهادات المهنية وإنشاء ُنظم قابلة للتشغيل البيني، بحيث تسمح للجهات التنظيمية بالتحقق من مؤهلات الممرضين والممرضات وحسن سيرتهم بسهولة وعلى وجه السرعة. وينبغي أن تيّسر الأطر التنظيمية، بما فيها نطاق الممارسة والتقييم الأولي للكفاءة ومتطلبات التطوير المهني المستمر، استغلال كامل نطاق التعليم والتدريب لكادر التمريض ضمن أفرقة دينامية متعددة التخصصات. التعاون ركن أساسي. وتشمل الإجراءات في هذا المجال إجراء حوار بين القطاعات بقيادة وزراء الصحة والمسؤولين الحكوميين في مجال التمريض، وتشارك فيه الوزارات الأخرى ذات الصلة (كوزارات التعليم والهجرة والمالية والعمل) والجهات صاحبة المصلحة من القطاعين العام والخاص. ويتمثل عنصر أساسي في تعزيز القدرات اللازمة لممارسة إشراف فعال للسياسة العامة بحيث يتسنى توجيه استثمارات القطاع الخاص والقدرات التعليمية وأدوار كادر التمريض في تقديم الخدمات الصحية، واستغلالها على النحو الأمثل ومواءمتها مع أهداف السياسة العامة. وفي هذا السياق، تشّكل رابطات التمريض المهنية والمؤسسات التعليمية والمعلمون والهيئات التنظيمية والنقابية في مجال التمريض، وطلبة التمريض والفئات الشبابية والقواعد الشعبية والحملات العالمية من قبيل حملة "التمريض الآن"، عناصر قّيمة تسهم في تعزيز دور التمريض في أفرقة الرعاية التي تسهر على تحقيق الأولويات الصحية للسكان. 9 01 يجب أن تتصدى سياسات مكان العمل للشواغل التي ُتعرف بتأثيرها على فرص استبقاء العاملين في مجال التمريض، بما يشمل دعم نماذج الرعاية القائمة على كادر التمريض وفرص الممارسة المتقدمة. قّدم هذا التقرير بيانات وبّينات متينة عن حالة القوى العاملة في مجال التمريض. وهذه البيانات التحليلية ضرورية لدعم الحوار السياساتي وتيسير عملية صنع القرار بشأن الاستثمار في مجال التمريض من أجل تعزيز الرعاية الصحية الأولية، وتحقيق التغطية الصحية الشاملة، والُمضي ُقدمًا على ُخطى أهداف التنمية المستدامة. ورغم مؤشرات التقدم المحرز في هذا المجال، يسّلط التقرير الضوء كذلك على بعض الشواغل الرئيسية. إذ يتعين تسريع وتيرة التقدم في العديد من البلدان ذات الدخل المنخفض والشريحة الدنيا من الدخل المتوسط في أقاليم أفريقيا وجنوب شرق آسيا وشرق المتوسط لسّد بعض الفجوات الهامة في هذه البلدان. غير أن ذلك لا يعفي البلدان ذات الدخل المرتفع والشريحة الدنيا من الدخل المرتفع من بذل الجهد اللازم، حيث يشّكل العرض المحدود محليًا وتقدم سن القوى العاملة في مجال التمريض والاتكال المفرط على التوظيف الدولي، خطرًا يهدد القدرة على تلبية المتطلبات الوطنية من القوى العاملة في مجال التمريض. الخلاصة الاستثمار في التعليم والوظائف والمهارات القيادية ويتعين على الحكومات الوطنية، بدعم من شركائها المحليين والدوليين حسب الاقتضاء، أن تعمل على حفز وتسريع وتيرة الجهود الرامية لتحقيق ما يلي: بناء القدرات القيادية والإشرافية والإدارية للنهوض بالأهداف المتعلقة بالتعليم والصحة والعمل ونوع الجنس بالنسبة للقوى العاملة في مجال التمريض؛ ترشيد عائد الاستثمارات الحالية في مجال التمريض من خلال اعتماد الخيارات السياساتية اللازمة في مجالات التعليم والعمل اللائق والأجر المنصف والتوظيف والممارسة والإنتاجية والتنظيم واستبقاء العاملين بالنسبة للقوى العاملة في مجال التمريض؛ تسريع وتيرة الاستثمار الإضافي وتعزيزه في مجالات التعليم والمهارات والوظائف في مجال التمريض. ستقتضي الاستثمارات المنشودة موارد مالية إضافية. وإذا أتيحت هذه الموارد فسيتسنى قياس العوائد بالنسبة للمجتمعات والاقتصادات من خلال تحسن الحصائل الصحية لمليارات الأشخاص، واستحداث ملايين فرص العمل المؤهلة، لا سيما لفئتي النساء والشباب، وتعزيز الأمن الصحي العالمي. وتتوفر بذلك حجة دامغة تبرر الاستثمار في مجالات التعليم والوظائف والمهارات القيادية لكادر التمريض وتقتضي من الجهات المعنية صاحبة المصلحة الالتزام بالعمل لتحقيق هذه الغايات. nodnoL ,latipsoH ’samohT tS © © Carrie Tudor/The Union xxiv2020 ماع ملاعلا يف ضيرمتلا ةلاح المقدمة ُتعد القوى العاملة في مجال التمريض، التي تشمل . 1 أخصائيي التمريض ومعاونيهم،1 أكبر المهن التي يتألف منها القطاع الصحي في العالم، وتشكل أساسًا للأفرقة الصحية المتعددة التخصصات التي تعمل على الوفاء بوعد تحقيق تمتع الجميع بالصحة. ولمسؤوليات الممرضين والممرضات وأدوارهم، . 2 بوصفهم ممارسين متقدمين وأطباء سريريين وقادة وراسمي سياسات وباحثين وعلماء ومدرسين، أهمية حيوية في تعليم المهنيين الصحيين وممارستهم مهام وظائفهم ممارسة فعالة. ويمكن تحقيق تحسينات في صحة السكان وعافيتهم، مع الاستمرار في تحقيقها باقتدار بفضل مجال التمريض وبفضل الابتكار والإلهام المتصلين بمهنة التمريض. فالتمريض قائم منذ قرون، وقد تطور تطورًا كبيرًا منذ . 3 ميلاد فلورنس نايتنغيل، التي ُتعتبر مؤسسة التمريض الحديث، قبل 002 عام. وظهر في القرن التاسع عشر التعليم المنظم والمعايير السريرية والرابطات المهنية في مجال التمريض، مما أدى تدريجيًا إلى تحسين الجودة وزيادة الكفاءات والارتقاء بشروط العمل في مهنة التمريض. وشهد القرن العشرون زيادة التخصصات وتحسُّ ن الإدارة الذاتية، إلى جانب تعزيز تنظيم المهنة بهدف ضمان تحقيق المساءلة والسلامة (1). وكانت أول منظمة دولية لأخصائيي الرعاية الصحية هي المجلس الدولي للممرضين والممرضات الذي تأسس في عام 9981. وُيعد المجلس، الذي تحل هذا العام ذكرى بدء عمله الحادية والعشرون بعد المائة، اتحادًا يضم أكثر من 031 رابطة وطنية معنية بالتمريض، ويمثل أكثر من 02 مليون ممرض وممرضة في جميع أنحاء العالم (2). وقد أدركت منظمة الصحة العالمية، منذ سنوات . 4 تأسيسها الأولى، القيمة والمساهمة الهائلتين للقوى العاملة في مجالي التمريض والقبالة (3). وعلى مر السنين، ساهمت أطقم التمريض والقبالة في بلوغ المعالم الصحية العالمية الرئيسية، ومنها استئصال الجدري، ومكافحة الأمراض السارية، وتحقيق خفض هائل في وفيات الأمهات والحديثي الولادة والأطفال في جميع أنحاء العالم (4، 5). وُترجم دورها البارز في تحقيق مستوى لا مثيل له من اهتمام جمعية الصحة العالمية، التي اعتمدت على مدى 07 عامًا 01 قرارات لتعزيز استيعاب المعايير الدولية لتعليم أطقم التمريض والقبالة وتوظيف أفرادها واستبقائها في إطار الأولويات الأوسع نطاقًا المتمثلة في الارتقاء بالقوى العاملة (3، 6). 1 وفقًا لتعريف التصنيف الدولي الموحد للمهن الذي وضعته منظمة العمل الدولية (/80ocsi/ocsi/tats/uaerub/hsilgne/cilbup/gro.oli.www//:sptth) المقدمة 1 الفصل 1 etsiL naitsabeS/ROON/OHW © ويستكشف تقرير حالة التمريض في العالم لعام 0202 . 5 هذا، الذي أعدته منظمة الصحة العالمية في إطار من الشراكة مع المجلس الدولي للممرضين والممرضات وحملة التمريض الآن العالمية، البينات المعاصرة بغرض توفير رؤية وخطة عمل استشرافيتين لرسم سياسة التمريض. وبينما يحتفل العالم في عام 0202 بالسنة الدولية لكادر التمريض والقبالة، على النحو الذي حددته جمعية الصحة العالمية (7)، يهدف هذا التقرير التاريخي إلى أن ُيسترشد به في اتخاذ الإجراءات الوطنية والإقليمية والعالمية المتعلقة بالقوى العاملة في مجال التمريض في العقد المتبقي قبل تحقيق أهداف التنمية المستدامة. ويقدم التقرير بينات شاملة ومحدثة عن القوى العاملة . 6 الحالية في مجال التمريض على مستوى العالم؛ ويحصر القضايا والتحديات والبينات المعروفة المتعلقة بدور مهنة التمريض في تحقيق الأهداف الصحية؛ ويعرض خيارات سياساتية ملموسة للنهوض بمهنة التمريض في إطار نهج متكامل يرمي إلى تعزيز القوى العاملة الصحية والرعاية الصحية الأولية والنظم الصحية. وهناك قسم متوافر على موقع منظمة الصحة العالمية . 7 على شبكة الإنترنت،2 يشتمل على ملفات تتضمن البيانات الموجزة المقدمة من كل بلد في سبيل إعداد هذا التقرير. 2 /latropawhn/tni.ohw.sppa//:sptth التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقًا- يعرض هذا الفصل مساهمات القوى الفصل 2 العاملة الصحية في تحقيق خطة التنمية المستدامة لعام 0302، ولاسيما الهدف 3 من أهداف التنمية المستدامة الذي يتناول أنماط العيش الصحية والرفاهية (8). أدوار التمريض في النظم الصحية في القرن الحادي والعشرين- يرسم هذا الفصل الخطوط العريضة الفصل 3 لدور أفراد كادر التمريض ومساهماتهم في تنفيذ التدخلات الصحية ذات الأولوية فيما يتعلق بغايات منظمة الصحة العالمية "المليارية الثلاثية" الرامية إلى تحقيق التغطية الصحية الشاملة، والاستجابة للطوارئ الصحية، وتعزيز تمتع الجميع بأنماط العيش الصحية وبالرفاهية (9). الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض- يصف هذا الفصل سوق العمالة الفصل 4 الصحية الأوسع نطاقًا والأدوات السياساتية ومحددات تصريف الشؤون اللازمة للتصدي للتحديات التي تواجه كادر التمريض في إطلاق كامل إمكاناته الكامنة في المرافق والتجمعات الصحية، سواء في البلدان أو على المستوى العالمي. الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض- يعرض هذا الفصل نظرة الفصل 5 عامة تحليلية على القوى العاملة الحالية في مجال التمريض، بما يشمل المجالات التي لها أكبر أهمية في رسم السياسات الوطنية والإقليمية والعالمية، أي الحصر والتكوين والتوزيع؛ والسعة الإنتاجية؛ وبيئة التعليم والتنظيم والممارسة والسياسات وتصريف الشؤون؛ والمهارات القيادية؛ وعوامل سوق العمل. ويسلط الضوء أيضًا على التقدم المحرز والتحديات المصادفة فيما يتعلق بمساهمة التمريض في معالجة النقص البالغ 81 مليون عامل صحي المتوقع حدوثه بحلول عام 0302. الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض- يرسم هذا الفصل الخطوط العريضة الفصل 6 لبرنامج عمل استشرافي يتضمن خيارات سياساتية ودعوة للعمل موجهة إلى الدول الأعضاء والمؤسسات التعليمية والهيئات التنظيمية والروابط المهنية والشركاء في التنمية والمنظمات الدولية وسائر أصحاب المصلحة. موضوعات الفصل الفردية 3المقدمة © Cecilie Arcurs/ Getty Image 42020 ماع ملاعلا يف ضيرمتلا ةلاح في عام 5102، دشَّ ن العالم خطة الأمم المتحدة للتنمية . 8 المستدامة لعام 0302 التي تتضمن 71 من الأهداف الطموحة والمتشابكة في مجالات ذات أهمية حاسمة للإنسانية ولكوكب الأرض (8). وتشمل أهداف التنمية المستدامة القضاء على الفقر (الهدف 1)، وتحقيق أنماط العيش الصحية والرفاهية (الهدف 3)، وضمان التعليم المنصف والشامل للجميع (الهدف 4)، وتحقيق المساواة بين الجنسين (الهدف 5)، وتوفير العمل اللائق وتحقيق النمو الاقتصادي الشامل للجميع والمستدام (الهدف 8). وتتولى منظمة الصحة العالمية زمام قيادة الجهود التي . 9 يبذلها مجتمع الصحة العالمي للتعجيل بالتقدم المحرز في تحقيق (الهدف 3) من أهداف التنمية المستدامة، المترسخ في مفهوم التغطية الصحية الشاملة. وتحقيق التغطية الصحية الشاملة تدريجيًا هدٌف التزمت به جميع الدول الأعضاء في الأمم المتحدة صراحة وبالإجماع، وقد جاء التزامها في صور منها إصدار الإعلان السياسي عن اجتماع الجمعية العامة للأمم المتحدة الرفيع المستوى المعني بالتغطية الصحية الشاملة (01) وقرار الاتحاد البرلماني الدولي (11). وتشكل الرعاية الصحية الأولية حجر الزاوية في . 01 التغطية الصحية الشاملة. وقد احتفل قادة العالم بالذكرى الأربعين لصدور إعلان ألما-آتا لعام 8791 بشأن الرعاية الصحية الأولية بإصدار إعلان أستانا (21)3 لإرساء دعائم الرعاية الصحية الأولية باعتباره النهج الرئيسي الكفيل بتحقيق التغطية الصحية الشاملة. وأدمجت المنظمة أهداف التنمية المستدامة ومنطق الرعاية الصحية الأولية في عملية وضع برنامج العمل العام الثالث عشر الخاص بها وتنفيذه، حيث جاء ذلك في شكل الغايات "المليارية الثلاثية": استفادة مليار شخص آخر من التغطية الصحية الشاملة، وحماية مليار شخص آخر من الطوارئ الصحية على نحو أفضل، وتمتع مليار شخص آخر بمزيد من الصحة والعافية (9). 3 إعلان أستانا بشأن الرعاية الصحية الأولية: من ألما-آتا إلى تحقيق التغطية الصحة الشاملة وأهداف التنمية المستدامة. التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقا ً 2 1 دور القوى العاملة الصحية في تحقيق خطة عام 0302 التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقا ً 2 الفصل 5 وانتهى تقرير الرصد العالمي لعام 9102 -الرعاية . 11 الصحية الأولية على طريق تحقيق التغطية الصحية الشاملة- الصادر عن منظمة الصحة العالمية إلى أن ثمة بينات على إحراز تقدم ملحوظ نحو تحسين التغطية بالخدمات، مع تزايد اضطلاع البلدان بإصدار تكليفات قانونية تستهدف تحقيق إتاحة الخدمات والمنتجات الصحية إتاحة شاملة في أطرها القانونية الوطنية (31). ومع ذلك، كان التقدم غير متساٍو بين البلدان وداخلها، ولاتزال كفالة الحماية المالية لأشد الفئات ضعفًا تمثل تحديًا. وتعرقل النظم الصحية الضعيفة والعوامل الاجتماعية الاقتصادية التقدم المحرز؛ وثمة حاجة إلى بيانات وبينات أفضل لتحديد أولويات الاستثمار وتتبع ذلك التقدم. وتوجد فرص للتحول من نماذج التنفيذ والأدوار الجامدة إلى نظم تتسم بمزيد من المرونة وسهولة الاستخدام والوضوح. وتفيد تقديرات المنظمة أن إجمالي الاستثمارات اللازمة . 21 لتحقيق الغايات الصحية الواردة ضمن الهدف 3 من أهداف التنمية المستدامة بحلول عام 0302 تبلغ 9.3 تريليونات دولار (01). وعلى مدار فترة الاثنتي عشرة سنة، كانت أكثر من 04% من هذا الاستثمار مخصصة لمكافآت ومرتبات واستحقاقات القوى العاملة الصحية اللازمة لمواجهة النقص المتوقع البالغ 81 مليون عامل صحي بحلول عام 0302 (41-61). وتشير التقديرات، التي تشمل الاستثمار الإضافي المطلوب لتلبية احتياجات التعليم والتعلم مدى الحياة في مجال القوى العاملة الصحية، إلى أن أكثر من ٪05، في المتوسط، من الاستثمارات ذات الصلة بالصحة سوف يلزم أن ُتوجَّ ه إلى الارتقاء بالقوى العاملة الصحية ودفع أجورها واستحقاقاتها واستبقائها. وهذا الاستثمار ليس "تكلفة". فعلى عكس الفكرة الراسخة . 31 -الخاطئة- التي مفادها أن القوى العاملة الصحية تمثل تكلفة يتعين احتواؤها (71، 81)، في عام 6102، نشرت الهيئة الرفيعة المستوى المعنية بالعمالة في مجال الصحة والنمو الاقتصادي ("الهيئة") بينات تفيد أن فرص العمل والتوظيف في الصحة تعزز النمو الاقتصادي وتزيد من إنتاجية سائر القطاعات (71، 81). ويساهم الاستثمار في النظام الصحي والقوى العاملة مساهمة كبيرة في تحقيق النمو الاقتصادي الشامل (الهدف 8 من أهداف التنمية المستدامة)، وخاصًة من خلال توظيف النساء والشباب وتمكينهم (الهدف 5) (91، 02). وتمثل النساء 07٪ من القوى العاملة في مجال الرعاية الاجتماعية والصحية على مستوى العالم (12)، ونحو 09٪ من القوى العاملة في مجالي التمريض والقبالة (22، 32). وقد قدمت الهيئة أساسًا منطقيًا للاستثمار في القطاعين . 41 الصحي والاجتماعي، وإطارًا يتناول كيف يكفل هذا الاستثمار توسيع نطاق القدرات التعليمية اللازمة لضمان توافر العاملين الصحيين على نحو مستدام وإحداث تحول في كفاءاتهم لتلبية تلك الاحتياجات، وإنتاج قوة عاملة صحية تتمتع بالمهارات اللازمة لشغل وظائف لائقة في الأماكن المناسبة لتحسين تقديم الخدمات الصحية، وبأعداد كافية لتفادي النقص المتوقع في القوى العاملة الصحية البالغ 81 مليون شخص. وفي عام 7102، اعتمدت الدول الأعضاء في المنظمة . 51 خطة مدتها خمس سنوات لتنفيذ توصيات الهيئة الواردة في برنامج العمل من أجل الصحة والصندوق الاستئماني المتعدد الشركاء التابع لمنظمة الصحة العالمية ومنظمة العمل الدولية ومنظمة التعاون والتنمية في الميدان الاقتصادي (51، 71). وتنفذ منظمة الصحة العالمية تلك التوصيات بما يتماشى مع نهوج تعزيز القوى العاملة الصحية المبيَّنة خطوطها العريضة في الاستراتيجية العالمية بشأن الموارد البشرية الصحية: القوى العاملة 0302 (الشكل 2-1) (61). ومن الممكن تسريع التقدم المحرز نحو تحقيق التغطية . 61 الصحية الشاملة وتحقيق الهدف 3 من أهداف التنمية المستدامة من خلال تغيير بؤرة التركيز لتصبح احتياجات الاستثمار في القوى العاملة الصحية. ويستلزم ذلك فهمًا شامًلا للعرض والطلب والاحتياجات وتقديرها كميًا، حيث ُتستخدم لإجراء تحليلات لسوق العمالة الصحية كي ُيسترشد بها في وضع الاستراتيجيات والخطط المتكاملة في مجال القوى العاملة الصحية. حالة التمريض في العالم عام 02026 الشكل 2 1 الاستراتيجية العالمية بشأن الموارد البشرية الصحية: الأغراض الاستراتيجية والأهمية لمجال التمريض فيما يخص التمريض، ينطوي الغرض على توخي الإيجابية في إدارة هجرة كادر التمريض وضمان جودة مؤسساته التعليمية، بوسائل منها معالجة النقص في أعضاء هيئة التدريس والاستثمار في استبقاء كادر التمريض في المناطق النائية أو غيرها من المجتمعات المحلية الناقصة الخدمات. فيما يخص التمريض، ينطبق هذا الغرض على مجالات من قبيل تعظيم مساهمات كادر التمريض من خلال تحقيق المستوى الأمثل في نطاق الممارسة ودور الكادر في تقديم الرعاية الوقائية والأولية. فيما يخص التمريض، يشمل ذلك إشراك قادة كادر التمريض في رسم السياسات الصحية وتطوير قدراتهم لرسم السياسات وتصريف الشؤون والاعتماد وشغل المناصب في الجهات التنظيمية. تشمل المجالات الرئيسية في التمريض القدرة على حصر "رصيد" القوى العاملة في مجال التمريض حصرا دقيقا، وفهم المعلومات المطلوبة التي ُيجرى باستخدامها تحليل سوق العمالة الصحية الذي ُيبين بدقة وضع كادر التمريض. ولا يستلزم توافر البيانات اللازمة للرصد والمساءلة إشراك وزارات الحكومة وحدها، بل يستلزم كذلك إشراك أصحاب المصلحة المعنيين بالتمريض من قبيل مؤسسات التعليم والتدريب، والرابطات المهنية، والجهات التنظيمية، وأصحاب العمل، والباحثين. تحقيق المستوى الأمثل لأداء القوى العاملة الصحية وجودتها ومزيج مهاراتها واستبقائها، ومعالجة أوجه القصور وسوء التوزيع تحقيقا للإنصاف وعملا باستراتيجية التغطية الصحية الشاملة. حفز الاستثمار في الموارد البشرية الصحية الُمصطفَّة لتلبية الاحتياجات الصحية للسكان، ومراعاة ديناميات سوق العمالة الصحية، وتعليمها وسياساتها والنقص فيها وسوء توزيعها. تعزيز البيانات من أجل رصد الموارد البشرية الصحية وضمان المساءلة إزاءها. بناء قدرة المؤسسات لتحقيق فعالية السياسة العامة والقوامة والقيادة وتصريف شؤون الإجراءات الخاصة بالموارد البشرية الصحية. 1 جي راتي لاست ض ا الغر الغرض الاستراتيجي 3 ض الاستراتيجي 2 الغر جي 4 راتي لاست ض ا غر ال وتواجه القوى العاملة في مجال التمريض تحديات . 71 مشتركة بين جميع المهن الصحية، ومنها كفاية الأعداد، وعدالة التوزيع والاستبقاء، والتعليم الجيد، والتنظيم الفعال، وشروط العمل المواتية، وتحقيق الجودة والكفاءة ضمن التغطية الصحية الشاملة (42-62). ومع ذلك، ثمة تحديات معينة تواجه مهنة التمريض، ومنها قضايا التحيز الجنساني، والدور القيادي في مجال السياسات، والتنظيم، وتنوع المستويات في أدوار التعليم والممارسة (52). ومن شأن الفهم الواضح لهذه القضايا والأولويات أن يسهل اعتماد القرارات المناسبة المتعلقة بالسياسات والاستثمارات. 7التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقا ً reetS-notliW rehpotsirhC/NDKA © يهدف هذا التقرير إلى تقديم أفضل البينات والبيانات . 81 المتاحة والقابلة للمقارنة دوليًا عن القوى العاملة في مجال التمريض. وتحقيقًا لهذه الغاية، من الضروري توخي الدقة بشأن "تعريف الممرض/ الممرضة". وتمثل البينات التي ُجِمعت في الفصلين 3 و4 تفسيرًا واسع النطاق للتمريض كما يتضح من الأعمال السابقة المنشورة. أمَّ ا في الفصل 5، الذي يعرض البيانات التي ُجِمعت والتحليلات التي أجريت خصيصًا في سبيل إعداد هذا التقرير، فتشير المصطلحات خصوصًا وحصرًا إلى فئتين مهنيتين محددتين في التصنيف الدولي الموحد للمهن لعام 8002 (80-OCSI)، هما: أخصائي التمريض (رمز التصنيف الدولي 1222)، ومعاون أخصائي التمريض (رمز التصنيف الدولي 1223). وقد أبلغت البلدان بالبيانات وفقًا لمن حددْت أنه يستوفي . 91 معايير تعريَفْي هاتين الوظيفتين؛ ولم ُيطلب إلى البلدان الإبلاغ بفئات الوظائف الأخرى (مثل أطقم الِقبالة أو مساعدي كادر التمريض أو غيرهم من العاملين الصحيين المساعدين). وتصنف بعض البلدان بعض العاملين الصحيين على أنهم "أفراد تمريض/ قبالة"، سلكوا طريقًا ويؤدون دورًا تعليمييِن هجينين. ونظرًا إلى أن "فرد كادر التمريض/ القبالة" ليس فئة مهنية مصنفة دوليًا، فلا يتضمن التقرير إلا البيانات التي تشير إلى العاملين الصحيين الذين صنفتهم البلدان ضمن فئة أخصائيي التمريض أو معاوني أخصائيي التمريض. ويمكن الاطلاع على مزيد من المعلومات حول هذه التعاريف وكيفية دعم البلدان للإبلاغ بأفراد كادر التمريض لديها في وصف الأساليب في الفصل 5، وكذلك في الملحق 1 المرفق بهذا التقرير. ويشمل التمريض الرعاية المستقلة والرعاية التعاونية . 02 المقدمتين إلى الأفراد من جميع الأعمار والأسر والفئات والمجتمعات المحلية، سواء أكانت مريضة أم صحيحة، وفي جميع الظروف؛ ويشمل تعزيز الصحة، والوقاية من الأمراض، ورعاية المرضى وذوي الإعاقة والُمحَتضرين (7، 72). 2 2 ما تعريف الممرض؟ وتشمل الأدوار التمريضية الرئيسية الأخرى الدعوَة، وتهيئة بيئة آمنة، والمشاركة في إدارة خدمات المرضى والخدمات الصحية، ورسم ملامح السياسة الصحية، والتعليم، والبحث (72، 82). ويقدم الممرضون والممرضات طائفة واسعة من خدمات الرعاية الصحية للأشخاص في جميع مرافق الرعاية الصحية، من المستشفيات إلى المراكز الصحية في المجتمعات المحلية النائية. وينبغي أن يشير المسمى الوظيفي "الممرض/ الممرضة"، على اختلاف أشكاله، إلى الشخص الذي استوفى الاشتراطات القانونية والتعليمية والإدارية اللازمة لممارسة التمريض. وهناك مجموعة متنوعة من المسارات التعليمية المؤدية . 12 إلى الممارسة تحت المسمى الوظيفي "الممرض/ الممرضة". وبعد الانتهاء من برامج تمريض للمبتدئين، تتوافر غالبًا أيضًا مؤهلات التعليم العالي والمتخصص، وتؤدي عادًة إلى منح مسميات وظيفية وإسناد أدوار مختلفة. وتكون النتيجة تشكيلة متنوعة من مسميات التمريض وأدواره وكفاءاته، حتى داخل البلد نفسه. ويتضخم التنوع الذي ُيرى في أي بلد واحد عند دراسته على المستوى الإقليمي ويزيد أكثر عند تقييمه على المستوى العالمي (الشكل 2-2). وتشير البيانات التي يتضمنها الأطلس التنظيمي العالمي (92) إلى وجود ما لا يقل عن 441 مسمى وظيفيًا متفردًا للممرضين والممرضات في جميع أنحاء العالم تتطلب اجتياز امتحان قبل منح ترخيص مزاولة المهنة، بما يشمل المسميات الوظيفية للممارسة المتخصصة والمتقدمة. ويعكس هذا الوضع تنوعًا في عدد أنواع الممرضين والممرضات من 01 مسميات وظيفية مختلفة في إقليم جنوب شرق آسيا إلى أكثر من 03 مسمى وظيفيًا في إقليم الأمريكتين والإقليم الأوروبي. وقد يختلف دور الممرض/ الممرضة في بلد ما عن دور . 22 الشخص الذي يحمل المسمى الوظيفي نفسه في بلد آخر. ويؤكد هذا الأمر أهمية التعاريف الموحدة دوليًا لدعم المناقشات الدائرة حول تعريف الممرض/ الممرضة، وفهم وظائفه/ وظائفها التمريضية، وتخطيط الخدمات الصحية التي ُتوصَّ ل عن طريقها مساهمات كادر التمريض إلى المستوى الأمثل سعيًا إلى تحقيق الأهداف الصحية للسكان. غرب أفریقیا الأمریكتان المحیط الھادئ جنوبشرق المتوسط شرق آسیا أوروبا مة نظ الم م الی أق من م قلی ل إ ك ــل اخ ض د ری تم ال ال مج ي ة ف رد تفــ الم ة فیــ ظی لو ت ا میا ســ الم د عــد أقالیم المنظمة 0 5 01 51 02 52 03 53 13 91 23 11 02 01 الشكل 2 2 عدد المسميات الوظيفية المتفردة في مجال التمريض داخل كل إقليم من أقاليم المنظمة ملحوظة: تشير الأرقام إلى المسميات الوظيفية التمريضية التي تتطلب اجتياز امتحان في كل بلد، مجمعة حسب الإقليم. المصدر: (92) saltA yrotalugeR labolG NBSCN. 9التمريض في سياق القوى العاملة والأولويات الصحية الأوسع نطاقا ً ekoL lutA/OHW © حالة التمريض في العالم عام 020201 يعرض هذا الفصل ملخصًا لقاعدة البينات المعاصرة . 32 (للاطلاع على التفاصيل المجمَّعة، انظر الملحق المنشور على شبكة الإنترنت) الذي يتناول أدوار ومسؤوليات كادر التمريض المساِهمة في تحقيق الهدف 3 من أهداف التنمية المستدامة وما يتعلق برسالة منظمة الصحة العالمية المتمثلة في "تعزيز الصحة والحفاظ على سلامة العالم وخدمة الضعفاء" والغايات المليارية الثلاثية الوارد النص عليها في برنامج العمل العام على نحو أكثر تحديدًا. 3 1 دور التمريض في تحقيق التغطية الصحية الشاملة أوضح استعراض كوكرين أن للممرضين والممرضات . 42 دورًا فعاًلا في تقديم الرعاية الصحية الأولية عبر مجموعة واسعة من الخدمات المتعلقة بالأمراض السارية والأخرى غير السارية، بما يشمل أدوار اتخاذ القرارات السريرية في بعض الحالات، وكذلك التثقيف في مجال الرعاية الصحية والخدمات الوقائية المتصلة به (03). ويوضح الاستعراض أن خدمات الرعاية الأولية التي يتولى زمام قيادتها الممرضون والممرضات يمكن أن تؤدي، في بيئات معينة ومتى توافرت الظروف الملائمة، إلى تحقيق حصائل صحية مماثلة أو، في بعض الحالات، حصائل أفضل لصالح المرضى ودرجة أعلى من رضائهم مقارنًة بنماذج تقديم الرعاية الأخرى؛ وربما أيضًا يقدم الممرضون والممرضات مشورة أطول زمنًا مع المرضى (03). وأوضحت استعراضات كوكرين الأخرى أن للممرضين والممرضات دورًا فعاًلا في بدء علاج فيروس العوز المناعي البشري ومتابعته (13)، وأن التدخلات التمريضية اللازمة للإقلاع عن التدخين تزيد من احتمال تحقيقه (23). وأوضح استعراض آخر لكوكرين أن العاملين الصحيين غير المتخصصين، بما في ذلك الممرضون والممرضات، قد يحسنون الحصائل المتصلة بالاكتئاب العام واكتئاب الفترة المحيطة بالولادة، واضطرابات الإجهاد التالي للصدمات، واضطرابات تعاطي الكحوليات، وحصائل المرضى ومقدمي الرعاية المتصلة بالخرف (33). وأوضح أحد استعراضات كوكرين المنهجية أن أفراد كادر التمريض، الذين ُيجرون فحوصات الاعتداءات أدوار التمريض في النظم الصحية في القرن الحادي والعشرين أدوار التمريض في النظم الصحية في القرن الحادي والعشرين 3 الفصل 11 الجنسية أو فحوصات الطب الشرعي، إنما يؤدون دورًا فعاًلا في فحوصات الاستدلال الجنائي للاعتداءات الجنسية وتوثيقها، وأن هؤلاء الأفراد يمكن أن يتيحوا الوقاية من العدوى المنقولة عن طريق الاتصال الجنسي والوقاية من الحمل، وأن هذه الرعاية تمثل قيمة جيدة مقابل ما ُينَفق عليها من مال (43). وللممرضين والممرضات أهمية في ضمان جودة . 52 الرعاية وسلامة المرضى، والوقاية من العدوى ومكافحتها، ومقاومة مضادات الميكروبات (53). ويتحقق ذلك من خلال أداء وظائف متعددة، منها رصد التدهور السريري لدى المرضى واكتشاف الأخطاء والمشاكل التي كانت وشيكة الوقوع (63)، وتنفيذ تدخلات الوقاية من العدوى ورصد مكافحتها وتعلُّم الدروس المستفادة منها (73)، وضمان الحفاظ على الممارسات الجيدة التي تتضمن المياه والإصحاح ونظافة الأيدي (83) وفي سياق فاشيات من قبيل كوفيد-91، حيث تؤدي نظافة اليد والتباعد البدني وتطهير الأسطح دورًا رئيسيًا في الاحتواء، تظهر الأهمية الحاسمة لدور الوقاية من العدوى ومكافحتها الذي يضطلع به كادر التمريض. (الإطار 3-1). وهناك توثيق جيد أيضًا للمساهمة التاريخية لكادر . 62 التمريض في الوقاية من الأمراض السارية أو الأمراض المعدية وعلاج المصابين بها ومكافحتها (4، 94). فعلى سبيل المثال، يمكن أن تؤدي التدخلات التي يتولى زمام قيادتها كادر التمريض إلى زيادة معدلات التطعيم (05). وما فتئ كادر التمريض ينشط في جميع أنحاء العالم في التدبير العلاجي للسل والوقاية منه، ويمكنه المشاركة بفعالية في كل من المهام السريرية وغير السريرية، مثل تعزيز الصحة والدعم النفسي الاجتماعي (15-45)، وإجراء الختان الطبي الطوعي للذكور (55–16)، وتصميم وتنفيذ برامج العلاج الوقائي قبل التعرض لفيروس العوز المناعي البشري (26). ويمكن أن يشارك كادر التمريض بفعالية في مكافحة أمراض المناطق المدارية المهملة من خلال التثقيف المجتمعي، والوقاية الكيماوية الجماعية، وتحديد حالات المرض وتشخيصها، وتحديد معدل انتشار المرض، والتحري عن الحالات المشتبه فيها التي حددها وأحالها العاملون الصحيون المجتمعون وتأكيد تلك الحالات، وصرف الأدوية، وإجراء أنواع معينة من الجراحات (ما يتعلق بالتراخوما على سبيل المثال)، وتثقيف المرضى بشأن التدبير العلاجي للأمراض، من قبيل الرعاية الذاتية في الإطار 3 1 مساهمة التمريض في تحقيق سلامة المرضى ُتعزى سنويا ًأكثر من 8 ملايين حالة وفاة تقع في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل إلى تدني جودة الرعاية (93). ويمكن أن يساهم الممرضون والممرضات في تحسين جودة الرعاية وسلامة المرضى من خلال منع وقوع الأحداث الضارة، ولكن هذا يتطلب أن يعملوا بقدراتهم المثلى ضمن أفرقة قوية وفي بيئة عمل جيدة. ويؤدي الممرضون والممرضات دورا ًأساسيا ًفي ضمان سلامة المرضى من خلال رصد التدهور السريري لديهم، واكتشاف الأخطاء والمشاكل التي كانت وشيكة الوقوع، وفهم عمليات الرعاية ومظاهر الضعف المتأصلة في بعض النظم، وتنفيذ العديد من الإجراءات الأخرى لضمان تلقي المرضى رعاية عالية الجودة (63). ولطالما ارتبط الإرهاق الذي يعاني منه الممرضون والممرضات والأطباء بسبب ِثقل عبء العمل والرحلات الطويلة والعلاقات الشخصية غير الفعالة بالتدهور المستمر في سلامة المرضى (04)، في حين أن ثمة ارتباطا بين بيئات العمل الجيدة، وتوظيف الممرضين والممرضات على نحو يحقق السلامة، وتعليمهم ضمن أفرقة مختلطة المهارات من جهة، وانخفض مدة الإقامة في المستشفى، وانخفاض معدل الأحداث الضارة، مثل الإصابة بالالتهاب الرئوي والتهاب المعدة ونزيف الجهاز الهضمي العلوي والقرح الناجمة عن الضغوط والتهابات المسالك البولية المرتبطة بالقسطرة، وانخفاض الوفيات الإجمالية من الجهة الأخرى (14-84) حالة التمريض في العالم عام 020221 aquojbaH ainaT/OHW © مواجهة الوذمة اللمفيَّة (36). ويساهم كادر التمريض أيضًا، في العديد من البيئات في جميع أنحاء أفريقيا، في تحسين جودة الرعاية إزاء الأمراض السارية من خلال تدريب العاملين في مجال صحة المجتمع وتوجيههم والإشراف عليهم (36-56). ويؤدي كادر التمريض دورًا لا غنى عنه في تعزيز . 72 الصحة ومحو الأمية الصحية والتدبير العلاجي للأمراض غير السارية (66-27). وهو، من خلال القدر الملائم المتاح له من المعرفة والمهارات والفرص والدعم المالي، في وضع فريد يسمح له بأداء دور الممارس الفعال والمدرب الصحي والمتحدث الرسمي والوسيط المعرفي للمرضى واُلأسر طوال عمرهم (37). وقد ثبت نجاح كادر التمريض مرارًا في الرعاية والوقاية في مواجهة الأمراض غير السارية (66-27) لدى أدائه طائفة من المهام المتعلقة بتلك الأمراض، بما يشمل التحري وتقديم خدمات الرعاية الصحية الأولية إزاء العديد من تلك الأمراض، من قبيل ارتفاع ضغط الدم والأمراض القلبية الوعائية والسكري والصحة النفسية والحالات العصبية وأمراض الجهاز التنفسي والسرطان (07). وما فتئ الممرضون والممرضات يحسنون، في إطار تنفيذ هذه المهام، الحصائل الصحية، مثل خفض ضغط الدم وخفض درجات الاكتئاب، وما برحوا يقدمون رعاية معادلة لمرضى قصور القلب أو السكري (03، 07). وما برح كادر التمريض يساهم أيضًا في تغيير السلوكيات، مثل زيادة الإقبال على الأدوية، ويكون المرضى الذين يعالجهم كادر التمريض أكثر عرضة للحفاظ على مواعيد المتابعة (03، 07). والدور الممتد لكادر التمريض في أفرقة الرعاية الصحية، الذي يعززه التوجيه المناسب المتمثل في تثقيف كادر التمريض ونطاق ممارسته، قد يدعم دمج الأمراض غير السارية في الرعاية الأولية (47، 57). والدور الممتد لكادر التمريض، وإن كان مهمًا في مجموعة متنوعة من البيئات، لديه، في البيئات التي تعاني من نقص الأطباء المتخصصين، من الطاقات الكامنة ما يكفل تعزيز الإنصاف في مجال الصحة (37، 67). ويساهم كادر التمريض في الرعاية طوال العمر. ويقدم . 82 كادر التمريض، العامل جنبًا إلى جنب مع كادر القبالة وأطباء التوليد وسائر الأطباء المتخصصين، للحوامل الرعاية السابقة للولادة والرعاية اللاحقة لها (77). ويؤدي كادر التمريض المعني بالأطفال الحديثي الولادة ذو المهارات المتخصصة المتعلقة بالمواليد دورًا فعاًلا في تقديم دعم خاص ورعاية عالية الجودة في الوقت المناسب للمرضى المقيمين في المرافق الصحية، بدعم من متخصصين آخرين في مجال الأطفال الحديثي الولادة. وفي معظم البلدان، يشكل كادر التمريض العمود الفقري لخدمات الصحة المدرسية، حيث يقدم الرعاية إلى الأطفال والمراهقين (87-18). ويقدم كادر التمريض خدمات في مختلف مجالات الصحة الجنسية والإنجابية؛ فعلى سبيل المثال، يقدم، على نحو مأمون وبفعالية، وسائل منع الحمل التي تؤخذ عن طريق الفم والتي ُتحقن والتي ُتزرع في الجسم والتي ُتوضع داخل الرحم (28). وتؤكد البينات أيضًا فعالية كادر التمريض في تحري سرطان عنق الرحم وتوفير الخدمات المتعلقة بفيروس العوز المناعي البشري للنساء اللاتي في سن الإنجاب وما بعدها (38، 48). وتوفير المعلومات والاضطلاع بأنشطة الدعوة للمراهقين المستحقين لها بحكم أعمارهم ولوالديهم أو مقدمي الرعاية إليهم عنصران رئيسيان من عناصر الدور الذي يؤديه كادر التمريض في توسيع خدمات التطعيم ضد فيروس الورم الحليمي البشري (38، 58، 68). ويؤدي الممرضون والممرضات دورًا رئيسيًا في توفير الرعاية لكبار السن، ويمكن أن يحققوا فائدة في تقديم الرعاية المتكاملة، مما يؤدي إلى تحقيق حصائل أفضل للفئات السكانية الأكبر سنًا (الإطار 3.2) (78). وُيمكِّن كادر التمريض، بما يضطلع به أفراده من دور رئيسي في تقديم الرعاية الملطفة، من تهيئة جو تنتهي فيه حياة المرضى بكرامة ورحمة. الإطار 3 2 نموذج الرعاية المجتمعية للفئات السكانية في مرحلة الشيخوخة الذي يقوده كادر التمريض بدافع من مكانة اليابان بوصفها مجتمعا ً"بالغ الاحترام للشيخوخة"، دشَّنت مؤسسة ساساكاوا التذكارية للصحة، في عام 4102، برنامجا ًلتمكين كادر التمريض من إنشاء مراكز تمريض للرعاية المنزلية وتشغيله (88). وتؤدي المراكز دور مراكز الصحة المجتمعية التي يقدم الممرضون والممرضات من خلالها خدمات ُتمكِّ ن كبار السن من العيش بكرامة في المنزل وتحسين نوعية حياة الناس في المجتمع المحلي. وتدعم المؤسسة أيضا ًشبكة ُتعزِّ ز التعاون بين المراكز، وتجمع البيانات، وتدعو إلى إنشاء مراكز تمريض للرعاية المنزلية تتخذ من المجتمع المحلي مركزا ًلها (98) وُيِعد برنامج مدته ثمانية أشهر في مجال رعاية المسنين والرعاية التمريضية المنزلية كادر التمريض لإجراء تقييمات بدنية، وتلبية احتياجات الرعاية الصحية الأولية لسكان المجتمع المحلي، ومساعدة الأسر على توفير الرعاية الملطفة ورعاية نهاية العمر في المنزل. وتركز الدورات الدراسية الإضافية على ريادة الأعمال والإدارة وخطط الأعمال اللازمة لتطوير مركز تمريض الرعاية المنزلية وتشغيله (98) وبحلول آذار/ مارس 9102، كان 76 ممرضا ًوممرضة قد أتموا البرنامج، وأكثر من 65 منهم يديرون مراكز تمريض الرعاية المنزلية في 32 مقاطعة في جميع أنحاء اليابان. ويستأثر الممرضون والممرضات بنسبة 07٪ من العاملين في المراكز في المتوسط، أمَّ ا النسبة الباقية البالغة 03%، فهي نسبة المهنيين الآخرين 03%، مما يدل على أن ثمة نهجا تعاونيا متعدد التخصصات مطبقا في تلبية احتياجات الرعاية الصحية الأولية للمجتمعات التي تتلقى الخدمة في المراكز وفي منازل أفرادها. وقد بلغ متوسط عدد زيارات المراكز التي تضمها الشبكة 000 52 زيارة شهريا.ً وساهم دعم الأسر في تقديم رعاية نهاية العمر في خفض تكاليف الرعاية الصحية المرتبطة بدخول المستشفى والإجراءات الطبية (09) حالة التمريض في العالم عام 020241 anihC fo cilbupeR s'elpoeP eht fo noissimmoC htlaeH lanoitaN © 3 2 دور التمريض في التعامل مع الطوارئ والأوبئة والكوارث يشارك الممرضون والممرضات في تقديم الرعاية . 92 في حالات الطوارئ السريرية (مثل الحوادث أو النوبات القلبية)، والوقاية من الفاشيات والاستجابة لها، والاستجابة للكوارث والأزمات الإنسانية. وغالبًا ما يكون كادر التمريض أول من يراه المريض في المرفق الصحي؛ وقد تختلف أدواره تبعًا للسياق، ولكنه غالبًا ما يشمل الفرز، والتعرف المبكر على الحالات المهدِّدة للحياة، وإعطاء الأدوية، وتنفيذ الإجراءات المنقذة للحياة، وبدء الإحالة المبكرة. وما فتئ كادر التمريض يؤدي دورًا محوريًا ضمن . 03 الأفرقة التي تتعامل مع الأوبئة التي تهدد الصحة في جميع أنحاء العالم، بما يشمل متلازمة الالتهاب الرئوي الحاد الوخيم (سارس) في عام 3002 (19)، وفاشية فيروس كورونا المسبب لمتلازمة الشرق الأوسط التنفسية في عام 5102 (29)، ومرض فيروس زيكا في عام 6102 (39، 49) ومرض فيروس الإيبولا في عام 4102 (59، 69) وفاشية كوفيد-91 في عام 9102. ومن خلال مبادرة أفرقة الطوارئ الطبية التابعة لمنظمة الصحة العالمية، ُيدرَّ ب أفراد كادر التمريض وغيرهم من العاملين الصحيين على دعم قدرات بلدانهم على الاستجابة لحالات الكوارث والطوارئ في المستقبل (79). وقد يكون لهذا أهمية خاصة في زيادة القدرة على الصمود لدى النظم الصحية التي أصبحت أكثر ضعفًا أمام الكوارث والنزاعات (89). وفي البيئات المتضررة من الهشاشة والنزاعات، يواجه . 13 العاملون الصحيون، بما في ذلك كادر التمريض، عددًا من التحديات الشخصية والمهنية، مثل خطر الاختطاف، وضرورة التعامل مع وفاة الزملاء، والخوف من وفاتهم هم، وزيادة عبء العمل، وزيادة درجة التعقُّد فيه (كالاضطرار إلى التعامل مع الجروح الناجمة عن الأسلحة النارية)، وكذلك تآكل المعايير الأخلاقية والمهنية (99). وعلى الرغم من هذه الظروف، يبدي الممرضون والممرضات وسائر العاملين الصحيين صمودًا والتزامًا في مواجهة تلك التحديات وما برحوا يقدمون الخدمات الأساسية (99). وقد تمكن كادر التمريض، في إطار من الدعم الذي يحصل عليه، في حالات النزعات أو لدى تلبية احتياجات اللاجئين، من تحقيق النجاح في علاج طائفة من الحالات المختلفة، مثل السل الرئوي (001) وسائر التهابات الجهاز التنفسي، وتسوس الأسنان، واضطراب الإجهاد التالي للصدمات (101). 51أدوار التمريض في النظم الصحية في القرن الحادي والعشرين 3 3 دور التمريض في تحقيق تمتع السكان بأنماط العيش الصحية وبالرفاهية يستلزم تحسين تمتع الفئات السكانية بأنماط العيش . 23 الصحية وبالرفاهية أن يتصدى الممرضون والممرضات وغيرهم من العاملين الصحيين للمحددات الاجتماعية للصحة، وبذلك يسهمون في تحقيق أهداف التنمية المستدامة. وتمثل الوقاية من أمراض الإسهال من خلال التشجيع على غسل اليدين والتغذية والإصحاح (201، 301) مجالات ذات بينات ناشئة تثبت فعالية التمريض في التصدي للمحددات الاجتماعية للصحة (4). وقد يكون الممرضون والممرضات ِمن أوائل َمن يتصدون لآثار تغيُّر المناخ (401-601)، التي تشمل الجهود الرامية إلى تعزيز صمود الفقراء والمعرضين للعوارض ذات الصلة بالمناخ، وكذلك تقليل الوفيات الناجمة عن الأمراض ذات الحساسية للمناخ من قبيل أمراض الإسهال والملاريا وداء المثقبيات الأفريقي وداء الليشمانيات والبلهارسية وعدوى النيماتودا المعوية وحمى الضنك. ويعتمد تمكين الفئات السكانية المتمتعة بمزيد من الصحة . 33 واستدامة تمتعهم بها على كل من ضمان صحة الشباب من خلال إتاحة التغطية الصحية الشاملة إتاحًة منصفًة، وضمان تمتعهم بموفور الصحة ورغبتهم في مواصلة العمل المعلق بتحقيق التنمية المستدامة حتى الجيل التالي. ويفهم كادر التمريض النهوج اللازمة لتحقيق سرعة تلبية توقعات الشباب ويمكنه تعديل تلك النهوج لتلائم الاحتياجات، بما في ذلك الجدارة بالثقة وعدم التسرع في الحكم والتركيز على تلبية احتياجات العملاء؛ وتلبية توقعات الشباب بشروط الشباب أنفسهم؛ وإمكانية التواصل مع كادر التمريض بسهولة (701-011). وما فتئ كادر التمريض يحقق نتائج إيجابية في . 43 المجالات التي تمثل تحديًا خاصًا للمرأة، من قبيل تنظيم الأسرة والرعاية المتعلقة بالإجهاض (111، 211). ويمكن أن يؤدي تحسين دوره في تقديم تلك الخدمات إلى تحسين إتاحة الرعاية الصحية الإنجابية للعديد من النساء. ويقدم كادر التمريض دعمًا اجتماعيًا للنساء متمثًلا في رعاية صحة الأم أثناء عوارض الحياة uzimihS ihsoY/OHW © الحرجة (من قبيل فترتي ما قبل الولادة وما بعدها (311) والإصابة بسرطان الثدي) وهو عنصر أساسي في ضمان حصول النساء على رعاية تحترمهن في مرافق الخدمات الصحية (411، 511). ولا غنى عن كادر التمريض أيضًا في مكافحة العنف القائم على نوع الجنس: فالدراسات المتعلقة بالتحري عن عنف العشير تفيد أن أفراد كادري التمريض والقبالة هم المهنيون الصحيون الذين يجرون في معظم الأحيان (54٪ و42٪ على التوالي) عملية تحديد الحالة شخصيًا (611). وفي ختام هذا الفصل، يلخص الشكل 3.1 مساهمة التمريض في تحقيق الغايات المليارية الثلاثية. كادر التمريض بوصفه جزءا من الأفرقة المتعددة التخصصات التغطية الصحية الشاملة تقديم الرعاية الأولية على الخطوط الأمامية الوقاية من طائفة واسعة من الأمراض السارية وغير السارية ومعالجة المصابين بها تقديم الرعاية في جميع مراحل العمر، من الميلاد إلى الوفاة الصحة والعافية التصدي للمحددات الاجتماعية للصحة من خلال العمل التعاوني التصدي لآثار تغير المناخ ومعالجتها ضمان الإتاحة للفئات الضعيفة ومنها النساء والشباب الطوارئ والأوبئة والكوارث تقديم الرعاية في حالات الطوارئ السريرية التصدي للأوبئة والكوارث والأزمات الإنسانية التعرف على الحالات المهددة للحياة وتنفيذ الإجراءات المنقذة لها الشكل 3 1 مساهمة التمريض في تحقيق الغايات المليارية الثلاثية 71أدوار التمريض في النظم الصحية في القرن الحادي والعشرين uzimihS ihsoY /OHW © حالة التمريض في العالم عام 020281 يتطلب تحسين المساهمة التي تقدمها مهنة التمريض، . 53 كما هو موضح في الفصل السابق، بيئة سياسات وممارسات مواتية. ويمكن تحليل العديد من العوامل التي تؤثر على التوافر والتوزيع والقدرة وبيئة العمل التمكينية وأداء القوى العاملة في مجال التمريض من خلال المنظور السياساتي، باستخدام إطار سوق العمالة الصحية الذي أعدته منظمة الصحة العالمية (711) (الشكل 4.1). وبناًء على هذا الإطار، يبحث التقرير أربعة أبعاد تميز . 63 الخطاب المتعلق بسياسات القوى العاملة الصحية في مجال التمريض، وهو ما يؤدي إلى تقوية قاعدة البينات المؤلفة من الدراسات الُمحكَّمة في المجالات التالية: (أ) التعليم والتدريب السابقين للخدمة؛ (ب) تدفقات القوى العاملة إلى الداخل وإلى الخارج؛ (ج) التوزيع المنصف والكفاءة؛ (د) التنظيم (بما يشمل القطاع الخاص). وُيشار أيضًا في الإطار إلى العوامل المجتمعية والاقتصادية والسكانية التي تؤثر على سوق العمالة الصحية. وترد مناقشة بعض هذه العوامل (التحيز الجنساني، مستوى دخل البلد) بالتفصيل في هذا التقرير، في حين أن العوامل الأخرى، مثل الاتجاهات الديموغرافية (الشيخوخة، أنماط النمو) وتغيُّر المناخ، ينبغي أن ُينظر فيها بطريقة مباشرة بدرجة أكبر في السياق الوطني عند تصميم السياسات المعنية المتعلقة بالقوى العاملة في مجال التمريض وتنفيذها. 4.1 التعليم والتدريب السابقان للخدمة الغرض من تعليم التمريض هو إنتاج قوة عاملة . 73 تمريضية قادرة على تلبية الاحتياجات الصحية للسكان، من النواحي الكمية والنوعية والتوزيعية. لذلك، ينبغي أن تكون مدخلات مؤسسات التعليم التمريضية ومخرجاتها مصممة لتلبية الاحتياجات الخاصة للقطاع الصحي وقدرته الاستيعابية. ويمكن أن يسهل الحوار المنتظم والتنسيق بين قطاعات الصحة والتعليم والعمل والمالية ضماَن عدم غياب التناسب. الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض 4 الفصل 91 ويتأثر عدد الطلاب المسجلين في برامج تعليم . 83 الممرضين والممرضات الذين يستكملون تلك البرامج أوًلا بمستويات التعليم الأساسية للسكان والمتطلبات التعليمية الواجب استيفاؤها قبل التسجيل في برنامج التمريض (811، 911). ويتأثر التسجيل في برامج التمريض بموقع البرنامج وتكلفته وطاقته الاستيعابية وانتماءاته السريرية ومستوى تعليم التمريض المقدم فيه. ويتأثر كل ما ُذكر بدوره بأعداد أعضاء هيئة التدريس المؤهلين لإنجاز مهمة البرنامج وأغراضه، إلى جانب البنية التحتية والقدرات اللازمة لتقديم التعليم السريري (021). ويقول سكويرز وآخرون (la te seriuqS.) إن العوامل "الكليَّة" مثل قدرة النظام الصحي على استيعاب العاملين الصحيين (عدد َأِسرة المستشفيات لكل َنسمة) والتمكين الجنساني تؤثر أيضًا على إنتاج كادر التمريض في كل بلد (121). ويمكن أن تؤثر القضايا الجنسانية على التحاق طلاب . 93 التمريض بالبرامج التعليمية، ومن ثم، تؤثر على المعروض من كادر التمريض. ويحد التقليل من القيمة الاجتماعية والاقتصادية لأعمال التمريض من فرص دینامیكیات سوق العمالة قطاع التعلیم المدرسة الثانویة التعلیم في مجال الصحة التعلیم في المجالات الأخرى رصید العاملین الصحیین المؤھلین خارج الوطن عاملون عاطلون عن العمل خارج القوى العاملة قطاع الخدمة الصحیة القوى العاملة الصحیة المجھزة لتقدیم خدمة صحیة ذات جودة التغطیة الصحیة الشاملة بالخدمات المأمونة والفعالة التي محورھا الإنسان السیاسات المتعلقة بالإنتاج • بخصوص البنیة التحتیة والمواد • بخصوص الالتحاق • بخصوص اختیار الطلاب • بخصوص ھیئة التدریس عوامل أخرى السیاسات اللازمة لمعالجة التدفقات إلى الداخل وإلى الخارج • معالجة الھجرة الوافدة والخارجة • اجتذاب العاملین الصحیین العاطلین عن العمل • إعادة العاملین الصحیین إلى قطاع الرعایة الصحیة السیاسات اللازمة لمعالجة سوء التوزیع وأوجھ القصور • تحسین الإنتاجیة والإنتاج • تحسین تركیبة مزیج المھارات • استبقاء العاملین الصحیین في المناطق المحرومة من الخدمات السیاسات اللازمة لتنظیم القطاع الخاص • إدارة الممارسات المزدوجة • تحسین جودة التدریب • الارتقاء بسبل تقدیم الخدمة الھجرة lasrevinu rof krowemarf tekram ruobal htlaeh evisneherpmoc A .T amreoB ,J inoyN ,MR reflfehcS ,A asuoS morf detpadA .4–298:19;3102 .noitazinagrO htlaeH dlroW eht fo nitelluB .egarevoc htlaeh المصدر الشكل 4.1 الأدوات السياساتية اللازمة لتشكيل أسواق العمالة الصحية حالة التمريض في العالم عام 020202 كادر التمريض في المشاركة في اتخاذ القرارات وفي أن يصبح أفراده قادة في نظم الرعاية الصحية (22، 32، 221)، مما قد يضعف الجهود المبذولة لتعيين المؤهلين من المتقدمين للالتحاق ببرامج تعليم التمريض. وتجعل التصورات المتحيزة لدور المرأة في تقديم الرعاية والمعايير الجنسانية الاجتماعية تعيين الطلاب الذكور تحديًا مستمرًا: ففي حين أن التحاق المرأة ببرامج تعليم التمريض يمكن اعتباره ِحراكًا صاعدًا، فإن هذا قد لا يكون حال الرجال (321- 521). وعلاوة على ذلك، قد تكون الفرص المتاحة أمام النساء في الفئات المهنية الأخرى مقيدة بقيود ثقافية أو تتعلق بالمنظومة المتبعة، مما يجعل تعليم التمريض هو المسار الوحيد أو أوضح المسارات لدخول المرأة ِسلك الرعاية الصحية، بدًلا من إتاحة خيار قيم للعاملين الصحيين الطامحين أيًا كان نوع جنسهم. وفي بعض البيئات، قد يكون تمثيل بعض الفئات . 04 العرقية أو الإثنية أو غيرها من الفئات الضعيفة تمثيًلا ناقصًا في مجال تعليم التمريض (621). وقد تكون لهذا آثار سلبية على الملاءمة الثقافية بين أفراد كادر التمريض والمجتمعات التي يخدمها. وعلى الرغم من أن هناك تركيزًا متزايدًا في مختلف مكونات مهنة التمريض على ضمان أن يشتمل التعليم والتدريب على تطوير الكفاءات الثقافية، فثمة حاجة إلى بذل مزيد من الجهود لزيادة اختيار وتوظيف الطلاب المنتمين إلى فئات سكانية ناقصة التمثيل (الإطار 4-1). وتؤثر مواقع مدارس وكليات التمريض وبرامج . 14 التدريب أيضًا على الرصيد المتاح من المتقدمين المؤهلين. فتقع برامج تعليم التمريض بصفة أساسية في المراكز الحضرية مع الجامعات والمستشفيات، مما ُيفوِّت الفرصة على الطلاب المحتملين المقيمين في المناطق الريفية والأخرى النائية الذين لا تتوافر أمامهم سوى خيارات تعليمية أقل كثيرًا (921). ومع زيادة التركيز على التوزيع الجغرافي للقوى العاملة الصحية، والمساءلة الاجتماعية لمؤسسات التدريب، ُتدمج بعض البرامج مواقَع التدريب الريفية أو ُتعيِّن وتدعم طلابًا من المجتمعات الممثلة تمثيًلا ناقصًا على مدى تاريخها في التعليم بعد الثانوي. وقد تتيح برامج التعليم عن ُبعد التي ُتقدَّم عبر الإنترنت جنبًا إلى جنب مع الفرص المناسبة للتعليم السريري خيارات فعالة للطلاب المحتملين في المناطق الريفية (031)؛ وفي حين ينبغي أن ُيولى اهتمام مستمر إلى رصد جودة التعليم والحفاظ عليه، يتمتع هذا النهج بطاقة كامنة تكفل، في بعض البيئات، تحسين تنوع الطلاب في برامج التمريض (131). ويمكن أن تؤثر التكاليف (من حيث الرسوم الدراسية . 24 ونفقات المعيشة) على قدرة الطلاب على الالتحاق ببرامج تعليم التمريض أو إتمامها. وفي حين يمكن أن تختلف تكلفة تعليم التمريض على نطاق واسع (الإطار 4-2)، فإن البرامج الحكومية مدعومة أكثر من غيرها دعمًا كبيرًا وغالبًا ما تكون أقل تكلفة من البرامج الخاصة المعتِمدة على الرسوم الدراسية الإطار 4.1 أستراليا: إشراك الفئات السكانية الناقصة التمثيل في القوى العاملة في مجال التمريض في أستراليا، ُيطالب الأستراليون من السكان الأصليين بمزيد من الرعاية التي يقدمها الممارسون من السكان الأصليين أنفسهم من أجل زيادة حصولهم لا على الرعاية فحسب، بل على الرعاية المأمونة ثقافيا ًأيضا ً(721). ومع ذلك، لم يكن الحل بسيطا ًكأن ُتزاد أعداد طلاب السكان الأصليين وسكان جزر مضيق توريس، بل إنه استلزم أيضا ًضمان مواجهة التحديات التي يصادفها هؤلاء الطلاب، من قبيل تهيئة بيئة تمكينية، وتوظيف معلمين من كادر التمريض المحلي، ودمج محتوى عن السكان الأصليين في المناهج الدراسية، وتلبية الاحتياجات المالية للطلاب (721، 821) 12الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض التي يدفعها الطلاب والمساهمات الخاصة التي ُتقدَّم إليها. وتكلفة المعيشة، إلى جانب انخفاض الدخل عند الدراسة التفرغية أو عدم تحقيقه على الإطلاق، تزيد من النفقات الشخصية على الدراسة. وتختلف برامج التمويل باختلاف البلدان، حيث إنها قد تتضمن خيارات أو حوافز للطلاب من الفئات الممثلة تمثيًلا ناقصًا أو للراغبين في الممارسة في المناطق المحرومة من الخدمات بعد التخرج. وهناك مجموعة متنوعة من البرامج التعليمية للمبتدئين . 34 التي ُتخرِّ ج ممرضين وممرضات من ذوي المؤهلات والأدوار المهنية المختلفة ولكنهم يستوفون معايير مهنة التمريض وتصنيف رابطات التمريض (80-OCSI). ويمكن لبرامج المبتدئين إعداد كادر التمريض على مستوى الشهادة ومستوى الدبلوم ومستوى الدرجة (البكالوريوس)؛ ويمكن أن تختلف المتطلبات الأكاديمية لبرنامج المبتدئين في مجال لتمريض من إتمام الصف التاسع أو ما دونه وبلوغ 71 سنة في حالة البرنامج الذي ُيمنح مجتازه شهادة إتمام الدراسة الثانوية (الصف الثاني عشر) إضافة إلى سنتين من التعليم الجامعي للالتحاق ببرنامج ُيمنح مجتازه درجة علمية (531، 631). في حين أن تنوع البرامج ومتطلبات الالتحاق من شأنه أن يمكن مجموعة واسعة من الناس من دخول المهنة، فإن أصحاب العمل يفشلون في كثير من الأحيان في التمييز بين أدوار الممارسة على أساس مستوى التعليم، مما يؤدي إلى عدم التناسب مع نظام العرض الذي ينتج ممارسًا عامًا من جهة وصاحب العمل الذي أسس هيكل خدماته في سياق تقديم الرعاية المتخصصة أو المتباينة من الجهة الأخرى. وتعلم بعض البلدان حول العالم نسبة كبيرة من القوى . 44 العاملة في مجال التمريض لديها على مستوى الشهادة والدبلومة، وغالبًا ما يكون ذلك في مؤسسات تدريب مستقلة تركز على المهارات السريرية الموجهة نحو تنفيذ المهام. وتشتمل برامج الدرجات الجامعية (البكالوريوس) عادًة على مواد دراسية إضافية في المهارات القيادية والتدبير العلاجي للحالات والعوامل الاجتماعية الاقتصادية التي تؤثر على الحصائل الصحية وحصائل المرضى في بيئات متنوعة في أقسام المرضى المقيمين والعيادات الخارجية؛ وتتضمن، في بعض الأحيان، عنصر البحث كذلك. وُتشدد هذه الإطار 4.2 تكلفة تعليم التمريض تفيد التقديرات أن 2 72 مليار دولار أمريكي ُتنفق سنويا،ً في جميع أنحاء العالم، على تعليم التمريض والقبالة (231) ورغم أن كادري التمريض والقبالة يشكلان أكثر من نصف القوى العاملة الصحية العالمية، فالإنفاق على تعليم التمريض والقبالة يمثل نحو ربع الإنفاق العالمي على تعليم العاملين الصحيين. وتفيد التقديرات المنشورة في عام 0102 أن متوسط تكلفة كل خريج تمريض يبلغ 000 05 دولار أمريكي على مستوى العالم، مع تراوحها من نحو 000 3 دولار أمريكي لكل ممرض أو ممرضة في الصين إلى أكثر من 000 001 دولار أمريكي في أمريكا الشمالية (231). ويمكن أن ُيعزى هذا التباين إلى الحصة النسبية للقطاعين العام والخاص في تمويل المؤسسات التعليمية وامتلاكها وإدارتها، حيث تختلف نماذج تمويل تعليم التمريض داخل البلدان وبين كل منها والآخر (331). وهناك عامل آخر يقف وراء التباين في تكلفة تعليم التمريض، ألا وهو اختلاف مستويات التأهيل الموجود أحدها إلى جانب الآخر مع التنوع في الاختبار المسبق لصلاحية البرامج التعليمية (431). وثمة حاجة إلى مزيد من البيانات المحسنة عن خريجي برامج التمريض والقبالة، وتكلفة التعليم والتدريب، لتوجيه الاستثمارات اللازمة لمواجهة النقص المقدَّ ر حدوثه بحلول عام 0302 حالة التمريض في العالم عام 020222 البرامج أيضًا على "مهارات التفكير النقدي" التي يمكن أن تسهم في إصدار تقديرات سريرية أكثر تقدمًا وأن تزيد من مأمونية توفير الرعاية (731). وتشير الاستنتاجات التي خلصت إليها الأبحاث إلى أن المرضى الذين يحصلون على خدمات الرعاية المقدمة إليهم من نسبة أعلى من كادر التمريض الذي ُأعد للحصول على درجات علمية أقل عرضة للوفاة، ويمكثون في المستشفيات فترات أقصر، ويتحملون تكاليف رعاية صحية أقل (64، 831، 931). ومع ذلك، ُأجري معظم الدراسات، التي تشير إلى تحسن الحصائل التي يحققها المرضى في حالة كادر التمريض الذي ُأعد للحصول على درجات علمية، في مستشفيات، ولم يتكرر إجراؤها في مرافق المرضى المتجولين والمرافق المجتمعية، مما يحد من تعميم الاستنتاجات (041). وتشير البينات الإضافية إلى أن كادر التمريض الذي ُأِعد للحصول على شهادة البكالوريا/ الثانوية قد لا يستخدم كامل مكونه المعرفي ومهاراته في مكان العمل (141). ويمكن كذلك إعداد كادر التمريض ليصبح أفراده . 54 متخصصين بعد التخرج في مرحلة ما بعد البكالوريا/ الثانوية أو بعد الحصول على الماجستير للتخصص المتقدم أو الممارسة المتقدمة، أو يمكن أن يحصل على درجة الدكتوراه في التمريض، إما دكتوراه التمريض القائمة على الممارسة وإما دكتوراه الفلسفة القائمة على البحث (241). وتتطلب زيادة المؤهلات التعليمية لأخصائي التمريض توضيح الفروق بين مستويات البرامج المختلفة التي تستكمل التعليم السابق وتعتمده (341). وفي البلدان التي يوجد فيها طلب على كادر التمريض الذي ُأعد للحصول على درجات علمية، يمكن أن تمثل البرامج التعليمية التي "تسد" فجوة في مسوغات تعيين كادر التمريض الحالية أو التي "ترقيها" آليًة مهمًة للتطوير الوظيفي وإدرار معدلات عالية من العائد الخاص. وتجدر الإشارة إلى أن إعداد كادر التمريض على مستوى البكالوريوس ضروري للحصول على التعليم في مرحلة الدراسات العليا على مستوى الماجستير أو الدكتوراه، وهو ما يمكن أن يؤثر بدوره على عدد ونوعية أعضاء هيئة التدريس اللازمين لتدريس برامج التمريض للمبتدئين. وثمة عنصر حاسم الأهمية في تعليم التمريض ولكنه . 64 يشكل تحديًا في كثير من الأحيان هو ضمان توافر الوقت الكافي للطلاب وإكسابهم الخبرة العملية في مرافق الممارسات السريرية. فأثناء التدريب العملي السريري، يطبق الطلاب ويدمجون مهارات التفكير النقدي والتقييم السريري وكفاءات الرعاية التمريضية المكتسبة في المرافق التعليمية. وُيطلب إلى هيئة التدريس السريري توفير الإشراف المناسب وتقييم المهارات السريرية. ونظرًا إلى وجود العديد من برامج التمريض في المناطق الحضرية، فإن إكساب خبرات سريرية مناسبة في المرافق الريفية أو النائية يمكن أن يكون أمرًا مضنيًا. ويمكن أن يكون هذا التعرض للخبرات مفيدًا في اتخاذ الطالب القرار النهائي بشأن مكان الممارسة (441). وقد تبين أن بعض البرامج التي ُتقدَّم عبر الإنترنت أو عن ُبعد تزيد من إمكانية الوصول إلى المرافق السريرية الريفية والنائية التي لم تكن مرتبطة في السابق بمؤسسة تعليمية "ذات وجود على أرض الواقع" (541، 641). وبدًلا من ذلك، يمكن أن توفر تكنولوجيا التعليم الصحي عن ُبعد ومختبراُت المحاكاِة التجارَب السريريَة اللازمَة والتكميليَة في مجال الرعاية الأولية (741-051). وينبغي رصد برامج التعليم عن ُبعد عبر الإنترنت وعقدها وفقًا لمعايير الاعتماد والجودة نفسها التي تتبعها سائر المؤسسات التعليمية. وقد شهد العديد من البلدان نموًا كبيرًا في مؤسسات . 74 التعليم الصحي التابعة للقطاع الخاص، سواء غير الهادفة للربح أو الهادفة له (151، 251). وترتبط المجموعة الأخيرة غالبًا بارتفاع الرسوم الدراسية وقد تخضع لمتطلبات السلطة التنظيمية المختلفة ومعايير الاعتماد (251). وقد تكون منفصلة عن أغراض السياسة العامة للصحة والتعليم، ومن ثم، قد لا تتماشى دائمًا مع الأولويات الصحية للسكان، لاسيما إذا ُقِصد تثقيف كادر التمريض لسوق العمالة الصحية الدولية المتنامية. وفي حالة عدم وجود آليات لضمان الجودة، فإن المحتوى وطرائق تقديم المناهج الدراسية قد 32الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض الإطار 4.3 معالجة النقص في معلمي كادر التمريض يمكن التخفيف من ِحدة التحدي المتمثل في نقص المعلمين في مجال التمريض، الذي تواجهه مناطق مختلفة في جميع أنحاء العالم، من خلال مزيد من النهج التعاونية من قبيل تجميع الموارد من شتى المؤسسات، بل ربما حتى شتى البلدان (651) ففي تايلند، هناك نهج تعاوني يرمي إلى زيادة المؤهلات الأكاديمية لهيئة تدريس التمريض، وهو برنامج تطوير تعليم التمريض العالي، الذي ُينفَّذ في جامعة شيانغ ماي وبتمويل من المجلس الطبي الصيني (751). ويركز هذا البرنامج، الذي بدأ في عام 4991، على تدريب معلمي التمريض المعدِّ ين لنيل درجتي الماجستير والدكتوراه للتدريس في عدد متزايد من برامج التمريض على مستوى البكالوريا/ الثانوية في جميع أنحاء الصين. وقد وسع البرنامج بعد ذلك تأثيره ليشمل 01 بلدان في شرق آسيا وجنوب شرقها، مما سمح بتوسيع نطاق برامج تعليم الممرضين والممرضات والاعتماد المتبادل لمؤهلاتهم في جميع أنحاء الإقليم (751) وفي الولايات المتحدة، يوفر برنامج الشراكة الأكاديمية لشؤون تمريض المحاربين القدماء التمويل َاللازَم لدفع المرتبات وتدريب كادر التمريض الخبراء بصفتهم أعضاء هيئة تدريس في المؤسسات الأكاديمية الشريكة لزيادة عدد الخريجين المعدِّ ين لتلبية احتياجات الرعاية الصحية الفريدة لقدامى المحاربين في مرافق الرعاية الوجيزة والأولية (851) وفي رواندا، ُعززت قدرات أعضاء هيئة تدريس التمريض من خلال التعليم المستمر الذي يركز على منهجيات التدريس المتقدمة وتطوير المناهج الدراسية، وغير ذلك من النهوج (951). وحظيت هذه المبادرة بالدعم عبر شراكة أكاديمية دولية، مع الاعتراف بأن البرنامج كان لابد أن تملك زماَمه رواندا، وأنه لابد من ممارسة التواضع الثقافي من خلال التعاون (951) لا تفي بالمعايير الوطنية، بما يشمل الخبرة السريرية المطلوبة، مما يؤدي إلى إنتاج خريجين غير معدِّين بالمعرفة أو المهارات أو السلوكيات اللازمة لتقديم رعاية مأمونة وذات جودة (351). ويمكن أن يؤدي انتشار المدارس الخاصة غير المنتسبة إلى المستشفيات أو المراكز الطبية الأكاديمية إلى الضغط على مواقع التوظيف السريرية الحالية والتشكيك في جودة التدريب المقدم فيها. وأحد أكبر التحديات التي يواجهها تعليم الممرضين . 84 والممرضات هو توظيف واستبقاء أعداد كافية من أعضاء هيئة تدريس التمريض المؤهلين (91، 02، 451). وتشمل التحديات بيئة التوظيف (المؤسسات التعليمية مقابل العمل السريري)، التي قد تنطوي على فروق في الرواتب والوقت المخصص للتدريس. وقد اقترح تقرير صادر عن الرابطة الأمريكية لكليات التمريض دمج الدور التعليمي ودور الممارسة السريرية اللذين تضطلع بهما هيئة تدريس التمريض (أي التعيينات المشتركة) لرفع مكانة الأطباء السريريين الخبراء في تعليم التمريض وزيادة مكافأتهم ومشاركتهم (551). وتشمل الاستراتيجيات الأخرى الشراكات الأكاديمية -السريرية التي يتلقى فيها الأطباء السريريون تدريبًا أكاديميًا لإعدادهم لاستيعاب الطلاب في مرافقهم السريرية، وكذلك حوافز لمواصلة تعليمهم، مثل الإعفاء من الرسوم الدراسية وإتاحة فرص تدريب إضافية. ويعتمد نجاح هذه الشراكات غالبًا على المواقع السريرية التي توفر وقتًا كافيًا يسمح لخبراء التمريض السريريين بالإشراف على الطلاب أو التواصل معهم في الموقع. ويتضمن الإطار 4-3 أمثلة داخل البلدان وبينها. حالة التمريض في العالم عام 020242 الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض ويقف نقص أعضاء هيئة التدريس الذين ُأعدوا على . 94 مستوى الماجستير والدكتوراه عائقًا أمام إنشاء برامج تعليم عاٍل في مجال التمريض، خاصًة عند تحديد الاشتراطات التي لابد أن يستوفيها المعلمون في معايير الاعتماد أو الموافقة. ويؤثر نقص أعضاء هيئة التدريس المدربين على مستوى الدكتوراه أيضًا على قدرة المهنة على إجراء البحوث التي يستلزمها تطوير البينات اللازمة لتسترشد بها الممارسات، وتولي أدوار قيادية في قطاعي الدراسات الأكاديمية والرعاية الصحية (02، 451، 061). ومن بين جميع تخصصات الرعاية الصحية، تبين أن . 05 التمريض يستفيد إلى أقصى حد من التعليم المتعدد التخصصات (161). ويقدر طلاب التمريض هذا النهج في التعليم أيضًا، حيث يرون أنه يسهل اكتسابهم الكفاءات التعاونية المتعددة التخصصات (941، 261). وإضافة إلى ذلك، من الممكن أن يؤدي دمج المعلمين من مختلف التخصصات في تدريس التمريض إلى جلب المعرفة المتخصصة من التخصصات الأخرى إلى مجال تعليم كادر التمريض، وقد يعزز كفاءاتهم اللازمة لرعاية المرضى من خلال أفرقة الرعاية (361). وفي الوقت الحالي، ُيستخدم نهج التدريس هذا في البلدان المرتفعة الدخل أكثر من استخدامه في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل (951)، غير أن الاستخدام المتزايد للتكنولوجيا، حتى في البيئات الشحيحة الموارد، يتيح فرصة حقيقية لتعزيز التعلم المتعدد التخصصات (261). 4.2 تدفقات القوى العاملة إلى الداخل وإلى الخارج يتحدد عدد أفراد التمريض المشتغلين بالمهنة (أو . 15 "الرصيد المتوافر" من القوى العاملة في مجال التمريض) بالعديد من العناصر. وتتألف "التدفقات إلى الداخل" من خريجي برامج التمريض الداخلي الذين يدخلون مجال الممارسة والممرضين والممرضات الذين يهاجرون من بلدان أخرى وأولئك الذين يعودون إلى مجال الممارسة. أمَّ ا "التدفقات إلى الخارج"، فتتألف من خريجي التمريض الذين يفشلون في الاستمرار في العمل في قطاع الصحة الداخلي، والممرضين والممرضات الذين يختارون العمل خارج القطاع الصحي والمتقاعدين والمهاجرين إلى الخارج. ويتمثل أحد المحددات الأساسية لتدفقات العاملين . 25 الصحيين في سوق العمالة الصحية إلى الداخل في القدرة الاقتصادية للبلد على إيجاد فرص عمل ممولة (سواء في القطاع العام أو في القطاع الخاص) أو فرص للحصول على الدخل من خلال تقديم الخدمات الصحية. ولذلك، يرتبط إيجاد فرص العمل ارتباطًا مباشرًا بالمستوى الاجتماعي الاقتصادي للبلد، ويرتبط -داخل ذلك- بمستوى الأولويات الذي يمنحه راسمو سياسات القطاع العام للاستثمار في القطاع الصحي وفي القوى العاملة الصحية على وجه الخصوص. والعوامل الأخرى التي تؤثر على الطلب هي التغيُّرات الديموغرافية، مثل شيخوخة السكان؛ وتغيير السمات الأساسية للأمراض، مثل الزيادة في الأمراض المزمنة والمراضات المتعددة؛ وارتفاع معدلات أفراد كادر التمريض الذين يتركون وظائفهم أو النقص في المهنيين الصحيين الآخرين؛ والزيادة في المرافق الصحية، بوسائل منها بناء المستشفيات أو تغيير سياسات التوظيف بالمستشفيات؛ أو التغيُّرات في التشريعات، مثل معايير التوظيف التي تراعي نسب كادر التمريض إلى المرضى (041، 461). وتشمل العوامل التي يمكن أن تقلل من الطلب على كادر التمريض التكنولوجيات الحديثة التي تؤثر على الحاجة إلى رعاية المرضى الداخليين أو مقدمي الرعاية، وارتفاع مستويات الاستبقاء، وزيادة الإنتاجية (بوسائل منها استخدام الممارسة المسندة بالبينات أو زيادة استخدام التكنولوجيا)، وتفويض الأدوار من ممرض أو ممرضة إلى فئة مهنية مغايرة (461). وثمة تزايدا في تنقل القوى العاملة التمريضية على . 35 المستوى الدولي، مع ما يصاحب ذلك من آثار عميقة على الرصيد المتاح من العاملين الصحيين في البلدان. 52 الإطار 4.4 الشراكات المتعلقة بالمهارات العالمية أدى اعتماد 251 دولة من الدول الأعضاء في الأمم المتحدة الاتفاق العالمي من أجل الهجرة الآمنة والمنظمة والنظامية في كانون الأول/ ديسمبر 8102 إلى إيجاد نهج شامل لمعالجة قضية الهجرة الدولية. وتتمثل إحدى الركائز الأساسية التي يقوم عليها الاتفاق العالمي في بناء شراكات عالمية في مجال المهارات - وهي عبارة عن اتفاقات ثنائية تستهدف الاستفادة من فرص الهجرة المتاحة من خلال تحقيق التناسب بين الطلب على العمال والمعروض منهم من جهة والدعم التعليمي المستهدف في بلدان المنشأ من الجهة الأخرى (661). وشكل الشراكات مصمم لتوجيه الضغوط التي تشكلها الهجرة نحو تحقيق فوائد ملموسة ومتبادلة ومشتركة إلى حد ما لكل من بلدان المنشأ وبلدان المقصد، وهو ما يتماشى مع مبادئ المدونة. وبوجب هذا الاتفاق، يوافق بلد المقصد على توفير التكنولوجيا والتمويل لتدريب المهاجرين المحتملين على المهارات المستهدفة في بلد المنشأ، قبل الهجرة، في حين يوافق بلد المنشأ على توفير هذا التدريب، ويتلقى أيضا ًالدعم لتدريب غير المهاجرين (661). وفي إطار هذه الشراكة، يمكن تدريب كادر التمريض، على سبيل المثال، على "المسار الداخلي" و"المسار الخارجي"، حيث يتلقى ممرضو وممرضات المسار الداخلي تدريبات على المهارات تتناسب مع احتياجات بلد المنشأ، بينما ُيعد ممرضو وممرضات المسار الخارجي للعمل في بلد المقصد. وبناء على احتياجات كل شريك، قد لا تقتصر هذه الشراكة على المهن الفردية. وتهدف الشراكة بين التعليم الصحي في إنجلترا (دائرة الصحة الوطنية في المملكة المتحدة) وحكومة جامايكا إلى الارتقاء بالقوى العاملة في مجال التمريض المتخصص في جامايكا. فيتدرب أفراد كادر التمريض في جامايكا على الرعاية الحرجة في مستشفيات المملكة المتحدة لمدة عامين، ثم يعودون إلى جامايكا للانتقال إلى أداء أدوار متخصصة. وفي إطار مواٍز، سيقضي كادر التمريض في المملكة المتحدة وقتا ًفي جامايكا لدعم أنشطة تعزيز النظام الصحي، بما يشمل تقديم الخدمات وتحسين الجودة والتدريب. وقد ُدشِّن برنامج التبادل في عام 9102 ولدى المنظمة الدولية للهجرة مشاريع مماثلة في جميع أنحاء العالم، تربط بين بلدان المنشأ وبلدان المقصد من خلال برامج تعزز الإدارة الفعالة لهجرة العاملين الصحيين، وبناء قدرات النظم الصحية في بلدان المنشأ، ونقل المهارات والمعارف من الشتات (761). وهي تفعل ذلك بالتعاون مع الحكومات الوطنية وأصحاب المصلحة الآخرين. والمنظمة الدولية للهجرة شريك رئيسي في الجهود التي تبذلها منظمة الصحة العالمية، حيث أقرت المدونَة التي وضعتها الأخيرة وكذلك السياسات وقرارات جمعية الصحة العالمية ذات الصلة (761) وتتضمن أسباب هجرة الممرضين والممرضات توافر وظائف ومرتبات وشروط عمل وبنية تحتية صحية وعيادات أو مستشفيات وفرص تعليمية أفضل. وإضافة إلى عوامل الجذب هذه، قد تكون أحكام التأشيرات لدى بلدان المقصد المنطبقة على الطلبات العائلية حافزًا للهجرة كذلك. وتشمل عوامل الجذب غياب فرص العمل وسوء شروط العمل وشروط الخدمة وانعدام الأمن في بلدان المنشأ. ويمكن أن تشكل تحويلات أفراد كادر التمريض العاملين في الخارج مصدرًا كبيرًا للدخل للعائلات ومساهمة كبيرة في اقتصادات بعض بلدان المنشأ. ويجب أن تكون الحلول السياساتية، مثل الاتفاقات المبرمة بين البلدان (الاتفاقات الثنائية)، مفيدة للطرفين: لبلدان المنشأ وبلدان المقصد، بما يتوافق مع الأحكام السياساتية الواردة في مدونة المنظمة العالمية لقواعد الممارسة بشأن توظيف العاملين الصحيين على المستوى الدولي (561) المتعلقة بالدعم والضمانات (انظر الإطار 4-4 الذي يتناول الشراكات المتعلقة بالمهارات العالمية). حالة التمريض في العالم عام 020262 الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض وقد ارتفع عدد أفراد كادر التمريض المدربين بالخارج . 45 العاملين في بلدان منظمة التعاون والتنمية في الميدان الاقتصادي بنسبة 02٪ على مدى فترة السنوات الخمس الممتدة من عام 1102 إلى عام 6102، وهو ما يفوق عدد الأطباء، حيث يصل إلى نحو 000 055 ممرض وممرضة (861). وتشير البيانات المحسَّ نة تحسينًا كبيرًا إلى عدم وضوح التفرقة بين بلدان "المنشأ" وبلدان "المقصد" حسب التصور التقليدي (961). ففي حين لايزال الطلب الاقتصادي مرتفعًا على كادر التمريض في البلدان المرتفعة الدخل (انظر الإطار 4-5 للاطلاع على أمثلة على ذلك)، هناك أنماط هجرة ناشئة من مناطق آسيا وأفريقيا والبحر الكاريبي إلى مناطق وبلدان أخرى (مثل دول الخليج) (071)، وكذلك الهجرة بين بلدان الجنوب التي تقع في المنطقة نفسها. 4.3 التوزيع المنصف والكفاءة بمجرد دخول القطاع الصحي، ُيوظَّ ف كادر التمريض . 55 في مجموعة من المرافق عبر سلسلة من نقاط تقديم الخدمات الصحية، العامة والخاصة على السواء (571- 871). ولا يوثق توثيقًا منهجيًا توزيع كادر التمريض في مختلف أنواع المرافق وشكل ملكيتها. ومع ذلك، قد يفضل كادر التمريض العمل في المستشفيات ومراكز الرعاية الوجيزة لا في مرافق الرعاية الصحية الأولية، ويختار كادر التمريض، في بعض السياقات، العمل في القطاع الخاص بسبب ارتفاع الأجور مقارنًة بالمرافق الحكومية (571، 771). وينبغي أن تسعى نماذج الرعاية إلى تحقيق المزيج . 65 الأمثل من المهارات في أفرقة الرعاية الصحية الأولية المتكاملة (971)، مما يسمح للممرضين والممرضات بالعمل على كامل نطاق تعليمهم التمريضي (081، 181). ويمثل كادر التمريض حجر الزاوية في أفرقة الرعاية المتكاملة، وغالبًا ما يتولون زمام عملية تقديم الرعاية ويضطلعون بأدوار ممارسة موسَّ عة، بما في ذلك، عند الاقتضاء، التعاون مع العاملين في مجال الصحة المجتمعية والإشراف عليهم (281-391). والسماح لأفراد كادر التمريض بالممارسة على أعلى مستويات تعليمهم وخبرتهم يمكن أن يؤدي إلى زيادة الرضاء الوظيفي وزيادة مستوى رضاء المرضى عن الرعاية (491). وتتمثل العوامل التمكينية في التدريب على الرعاية الصحية الأولية، ووضع إرشادات للممارسات الموحدة معياريًا أو الأوامر المستديمة، وأنظمة البيانات اللازمة لتتبع الحصائل المحققة في مجال رعاية المرضى (591، 691). الإطار 4.5 أمثلة على الطلب الاقتصادي على كادر التمريض في البلدان المرتفعة الدخل تشير التحولات السكانية والوبائية والصحية إلى تزايد الطلب على كادر التمريض في البلدان المرتفعة الدخل. ومن أمثلة ذلك ما يلي: • تقدر مؤسسة الصحة في المملكة المتحدة أن ثمة حاجة إلى أن توظف من الخارج 000 5 ممرض وممرضة على الأقل سنويا ًحتى عام 4202 (171) • وفي اليابان، اسُتحدث برنامج تأشيرات جديد لجذب ما يصل إلى 000 542 عامل أجنبي، بما في ذلك 000 06 مساعد تمريض (271) • وأبلغت الحكومة الألمانية بوجود نحو 000 63 وظيفة شاغرة في مجال رعاية المسنين والمرضى (371)، مشيرًة إلى أنه يلزم توظيفهم من الخارج (471) 72 ويدخل وصف الأدوية والعلاجات في العديد من البلدان . 75 في نطاق ممارسة مهام وظيفة أخصائي التمريض أو فرد كادر التمريض المسجل (791، 891). ويمكن أن يقتصر وصف كادر التمريض الأدويَة والعلاجات على فئات أو جداول أدوية محددة في التشريعات أو الإطار التنظيمي المهني (991). وفي حالات أخرى، يكون وصف الأدوية مقصورًا على تلبية الأولويات الصحية للسكان، مثل الخط الأول من العلاج بمضادات الفيروسات القهقرية في البلدان المثقلة بعبء فيروس العوز المناعي البشري في أفريقيا جنوب الصحراء الكبرى، أو مقاومة مضادات الميكروبات، أو اتخاذ ما يلزم حيال الحالات المزمنة (002-202) (انظر الإطار 4-6 الذي يتناول وصف الأودية في بولندا). ويؤدي كادر التمريض أيضًا دورًا مهمًا في تشجيع الالتزام بالأدوية، ورصد قرارات وصفها، والحد من أخطاء وصفها (302، 402). واسُتحدث دور فرد كادر التمريض الممارس المسجل . 85 المتقدم لزيادة الإتاحة أمام الفئات السكانية التي تعاني من نقص الخدمات في المناطق النائية ولمعالجة نقص الموظفين في مرافق الرعاية الأولية (291، 702). وأكثر أنواع دور فرد كادر التمريض شيوعًا هو دور فرد كادر التمريض الممارس، الذي يشمل نطاق عمله السريري صلاحية طلب الاختبارات التشخيصية بنفسه، وإجراء التشخيصات، ووصف العلاجات والأدوية (702). وعادة ما يشترط الحصول على اعتماد المنظمات المهنية وعلى التعليم بدرجة الماجستير (802). وفي عدد قليل من البلدان المرتفعة الدخل، هناك بينات قوية على فعالية أفراد كادر التمريض الممارسين المتقدمين في تقديم الرعاية الجيدة، وتعزيز إتاحة الرعاية وتحسين مستوى رضاء المرضى عن الرعاية، عند تدريبهم تدريبًا وافيًا (802، 902)، على الرغم من محدودية البيانات المتعلقة بفعالية التكلفة (802-012). ويتزايد عدد درجات الماجستير التي ُتمنح في برامج التمريض وأفراد كادر التمريض الممارسين في بلدان أخرى كذلك (951، 112-412)، على الرغم من الاختلاف الشديد بين الأحكام التنظيمية التي تؤثر على الإعداد التعليمي والاعتماد أو منح الإطار 4.6 توسيع نطاق الإتاحة من خلال وصف كادر التمريض الأدوية والعلاجات في بولندا كان من بين الأولويات الصحية الوطنية لبولندا تحسين التدبير العلاجي للحالات المزمنة على مستوى المجتمع المحلي، وزيادة إتاحة العلاج والأدوية في مرافق الرعاية الصحية الأولية. وأدت القرارات السياساتية المتعلقة بتعليم التمريض والآليات التنظيمية إلى توسيع نطاق وظيفة كادر التمريض في نظام الرعاية الصحية توسيعا ًفعالا،ً وزيادة إتاحة الخدمات الصحية أمام المرضى (502) وفي عام 6102، ُمنح كادر التمريض ذو المؤهلات الخاصة صلاحية وصف الأدوية في ظروف معينة. وبغية إعداد أفراد كادر التمريض المتخرجين للاضطلاع بهذا الدور، أُدرج وصف الأدوية في كل برنامج تعليمي أولي للتمريض والقبالة، وسمحت الأحكام التنظيمية لجميع أفراد كادر التمريض المتخرجين الحاصلين على درجة البكالوريوس في التمريض بوصف قائمة بالأدوية المحددة سلفا ً(602). وبالتوازي مع هذا، قدمت استراتيجية وطنية جديدة تستهدف تطوير التمريض والقبالة معايير تنظيمية لمختلف الأدوار والكفاءات المهنية لكادر التمريض وحسنت شروط العمل. ومنذ عام 6102، أكمل 782 01 من كادر التمريض و997 4 من كادر القبالة تدريبات تمكنهم من وصف الأدوية. وحتى كانون الأول/ ديسمبر 8102، حرر كادرا التمريض والقبالة بنفسه 835 2 وصفة طبية وإذنا ًبمواصلة صرف 882 363 وصفة طبية سابقة الإصدار. حالة التمريض في العالم عام 020282 الإطار 4.7 مثال على دور فرد كادر التمريض المتخصص في الإقليم الأفريقي يستثمر عدد متزايد من الحكومات في شرق أفريقيا وجنوب شرقها في دور الممرض المتخصص تحقيقا ًلصحة الأطفال في إطار استراتيجيات الحد من وفيات الأطفال. وأخصائي صحة الأطفال ممرض مسجَّ ل تلقى تدريبا ًبعد التدريب الأساسي يؤهله للحصول على مؤهل إضافي معترف به بوصفه ممرضا ًمتخصصا ًفي طب الأطفال أو ممرض صحة أطفال. وأكثر المسارات شيوعا ًهو التخصص بعد إتمام التدريب الأساسي (دبلوم متقدم أو درجة البكالوريا/ الثانوية في التمريض) عن طريق الحصول على دبلوم دراسات عليا لمدة 21 شهرا ًفي مجال تمريض الأطفال. ويختلف المسمى الوظيفي الناتج عن ذلك وكذلك اسم المؤهل باختلاف البلد - وتشمل الصيغ المعتادة أخصائي تمريض الأطفال المسجل أو أخصائي التمريض المتخصص في طب الأطفال. ويوجد في الإقليم حوالي 056 3 فرد كادر تمريض أطفال مسجلا،ً بما في ذلك حوالي 057 في كينيا وملاوي وأوغندا وزامبيا، و009 2 في جنوب أفريقيا (612). وُتخرِّ ج 21 برنامجا ًتعليميا ًمختلفا ً(معظمها في جنوب أفريقيا) حوالي 502 متخصصين في تمريض الأطفال سنويا.ً وهناك ثلاثة برامج أخرى (بوتسوانا وجمهورية تنزانيا المتحدة وزيمبابوي) قيد التطوير (612) ونظم المعلومات القطرية المنشأة في الإقليم حاليا ًلتقسم كادر التمريض حسب التخصص عددها قليل. ويدعم مرصد القوى العاملة في مجال تمريض الأطفال التخطيط الوطني من أجل التوصل إلى مزيج مثالي من المهارات يلبي الاحتياجات الصحية الخاصة للأطفال في الإقليم. ومنذ عام 5102، يتعاون الباحثون ومعلمو التمريض وسائر أصحاب المصلحة على رسم ملامح دور القوى العاملة في مجال تمريض الأطفال والإبلاغ به في شرق أفريقيا وجنوب شرقها. ترخيص مزاولة المهنة (291). ويختلف الاعتراف بتعريف دور فرد كادر التمريض الممارس المتقدم في مجال التمريض والكفاءات ذات الصلة اختلافًا كبيرًا باختلاف البلدان (291، 512)، على الرغم من أن التجربة القطرية تشير إلى أن أدوار الممارسة المتقدمة تزيد من جاذبية التمريض من حيث كونه حياة مهنية (112، 412). وقد يكون فرد كادر التمريض معدًا على مستوى الباكالوريا/ الثانوية ولديه خبرة في رعاية فئة محددة من المرضى مؤهلة أفرادها للحصول على الاعتماد بوصفهم أخصائيين، وإن لم يكن حاصًلا على ترخيص مزاولة مهنة الممرض الممارس المتقدم (انظر الإطار 4-7 للاطلاع على مثال على دور فرد كادر التمريض المتخصص). ويمثل سوء التوزيع الجغرافي للقوى العاملة الصحية . 95 بين المناطق الريفية ونظيرتها الحضرية تحديًا عالميًا. وتستخدم البلدان مجموعة متنوعة من التدابير السياساتية في مجالات متعددة (التعليم، والتنظيم، والمالية، وشؤون المهنة) في إطار محاولات لنشر العاملين الصحيين على مراكز العمل واستبقائهم على نحو منصف في المناطق الريفية أو نظيرتها النائية (712) (انظر الإطار 4-8 الذي يتناول الاستبقاء في المناطق الريفية). وبالنظر إلى الحاجة إلى اتباع نهج متعدد الجوانب في معالجة هذه المشكلة المتعددة الأوجه، يغدو فهم تأثير التدخلات المتنوعة أمرًا أساسيًا لتوسيع نطاق هذه الاستراتيجيات وتقاسمها في مختلف بيئات الممارسة والمناطق الجغرافية (441). وفي دراسة قطرية، تبين أن التدابير الإضافية مهمة لمقدمي الخدمات الريفية، وأبرزها 92الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض الإنصاف والشفافية وإمكانية تنبؤ وزارة الصحة بإدارة الموارد البشرية في مجال الصحة، وحالة التوظيف (دائم أو بعقد) (812). وانتهت الدراسات التي ُأجريت في البلدان المتوسطة الدخل والأخرى المرتفعة الدخل إلى أن الالتزام التنظيمي، وكذلك الدعم المكثف من مديري التمريض، مرتبطان باستبقاء كادر التمريض في الممارسة الريفية (912، 022). وقد يؤدي توظيف طلاب التمريض من المجتمعات المحلية التي يصعب الوصول إليها إلى تحسين الاستبقاء إذا عادوا إلى العمل في مجتمعاتهم المحلية (641، 122). ويمكن أن يكون استبقاء كادر التمريض في بيئات . 06 الممارسة الخاصة بهم أمرًا صعبًا. وتغيُّر كادر التمريض نتيجة حتمية لقوى السوق التي يمكن أن تكون لها آثار إيجابية وأخرى سلبية على منظمات الرعاية الصحية والمرضى وكادر التمريض نفسه (022، 222). فعلى سبيل المثال، يمكن أن تكون معدلات التغيُّر المتواضعة مفيدة لتطوير الكفاءات المهنية والمواءمة التنظيمية، من قبيل ما يحدث عندما يخرج أفراد كادر التمريض من إطار أدوارهم لمواصلة التقدم الوظيفي داخل منظمة أو نظام صحي (322). ومن الناحية الأخرى، يمكن أن تنطوي الاستقالة من الوظائف وتغيُّر الموظفين دائمًا على تكبد تكاليف تنظيمية وتكون لها آثار سلبية على رعاية المرضى. وتؤثر كل من العوامل التنظيمية والفردية على نية . 16 كادر التمريض ترك وظيفة معينة أو مواصلتها. وتشمل العوامل الفردية التغييرات في الحياة الشخصية أو الأسرية أو الصحة أو الأهداف التعليمية أو ضغوط العمل أو عدم الرضاء الوظيفي أو، على العكس من ذلك، الإحساس بالتمكين في مجال اتخاذ القرار (422، 522). وتشمل العوامل التنظيمية التي تؤثر على الاستبقاء بيئَة العمل وعلاقاته وشروطه ومرتباته وأسلوب إدارته والإشراف الفعال فيه (622). وفي الدراسات التي شملت أستراليا ومصر وجمهورية إيران الإسلامية والأردن والفلبين، خلصت الأبحاث إلى أن أسلوب قيادة المديرين السريريين والثقافة التنظيمية يؤثران تأثيرًا مباشرًا على رضاء كادر التمريض وتغيُّره، وقد تؤثر على جودة الرعاية، في مرافق المستشفيات (722-922) والمرافق الريفية على حد سواء (912، 022). العمل اللائق وفقًا لما أفادت به منظمة العمل الدولية، ينطوي العمل . 26 اللائق "على فرص لعمل ُمنِتج ويدّر دخًلا معقوًلا ويوفِّر الأمن في موقع العمل والحماية الاجتماعية للأسر وآفاقًا أفضل للتنمية الشخصية والتكامل الاجتماعي وحرية تتاح لكي يعبِّر الناس عن شواغلهم وينظموا صفوفهم ويشاركوا في القرارات التي تؤثر على حياتهم فضًلا عن إتاحة تكافؤ في الفرصة والمعاملة للنساء والرجال على السواء" (032). والتحديات المعتادة التي تواجه برنامج العمل اللائق في سياق مهنة التمريض تشمل القضايا الجنسانية، وخطر التعرض للاعتداءات، وساعات العمل المتجاوزة للحدود، ومعاملة كادر التمريض من المهاجرين معاملًة غير عادلة. وتواجه الممرضات، إلى جانب نساء أخريات في القوى . 36 العاملة الصحية، عوائق في العمل تفوق ما يواجهها زملاؤهن الذكور (12، 132). وتشمل تلك العوائق التصورات المتحيزة لأدوار المرأة في تقديم الرعاية، والمعايير الاجتماعية الجنسانية، والتحيز الجنساني والقوالب النمطية، وهو ما يضعف جميعه قدرة كادر التمريض على العمل في ظروف جيدة، والحصول على أجر عادل ومعاملة متساوية، والمشاركة في اتخاذ القرار، وتولي المناصب القيادية في مجال الرعاية الصحية (12، 22، 221). وقد انتهى تقرير صادر عن منظمة الصحة العالمية في عام 9102 تحت عنوان ُتنفِّذه النساء ويتولى زمام قيادته الرجال إلى أن زيادة عبء التمييز، في كثير من الأحيان، يكون في الوظائف التي تشكل فيها النساء الأغلبية: فقد أفادت نسبة بلغت 63٪ من الممرضات في أحد السياقات أنهن لا يلاقين الاحترام الواجب من رؤسائهن، بينما أفادت نسبة بلغت 23٪ منهن أنهن يوددن لو ُسمعت أصواتهن وعبَّرن عن آرائهن (12). وتنال هذه العوائق من عافية العاملات الصحيات وسبل عيشهن، وتقيد التقدم المحرز في مجال المساواة بين الجنسين (12). والتمييز بين حالة التمريض في العالم عام 020203 الجنسين له أيضًا أثر مباشر على الرعاية، حيث يحسن الدعُم المؤسسُي واحتراُم الممرضات جودَة الرعاية (232). ويمثل التحرش الجنسي في مكان العمل مشكلة تواجهها النساء في مختلف فئات القوى العاملة الصحية، ومنها فئتا الممرضات (٪52) (332) والقابلات (٪73) (12). وفي بعض البيئات، يتعرض كادر التمريض والعاملون . 46 الصحيون لخطر التعرض للاعتداءات. ففي الفترة من 1 كانون الثاني/ يناير 9102 إلى 1 كانون الثاني/ يناير 0202، سجلت منظمة الصحة العالمية، من خلال نظام ترصد الاعتداءات على مرافق الرعاية الصحية، شنَّ 500 1 اعتداءات على مرافق الرعاية الصحية، مما أسفر عن مقتل 891 شخصًا وجرح 626 آخرين من العاملين في مجال الرعاية الصحية والمرضى في 11 بلدًا تواجه حالات طوارئ معقَّدة (432). ويتطلب تقديم الخدمات الصحية استجابة سريعة مستمرة . 56 لاحتياجات المرضى، مما يطرح تحديات خاصة فيما يتعلق بالساعات الطويلة وغير المنتظمة، مع ما يصاحب ذلك من تداعيات سلبية محتملة على كادر التمريض نفسه (بما يشمل الإرهاق المفرط) وعلى المرضى (بما يشمل زيادة الأخطاء الطبية) (532). وُتلِزم اتفاقية منظمة العمل الدولية بشأن العاملين بالتمريض لعام 7791 (الاتفاقية رقم 941) الموقعين عليها بضمان تمتع العاملين بالتمريض بساعات عمل معادلة لساعات عمل العاملين الآخرين، وبتنظيم العمل الإضافي وساعات العمل غير الملائمة والعمل بنظام النوبات والتعويض عنها. وأفراد كادر التمريض من المهاجرين معرضون بشدة . 66 لعدم التمتع بشروط العمل اللائقة. وهم وأفراد الأقليات الإثنية أكثر عرضة للإصابات والتمييز المرتبطة بالعمل من أفراد كادر التمريض المنتمين إلى بلد المقصد أو الأغلبية الإثنية (632). وتفيد التقارير أن التمييز هو السبب الرئيسي لضعف الصحة في صفوف أفراد كادر التمريض من المهاجرين والأقليات (632). ومع ذلك، قد يكون الافتقار إلى العمل اللائق في الوطن عامًلا دافعًا لتشجيع كادر التمريض على الهجرة (732- 042). 4 4 الأحكام التنظيمية تعمل الأحكام التنظيمية على حماية الجمهور من خلال . 76 وضع وتطبيق معايير السلوك والتعليم والممارسة. ويمكن أن تفيد أيضًا مقدمي الخدمات وتساعد في تحسين الإطار 4.8 المبادئ التوجيهية لاستبقاء كادر التمريض في المناطق الريفية يمثل جذب العاملين في مجال التمريض وتوظيفهم واستبقاؤهم في المناطق الريفية ونظيرتها النائية مصدر قلق متزايد في العديد من البلدان. وفي عام 0102، أصدرت منظمة الصحة العالمية توصيات سياساتية عالمية بشأن زيادة توافر العاملين الصحيين في المناطق النائية ونظيرتها الريفية من خلال زيادة درجة استبقائهم (712) 4 وتغطي التوصيات أربعة مجالات تدخلات رئيسية، هي: التعليم، والأحكام التنظيمية، والحوافز المالية، والدعم الشخصي والمهني. وعلى الرغم من تزايد البحوث الخاصة بالتمريض في المناطق الريفية، فهي لاتزال محدودة للغاية. وترد هذه البينات في الغالب من البلدان المرتفعة الدخل (ولاسيما أستراليا وكندا والولايات المتحدة)، لكنها تشير إلى أن الحوافز المالية، والدعم الشخصي والمهني، ومسارات الحياة المهنية الصحية المعجلة تؤثر على استبقاء كادر التمريض في المناطق الريفية. 4 ُيلاحظ أن هذه المبادئ التوجيهية تخضع للتحديث حاليًا. 13الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض الجودة في تعليم التمريض (142، 242) والممارسة في جميع كيانات القطاعين العام والخاص. وتنتج الهيئات التنظيمية أيضًا بيانات وبينات عن القوى العاملة الصحية وتستبقيها على نحو متزايد (342): فقد شهدت السنوات الخمس عشرة الماضية زيادة ملحوظة في إنتاج بينات مصدرها البحوث التنظيمية التي ُتجرى في العديد من التخصصات، مع استئثار تخصص التمريض بأكثرها (442، 542). ويمكن أن يشمل تنظيم التعليم وضع معايير وطنية . 86 لتعليم التمريض، والموافقة على برامج تعليم التمريض والتدريب عليه من الهيئة التنظيمية للتمريض، والاعتماد التعليمي للمؤسسات من وكالات خارجية. ومن شأن الاعتماد، حيث ُتقيَّم المؤسسات وفقًا لمعايير تقديم التعليم، أن يحفز المؤسسات على إنتاج خريجين يمكن أن يحسنوا جودة الخدمات الصحية وإنصافها وأهميتها وفعاليتها لصالح السكان (642). ومع ذلك، يجب أن تواكب المعايير ودورات الاعتماد التغييرات الحاصلة في العلوم ونماذج تقديم الرعاية الصحية وأن تكون ميسورة التكلفة أو دون تكلفة تتحملها المؤسسات. ويلزم إنفاذ المعايير لعلاج أوجه القصور في البرنامج أو، كتدبير شديد وإن كان ضروريًا في بعض الأحيان، وقف البرامج التي لا يمكن رفعها إلى مستوى المعايير المقبولة. وقد انتهت دراسة ُأجريت في عام 3102 في 71 بلدًا من بلدان أفريقيا جنوب الصحراء إلى أن هناك تكليفًا قانونيًا قويًا باعتماد تعليم التمريض؛ ومع ذلك، كانت مستويات الاعتماد منخفضة في البرامج التي أنتجت أغلبية كادر التمريض في المنطقة وكانت أعلى في البرامج العامة منها في البرامج الخاصة (742). وفي بعض الحالات، طعن القطاع الخاص في نتائج الاعتماد على أساس أن من يتخذون القرارات لديهم تضارب في المصالح؛ ونتيجة لذلك، تعكف الحكومات على تغيير تشكيل هيئات اتخاذ القرار لزيادة مشاركة الأعضاء العاديين (842). وفي داخل البلدان، يمكن أن يختلف الاعتماد باختلاف . 96 نوع البرنامج (942). وفي بعض البلدان، تنشئ الهيئات الحكومية الجامعات الحكومية وتشرف عليها، ولا يلزم اعتماد غير المؤسسات الخاصة؛ أمَّ ا في أماكن أخرى، فإذا لم يكن هناك تكليف حكومي، قد لا ُيشترط اعتماد المؤسسات الخاصة على الإطلاق. وُيمِكن التكليف بالاعتماد التعليمي مباشرة بموجب القانون أو بطريقة غير مباشرة من خلال اشتراط أن يكون الخريجون المتقدمون للالتحاق أو التسجيل في المجلس أو الذين يخوضون امتحانات ترخيص مزاولة المهنة قد تخرجوا في برنامج وافق عليه من قبُل مجلس التمريض أو كان معتمدًا لدى منظمة مختصة. وتحدد معظم معايير تعليم التمريض الحد الأدنى لعدد . 07 الساعات السريرية والحد الأدنى من الكفاءات اللازم توافرها لضمان سلامة محتوى البرنامج واتساعه. وغالبًا ما تكون معايير تعليم التمريض خاصة بمنطقة واحدة ذات نظام قانوني فريد (مثل البلدان أو الولايات أو أي منطقة أخرى يجب فيها الالتزام بمجموعة معينة من القوانين أو القواعد)، مما قد يؤثر على تنقل كادر التمريض من الخريجين. وتعمل اتفاقات الاعتراف المتبادل ومتطلبات التعليم المنسقة على زيادة التوحيد وتنقل الممارسين بأمان وكفاءة. ومن الأمثلة على ذلك اتفاق منح تراخيص مزاولة مهنة التمريض في الولايات المتحدة (052، 152)، وامتحان منطقة البحر الكاريبي لتسجيل كادر التمريض (252)، والتوجيه المهني الصادر عن الاتحاد الأوروبي (352، 452)، واتفاق رابطة أمم جنوب شرق آسيا (552)، واتفاق أستراليا ونيوزيلندا (652). ويعرض الإطار 4-9 أمثلة على تحقيق التواؤم بين معايير التعليم وامتحانات منح التراخيص. وفيما يتعلق بفرد من أفراد كادر التمريض، يتضمن . 17 التنظيم المهني ما يلي: (أ) تحديد متطلبات الاعتراف الأولي بحمل المسمى الوظيفي "الممرض/ الممرضة" (أي المسجل/ المسجلة، أو المسجل/ المسجلة والمرخص/ المرخصة)، التي يمكن أن تشمل عقد امتحان منح ترخيص مزاولة المهنة؛ (ب) متطلبات إعادة الالتحاق أو التسجيل أو منح الترخيص، التي يمكن أن تشمل متطلبات التطوير المهني المستمر؛ (جـ) تحديد نطاق الممارسة لكادر التمريض ومدونة قواعد السلوك والأخلاقيات؛ (د) تسهيل التحقيق مع كادر التمريض حالة التمريض في العالم عام 020223 واتخاذ الإجراءات التأديبية المحتملة ضده (952). وتكلف الهيئات التنظيمية أيضًا على نحو متزايد بمسؤولية إمساك سجل محدث للقوى العاملة التمريضية المشتغلة بالمهنة. ويستخدم أكثر من 06٪ من البلدان امتحان الحصول . 27 على الترخيص لتقييم وإنفاذ الحد الأدنى من المعرفة الأولية أو "اللياقة للممارسة" لخريجي التمريض قبل اعتمادهم مهنيًا لدخول مجال الممارسة (92). وهناك طريقة أخرى لتقييم اللياقة الأولية للممارسة ألا وهي الامتحان السريري الموضوعي المنظم، الذي يحاول مراقبة الكفاءة مراقبًة مباشرًة في إطار من محاكاة البيئة السريرية؛ ومع ذلك، يمكن أن يكون ذلك مكلفًا ويتطلب عمالة كثيفة (062-262). وهناك جدل مثار حول ما إذا كان ينبغي استخدام امتحانات اللياقة للممارسة لإعادة منح الترخيص، أو للعودة إلى المهنة، أو في حالة الممرضين المدربين بالخارج. الإطار 4.9 أمثلة على المواءمة بين معايير التعليم وامتحانات منح التراخيص في عام 2791، أنشأت المناطق التابعة للجماعة الكاريبية هيئة التمريض الإقليمية مكلِّفًة إياها بمهمة أولية تتمثل في إنشاء رصيد متاح مشترك من المعلمين المؤهلين لتخفيف حدة الاختناقات التي يواجهها إجراء تقييمات الكفاءة لكادر التمريض من الخريجين (252). وعندما أشارت التحليلات إلى أن أغراض مناهج تعليم التمريض ومحتواها وطرق تدريسها متشابهة في جميع أنحاء المنطقة الفرعية، وافقت البلدان على عقد امتحان فردي ومشترك لكادر التمريض، وقد بدأ العمل به في عام 0991. وتنسق هيئة التمريض الإقليمية الامتحان، الذي يعتمد على الكفاءات المتفق عليها على نحو متبادل لإجازة كادر التمريض المسجل للممارسة؛ ويشترك في إدارته رئيس التمريض أو مسؤولو التمريض الرئيسيون ومعلمو التمريض الخاصون ومجلس التمريض في كل بلد، وكذلك معلمون من جامعات المنطقة الفرعية (752). ويسمح الامتحان بتوحيد معايير تعليم التمريض وتحسينه، وكذلك تبادل كادر التمريض المسجل وسهولة حركته بين بلدان المنطقة الفرعية. وفي الاتحاد الأوروبي، بدأت الجهود المبذولة لتحقيق التواؤم إزاء التنوع والتعقيد اللذين تتسم بهما هياكل درجات كادر التمريض وبرامج المناهج الدراسية بإدخال التوجيهات القطاعية في أواخر سبعينيات القرن العشرين، وقد تسارعت مع التنقيحات التي أُجريت في عام 5002 (التوجيه 63) والتحديثات اللاحقة التي أدخلت مجموعة معيارية من الكفاءات (التوجيه 55) (352، 452). وأسفرت هذه التغييرات، مقترنًة باتفاق بولونيا (سنة 9991)، عن بنية تعليمية من ثلاث مراحل مؤهلة هي: البكالوريوس والماجستير والدكتوراه، إلى جانب مؤهلات أكاديمية منسقة في جميع التخصصات المختلفة (852) 33الأدوات السياساتية اللازمة لتمكين القوى العاملة في مجال التمريض vokloV yegreS/OHW © حالة التمريض في العالم عام 020243 يقدم هذا الفصل، لأول مرة في تاريخ منظمة الصحة . 37 العالمية، بيانات عن القوى العاملة في مجال التمريض في أكثر من 091 بلدًا بناًء على مجموعة من المؤشرات الموحدة معياريًا ومن خلال عملية واحدة للإبلاغ بالبيانات، وفقًا لنهج حسابات القوى العاملة الصحية الوطنية (الحسابات). وقد ُجِمعت البيانات المتعلقة بتوافر القوى العاملة في . 47 مجال التمريض وتكوينها وتوزيعها وتعليمها وتدريبها ومهاراتها وإدارتها وتنظيمها وتمويلها وقيادتها.5 وإجماًلا، ُجمعت البيانات وُحللت وفقًا لأكثر من 03 مؤشرًا. وشملت جهود جمع البيانات مختلف أصحاب المصلحة مثل وزارات الصحة وسائر الوزارات من قبيل العمل والتعليم، ومراصد الموارد البشرية الصحية، والمعاهد الوطنية للصحة العامة، ومنظمات التمريض المهنية، وكبار المسؤولين الحكوميين في مجالي التمريض والقبالة، وسائر المنظمات الوطنية والإقليمية والدولية. وُجِمعت بيانات من خلال نظام وحيد لتعريف البيانات والإبلاغ بها، وهي منصة حسابات القوى العاملة الصحية الوطنية، التي تؤدي دور المستودع المتاح عبر الإنترنت للدول الأعضاء للإبلاغ بمواردها البشرية ورصدها واستخدامها للبيانات الصحية. وترد الأساليب التفصيلية في الملحق 2. وقد انصب تركيز التحليل على القوى العاملة الحالية . 57 في مجال التمريض، لكن الجزء الأخير من هذا الفصل يتناول السيناريوهات المحتملة المستقبلية للقوى العاملة التمريضية في ظل افتراضات مختلفة لتقييم التقدم المحرز صوب تحقيق الأغراض المحددة في الاستراتيجية العالمية بشأن الموارد البشرية الصحية: القوى العاملة 0302، وفيما يتعلق بهدف التنمية المستدامة لعام 0302 وخطة التغطية الصحية الشاملة (61). عدد البلدان التي أبلغت برصيد كادر التمريض لم يسبق . 67 له مثيل، وهو يمثل أكثر ما ُجمع من البيانات شموًلا وتحديثًا عن القوى العاملة في مجال التمريض (الشكل الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 باستخدام تعريف منظمة العمل الدولية للقوى العاملة التمريضية: انظر الملحق 1. 5 الفصل 53 5-1). وقد زادت المعلومات المتعلقة بالتمريض للفترة 3102-8102 زيادة كبيرة مقارنة بالمهن الأخرى بفضل الزخم الناتج عن إعلان سنة 0202 السنة الدولية لكادر التمريض والقبالة. وقد زادت البيانات المتعلقة برصيد القوى العاملة الصحية في السنوات الأخيرة، ليس فقط من حيث كمية المعلومات، بل أيضًا من حيث تحسُّ ن توقيت الإبلاغ، حيث أبلغت غالبية البلدان ببيانات بالمهن الخمس المدرجة في المؤشر -3ج1- من مؤشرات أهداف التنمية المستدامة (الأطباء والعاملون في مجالي التمريض والقبالة وأطباء الأسنان والصيادلة) خلال السنوات الخمس الماضية. وأتاح توافر البيانات الحالية والسابقة تحديث التقديرات السابقة بأثر رجعي، وأتاح كذلك معالجة مسألة القيود المفروضة على البيانات المتعلقة بالتحليلات والتقارير السابقة. ومن بين 63 مؤشرًا عن القوى العاملة في مجال . 77 التمريض المستخدمة في إعداد هذا التقرير (انظر الإطار (أ) 2-1 في الملحق 2)، تمكنت جميع الدول الأعضاء في منظمة الصحة العالمية تقريبًا من الإبلاغ ببيانات عن رصيدها التمريضي وأبلغت الغالبية العظمى وفقًا للمؤشرات الرئيسية الأخرى، مثل التوزيع العمري والتكوين الجنساني ومدة التدريب. وقدمت نسبة بلغت نحو 08٪ من البلدان بيانات وفقًا لما لا يقل عن 51 مؤشرًا، بينما قدمت نسبة بلغت 32٪ منها بيانات وفقًا لما لا يقل عن 52 مؤشرًا. ويعرض هذا الفصل معلومات عن مؤشرات حظيت بمعدل إجابة مرتفع من الدول الأعضاء (القائمة الكاملة متوافرة في الملحق 2). عدد البلدان التي تتوافر بشأنها بيانات عن القوى العاملة في حسابات القوى العاملة الصحية الوطنية لدى المنظمة (0991-8102) الشكل 5.1 ملاحظات: (أ) بالنظر إلى السنوات الخمس الماضية، ُجِمعت بيانات عن رصيد كادر التمريض في 191 بلدًا. وقد تشير أحدث نقطة َأخذ بيانات إلى سنوات مختلفة؛ حيث قدمت معظم البلدان (٪38) بيانات عن عدد الموظفين اعتبارًا من عام 7102 أو عام 8102؛ (ب) يفسر وقت التأخر في توافر البيانات والإبلاغ الاتجاَه النزولَي الظاهر في السنوات الأخيرة؛ ومن المتوقع أن ُيتاح مزيد من نقاط البيانات للفترة 4102-8102، مع الاستمرار في الاتجاه الصعودي الإيجابي لبيانات رصيد القوى العاملة في مجال التمريض. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. البلدان المتوافر بشأنھا بیانات تخص كادر طب الأسنان البلدان المتوافر بشأنھا بیانات تخص كادري التمریض والقبالة البلدان المتوافر بشأنھا بیانات تخص كادر الصیدلة البلدان المتوافر بشأنھا بیانات تخص الأطباء ان بلد ال دد ع 061 041 021 001 08 06 04 02 0 191 بلدا لدیھا بیانات حدیثة 38% لعام 7102 وعام 8102 8102 7102 6102 5102 4102 3102 2102 1102 0102 9002 8002 7002 6002 5002 4002 3002 2002 1002 0002 9991 8991 7991 6991 5991 4991 3991 2991 1991 0991 حالة التمريض في العالم عام 020263 5 1 2 الرصيد المتوافر من كادر التمريض عالميا ًوإقليميا ً تشير البيانات الواردة من 191 بلدًا إلى وجود رصيد . 87 عالمي يضم حوالي 82 مليون فرد من أفراد كادر التمريض، يشمل كلا القطاعين العام والخاص (الجدول 5-1). ويترجم هذا الرصيد في شكل كثافة عالمية تبلغ 9.63 ممرضًا/ ممرضة لكل 000 01 نسمة. ومع ذلك، يحجب هذا الرقم العالمي الاختلافات العميقة داخل الأقاليم وفيما بينها.6 وفي حين أن عدد السكان في إقليم الأمريكتين والإقليم . 97 الأفريقي متشابه، فعدد أفراد كادر التمريض في الأمريكتين يزيد بنحو 01 أضعاف عن عددهم في الإقليم الأفريقي، حيث يبلغ 4.38 فردًا لكل 000 01 نسمة في الأول، في حين يبلغ في الأخير 7.8 أفراد لكل 000 01 نسمة. والكثافة في إقليمي شرق المتوسط وجنوب شرق آسيا هي ثاني وثالث أقل كثافة (6.51 و5.61 فرادًا لكل 000 01 نسمة، على التوالي)، لكن هذه الكثافة لاتزال ضعف الكثافة التي لوحظت في الإقليم الأفريقي. وتعمل نسبة تبلغ حوالي 18٪ من كادر التمريض في . 08 العالم في ثلاثة أقاليم (هي الأمريكتان وأوروبا وغرب المحيط الهادئ)، تضم مجتمعة 15٪ من سكان العالم. الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 1 1 الاستنتاجات الرئيسية تشير البيانات الواردة من 191 بلدا ًإلى أن رصيد كادر التمريض العالمي قد بلغ حوالي 82 مليون شخص في عام 8102، معظمهم من أخصائيي التمريض (96٪). وحدثت زيادة فعلية بلغت 7 4 ملايين شخص على مستوى العالم في رصيد كادر التمريض بين عامي 3102 و8102، حتى بعد احتساب تحسُّ ن توفر البيانات وجودتها. ويمثل أخصائيو التمريض ومعاونوهم نحو 95٪ من المهنيين الصحيين (أي الأطباء وأفراد التمريض وأفراد القبالة وأطباء الأسنان والصيادلة) في 271 بلدا ًتتوافر بشأنها بيانات. وتبلغ الممرضات تسعة من بين كل 01 من أفراد كادر التمريض على مستوى العالم، مع وجود اختلافات إقليمية ذات أهمية: ففي الإقليم الأفريقي، تبلغ نسبة الإناث إلى الذكور 1:3. وفاق عدد الممرضين عدَد الممرضات في 31 بلدا.ً وهناك أيضا ًتفاوتات كبيرة في التوزيع داخل الأقاليم. ففي إقليم الأمريكتين، يعمل أكثر من ثمانية من كل 01 من أفراد كادر التمريض في ثلاثة بلدان (البرازيل وكندا والولايات المتحدة)، تستضيف 75٪ من السكان. وفي الإقليم الأفريقي وإقليم شرق المتوسط، تختلف كثافة كادر التمريض لكل نسمة اختلافا ًكبيرا ًيبلغ 001 ضعف بين أقل البلدان وأعلاها. ومن المتوقع أن يتقاعد واحد من كل ستة من أفراد كادر التمريض في العالم خلال السنوات العشر المقبلة؛ وهذه النسبة أعلى كثيرا ًفي إقليم الأمريكتين (42٪)، مما يشكل تحديا ًإضافيا ًأمام تجديد الموارد. 6 انظر الفرع 5-2 الذي يتناول الإنصاف. 5.1 توفر القوى العاملة في مجال التمريض وتكوينها وتوزيعها 73 وينبغي توخي الحذر في التفسير لدى مقارنة هذا التقدير . 18 الإجمالي البالغ 9.72 مليون ممرض/ ممرضة لعام 8102 بالتقدير الوارد في الاستراتيجية العالمية بشأن الموارد البشرية الصحية، الذي يفيد وجود 7.02 مليون فرد من أفرد كادري التمريض والقبالة (منهم 8.81 مليون ممرض/ ممرضة) باستخدام بيانات عام 3102. وُيعَزى جزء من الزيادة في عدد كادر التمريض من عام 3102 إلى عام 8102 إلى تحسين توافر البيانات (حيث تمثل 4.4 ملايين ممرض/ ممرضة)، بينما تقدر الزيادة الفعلية بـ 7.4 ملايين ممرض/ ممرضة (الجدول 5-2)، منها 6.3 ملايين أخصائي/ أخصائية تمريض، بافتراض ثبات نسبة الأخصائيين إلى معاونيهم (الشكل 5-2). عدد كادر التمريض على مستوى العالم وكثافته لكل 000 01 نسمة، حسب إقليم المنظمة، 8102 الجدول 5.1 التغيُّرات في رصيد كادر التمريض بسبب تحسين البيانات والزيادة الفعلية المحققة بين عامي 3102 و8102 الجدول 5.2 أقاليم المنظمة عدد البلدان التي أبلغت بعدد الموظفين/ المجموع عدد أفراد كادر التمريض (أ) الكثافة لكل 000 01 نسمة(بالملايين) (٪) 7.89.0 (3%)44/74أفريقيا 4.384.8 (03%)53/53الأمريكتان 5.613.3 (21%)11/11جنوب شرق آسيا 3.973.7 (62%)35/35أوروبا 6.511.1 (4%)12/12إشرق المتوسط 0.639.6 (52%)72/72غرب المحيط الهادئ 9 639 72 (001%)191/491العالم (أ) يشمل أخصائيي التمريض ومعاونيهم. ملحوظة: لم تكن بيانات الرصيد متاحة عن الكاميرون وجزر القمر وجنوب السودان. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث كثافة متاحة أبلغت بها البلدان بين عامي 3102 و8102. وفيما يتعلق بالبلدان التي أبلغت بعدد الموظفين فيها بين عامي 3102 و7102، وبغية توحيد جميع البلدان معياريًا حتى عام 8102، ُأبلغ بعدد الموظفين بتطبيق أحدث كثافة متاحة على الفئات السكانية الخاصة بعام 8102. واسُتخِرج حجم السكان لكل بلد وسنة المستخدم لحساب قيم الكثافة من تقرير التوقعات السكانية في العالم، في نسخته المنقحة لعام 9102، الصادر عن إدارة الشؤون الاقتصادية والاجتماعية بالأمم المتحدة (362). (أ) تتضمن المطبوعة الأصلية كادر القبالة: 7.02 مليون فرد من أفراد كادري التمريض والقبالة. ويتوافق هذا مع الرقم البالغ 8.81 مليون ممرض/ ممرضة عند تصحيحه بحصة كادر التمريض. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. رصيد كادر التمريض في عام 8102رصيد كادر التمريض في عام 3102 التغيُّر بسبب الزيادة الفعلية في الرصيد المصدر (بالملايين) عدد البلدان التي لديها بيانات عن الفترة 9002- 3102 الرصيد (بالملايين) عدد البلدان التي لديها بيانات عن الفترة 3102- 8102 الرصيد (بالملايين) a8.81201تقدير الاستراتيجية العالمية بشأن الموارد البشرية الصحية، 6102 7 49.721912.32471تقدير تقرير حالة التمريض في العالم لعام 0202 4 4التغيُّر بسبب تحسين البيانات (بالملايين) حالة التمريض في العالم عام 020283 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض ومن ثم، يسلط إجمالي الرصيد البالغ 9.72 مليون . 28 ممرض/ ممرضة المبلغ به في عام 8102 الضوء على اتجاهين إيجابيين منفصلين، هما: تحسُّ ن توافر بيانات القوى العاملة في مجال التمريض، وهو ما يسمح بإجراء تفسير وتقييم أفضل للتحليلات السابقة؛ حدوث زيادة فعلية في سوق القوى العاملة في مجال التمريض على الصعيد العالمي، مما يعكس تزايد الطلب على سوق العمل واستثمار الدول الأعضاء في هذه الفئة المهنية. وبمقارنة رصيد أفراد كادر التمريض بالمجموع الكلي . 38 للأطباء وكادر القبالة وأطباء الأسنان والصيادلة في 271 بلدًا بالبيانات المتاحة، يتبين أن كادر التمريض يمثل، في المتوسط، 95٪ من المهنيين الصحيين، حيث تتراوح نسبته بين 94٪ في إقليم شرق المتوسط و86٪ في إقليم غرب المحيط الهادئ (الجدول 5-3). تمكنت ستة وستون بلدًا من الإبلاغ برصيد القوى . 48 العاملة الصحية في 01 مهن على الأقل؛ وبمقارنة كادر التمريض بجميع هؤلاء العاملين الصحيين المحتملين، يتبين أن رصيد كادر التمريض يستأثر بحصة تتراوح نسبتها بين 04٪ و05٪ من القوى العاملة الصحية. 5 1 3 التكوين من بين 9.72 مليون ممرض وممرضة في العالم، . 58 ُصنِّف 3.91 مليونًا (96٪) على أنهم أخصائيو تمريض (الرمز 1222 في التصنيف الدولي الموحد للمهن)، و0.6 ملايين (22٪) على أنهم معاونو أخصائيي تمريض (الرمز 1223 من التصنيف الدولي). وهذا يترك 6.2 مليون (9٪) منهم دون تصنيف بأي من الطريقتين، مما يشير إلى احتمال مواجهة تحديات في المواءمة بين نظام البيانات الوطنية ونظام التصنيف الدولي الموحد للمهن. وهؤلاء الممرضون والممرضات هم إما أخصائيو تمريض وإما معاونو أخصائيي تمريض، ولا تشمل هذه الفئة مساعدي التمريض أو مساعدي الرعاية الصحية. وتختلف النسب التقديرية لمختلف فئات القوى العاملة في مجال التمريض اختلافًا كبيرًا باختلاف الإقليم، كما هو مبين في الشكل 5-2. نسبة كادر التمريض إلى المهنيين الصحيين (الأطباء وكادر التمريض وكادر القبالة وأطباء الأسنان والصيادلة) حسب إقليم المنظمة الجدول 5.3 (أ) يشمل أخصائيي التمريض ومعاونيهم. ملحوظة: المؤشر 3-ج-1 من مؤشرات أهداف التنمية المستدامة هو المؤشر المستخدم لتقييم التقدم المحرز في تحقيق الغاية 3-ج. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. أقاليم المنظمة رصيد كادر التمريض (أ) مقارنة برصيد المهنيين الصحيين وفقا ًللمؤشر -3ج1- من مؤشرات أهداف التنمية المستدامة متوسط حصة كادر التمريضعدد البلدان الُمبلِّغة/ الإجمالي 66%54/74أفريقيا 65%42/53الأمريكتان 35%11/11جنوب شرق آسيا 75%05/35أوروبا 94%02/12شرق المتوسط 86%22/72غرب المحيط الهادئ 95%271/491العالم 93 أفریقیا الأمریكتان جنوب شرق آسیا أوروبا شرق المتوسط غرب المحیط الھادئ العالم نسبة العدد الإجمالي أفراد كادر التمریض أقالیم المنظمة أفراد كادر تمریض لیس لھم تعرف آخر أخصائیو التمریض أخصائیو التمریض 001% 08% 06% 04% 02% 0% الشكل 5.2 نسبة عدد العاملين في مجال التمريض داخل كل فئة مهنية، حسب إقليم المنظمة 5 1 4 التركيبة السكانية للتمريض: التوزيع حسب الجنس والتوزيع حسب العمر التوزيع حسب الجنس ثمة حاجة لتعميم المنظور الجنساني في استراتيجيات . 68 القوى العاملة الصحية لضمان اتباع نهوج تراعي الفوارق بين الجنسين في تخطيط القوى العاملة الصحية وإدارتها. ولطالما تعرض توزيع كادر التمريض حسب الجنس والشيخوخة للتجاهل لأسباب مختلفة، بما في ذلك عدم وجود بيانات عالية الجودة للتخطيط الوطني والمقارنة على الصعيدين الإقليمي والعالمي. ومن بين 491 دولة عضوًا في منظمة الصحة العالمية، قدمت 231 دولة بيانات مصنفة حسب الجنس، وقدمت 601 دول بيانات عن العمر. وفي هذه البلدان البالغ عددها 231 بلدًا، تبلغ نسبة الممرضات نحو 9 من أصل 01 ممرضين وممرضات (98٪) من أفراد كادر التمريض، مع وجود تباينات إقليمية لا ُيستهان بها. وتبلغ نسبة النساء في مجال التمريض أعلى مستوى لها (59٪) في إقليم غرب المحيط الهادئ، وأدنى مستوى لها (67٪) في الإقليم الأفريقي. وقد أبلغت ثلاثة عشر بلدًا بارتفاع عدد الممرضين عن عدد الممرضات (الجدول 5-4). التوزيع حسب العمر تجعل الأنماط العالمية للسكان وشيخوخة القوى العاملة . 78 من الضروري احتساب الهيكل العمري للقوة العاملة في التوصل إلى التوقعات. ففي العديد من البلدان، يعتمد المخططون على سن تقاعد موحد معياريًا، ولكن هذا النهج له قيود، بالنظر إلى الاختلافات القائمة في سن التقاعد الفعلي في مختلف المهن وبين الجنسين وفي شتى مستويات الدرجات الوظيفية. وقد اسُتخدمت البيانات المتعلقة بالعمر الواردة من 601 بلدان لتوضيح الاتجاهات الحالية في التركيبة السكانية للتمريض. وبوجه عام، تشير المعلومات المتاحة إلى قوة عاملة تمريضية شابة نسبيًا: 83٪ من أفراد كادر التمريض تقل أعمارهم عن 53 عامًا،7 مقارنًة بـ 71٪ ممن تبلغ أعمارهم 55 عامًا أو أكثر (الفئة الأخيرة تعتبر متقاعدة على مدار العقد المقبل) (الشكل 5-3). بيد أن الاختلافات الإقليمية ذات أهمية: ففي إقليم شرق المتوسط، هناك 41 شابًا/ شابة مقابل كل فرد تمريض مقبل على التقاعد؛ وعلى النقيض من ذلك، تبلغ هذه النسبة في الأمريكتين 1:2,1، أمَّ ا في أوروبا وأفريقيا، فتبلغ 1:9,1، وهو ما يشير إلى أن الرصيد المتاح الذي سُتسيبدل أصغر كثيرًا. 7 باستخدام تعريف منظمة العمل الدولية للقوى العاملة التمريضية: انظر الملحق 1. حالة التمريض في العالم عام 020204 النسبة المئوية لأفراد كادر التمريض الذين تقل أعمارهم عن 53 عاما ًوالذين تبلغ أعمارهم 55 عاما ًأو أكثر، حسب إقليم المنظمة الشكل 5.3 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض نسبة الذكورنسبة الإناثعدد البلدان الُمَبلِّغة/ الإجماليإقليم المنظمة 42%67%03/74أفريقيا 31%78%62/53الأمريكتان 11%98%9/11جنوب شرق آسيا 11%98%23/35أوروبا 22%87%11/12شرق المتوسط 5%59%42/72غرب المحيط الهادئ 11%98%231/491العالم أفریقیا )العدد=02( الأمریكتان )العدد=52( جنوب شرق آسیا )العدد=8( أوروبا )العدد=03( شرق المتوسط )العدد=5( غرب المحیط الھادئ )العدد=81( 55 سنة 53 سنة 02% 04% 06% 08%04% 02% %0 أقالیم المنظمة العالم )العدد=601( < ≤ الجدول 5.4 النسبة المئوية للعاملات في مجال التمريض، حسب إقليم المنظمة ملحوظة: يشمل "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث عدد متاح العاملين في مجال التمريض أبلغت به البلدان بين عامي 3102 و8102. ملحوظة: يشمل "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. 14 ونظرًا إلى أن ٪71 من أفراد كادر التمريض على . 88 مستوى العالم يبلغون من العمر 55 عامًا أو أكثر -ومن ثم، من المتوقع أن يتقاعدوا خلال السنوات العشر القادمة- سيتعين تعليم 7.4 ملايين فرد جديد وتوظيفهم على مدار العقد المقبل لمجرد الحفاظ على الوضع الراهن. وبغية مواكبة النمو السكاني والقضاء على نقص القوى العاملة في مجال التمريض، ستكون هناك حاجة إلى مزيد من هؤلاء (انظر الفرع 5-8). بغية توضيح شيخوخة القوى العاملة في مجال . 98 التمريض، ُوضِّ حت نسبة صغار السن إلى كبار السن في القوى العاملة في مجال التمريض في الشكل 5-4. ولئن كان لدى العديد من البلدان نسبة عالية من شباب الممرضين/ الممرضات، فإن العديد منها يكاد يكون في حالة توازن (نسبتان متماثلتان من أفراد كادر التمريض الذين تقل أعمارهم عن 53 عامًا والذين تزيد أعمارهم على 55 عامًا، كما هو مبين بالخط الأخضر في الشكل 5-4)، فهناك 81 بلدًا (واحد من كل ستة لديه بيانات متوافرة) تواجه موقفًا صعبًا للغاية، إذ إن لديها قوة عاملة مسنة إلى جانب عدد أقل من شباب الممرضين/ الممرضات مقارنًة بأفراد كادر التمريض المقبلين على بلوغ سن التقاعد. نسبة أفراد كادر التمریض دون 53 سنة 07% 06% 05% 04% 03% 02% 01% 0% ر كث فأ نة س 55 د عن ض ری تم ال در كا راد أف بة نس %07 %05 %04 %03 %02 %01 %0%06 81 بلدا تواجھ خطر شیخوخة القوى العاملة الصحیة یشیر الخط الأخضر إلى حیث یساوي عدد أفراد كادر التمریض المقبلین على كل نقطة تمثل خطا بلوغ سن التقاعد عدد شباب كادر التمریض في القوى العاملة النسب التقريبية لكادر التمريض الذين تزيد أعمارهم على 55 عاما ًوالذين تقل أعمارهم عن 53 عاماً الشكل 5.4 ملحوظة: تشمل "القوى العاملة في مجال التمريض" أخصائيي التمريض ومعاونيهم من 601 بلدان تتوافر بشأنها بيانات مصنفة حسب العمر. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث عدد متاح للعاملين في مجال التمريض أبلغت به البلدان بين عامي 3102 و8102. حالة التمريض في العالم عام 020224 ويتطلب الطريق صوب تحقيق التغطية الصحية الشاملة . 09 معالجة التباينات الديموغرافية والجغرافية والمهارية في توافر القوى العاملة الصحية وإتاحتها. 5 2 2 الإنصاف في مختلف الأقاليم يبين الشكل 5-5 التباين العالمي في كثافة أفراد كادر . 19 التمريض لكل 000 01 نسمة، حيث تتركز أوسع الفجوات في الإقليم الأفريقي وإقليمي جنوب شرق آسيا وشرق المتوسط وبعض بلدان أمريكا اللاتينية. 5 2 3 الإنصاف في توافر الممرضين والممرضات داخل الأقاليم يوضح الشكل 5-6 التباين في كثافة الممرضين . 29 والممرضات داخل الأقاليم: حيث تمثل كل نقطة بلدًا. ويتضح أن ثمة تباينًا كبيرًا في جميع الأقاليم في كثافة التمريض، لكن التباين هو أكبر ما يكون في إقليم شرق المتوسط، حيث يتراوح معدل الكثافة من أعلاه، أي 121، إلى أدناه، أي 1، وفي الإقليم الأفريقي، يتراوح من 001 إلى 1. أمَّ ا في إقليم الأمريكتين، فيوجد عدد قليل من البلدان الكبيرة ذات الكثافة العالية من أفراد كادر التمريض، في حين أن معظم البلدان الأخرى لديها كثافة منخفضة نسبيًا: فتوجد نسبة تبلغ ٪78 من كادر التمريض في هذا الإقليم في البرازيل وكندا والولايات المتحدة، التي تضم حوالي ٪75 من السكان. ولوحظت تباينات أقل كثافة -من 01 إلى -1 في الإقليم الأوروبي. وتتجمع بلدان الإقليم الأفريقي في الطرف السفلي من العمود، وهو ما يشير إلى أن عددًا قليًلا فقط من البلدان الأفريقية لديها كثافة تزيد على 52 ممرضًا/ ممرضة لكل 000 01 نسمة. وقد لوحظت أنماط مماثلة في إقليمي جنوب شرق آسيا وشرق المتوسط. وتباُين الكثافة َمردُّه، إلى حد كبير، إلى مستويات الدخل، حيث تبلغ الكثافة 1.9 ممرضين/ ممرضات لكل 000 01 نسمة في البلدان المنخفضة الدخل مقابل 7.701 ممرضين/ ممرضات لكل 000 01 نسمة في البلدان المرتفعة الدخل (الجدول 5-5 والشكل 5-7). الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 2 1 الاستنتاجات الرئيسية يوجد حوالي 18٪ من كادر التمريض في العالم في إقليم الأمريكتين والإقليم الأوروبي وإقليم غرب المحيط الهادئ، التي تضم 15٪ من سكان العالم. وفرادى البلدان التي تعاني من قلة أفراد كادر التمريض تقع معظمها في الإقليم الأفريقي وإقليمي جنوب شرق آسيا وشرق المتوسط، وأجزاء من أمريكا اللاتينية. والتفاوتات العالمية في توافر أفراد كادر التمريض مردها إلى حد كبير إلى الدخل، حيث تبلغ الكثافة 1 9 ممرضين/ ممرضات لكل 000 01 نسمة في البلدان المنخفضة الدخل مقابل 7 701 ممرضين/ ممرضات لكل 000 01 نسمة في الاقتصادات ذات المرتفعة الدخل. وهناك تباينات لا ُيستهان بها داخل البلدان: ففي 53 بلدا ًتتوافر بشأنها بيانات مصنفة حسب المناطق الحضرية- الريفية، ُتنشر نسبة تبلغ 63٪ من كادر التمريض على مراكز العمل في المناطق الريفية، حيث يعيش 94٪ من السكان. وفي 67 بلدا ًتتوافر بشأنها بيانات، تعمل نسبة تبلغ 57٪ من كادر التمريض في القطاع العام، في حين تعمل النسبة المتبقية البالغة 52٪ في القطاع الخاص. 5.2 الإنصاف في توافر القوى العاملة في مجال التمريض وإتاحتها 34 الشكل 5.5 كثافة أفراد كادر التمريض لكل 000 01 نسمة في عام 8102 الشكل 5.6 التفاوتات الإقليمية في كثافة أفراد كادر التمريض لكل 000 01 نسمة (8102) لا ینطبقلم یبلغ عنھا 005000,4 000,3 000,2 000,1 0 mk + 001 57 إلى 99 05 إلى 47 04 إلى 94 03 إلى 93 02 إلى 92 01 إلى 91 01 < 0 05 001 051 002 المعدل الأقصى: الأدنى للمعدل الكثافة 1:0011:221:811:011:211:33 أقالیم المنظمة إقلیم جنوب الإقلیم الأفریقي شرق آسیا إقلیم شرق إقلیم الأمریكتینالإقلیم الأوروبي المتوسط إقلیم غرب المحیط الھادئ مة نس 1 0 00 0 كل ض ل ری تم ال در كا راد أف دد ع ملحوظة: يشمل "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. أحدث البيانات المتاحة خلال الفترة 3102-8102. ملحوظة: يشمل "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث عدد للعاملين في مجال التمريض متاح من البلدان التي أبلغت به بين عامي 3102 و8102. حالة التمريض في العالم عام 020244 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض الشكل 5.7 كثافة أفراد كادر التمريض لكل 000 01 نسمة حسب فئة الدخل (8102) 0 05 001 051 002 مستوى الدخل بلدان الشریحة العلیا من البلدان المنخفضة الدخل الدخل المتوسط بلدان الشریحة الدنیا من الدخل المتوسط البلدان المرتفعة الدخل مة نس 1 0 00 0 كل ض ل ری تم ال در كا راد أف دد ع ملحوظة: يشمل مصطلح "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث عدد للعاملين في مجال التمريض متاح من البلدان التي أبلغت به بين عامي 3102 و8102. والتقسيم حسب فئة الدخل مأخوذ من تصنيف البنك الدولي حتى عام 8102. وعند النظر في وضع 64 بلدًا صنفتها لجنة السياسة . 39 الإنمائية التابعة للأمم المتحدة ضمن أقل البلدان نموًا حتى كانون الأول/ ديسمبر 8102، يتبين أن كثافة أفراد كادر التمريض تبلغ 4.6 أفراد لكل 000 01 نسمة، أي أقل بستة أضعاف من المتوسط في جميع البلدان الأخرى، وأقل كثيرًا من المتوسط في البلدان المنخفضة الدخل. وُتعتبر الغالبية العظمى من هذه البلدان أيضًا بلدانًا ضعيفة ("ذات تحذيرات شديدة" أو "ذات تنبيهات") وفقًا لمؤشر الدول الهشة.8 ويعرض الإطار 5-1 مزيدًا من المعلومات عن الإنصاف داخل البلدان. 8 البلدان التي حصلت، حسب مؤشر الدول الهشة، على درجة +08. المصدر: /gro.xednisetatseligarf//:sptth 54 الجدول 5.5 كثافة أفراد كادر التمريض حسب كل فئة دخل (8102) ملحوظة: يشمل مصطلح "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث رصيد متاح أبلغت به البلدان بين عامي 3102 و8102. فيما يخص جزر كوك ونيووي، لم تكن تصنيفات فئة الدخل متاحة. لذلك، ُصنِّفت على أنها من بلدان الشريحة العليا من الدخل المتوسط، على غرار البلدان الأخرى في المنطقة نفسها. والتقسيم حسب فئة الدخل مأخوذ من تصنيف البنك الدولي حتى عام 8102. فئات الدخل عدد البلدان الُمَبلِّغة/ الإجمالي الكثافة لكل 000 01 نسمة أعلى مستوى للمعدلأدنى مستوى للمعدلالإجمالي المعدل من أعلاه إلى أدناه 1:860.246.01.903/13البلدان المنخفضة الدخل بلدان الشريحة الدنيا من الدخل المتوسط 1:756.4018.17.6144/64 بلدان الشريحة العليا الدخل المتوسط 1:522.4210.56.5306/06 1:011.6914.917.70175/75البلدان المرتفعة الدخل 1:9131 6916 09 63191/491العالم الإطار 5.1 الإنصاف داخل البلدان توافر التمريض في المناطق الريفية يتسم توزيع القوى العاملة في مجال التمريض داخل البلدان بالقدر نفسه من الأهمية فيما يتعلق بالإتاحة المنصفة. وقد قدم ما مجموعه 53 بلدًا (معظمها في أمريكا اللاتينية وأفريقيا)9 بيانات عن نسبة القوى العاملة في مجال التمريض في المناطق الريفية. ففي المتوسط، يعمل حوالي 63٪ من كادر التمريض، في هذه البلدان، في المناطق الريفية، مقارنًة بـ 05٪ من السكان المقيمين هناك. توافر التمريض في القطاعين العام والخاص داخل البلدان، هناك مصدر محتمل آخر لعدم الإنصاف وهو التوزيع حسب القطاع العام مقابل القطاع الخاص. ففي 67 بلدًا قدمت بيانات، كانت نسبة تبلغ 57٪ في المتوسط من كادر التمريض تعمل في القطاع العام، مع تفاوت محدود نسبيًا بين الأقاليم. 9 أنتيغوا وبربودا، بليز، البرازيل، بروني دار السلام، كمبوديا، إكوادور، مصر، السلفادور، إسواتيني، غامبيا، غانا، غينيا-بيساو، غيانا، هندوراس، آيسلندا، كينيا، جمهورية لاو الديمقراطية الشعبية، مدغشقر، جزر مارشال، منغوليا، ميانمار، باكستان، باراغواي، بيرو، ساموا، صربيا، سيراليون، سري لانكا، طاجيكستان، تايلند، تيمور- ليشتي، أوغندا، جمهورية تنزانيا المتحدة، أوروغواي، جمهورية فنزويلا البوليفارية. حالة التمريض في العالم عام 020264 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 3 2 التحديات التي يواجهها قياس تنقل كادر التمريض على المستوى الدولي أدت الاتجاهات الديموغرافية والوبائية والمالية والصحية . 49 والسياساتية إلى تسارع تنقل العاملين الصحيين على المستوى الدولي في العقود الأخيرة، ومن المتوقع أن يزداد هذا التنقل (81). وُتعد مدونة المنظمة العالمية لقواعد الممارسة بشأن توظيف العاملين الصحيين على المستوى الدولي، التي اعتمدتها جمعية الصحة العالمية في عام 0102، أداة قانونية دولية رئيسية تستهدف تعزيز الإدارة الأخلاقية لتنقل العاملين الصحيين على المستوى الدولي. ولطالما اعُترف بحركة العاملين الصحيين من البلدان . 59 المنخفضة الدخل إلى البلدان المرتفعة الدخل ونوقشت تلك الحركة، علاوة على ما يصاحبها من تحديات. ومع ذلك، تقتصر البيانات اللازمة للاسترشاد بها في اتخاذ القرارات السياساتية، إلى حد كبير، على عدد مختار من البلدان المرتفعة الدخل. وتشير التحسينات التي ُأجريت مؤخرًا في توافر البيانات، وخاصة من خلال نظام حسابات القوى العاملة الصحية الوطنية، إلى وجود تفرقة أقل وضوحًا بين المنشأ (في جنوب العالم) والمقصد (في شمال العالم) مقارنة بما كان ُيعتقد سابقًا. وحتى عام 8102، قدم ما مجموعه 68 بلدًا بيانات . 69 عن نسبة أفراد كادر التمريض المولودين أو المدربين في الخارج بوصفه مؤشرًا بديًلا لحجم ظاهرة الهجرة (الجدول 5-6) من خلال الحسابات ونظم الإبلاغ لدى منظمة التعاون والتنمية في الميدان الاقتصادي والمكتب الإحصائي للاتحاد الأوروبي والمكتب الإقليمي لأوروبا التابع لمنظمة الصحة العالمية. وفي البلدان المبلغة، ُولد أو تدرب واحد من أفراد كادر التمريض من كل ثمانية أفراد (31٪) في بلد غير البلد الذي يزاول فيه مهنته حاليًا. وتطبيق هذه الحصة على رصيد أفراد كادر التمريض يعطي تقديرًا يفيد أن نحو 7.3 ملايين ممرض وممرضة مولودون أو مدربون في الخارج على مستوى العالم. ويوجد أفراد كادر التمريض المولودون أو المدربون بالخارج بصفة رئيسية في البلدان المرتفعة الدخل، حيث تستأثر بحصة تبلغ نسبتها 2.51٪، مقارنة بحصة أقل من 2٪ في البلدان المنتمية إلى فئات الدخل الأخرى. 5 3 1 الاستنتاجات الرئيسية بناء على البيانات الواردة من 68 بلدا،ً ُولد واحد من كادر التمريض من أصل ثمانية (31٪) أو تدرب في بلد غير البلد الذي يزاول فيه مهنته حاليا.ً ومن بين البلدان المجيبة، كان هناك اعتماد كبير على أفراد كادر التمريض المولودين في الخارج في البلدان المرتفعة الدخل، حيث بلغت نسبة أفراد كادر التمريض من المولودين أو المدربين في الخارج 2 51٪ حسبما أُبلغ به. وعلى الرغم من التحسن في التوافر، لاتزال البيانات المتعلقة بالهجرة والتنقل غير كافية للتمكين من إجراء تقييم شامل لتعقُّد أنماط الهجرة. 5.3 هجرة أفراد كادر التمريض وتنقلهم على المستوى الدولي 74 ymalA/serutciP tniophsalF-seliM naI © الجدول 5.6 النسبة المئوية لأفراد كادر التمريض المولودين (أو المدربين) في الخارج حسب كل فئة دخل عدد البلدان الُمَبلِّغة/ الإجماليفئة الدخل نسبة أفراد كادر التمريض المولودين أو المدربين في الخارج غير ُمبّلغ به3/13البلدان المنخفضة الدخل 4 0%81/64 الشريحة الدنيا من الدخل المتوسط 7 0%72/06الشريحة العليا من الدخل المتوسط 2 51%83/75البلدان المرتفعة الدخل 2 31%68/491المجموع ملحوظة: يشمل مصطلح "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. وقد اسُتخدم مصطلح "المدربين في الخارج" بوصفه مؤشرًا غير مباشر لعدد يبلغ 03 بلدًا لم تستطع تقديم بيانات عن النسبة المئوية للمولودين في الخارج. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث رصيد متاح أبلغت به البلدان بين عامي 3102 و8102. والتقسيم حسب فئة الدخل مأخوذ من تصنيف البنك الدولي حتى عام 8102. غير ُمبلَّغ به = لم يبلغ به بسبب قلة عدد البلدان. حالة التمريض في العالم عام 020284 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 4 2 تحليل النتائج تتضمن الاستراتيجية العالمية بشأن الموارد البشرية . 79 الصحية: القوى العاملة 0302 مرحلة رئيسية مخططًا لبلوغها في عام 0202 هي أن تكون لدى البلدان آليات تنظيم واعتماد لتعليم القوى العاملة الصحية. ويعرض هذا الفرع توليفة من تسعة مؤشرات أبلغ بها ذاتيًا تتعلق بتنظيم تعليم التمريض والتدريب عليه (الشكل 5-8). وأبلغت الغالبية العظمى من البلدان بوجود معايير تتعلق . 89 بمدة تعليم التمريض ومحتواه وآليات اعتماد المؤسسات التعليمية وقائمة رئيسية تضم مؤسسات التعليم المعتمدة (19٪ و98٪ و18٪ من البلدان المجيبة، على التوالي). ومن بين البلدان المجيبة، أبلغت نسبة هي 77٪ بوجود معايير لمؤهلات أعضاء هيئة التدريس، في حين أبلغت 37٪ بوجود نظم للتطوير المهني المستمر. ولدى نحو ثلثي البلدان المجيبة معايير للتعليم المتعدد التخصصات، وامتحانات اللياقة للممارسة، ورابطة وطنية للطلاب الذين لم يحصلوا بعُد على ترخيص مزاولة المهنة (76٪ و46٪ و26٪ على التوالي). ومن بين 59 بلدًا مجيبة، أبلغت نسبة هي 35٪ عن وجود أدوار ممارسة متقدمة في مجال التمريض. ولا يعني وجود هذه العمليات أو النظم التنظيمية بالضرورة أنها تعمل بطريقة وافية. يعرض الجدول 5-7 بيانات عن وجود آليات وأنظمة . 99 تنظيمية تتعلق بالتعليم والتدريب في مختلف أقاليم منظمة الصحة العالمية. وقد أبلغت البلدان في الإقليم الأفريقي وإقليم الأمريكيتين والإقليم الأوروبي بوجود أحكام تنظيمية تتناول التعليم أكثر مما لدى البلدان في سائر الأقاليم. ففي إقليم شرق المتوسط، أبلغت البلدان بتوافر قدر أكبر من امتحانات اللياقة للممارسة ووجود أدوار تمريضية متقدمة. ولم يبلغ سوى عدد أقل من البلدان في إقليم جنوب شرق آسيا بوجود نظم للتطوير المهني المستمر، ورابطات وطنية للطلاب الذين لم يحصلوا بعد على ترخيص مزاولة المهنة أو معايير التعليم المتعدد التخصصات مقارنًة بالبلدان في سائر الأقاليم. وهذه الاختلافات الإقليمية قد تعكس، إلى حد ما، اختلاف التفسيرات المتعلقة بهذه المؤشرات. 5 4 1 الاستنتاجات الرئيسية أبلغت جميع البلدان تقريبا ًوفقا ًلمؤشرات تنظيم تعليم التمريض، وأجابت نسبة زادت على ٪05 من البلدان عن أسئلة تندرج تحت كل مؤشر من المؤشرات التسعة ذات الصلة. وأُبلغ بوجود آليات وعمليات تنظيمية بدرجة مرتفعة في الإقليم الأفريقي وإقليم الأمريكتين والإقليم الأوروبي. وهناك اهتمام أكبر بتنظيم محتويات التعليم (مثل معايير المدة والمحتوى أو آليات اعتماد المؤسسات التعليمية) أكثر من الاهتمام بقيادة التعليم وتصريف شؤونه. وتبدو نظم تعليم التمريض أكثر تنظيما ًفي الإقليم الأوروبي وأقل تنظيما ًفي أقاليم جنوب شرق آسيا وشرق المتوسط وغرب المحيط الهادئ، لاسيما فيما يتعلق بامتحان اللياقة للممارسة ومعايير تأهيل أعضاء هيئة التدريس. 5.4 تنظيم تعليم التمريض وممارسته 94 001% 08% 06% 04% 02% 0% معاییر مدة التعلیم ومحتواه )451 نعم من أصل 961( آلیات اعتماد المؤسسات التعلیمیة )741 نعم من أصل 561( القائمة الرئیسیة التي تضم مؤسسات التعلیم )811 نعم من أصل 641( معاییر مؤھلات أعضاء ھیئة التدریس )67 نعم من أصل 99( التطویر المھني المستمر )69 نعم من أصل 231( معاییر التعلیم المتعدد التخصصات )66 نعم من أصل 99( امتحان اللیاقة للممارسة )37 نعم من أصل 411( الرابطة الوطنیة للطلاب الذین لم یحصلوا بعد ترخیص مزاولة المھنة )55 إجابة بنعم من أصل 98( وجود الأدوار التمریضیة المتقدمة )05 نعم من أصل 59( نسبة البلدان المجیبة بنعم 19% 35% 26% 46% 76% 37% 77% 18% 98% الشكل 5.8 النسبة المئوية للبلدان المجيبة التي أشارت إلى وجود نظم ومعايير في مجال التمريض النسبة المئوية للبلدان المجيبة التي أبلغت بوجود أحكام تنظيمية تتعلق بالتعليم والتدريب في مجال التمريض، حسب إقليم المنظمة الجدول 5.7 أقاليم المنظمة قائمة رئيسية تضم المؤسسات التعليمية المعتمدة معايير لمدة التعليم ومحتواه آليات اعتماد المؤسسات التعليمية معايير التعليم المتعدد التخصصات التطوير المهني المستمر وجود أدوار تمريضية متقدمة امتحان اللياقة للممارسة معايير مؤهلات هيئة التدريس رابطة وطنية للطلاب الذين لم يحصلوا بعد على ترخيص مزاولة المهنة 66%87%86%47%86%18%09%001%19%أفريقيا 19%57%75%55%17%94%49%19%77%الأمريكتان 83%46%27%57%16%06%87%58%96%جنوب شرق آسيا 76%49%46%03%19%78%89%49%58%أوروبا 03%08%07%05%05%02%07%08%08%شرق المتوسط 53%17%65%25%36%25%87%77%07%غرب المحيط الهادئ 26%77%46%35%37%76%98%19%18%العالم المصدر: حسابات القوى العاملة الصحية الوطنية، 9102، وتقرير حالة التمريض في العالم مؤشرات لعام 0202 للعوامل الثلاثة الأخيرة. وأحدث البيانات المتاحة التي أبلغت بها البلدان بين عامي 3102 و8102. حالة التمريض في العالم عام 020205 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض ملحوظة: مع دمج أسئلة كثافة التعليم، يصبح التقييم الخام من صفر إلى 9. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102 وقد اسُتخدمت البيانات الخاصة بالمؤشرات التسعة . 001 لاستخلاص درجة الُمَركَّب "تنظيم التعليم والممارسة" لكل بلد (انظر الملحق 2). ويمكن تسجيل كل مؤشر من صفر (الغياب) إلى 1 (الوجود)، وبقيمة 5.0 للوجود الجزئي؛ مع اعتبار الإجابات المفقودة صفرًا. ثم ُلخصت هذه الدرجات بحد أقصى 9. ونظرًا إلى أن التحليل يعَتِبر ضمنيًا أن الإجابة المفقودة لمؤشر تعطي درجة صفر، فقد ُأجري تحليل حساسية لاستكشاف الآثار المترتبة على تصنيف القيم المفقودة بطريقة مختلفة، وهذا لم يغير تفسير النتائج. ويعزز الشكل 5-9 الاستنتاج الذي مفاده أن وجود آليات تنظيمية ُنِظر فيها هذا التقرير إنما يشير إلى وجود بيئة تنظيمية تعليمية أقوى نسبيًا في أمريكا الشمالية وأوروبا الغربية وأفريقيا جنوب الصحراء الكبرى. 9 8 7 6 5 4 فأقل لا ینطبقلم ُیبلغ عنھا الشكل 5.9 خريطة درجات تنظيم تعليم التمريض، حسب البلد 15 5 5 2 العمليات الجارية في مجال التعليم يلزم تخصيص استثمارات كبيرة للتعليم والتدريب . 101 لتحقيق التناسب مع الاحتياجات الحالية والمتوقعة للنظم الصحية وتلبية الاحتياجات الوطنية ودون الوطنية. وبغية تقييم مدى كفاية العمليات الجارية في مجال . 201 التعليم، ُطلب إلى البلدان الإبلاغ بعدد من خريجي التمريض في آخر سنة متاح عنها بيانات. وإجماًلا، أبلغ 88 بلدًا، نصفها تقريبًا (14) في أوروبا، وفقًا لهذا المؤشر. لذلك، ينبغي تفسير الأرقام "الإجمالية" الواردة في الجدول 5-8 بحذر شديد، إذ إنها منحرفة بفعل البيانات الواردة من إقليم جنوب شرق آسيا والإقليم الأوروبي، ولا تمثل الحالة السائدة في سائر الأقاليم. وعلى غرار الارتباط بكثافة التمريض، كان مستوى . 301 الدخل عامًلا مرتبطًا بزيادة عدد الخريجين لكل 000 001 نسمة. بالمحاكاة المستندة إلى البيانات المتاحة وتطبيقها . 401 على سكان العالم، ستنتج الكثافة الإجمالية، البالغة 6.22 خريجًا لكل 000 001 نسمة، 27.1 مليون خريج تمريض في السنة. وينبغي أن ُينظر إلى هذا التحليل على أنه مجرد مثال توضيحي نابع من عدد صغير من البلدان لكل إقليم، باستثناء الإقليم الأوروبي. ومع ذلك، لم ُتظِهر البيانات، رغم محدوديتها في التغطية، تباينًا كبيرًا في نسبة الخريجين إلى رصيد كادر التمريض. وإضافة إلى ذلك، ُقورنت هذه النتائج المقدرة للرصيد بحصة الفئة العمرية التي تقل عن 53 عامًا، أي القوى العاملة التي بدأت العمل خلال السنوات العشر الماضية تقريبًا. وباستخدام ُعشر هذه الفئة الأصغر سنًا بوصفها مؤشرًا للرصيد الذي يدخل السوق سنويًا، يتبين أن هذا يتوافق مع الرصيد البالغ 60.1 مليون المقرر مقارنته بالتقدير الحالي البالغ 7.1 مليون خريج. ونظرًا إلى عدم التحاق جميع العاملين بالعمل، يبدو ترتيب الحجم معقوًلا. 5 5 1 الاستنتاجات الرئيسية أبلغ ما مجموعه 88 بلدا،ً معظمها من جنوب شرق آسيا وأوروبا، ببيانات عن عدد خريجي القوى العاملة في مجال التمريض سنويا.ً أمَّ ا الأقاليم ذات كثافة كادر التمريض الأدنى (الإقليم الأفريقي وإقليما شرق المتوسط وجنوب شرق آسيا)، فقد سجلت أيضا ًأدنى معدلات التخرج (7 7 و1 7 و2 21 لكل 000 001 نسمة، على التوالي). وسجل إقليم الأمريكتين عددا ًبلغ 01 أضعاف خريجي الإقليم الأفريقي وإقليم شرق المتوسط منسوبا ًإلى عدد سكان تلك الأقاليم. ومن بين البلدان التي أبلغت بالبيانات، كان متوسط مدة التعليم المهني التمريضي في الإقليم الأفريقي وإقليم غرب المحيط الهادئ ما بين سنتين وثلاث سنوات لنحو 57٪ من البلدان، في حين كان ما بين أربع وخمس سنوات لأكثر من نصف البلدان في أقاليم الأمريكتين وجنوب شرق آسيا وشرق المتوسط.وغرب المحيط الهادئ، لاسيما فيما يتعلق بامتحان اللياقة للممارسة ومعايير تأهيل أعضاء هيئة التدريس. 5 5 المعروض من القوى العاملة في مجالي التعليم والتمريض حالة التمريض في العالم عام 020225 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض uzimihS ihsoY/OHW © عدد البلدان الُمَبلِّغة/ الإجمالي متوسط عدد خريجي التمريض لكل 001 فرد تمريض مشتغل بالمهنة عدد الخريجين لكل أعلى مستوى للمعدلأدنى مستوى للمعدلالإجماليحسب أقاليم المنظمة 000 001 نسمة 7.77.328.28.841/74أفريقيا 2.188.038.08.941/53الأمريكتان 2.218.319.35.78/11جنوب شرق آسيا 9.139.130.10.414/35أوروبا 1.75.616.06.45/12شرق المتوسط 6.020.214.37.56/72غرب المحيط الهادئ حسب فئة الدخل 4.019.131.48.318/13البلدان المنخفضة الدخل بلدان الشريحة الدنيا من الدخل المتوسط 8.218.318.27.751/64 بلدان الشريحة العليا من الدخل المتوسط 7.228.036.04.662/06 7.836.75.16.304/75البلدان المرتفعة الدخل 6 229 136 02 688/491المجموع الجدول 5.8 الإنتاج من خريجي التمريض، حسب إقليم المنظمة وفئة الدخل المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. والتقسيم حسب فئة الدخل مأخوذ من تصنيف البنك الدولي حتى عام 8102. 35 5 5 3 مدة التعليم السابق للخدمة وردت من مصادر متنوعة بيانات عن مدة برامج . 501 تعليم التمريض السابق للخدمة بخصوص 751 بلدًا. وهناك عدد قليل من البلدان، تقع بصفة أساسية في الإقليم الأفريقي وإقليمي شرق المتوسط وغرب المحيط الهادئ، لديها برامج مدتها سنتان، في حين أن غالبية البلدان في جميع الأقاليم لديها برامج مدتها ثلاث أو أربع سنوات؛ أمَّ ا البرامج التي مدتها خمس سنوات، فنادرة في مختلف الأقاليم (الشكل 5-01). وفي الإقليم الأفريقي وإقليم غرب المحيط الهادئ، يوجد لدى حوالي ثلاثة أرباع البلدان برامج مدتها ثلاث سنوات، أمَّ ا في إقليم جنوب شرق آسيا، فنحو ثلاثة أرباع البلدان لديها برامج مدتها أربع سنوات. وفي عصر التوسع في مجالات الممارسة . 601 التمريضية، من المهم مراعاة تعليم التمريض خارج إطار التعليم السابق للخدمة، وكذلك المدخلات المتغيرة عبر مسارات الدخول المباشر (بشروط مسبقة محددة). ويتأثر الإبلاغ عن طول مدة برنامج التعليم السابق للخدمة بهذه القيود المتأصلة، مما يحد من قدرة البيانات المقدمة على وصف تعليم كادر التمريض بما يتسم به من تنوع وثراء على مستوى العالم، خاصة فيما يتعلق بأدوار الممارسة المتقدمة. 5 سنوات 4 سنوات 3 سنوات سنتان 001% 08% 06% 04% 02% 0% أفریقیا الأمریكتان شرق المتوسط أوروبا جنوب شرق آسیا غرب المحیط الھادئ أقالیم المنظمة العالم الشكل 5.01 متوسط مدة (سنوات) تعليم أخصائيي التمريض، حسب إقليم المنظمة المصدر: حسابات القوى العاملة الصحية الوطنية، 9102 بشأن 99 بلدًا، وقاعدة بيانات سيغما بشأن 85 بلدًا. وأحدث البيانات المتاحة التي أبلغت بها البلدان بين عامي 3102 و8102. حالة التمريض في العالم عام 020245 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 5 6 2 تحليل النتائج سمات الوظيفة وشروط العمل عاملان رئيسيان . 701 يؤديان إلى زيادة جاذبيتها وزيادة الأداء والإنتاجية واستبقاء القوى العاملة الصحية. وتدعو الاستراتيجية العالمية بشأن الموارد البشرية الصحية: القوى العاملة 0302 إلى الحفاظ على "دعم الحقوق الشخصية والمتعلقة بالعمل والمهنية لجميع العاملين الصحيين، بما في ذلك بيئات العمل المأمونة واللائقة والتحرر من جميع أنواع التمييز والإكراه والعنف". وقد استلزم تقييم هذا البعد دراسة ستة مؤشرات تتعلق بتنظيم سمات الوظيفة وشروط العمل (الشكل 5-11). وتجدر الإشارة إلى أن ثلاثة مؤشرات (تنظيم ساعات العمل وشروطه، ومجلس التمريض، ووجود أدوار تمريضية متقدمة) تخص التمريض وحده: فالباقي ينطبق على القوى العاملة الصحية برمتها، بما يشمل كادر التمريض. ومن بين البلدان المجيبة، أبلغت أكثر من 08٪ بوجود . 801 أحكام تنظيمية تنظم ساعات العمل وشروطه، والحماية الاجتماعية والحد الأدنى للأجور، ولديها مجلس تمريض أو ما يعادله، لكن عددًا أقل منها (35٪) لديه أدوار تمريض متقدمة. وأجاب ما مجموعه 55 بلدًا وفقًا لمؤشر وجود تدابير لمنع الاعتداءات على العاملين الصحيين، التي أفاد أكثر من الثلث بقليل (73٪) بأنها قائمة. ويشير الجدول 5-9 إلى أن بلدانًا في إقليم شرق . 901 المتوسط قد أبلغت بوجود مستويات أعلى للأحكام التنظيمية المتعلقة بتوظيف كادر التمريض مقارنة بما ُنِظر في سبيل إعداد هذا التقرير: فأكثر من 07٪ من البلدان أجابت بنعم وفقًا لجميع المؤشرات الستة. وكان إقليما جنوب شرق آسيا وشرق المتوسط الإقليمين الوحيدين اللذين أبلغت فيهما أغلبية البلدان باتخاذ تدابير لمنع الاعتداءات على العاملين الصحيين، مما يحتمل أن يعكس ارتفاع عدد هذه الاعتداءات نسبيًا في هذين الإقليمين.01 وأجاب الإقليم الأفريقي وإقليم الأمريكيتين والإقليم الأوروبي بنعم وفقًا لمعظم المؤشرات التي جرى تتبعها؛ إلا أن 03٪ فقط من البلدان الأوروبية المجيبة أبلغت بوجود أدوار تمريضية متقدمة، بينما أبلغت 62٪ عن وجود تدابير تستهدف الحيلولة دون وقوع الاعتداءات على العاملين الصحيين. 5 6 1 الاستنتاجات الرئيسية أبلغ الإقليم الأفريقي وإقليم الأمريكتين والإقليم الأوروبي وإقليم شرق المتوسط بمستويات عالية من وجود آليات تنظيمية تتعلق بشروط عمل كادر التمريض. وأبلغت بعض البلدان، معظمها في إقليمي جنوب شرق آسيا وغرب المحيط الهادئ، بل في الإقليم الأفريقي وفي أمريكا الجنوبية أيضا،ً بانخفاض مستويات هذه الأحكام التنظيمية. وأبلغ ما يزيد قليلاً على ثلث البلدان (73٪) بوجود تدابير لمنع الاعتداءات على العاملين الصحيين، معظمهم في إقليمي جنوب شرق آسيا وشرق المتوسط. ووجود دور تمريض متقدم (أبلغت به 35٪ من 59 بلدا ًمجيبة) أكثر شيوعا ًفي البلدان ذات الكثافة المنخفضة للأطباء، مما يشير إلى أن وجود مزيد من الاستقلالية المهنية التي يتمتع بها كادر التمريض قد يكون استجابة سياساتية رامية إلى تقليل درجة النقص في الأطباء. 5.6 الممارسة: تنظيم الوظيفة وشروط العمل 01 نظام ترصد الاعتداءات على مرافق الرعاية الصحية: xpsa.draobhsaDcilbuP/segaPetiS/ass/setis/tni.ohw.ecapscilbup//:sptth. 55 001% 08% 06% 04% 02% 0% 49% 35% 68% 73% 98% 19% أحكام تنظیمیة لساعات وشروط العمل )331 نعم من أصل 241( أحكام تنظیمیة للحمایة الاجتماعیة )521 نعم من أصل 731( أحكام تنظیمیة للحد الأدنى للأجور )911 نعم من أصل 431( إنشاء مجلس لمھنة التمریض )141 نعم من أصل 461( إتاحة أدوار متقدمة في مھنة التمریض )05 نعم من أصل 59( تطبیق تدابیر لحمایة العاملین الصحیین من الاعتداءات )02 نعم من أصل 55( نسبة البلدان المجیبة بنعم أقاليم المنظمة أحكام تنظيمية لساعات العمل وشروطه أحكام تنظيمية للحد الأدنى للأجور أحكام تنظيمية للحماية الاجتماعية تدابير لمنع شن الاعتداءات على العاملين الصحيين وجود أدوار تمريضية متقدمة إنشاء مجلس التمريض 87%47%14%58%09%09%أفريقيا 19%55%73%49%58%79%الأمريكتان 08%05%76%05%05%57%جنوب شرق آسيا 69%03%62%001%29%89%أوروبا 58%57%37%29%001%58%شرق المتوسط 87%25%03%75%68%001%غرب المحيط الهادئ 68%35%73%19%98%49%العالم الشكل 5.11 نسبة البلدان التي لديها أحكام تنظيمية لشروط العمل المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102، والمؤشرات المحددة الخاصة بالعامل الأخير الواردة في تقرير حالة التمريض في العالم لعام 0202. وأحدث البيانات المتاحة التي أبلغت عنها البلدان بين عامي 3102 و8102. النسبة المئوية للبلدان المجيبة التي أبلغت بوجود أحكام تنظيمية تتعلق بالتمريض من حيث شروط العمل، حسب إقليم المنظمة الجدول 5.9 حالة التمريض في العالم عام 020265 ذكرت نسب عالية من البلدان في إقليم غرب المحيط . 011 الهادئ أن لديها أحكاما تنظيمية تتناول ساعات العمل وشروطه والحد الأدنى للأجور، ولديها مجلس التمريض أو ما يعادله. ومع ذلك، أبلغت بانخفاض مستويات وجود آليات التنظيم الثلاث الأخرى. وبلغت إجابات إقليم جنوب شرق آسيا بنعم أدنى مستوى لها وفقًا للمؤشرات التي تقيم البيئة التنظيمية، على الرغم من أن نصف بلدان هذا الإقليم أجابت بنعم وفقًا لكل مؤشر من المؤشرات الستة. وكما ُذكر في الفرع 5-4، قد تعكس هذه الاختلافات بين الأقاليم إلى حد ما تصورات مختلفة لمعنى هذه المؤشرات، وكذلك معدلات الإبلاغ المختلفة في مختلف الأقاليم. والبيانات التي ُجِمعت لا توفر معلومات عن مدى كفاية الأحكام التنظيمية أو مستوى تنفيذ أحكامها ذات الصلة. وقد اسُتخدمت البيانات الخاصة بالمؤشرات التسعة . 111 لاستخلاص درجة الُمَركَّب "تنظيم شروط العمل" لكل بلد باستخدام منهجية مماثلة لتلك المستخدمة في الفرع 5-4، وبالأساليب الموضحة في الملحق 2. ويعزز الشكل 5-21 الاستنتاج الذي مفاده، كما هو الحال فيما بتعلق بالنظام التعليمي الذي ورد تحليله في الفرع 5-4، أن البيئة التنظيمية أقوى نسبيًا، حسبما أبلغ، في أمريكا الشمالية وأفريقيا جنوب الصحراء الكبرى والإقليم الأوروبي. ملحوظة: مع دمج الأسئلة المتعلقة بظروف العمل، يصبح التقييم الخام من صفر إلى 6. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102 الشكل 5.21 خريطة درجات تنظيم تعليم التمريض، حسب البلد 1 أو لا توجد6 5 4 3 2 لا ینطبقلم ُیبلغ عنھا 75الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض وُوجد أن الأدوار التمريضية المتقدمة أكثر تواترًا . 211 في البلدان ذات كثافة الأطباء المنخفضة، كما هو مبين في الشكل 5-31. reetS-notliW rehpotsirhC/NDKA © كثافة الأطباء لكل 000 01 نسمة 08% 06% 04% 02% 0% 5-91 95% 5< 56% 02+ 34% مة قد مت ض ری تم ر وا أد ھا لدی ي الت ن لدا الب % النسبة المئوية للبلدان ذات الدور التمريضي المتقدم حسب مستوى كثافة الأطباء لكل 000 01 نسمة الشكل 5.31 المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. حالة التمريض في العالم عام 020285 5 7 2 تحليل النتائج يتطلب التطور المستقبلي لمهنة التمريض توافر . 311 مهارات قوية في مجالي القيادة وتصريف الشؤون في أوساط كادر التمريض (462، 562). واسُتخدم مؤشران من مؤشرات تقرير حالة التمريض في العالم لعام 0202 لتقييم حالة القيادة تصريف الشؤون في أوساط كادر التمريض، هما: وجود منصب حكومي لرئيس التمريض، ووجود برامج مدعومة وطنيًا لتطوير المهارات القيادية أو مهارات البحث أو الإلمام بمبادئ السياسات في مجال التمريض (أجابت 511 بلدًا و67 بلدًا على التوالي). ومن بين 511 بلدًا مجيبة، أبلغت 17٪ بأن . 411 لديهم منصبًا حكوميًا لرئيس التمريض، وهي تتراوح بين 45٪ في إقليم شرق المتوسط و68٪ في الإقليم الأوروبي (الجدول 5-01). ولم يبلغ سوى عدد أقل من البلدان (35٪ من 67 بلدًا مجيبة) عن وجود برنامج لتطوير المهارات القيادية في مجال التمريض، وهي تتراوح بين 04٪ في إقليم جنوب شرق آسيا و46٪ في الإقليم الأفريقي. وهناك ارتباط لا ُيستهان به بين ما ُأبلغ بوجوده من بيئة . 511 تنظيمية قوية من جهة ومهارات قيادية تمريضية وبيئة تصريف شؤون من الجهة الأخرى. ويوضح الشكل 5-41 أن البلدان التي لديها منصب حكومي لرئيس التمريض وبرنامج لتطوير المهارات القيادية في مجال التمريض حققت، في المتوسط، درجات أعلى في مجال تنظيم شروط العمل لكادر التمريض وتنظيم تعليم التمريض. وعلى الرغم من أن وجود المنصب الحكومي . 611 وبرنامج تطوير المهارات مرتبطان كلاهما بوجود ببيئة تنظيمية قوية، فالارتباط أقوى قليًلا فيما يتعلق ببرامج المهارات القيادية منه فيما يتعلق بالمنصب. وبعبارة أخرى، لا يؤدي وجود منصب تمريض رفيع المستوى داخل الحكومة الوطنية بالضرورة إلى اتخاذ إجراءات مثل استحداث برامج لتطوير المهارات القيادية: ففي الواقع، لم يكن لدى 73٪ من البلدان، التي لديها ذلك المنصب، برامج التطوير. وبغية اختبار فرضية ما إذا كانت مهارات القيادة . 711 وتصريف الشؤون في مجال التمريض يترجمان أيضًا إلى زيادة في الاستثمارات، كما يتضح من تسارع التخرج في التمريض وما يلحق به من توظيف بغية معالجة النقص، قورن معدل الخريجين في البلدان التي توجد فيها تدابير للقيادة وتصريف الشؤون بتلك الموجودة في البلدان التي لا توجد بها تلك التدابير. ولم ُيستبن وجود أي ارتباط ذي دلالة، مما يشير إلى أن تطوير مهارات القيادة وتصريف الشؤون في مجال التمريض لا ُيترجمان بالضرورة إلى تسريع في إنتاج خريجي التمريض. 5 7 1 الاستنتاجات الرئيسية من البلدان المجيبة البالغ عددها 511 بلدا ًو67 بلدا،ً أبلغت ٪17 من الأولى بأن لديهم منصبا ًحكوميا ًهو رئيس التمريض أو القبالة، في حين أبلغت 35٪ من الأخرى بأن لديها برنامجا ًلتطوير المهارات القيادية في مجال التمريض. ووجود منصب لرئيس التمريض في الحكومة وبرنامج لتطوير المهارات القيادية في مجال التمريض مرتبطان كلاهما بوجود بيئة تنظيمية أقوى للتمريض. إلا أن المناصب الحكومية أو برامج تطوير المهارات القيادية لا ترتبط بزيادة معدلات إنتاج كادر التمريض. 5.7 تصريف الشؤون والقيادة 95الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض برنامج تطوير المهارات القيادية في مجال التمريضمنصب رئيس التمريض نسبة الإجابة بنعمعدد البلدان المجيبة/ المجموعنسبة الإجابة بنعمعدد البلدان المجيبة/ المجموعأقاليم المنظمة 46%82/7406%62/74أفريقيا 64%61/5397%62/53الأمريكتان 04%4/1106%6/11جنوب شرق آسيا 65%01/3568%03/35أوروبا 26%8/1245%7/12شرق المتوسط 34%01/7247%02/72غرب المحيط الهادئ 35%67/49117%511/491العالم 0 2 4 6 یوجد برنامج مھارات قیادیة لا یوجد برنامج مھارات قیادیة 0 2 4 6 8 01 یوجد منصب لا یوجد منصب 0 2 4 6 8 01 یوجد منصب لا یوجد منصب 0 2 4 6 8 01 یوجد برنامج مھارات قیادیة لا یوجد برنامج مھارات قیادیة برنامج تطویر المھارات القیادیة في مجال التمریض ض ری لتم ل ا جا م في ل عم ال ف رو ظ جة منصب حكومي لرئیس التمریض در ض ری لتم ل ا جا م في ل عم ال ف رو ظ جة در ض ری لتم ل ا جا م في ل عم ال ف رو ظ جة در ض ری لتم ل ا جا م في ل عم ال ف رو ظ جة در شروط العمل الأحكام التنظیمیة في مجال التعلیم منصب حكومي لرئیس التمریض برنامج تطویر المھارات القیادیة في مجال التمریض 100.0< P )اختبار كروشال-والیس(700.0 = P )اختبار كروشال-والیس( 100.0< P )اختبار كروشال-والیس(800.0 = P )اختبار كروشال-والیس( الارتباط بين منصب رئيس التمريض في الحكومة وبرنامج تطوير المهارات القيادية في مجال التمريض من جهة والبيئة التنظيمية من الجهة الأخرى الشكل 5.41 مؤشرا القيادة وتصريف الشؤون: النسبة المئوية للبلدان التي لديها منصب لرئيس التمريض وبرنامج لتطوير المهارات القيادية في مجال التمريض، حسب إقليم المنظمة الجدول 5.01 المصدر: مؤشرات عام 9102 الخاصة بتقرير حالة التمريض في العالم لعام 0202. وأحدث البيانات المتاحة التي أبلغت بها البلدان بين عامي 3102 و8102. المصدر: حالة التمريض في العالم، 0202، المؤشرات المحددة، 9102. حالة التمريض في العالم عام 020206 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض وستحتاج الدول الأعضاء في منظمة الصحة العالمية . 811 في إطار السعي إلى تحقيق أهداف التنمية المستدامة ذات الصلة بالصحة، إلى تعليم عدد كاٍف من كادر التمريض من أجل ما يلي: (أ) التعويض عن الخسائر المتكبدة في المهنة (بسبب الوفاة أو الهجرة أو التقاعد، على سبيل المثال)؛ (ب) تلبية الطلب المتزايد في أجزاء كثيرة من العالم بسبب النمو السكاني والشيخوخة وتغيير احتياجات الرعاية الصحية؛ (ج) سد النقص العالمي الحالي. 5 8 2 توقعات رصيد كادر التمريض وكثافته حتى عام 0302 ابتكر نموذج "الرصيد والتدفق" الأساسي لكل . 911 بلد، باحتساب العاملين في مجال التمريض حاليًا، ومعدل التقاعد الُمقدَّر (على أساس التوزيع العمري للقوى العاملة في مجال التمريض)، والنمو السكاني، والافتراضات المتعلقة بدخول سوق العمل (انظر الملحق 2 للاطلاع على بيان للسيناريوهات). ووفقًا للاتجاهات الحالية، من المتوقع أن يزيد عدد أفراد كادر التمريض من 9.72 مليون ممرض وممرضة في عام 8102 إلى 9.53 مليون ممرض وممرضة في عام 0302. وسوف تتركز الزيادة المتوقع حدوثها في موعد . 021 غايته عام 0302 في البلدان المرتفعة الدخل، إلى جانب نمو محدود للغاية في البلدان المنخفضة الدخل (الشكل 5-51). ومن المتوقع أن تستمر التباينات الموثقة في عام 8102 (انظر الفرع 5-2) دون توقف إلى حد كبير حتى عام 0302. 5 8 1 الاستنتاجات الرئيسية تفيد تقديراتنا أن النقص يبلغ 9 5 ملايين ممرض وممرضة مقارنة ببيانات عام 8102 حسب القيم المرجعية المحددة في الاستراتيجية العالمية بشأن الموارد البشرية الصحية؛ حيث تتركز معظم الفجوات (98٪) في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط. وإذا حافظت جميع البلدان على مستوى إنتاجها الحالي من أفراد كادر التمريض الخريجين، فمن المتوقع أن يرتفع عدد العاملين في مجال التمريض من حوالي 82 مليونا ًفي عام 8102 إلى حوالي 63 مليونا ًفي عام 0302؛ ومع ذلك، من المتوقع أن تحدث نسبة تبلغ 07٪ من هذه الزيادة المتوقعة في البلدان المتوسطة الدخل والبلدان المرتفعة الدخل وحيث لا توجد أوسع فجوات. ومع احتساب النمو السكاني المتوقع وشيخوخة القوى العاملة في مجال التمريض، من المتوقع أن تظل الكثافة في الإقليم الأفريقي وإقليمي جنوب شرق آسيا وشرق المتوسط في عام 0302 أقل من 52 ممرضا/ً ممرضة لكل 000 01 نسمة. ومن المتوقع ألاَّ تتحسن الكثافة في الإقليم الأفريقي إلاَّ تحسنا ًهامشيا.ً وتستلزم معالجة النقص في أفراد كادر التمريض في البلدان المنخفضة الكثافة زيادة متوسط عدد من يتخرجون سنويا ً بنسبة 8 8٪ في الفترة من عام 8102 إلى عام 0302 (المدى: 2 0-4 31٪)، وتحسين قدرة الاستيعاب إلى 07٪ على الأقل. وقد يكلف رفع مستوى تعليم كادر التمريض من أجل سد الفجوات ما يقرب من 01 دولارات أمريكية للفرد الواحد للفترة 8102-0302 في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط المتضررة. 5 8 تقييم المسار المتجه حاليا ًصوب تحقيق حصائل أهداف التنمية المستدامة لعام 0302 16 ومسار نمو الرصيد المتوقع لا يكفي لتلبية . 121 الاحتياجات تلبية كاملة، خاصًة في الإقليم الأفريقي، حيث يتوقع أن يبلغ النمو السكاني 43٪. وكذلك، من المتوقع ألاَّ يشهد إقليم شرق المتوسط إلا زيادات هامشية في رصيد أفراد كادر التمريض (الجدول 5-11). ُأجريت التوقعات بافتراضات وسيناريوهات مختلفة، . 221 مع الاعتماد على توافر البيانات وجودتها إزاء العوامل المستخدمة في التحليل. وترد مناقشة القيود المحتملة في الملحق 2. وفي المقابل، من المتوقع أن يزداد الرصيد المتوافر . 321 من كادر التمريض زيادة كبيرة في أقاليم الأمريكتين وجنوب شرق آسيا وغرب المحيط الهادئ. وعند أخذ التجميع حسب مستوى الدخل في الحسبان، ُيتوقع تحقيق نسبة تبلغ 88٪ من الزيادة في الرصيد في البلدان المتوسطة الدخل (الشكل 5-61). 5 8 3 النقص في القوى العاملة في مجال التمريض قدرت الاستراتيجية العالمية بشأن الموارد البشرية . 421 الصحية الصادرة في عام 6102 أنه بحلول عام 0302 سيكون هناك نقص عالمي قدره 6.7 ملايين فرد في كادري التمريض والقبالة في البلدان التي تقل الكثافة فيها عن 54.4 أفراد من كوادر الطب والتمريض والقبالة لكل 000 1 نسمة؛ واستبعدت هذه القيمة المبدئية معظم البلدان المرتفعة الدخل. وباعتماد المنهجية والقيم المرجعية نفسها، ولكن باستخدام بيانات أحدث، ُقدِّر أن عام 8102 قد شهد نقصًا بلغ 9.5 ملايين ممرض وممرضة، وسيبلغ 7.5 ملايين بحلول عام 0302. والبلدان التي تستأثر بأكبر درجة من النقص (من حيث العدد) في عام 8102 تضم بنغلاديش والهند وإندونيسيا ونيجيريا وباكستان. ويرتبط مستوى الدخل ارتباطًا قويًا بالنقص في القوى العاملة في مجال التمريض (الملحق 2، الجدول (أ)2-2)، حيث تتركز نسبة تبلغ 98٪ من الفجوات في عام 8102 ۰٥٥۰۰٤,٤ ۰۰۳,۳ ۰۰۲,۲ ۰۰۱,۱ ۰ mk 01 فأقل+001 57 إلى 99 05 إلى 47 04 إلى 94 03 إلى 93 02 إلى 92 01 إلى 91 لا ینطبقلم ُیبلغ عنھا الشكل 5.51 توقعات كثافة أفراد كادر التمريض لكل 000 01 نسمة في عام 0302 (التوزيع العالمي) ملحوظة: يشمل مصطلح "أفراد كادر التمريض" أخصائيي التمريض ومعاونيهم. حالة التمريض في العالم عام 020226 الزيادة المتوقعة (حتى عام 0302) في رصيد كادر التمريض، حسب إقليم المنظمة وفئة الدخل القطرية الشكل 5.61 الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض الرصيد الملحوظ في عام 8102 (بالملايين) الرصيد المتوقع حتى عام 0302 (بالملايين) أقاليم المنظمة السيناريو 1: الشيخوخة واستقرار الفئة العمرية للشباب السيناريو 2: الشيخوخة والتخرج حتى السنوات الأخيرة السيناريو 3: الشيخوخة والتخرج بنسبة ٪05 بحلول عام 0302 0.25.12.19.0أفريقيا 7.714.212.94.8الأمريكتان 1.60.57.43.3جنوب شرق آسيا 4.010.86.83.7أوروبا 7.15.19.11.1شرق المتوسط 2.110.93.019.6غرب المحيط الهادئ 3 944 739 539 72العالم محاكاة الرصيد المتوقع لأفراد كادر التمريض من عام 8102 إلى عام 0302 وفقا ًلثلاثة سيناريوهات، حسب إقليم المنظمة الجدول 5.11 ملحوظة: التقسيم حسب فئة الدخل مأخوذ من تصنيف البنك الدولي حتى عام 8102. الشریحة الدنیا من الدخل المتوسط %72 الشریحة العلیا من الدخل المتوسط 16% الدخل المرتفع 6% الدخل المنخفض 6% الأمریكتان 34% أوروبا 7% أفریقیا 6% شرق المتوسط 4% غرب المحیط الھادئ 22% جنوب شرق آسیا 81% CIBARA حسب الدخل حسب الإقليم 36 في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط. ويمكن مقارنة هذا التقدير بنتائج الاستراتيجية . 521 العالمية الصادرة في عام 6102 عن طريق تصحيح التقدير السابق لعرض النقص في كادر التمريض دون غيره (أي باستثناء عنصر القبالة) ولاحتساب تحسُّ ن البيانات (الشكل 5-71). وُقدِّر النقص بالنظر إلى القيمة المرجعية المستخدمة . 621 في الاستراتيجية العالمية. وعلى هذا النحو، ُتستبعد جميع البلدان الموجودة فوق المؤشر من هذا التقدير. وهذا لا يعني أن البلدان التي فوق المستوى المرجعي لا تعاني من نقص في عدد أفراد كادر التمريض. فمعظمها، في الواقع، يعاني من مستوى لا ُيستهان به من النقص المحدد مقابل غايات تقديم الخدمات المحددة وطنيًا وتشكيل المكونات التي يتألف منها النظام الصحي. وفيما يتعلق بتلك البلدان، ينبغي إجراء تقديرات محددة للنقص. وينبغي أن تطبق تلك البلدان المنهجيات التي تحتسب شيخوخة السكان والقوى العاملة، وتغيير الأنماط الوبائية، وتنفيذ استراتيجيات الاستبقاء، وديناميات سوق العمل الأخرى. فعلى سبيل المثال، خلص تحليل قائم على الاحتياجات السكانية المحددة وطنيًا ومتطلبات النظام الصحي إلى احتمال وجود نقص يصل إلى 2.3 ملايين ممرض في 13 بلدًا من دول منظمة التعاون والتنمية في الميدان الاقتصادي المرتفعة الدخل حتى عام 0302 (662). وُأبلغ عن تقديرات مماثلة للنقص المستقبلي في كادر التمريض في اليابان (000 072 فرد تمريض بحلول عام 5202) (762)، وألمانيا (حوالي 000 005 عامل صحي بحلول عام 0302، وخاصة العاملين وأفراد كادر التمريض العاملين في مجال رعاية المسنين) (862)، والمملكة المتحدة (نقص يفوق 000 801 ممرض وممرضة بحلول عام 0302) (962)، وغير ذلك. الشكل 5.71 تقدير النقص في القوى العاملة في مجال التمريض في الأعوام 3102 و8102 و0302 عوامل التصحيح المستخدمة: 1. حذف حصة القابلات من مجموع رصيد العاملين في التمريض والقبالة الوارد في الاستراتيجية العالمية باستخدام بيانات أحدث (%09 من الممرضات من مجموع الممرضات + القابلات). 2. ُأدخل تصحيح لتحسين البيانات، مما أّدى إلى تقديرات أعلى لمجموع العاملين ونسبة نقص أقل: 4.4 مليون ممرض وممرضة من أصل 8.72 مليون في عام 8102، نتيجة تحسين البيانات مقارنة بما جاء في الاستراتيجية العالمية. ملحوظة: ُيقدَّر النقص بمقارنة رصيد كادر التمريض في كل بلد في كل عام بالكثافة المرجعية. المصدر: الاستراتيجية العالمية بشأن الموارد البشرية الصحية لعام 6102 وتقرير حالة التمريض في العالم لعام 0202 على المستوى العالمي. ويتماشى التقدير الوارد في تقرير حالة التمريض في العالم لعام 0202 للنقص المتوقع في مجال التمريض بحلول عام 0302، متى استمرت الاتجاهات الحالية، مع التقدير الوارد في الاستراتيجية العالمية (7.5 ملايين ممرض وممرضة مقابل 6.5 ملايين ممرض وممرضة). استراتيجية عام 6102 تقرير حالة التمريض لعام 0202 6.7 ملايين فرد في كادر التمريض والقبالة 9.6 ملايين ممرض وممرضة تقدير متسق للنقص 5.6 ملايين ممرض وممرضة المقدر حدوثه بحلول عام 0302 1 التصحيح للتمريض فقط 2 التصحيح للبيانات المحسنة 9.5 ملايين ممرض وممرضة 7.5 ملايين ممرض وممرضة 030281023102 9 ملايين فرد في كادر التمريض والقبالة 2.8 ملايين ممرض وممرضة 6.6 ملايين ممرض وممرضة حالة التمريض في العالم عام 020246 5 8 4 الإنتاج والتكلفة اللازمان لسد النقص في كادر التمريض بحلول عام 0302 ُقدِّرت الزيادة المطلوبة في التخرج والوظائف . 721 اللازمة لسد النقص بالكامل بحلول عام 0302 بفرضيات مختلفة. ووفقًا للاتجاهات الحالية، سيتطلب الأمر تحقيق زيادًة بمعدل 01٪ تقريبًا في السنة في عدد الخريجين (الذين تتراوح نسبتهم بين 5.1٪ و9.41٪). وإذا تحسنت قدرة سوق العمل على استيعاب خريجي التمريض، باستخدام معدل استيعاب يبلغ 07٪ من الخريجين في سوق العمل، فإن متوسط الزيادة السنوية في الخريجين اللازمة لسد الفجوة سيبلغ ٪8.8 (تتراوح النسبة بين 2.0٪ و4.31٪). وفي إطار سيناريو يتضمن حدوث زيادة أخرى في تحسن قدرة سوق العمل على الاستيعاب (08٪ من الخريجين)، سيكون متوسط الزيادة المطلوبة في معدل التخرج 1.8٪ سنويًا (من 30.0٪ إلى 2.21٪) لسد النقص في كادر التمريض بحلول عام 0302. وبغية تقدير الاستثمار المطلوب لمعالجة النقص . 821 معالجة تامة بحلول عام 0302، ُضِرب العدد الإضافي لأفراد كادر التمريض (المتوقع في إطار سيناريو توظيف 08٪ من الخريجين) من عام 8102 إلى عام 0302 لكل بلد في متوسط تكلفة تدريب كل فرد (072). وبناء على المؤلفات المنشورة وغير المنشورة التي تتناول تكاليف التعليم في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط، اسُتخدمت ثلاثة افتراضات مختلفة لحساب متوسط تكلفة التدريب لكل ممرض/ ممرضة: 000 5 دولار أمريكي و000 01 دولار أمريكي و000 02 دولار أمريكي (172). وبلغت الاستثمارات المطلوبة لتدريب أفراد كادر تمريض إضافيين لمعالجة النقص معالجة تامة، على التوالي، 2.5 دولارات أمريكية و5.01 دولارات أمريكية و12 دولارًا أمريكيًا للفرد في المتوسط.11 وبالنظر إلى الحساسية التحليلية للافتراضات المقدمة وقلة البينات، قد يكون من المعقول اعتماد تقدير مركزي يبلغ نحو 01 دولارات أمريكية للفرد الواحد لوضع عمليات محاكاة توضيحية. الوضع الحالي للبينات والبيانات المتعلقة بالقوى العاملة في مجال التمريض 11 تشكل الأرقام المقتبسة استثمارًا لمرة واحدة في البلدان التي تعاني من نقص في تغطية تدريب جميع الخريجين. 56 uzimihS ihsoY/OHW © حالة التمريض في العالم عام 020266 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض توفر البينات المقدمة في هذا التقرير، بناء على كل . 921 من الأطر الحالية والمؤلفات المنشورة (الفصول 2 و3 و4) وتحليل الوضع الحالي للقوى العاملة التمريضية (الفصل 5)، حجًة دامغًة على ضرورة إحداث تغيير جذري في طريقة تعليم القوى العاملة في مجال التمريض ونشرها على مراكز العمل وإدارتها ودعمها، في إطار سياسات القوى العاملة الصحية والنظام الصحي الأوسع نطاقًا. وستكون الاستثمارات المطلوبة كبيرة، ولكن ستكون . 031 العائدات التي تجنيها المجتمعات والاقتصادات منها أكبر من حيث تحسين الحصائل الصحية لمئات الملايين من الناس، وإيجاد الملايين من فرص العمل الذي يشترط فيه توافر المؤهلات، خاصًة للنساء والشباب، وتعزيز الأمن الصحي العالمي. ويتطلب تسخير هذه الإمكانات بذل جهود متضافرة . 131 تشمل قطاعات مختلفة على المستويات المحلية والوطنية والعالمية. وفي هذا الفصل، نناقش بدورنا الاستنتاجات الرئيسية الناشئة عن الخطاب العالمي والبينات المحددة المجمعة في سبيل إعداد هذا التقرير؛ وعلى هذا الأساس، نرسم الخطوط العريضة للإجراءات اللازمة لتحفيز الاستثمارات المستدامة، وبناء القدرات المؤسسية، وتحفيز العمل السياساتي اللازم لدعم القوى العاملة في مجال التمريض المناِسبة للغرض والمناِسبة للممارسة. وهذه الخيارات السياساتية موجهة إلى كل من . 231 الدول الأعضاء، وإلى أصحاب المصلحة الآخرين عند الاقتضاء. وينبغي أن تنظر البلدان في قابليتها للتطبيق وأهميتها على أساس كل حالة على حدة، وهذا يتوقف على أغراض نظامها الصحي وظروفها الأساسية وقدرتها التنفيذية. الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض 6 الفصل 76 الإطار 6.1 تحليل سوق العمالة الصحية في اسكتلندا في كانون الأول/ ديسمبر 9102، أعلنت حكومة اسكتلندا عن خطة متكاملة للقوى العاملة في مجالي الرعاية الصحية والخدمات الاجتماعية لاسكتلندا (272). وتتضمن الخطة رؤية لتمكين الناس من البقاء في المنزل بدلا ًمن الإقامة في المستشفى. ومع ذلك، يتطلب التنفيذ زيادة في عدد أفراد كادر التمريض في كل مقاطعة. واستخدمت الحكومة الاسكتلندية بيانات واردة من شعبة خدمات المعلومات في دائرة الصحة الوطنية في اسكتلندا، لوضع سيناريوهات ذات نماذج محددة لعدد طلاب التمريض الإضافيين المطلوبين. وقد نظرت الحكومة أيضا ًفي المعروض من المهن الصحية الأخرى والنقص فيها، وكيفية تأثير النقص على الرعاية التي يجب تقديمها، وكيف يمكن معالجة ذلك. وأُطلِعت المجموعة المرجعية لمدارس التمريض والقبالة وأصحاب المصلحة الآخرين على البيانات والاستنتاجات. وأدى هذا الحوار إلى اتخاذ قرارات لاتباع نهج استباقي في تدريب كادر التمريض في المقاطعات، وزيادة الاستثمار في تعليم كادر التمريض وتدريبه في المقاطعات، ودراسة ترتيبات التوظيف التي تسمح لكادر التمريض العامل بالفعل بتلقي هذا التعليم والتدريب. ويمثل هذا أول محاولة للحكومة لمعالجة قضايا القوى العاملة الصحية والاجتماعية بطريقة متكاملة على المستوى الوطني والانتقال من التخطيط لمهنة واحدة إلى التخطيط للرعاية التي تقدمها أفرقة رعاية متعددة التخصصات. 6 1 تعزيز قاعدة البينات من أجل التخطيط والرصد والمساءلة مستخلص النتائج يمثل تقرير حالة التمريض في العالم لعام 0202 . 331 أشمل البيانات والبينات العالمية الخاصة بالتمريض. ففي حين أن 08٪ من البلدان أبلغت وفقًا لـ 51 مؤشرًا على الأقل، فإن الفجوات التي انُتهي إلى وجودها في البيانات تعكس القدرة المتفاوتة لنظم معلومات القوى العاملة الصحية بالبلدان، وتمثل فرصًا ثمينة ينبغي اغتنامها لتركيز الاهتمام على ُسبل المضي قدمًا. وقد بلغ توافر البيانات أعلى مستوى له حسب . 431 مؤشرات من قبيل رصيد القوى العاملة في مجال التمريض المشتغلة بالمهنة وتكوينها العمري (191 و231 بلدًا على التوالي)، لكن الإبلاغ وفقًا للمؤشرات المتعلقة بالتعليم والتمويل وتدفقات سوق العمالة الصحية كان أقل كثيرًا، مما أضعف القدرة على إجراء تحليلات صحية شاملة للسوق. فعلى سبيل المثال، الاقتصار على معرفة بيانات الرصيد دون فهم القدرة الإنتاجية ومعدلات الشغور والبطالة والخروج من الخدمة من حيث الكم قد تجعل راسمي السياسات غير متأكدين هل ينبغي زيادة الإنتاج أم هو كاٍف بالفعل. وينبغي أن يعرف راسمو السياسات والمخططون ما إذا كان إنتاج قطاع التعليم والاستيعاب في سوق العمالة الصحية متكافئين أم يؤديان إلى أي شكل من أشكال عدم التوازن (النقص في مقابل البطالة) (انظر الإطار 6-1 في سوق العمالة الصحية في اسكتلندا). حالة التمريض في العالم عام 020286 وتشمل العوامل التي تؤثر على توافر البيانات وقدرة . 531 البلدان على الإبلاغ وفقا لهذه المؤشرات مستوى التنسيق بين وزارات الصحة والعمل والتعليم والمالية، إضافًة إلى العمل مع سائر أصحاب المصلحة، مثل الرابطات المهنية والمجالس والمؤسسات التعليمية. الخيارات السياساتية ينبغي للبلدان أن تسرع في تنفيذ حسابات القوى . 631 العاملة الصحية الوطنية لديها، بما يشمل إصدار التقارير المفصلة عن القوى العاملة التمريضية. وسد الفجوات الكائنة في عناصر البيانات الأساسية من أجل إجراء تحليلات وطنية لسوق العمالة الصحية مسألة لها أهمية خاصة. وينبغي تحقيق ذلك من خلال بذل جهد شامل لتعزيز وبناء قدرات الموارد البشرية في نظام المعلومات الصحية (372). وقد أمكن وصف القوى العاملة في مجال التمريض عالميًا بفضل الجهود العالمية التي ُبِذلت لتنفيذ الحسابات والالتزام بتنويع مصادر البيانات. وقد يستلزم بناء القدرات المؤسسية للموارد البشرية في نظم المعلومات الصحية إنشاء آليات دائمة لجمع أصحاب المصلحة، بما في ذلك قادة التمريض، وإنشاء آليات واضحة لجمع البيانات وتبادلها، ومناقشة توافر البيانات والجودة والتحديات، وتنفيذ نظم البيانات القابلة للاستعمال المتعدد بين أكثر من جهة. وقد يوفر التنسيق بين مختلف القطاعات وأصحاب المصلحة أيضًا فرصًا لإضفاء الطابع الرسمي على التكليف السياسي بجمع البيانات وتقاسمها، ولإجراء حوار في مجال السياسات بين القطاعات لترجمة البيانات إلى تغييرات سياسية ذات جدوى. وينبغي للبلدان الاستفادة من تحسين بيانات القوى العاملة في مجال التمريض والصحة لإدراجها في تحليلات سوق العمالة الصحية كي ُيسترشد بها في اتخاذ القرارات المتعلقة بالسياسات والاستثمار على المستوى الوطني (انظر الإطار 6-2 الذي يتناول أفرقة القيادة التمريضية التي تستخدم مؤشرات الحسابات لتحليل سوق العمل في مجال التمريض). 6 2 التنقل والهجرة مستخلص النتائج يزاول نحو 7.3 ملايين ممرض وممرضة (أو واحد . 731 من بين كل ثمانية) المهنة في بلدان أخرى غير تلك التي ُولدوا أو تدربوا فيها على التمريض. وتشير الاستنتاجات إلى ارتفاع درجة تنقل كادر التمريض على المستوى الدولي مدفوعًا بالاعتماد القوي على كادر التمريض من المهاجرين في البلدان ذات الإنتاج المحلي المنخفض. ويمكن للطلب الوارد من البلدان المرتفعة الدخل (حيث أبلغ أن أكثر من 51٪ من كادر التمريض مولودون أو مدربون في الخارج) أن يجذب أكثر أفراد كادر التمريض تأهيًلا من البلدان ذات الدخل الأقل وأن يوسع الفجوة الكائنة في الجودة والتوزيع التي تضر بصحة السكان (انظر الإطار 6-3 الذي يتناول نهج ألمانيا في إدارة الهجرة). ويمكن تفسير ارتفاع مستويات الهجرة الخارجية . 831 (عندما لا تكون نتيجًة لسياسة متعمدة لتصدير القوى العاملة في مجال التمريض إلى الخارج) على أنها أحد أعراض عدم جاذبية شروط العمل في الوطن. ولذلك، ينبغي أن تركز الوصفة السياسية على معالجة الأسباب الكامنة (من حيث تحسين بيئة العمل ونظم الدعم والأجور)، بدًلا من محاولة معالجة ظاهرة الهجرة بمعزل عن غيرها. وكذلك، يجب، في إعداد كادر التمريض، إيجاد توازن مناسب بين المهارات والكفاءات اللازمة لإعداد كادر التمريض للعمل في بيئته المحلية وفي الرعاية الأولية من جهة، ورغبة الطلاب في اكتساب المهارات التي تتيح لهم زيادة فرص الدخل إلى أقصى حد والهجرة للعمل في بيئة مهنية أكثر تخصصًا أو أخرى عالمية من الجهة الأخرى. فمع تزايد أعداد أفراد كادر التمريض المهاجرين . 931 تزايدًا كبيرًا، يصبح النهج المعتاد لوضع حلول لحماية الجمهور في منطقة واحدة بعينها غير كاٍف، كما أن النظم التي تخضع للإصلاح يلزم أن توفر الحلول الإقليمية والعالمية وتعززها (542، 872، 972). وعلاوة على ذلك، نظرًا إلى أن العديد من البلدان 96الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض الإطار 6.2 الجماعة الصحية لشرق أفريقيا ووسطها وجنوبها: التعاون الوطني في الإبلاغ ببيانات التمريض باستخدام مؤشرات حسابات القوى العاملة الصحية الوطنية الجماعة الصحية لشرق أفريقيا ووسطها وجنوبها منظمة صحية حكومية دولية تعمل على تعزيز التعاون الإقليمي في مجال الصحة وتشجيعه (472). فالنقص في كادر التمريض شائع في المنطقة دون الإقليمية. ويساهم سوء شروط العمل وارتفاع عدد الحالات في عدم وجود حوافز لكادر التمريض لدخول سوق العمل وارتفاع مستويات الهجرة إلى الخارج. وغالبا ًما يعوق نظَم التعليم التي تتسم بالتجزؤ عدُم كفاية قدرات أعضاء هيئة التدريس والقدرات التنظيمية، مما يؤدي إلى محدودية القدرة على تدريب عدد كاٍف من أفراد كادر التمريض ذوي المهارة. وقد تعاونت مجموعة البنك الدولي مع مؤسسة جبيجو، والمجلس الدولي للممرضين والممرضات، وكلية التمريض في شرق أفريقيا ووسطها وجنوبها على إجراء دراسة لتقييم سوقي العمل في مجالي التمريض وتدريسه. وكان الغرض هو تقدير حجم التحديات في هذه النظم وتحديد السياسات اللازم رسمها لتوسيع نطاق تعليم التمريض في المنطقة من خلال الاستثمارات العامة والخاصة المحددة الأهداف. وقد تناولت الدراسة كيف توسط سوق عمل كادر التمريض في التفاعل بين نظام التعليم والنظام الصحي، مع وضع التحديات التنظيمية وتصريف الشؤون في الاعتبار. وكانت البيانات التي ُجِمعت عبارة عن مؤشرات من الحسابات التي وضعتها منظمة الصحة العالمية (372) علاوة على بيانات نوعية إضافية ُجِمعت خلال المشاورات الإقليمية. وكانت الأفرقة القطرية التي تنسق الإبلاغ بالبيانات لأغراض إجراء الدراسة عبارة عن "رباعي" مؤلف من قيادات التمريض الوطنية مصحوب بالدعم الإضافي المقدم من المنظمة في عملية الاستعراض (انظر أيضا ًالفرع 6-3-3). وكشفت النتائج عن عدم توازن السوق، وعن اختلال شديد في الطلب على كادر التمريض والمعروض منه في المنطقة دون الإقليمية. ولئن زاد المعروض من كادر التمريض بوتيرة أسرع من وتيرة الزيادة السكانية على مدى السنوات العشر الماضية، فإنه يأتي مصحوبا ًبانخفاض معدلات استيعاب كادر التمريض في وظائف القطاع العام (غالبا ًبسبب أوجه القصور في التوظيف أو شروط العمل غير المرغوب فيها) في العديد من البلدان، والنقص الكبير في تلبية الاحتياجات. وقد قدَّ ر تحليل التوقعات أن الطلب الفعال سيزيد بنسبة 33٪ بين عامي 9102 و9302، لكنه لايزال يترك فائضا ًيفوق 022 000 ممرضة لم يكن القطاعان العام والخاص قادريِن على تلبيته. وفي المقابل، ُيقدَّ ر النقص في تلبية الاحتياجات بنحو 000 148 ممرض وممرضة بحلول عام 0302، مما يوسع من نطاق الاختلالات الحالية في سوق العمل في مجال التمريض. وخلصت الدراسة إلى أن زيادة المعروض من كادر التمريض لتحقيق أهداف التنمية المستدامة في بلدان شرق أفريقيا ووسطها وجنوبها سوف يتطلب رفع مستوى تعليم التمريض، وتحسين جودة مدارس التمريض (بما يشمل تطبيق آليات ضمان الجودة)، وزيادة الموارد اللازمة لاستيعاب كادر التمريض في سوقي العمل المحلية والإقليمية. ويمكن تسهيل ذلك من خلال الاستثمارات الكافية في الموارد المادية والبشرية وتصريف شؤون التمريض والتنظيم وإنتاج البيانات والقدرات التحليلية لتمكين البلدان من رصد تأثير الاستثمارات. حالة التمريض في العالم عام 020207 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض الإطار 6.3 نهج ألمانيا في إدارة الهجرة في 9 تشرين الثاني/ نوفمبر 8102، أصدر البرلمان الألماني قانون تعزيز الرعاية، الذي يهدف إلى زيادة انجذاب العاملين وموظفي الرعاية في المستشفيات والمنازل السكنية للرعاية الصحية والرعاية الطويلة الأجل (572). وكان تحسين عدد الموظفين في هذه المرافق هو جوهر السياسة الصحية للحكومة الجديدة. فلطالما عانت الرعاية الصحية والرعاية الطويلة الأجل على مدى سنوات عديدة من نقص حاد في عدد أفراد كادر التمريض، مع انتشار النقص في العاملين فيهما على نطاق واسع في المستشفيات والمنازل السكنية. وكانت أعداد المهنيين الذين يتركون الخدمة الصحية بسبب التقاعد وعدم الرضاء عن العمل أكبر من الأعداد التي تدخل سوق العمل بعد التخرج في برامج التدريب المهني. وعلاوة على ذلك، كان من المتوقع أن يؤدي النقص في عدد الموظفين إلى تدهور شروط العمل للموظفين وتدني جودة الرعاية. وفي عام 2102، صدرت توقعات مفادها أن ألمانيا ستعاني من نقص في الرعاية التمريضية يتراوح بين 000 362 و000 005 فرد بحلول عام 0302 (672). وقد اعتمدت ألمانيا، في محاولة منها للحد من النقص في عدد الموظفين، استراتيجية متعددة الجوانب تشمل رفع مستوى التعليم، وإيجاد وظائف جديدة للتمريض، وتحسين توظيف العاملين الصحيين المهاجرين على المستوى الدولي، مثل استقدام كادر التمريض من وسط أوروبا وجنوب شرقها (772). وفيما يتعلق بهذا العنصر الأخير، اتخذت ألمانيا خطوات لتسخير الفرص لتحقيق منافع متبادلة مع دول المنشأ من تنقل العاملين الصحيين على الصعيد الدولي، بوسائل منها التعاون التقني والاتفاقيات الثنائية التي توِجد فرص التدريب والاستثمار في بلد المنشأ (861) هي بلدان منشأ ومقصد في الوقت نفسه، فلا غنى عن تحسين فهم أنماط الحركة من أجل إدارة التنقل بفعالية وتخطيط متطلبات القوى العاملة الصحية في المستقبل. ومع ذلك، لم ُتبلِّغ بالنسبة المئوية لكادر التمريض المولودين بالخارج أو المدربين في الخارج في القوى العاملة إلا 68 دولة عضوًا، وهو أحد متطلبات الإبلاغ الأساسية المنصوص عليها في مدونة المنظمة العالمية لقواعد الممارسة بشأن توظيف العاملين الصحيين على المستوى الدولي. الخيارات السياساتية ينبغي للبلدان والهيئات التنظيمية تعزيز تنفيذ . 041 الأحكام التنظيمية التي تنظم تنقل العاملين الصحيين على المستوى الدولي، بما في ذلك القوى العاملة في مجال التمريض. ويتعين على الهيئات التنظيمية في بلدان المقصد إثبات أن إعداد كادر التمريض وتأهيله وسجله الانضباطي تلبي جميعًا متطلبات الترخيص المطلوب والمعايير التعليمية والأخلاقية ومدونات قواعد السلوك، من أجل حماية الجمهور. ويمكن أن تسهل النماذج المعززة لتنظيم التنقل من خلال تحقيق المواءمة بين متطلبات الالتحاق ببرنامج التمريض والمحتوى التعليمي المطلوب للحصول على اعتماد مزاولة المهنة واستبقاء كادر التمريض. وتوفر الخبرات الإقليمية المتعلقة بإبرام اتفاقات الاعتراف المتبادل بمؤهلات التمريض المهنية أساسًا يمكن البناء عليه لإبرام اتفاقيات أوسع نطاقًا في المستقبل. ينبغي للبلدان وأصحاب المصلحة الدوليين تعزيز . 141 تنفيذ مدونة الممارسات العالمية التي وضعتها المنظمة. وقد تتطلب القدرة على رصد تنقل القوى العاملة التمريضية على المستوى الدولي والتحكم فيه وتنظيمه بفعالية بناَء القدرات والاستفادَة من الشراكات والتعاوَن بين الهيئات التنظيمية ونظم معلومات القوى العاملة الصحية وأرباب العمل والوزارات الحكومية وسائر أصحاب المصلحة من قبيل الرابطات المهنية. وينبغي للبلدان التي تعاني من خسارة فادحة في القوى العاملة في مجال التمريض من جراء الهجرة إلى الخارج أن تنظر في وضع تدابير مخففة، من قبيل تحسين الرواتب 17 (والتكافؤ في الأجور) وشروط العمل، وضمان العمل اللائق، وتنفيذ حزم استبقاء مصممة خصيصًا حسبما تقتضي الحالة. 6 3 تطوير القوى العاملة في مجال التمريض ودعمها 6 3 1 التعليم مستخلص النتائج ترسم الاستنتاجات التي خلص إليها هذا التقرير . 241 ملامح وضع معقد فيما يتعلق بإنتاج خريجي برنامج التمريض. وقد ظهر في الإقليم الأوروبي وإقليم شرق المتوسط والبلدان المرتفعة الدخل أقل عدد من الخريجين منسوبًا إلى الرصيد المتوافر. وما لم تتمكن البلدان المتوسطة الدخل والأخرى المرتفعة الدخل من زيادة الإنتاج، فإن البيانات تشير إلى استمرار اعتماد البلدان المرتفعة الدخل المحتمل على التوظيف على المستوى الدولي، مما قد يؤدي إلى تفاقم النقص الحالي وزيادة مشكلتي الإتاحة والإنصاف. وهناك تنوع كبير في مدة برامج تعليم وتدريب . 341 التمريض في أقاليم مختلفة من العالم. ومع ذلك، أبلغت البلدان بأغلبية ساحقة (451 من أصل 961 بلدًا مجيبة) بوجود معايير لمحتوى التعليم والتدريب ومدتهما. وتشمل الأمور البالغة الأهمية التي يجب وضعها في الاعتبار لدى وضع مثل هذه المعايير ما إذا كانت تساعد المعلمين على تزويد الطلاب بالكفاءات المطلوبة لتلبية الاحتياجات الصحية للسكان، بما في ذلك الإعداد لتقديم خدمات الرعاية الأولية والوقائية، والكوارث، وحالات الطوارئ، والكفاءات المتصلة بالنزاعات عند ِذكر ذلك، ومهارات القيادة، والاستخدام الملائم للتكنولوجيا (انظر الإطار 6-4 الذي يتناول استخدام التكنولوجيا في تعليم التمريض وممارسته). وأبلغت معظم البلدان (98٪) أيضًا بوجود آليات . 441 اعتماد للمؤسسات التعليمية والاحتفاظ بقائمة رئيسية تضم المؤسسات المعتمدة. ويشير هذا، فيما يتعلق بمعظم البلدان، إلى وجود فرصة للتركيز على تعزيز مجالات الاعتماد الرئيسية، بما في ذلك النماذج الفعالة وذات الأسعار المعقولة، وضمان المساءلة الاجتماعية للبرامج وأهميتها في تحقيق أولويات صحة السكان. ويمكن لآليات الاعتماد القوية أن تغطي المحتوى، والمناهج الدراسية، والخبرات السريرية للطلاب، ومؤهلات أعضاء هيئة التدريس، والتعلم المتعدد التخصصات. وقد أشارت الاستنتاجات التي توصلنا إليها إلى أن 76٪ من البلدان المجيبة لديها معايير للتعلم المتعدد التخصصات، ولكن في بعض الأقاليم كان هذا أقل من النصف أو منخفضًا بنسبة 02٪. ويتطلب ضمان وجود قوة عاملة صحية ممثِّلة، . 541 إلى جانب تركيبة تعكس تركيبة السكان الذين يحصلون على الخدمات، التنوع في أولئك الذين يلتحقون ببرامج التمريض وينجزونها. وتشير الاستنتاجات التي خلص إليها هذا التقرير إلى أن القوى العاملة في مجال التمريض لاتزال تغلب عليها الإناث، لاسيما في إقليمي الأمريكتين وغرب المحيط الهادئ. وتعزيز التكوين المناسب للقوى العاملة في مجال التمريض لن يتطلب زيادة التحاق فئات الطلاب المتنوعة فحسب؛ بل سيتطلب أيضًا التصدي للتحديات الهيكلية والتنظيمية التي إما تستبعد بعض الطلاب من التمريض (إكمال التعليم الثانوي على سبيل المثال) وإما تمنع إتمام دراساتهم (التكاليف الزائدة على الحد على سبيل المثال) (621). وقد يتأثر الطلب على برامج التمريض أيضًا بالفصل المهني القائم على نوع الجنس وتدني المركز الذي يتبوؤه كادر التمريض في بعض البلدان. ولابد من مواجهة هذه التحديات لجعل مهنة التمريض اختيارًا جذابًا، خاصة في أقاليم مثل إقليم الأمريكتين، حيث يصل عدد الخريجين إلى أدنى مستوى له نسبًة إلى عدد السكان. حالة التمريض في العالم عام 020227 الخيارات السياساتية ينبغي أن تضمن البلدان أن ُتزوِّ د برامج تعليم . 641 التمريض والتدريب عليه كادَر التمريض بالكفاءات اللازمة لتقديم خدمات عالية الجودة ومتكاملة محورها الإنسان. وتتمثل إحدى القضايا ذات الأولوية في التقييم الدقيق لمزيج المهارات داخل مهنة التمريض وتحديد ما إذا كانت مستويات كادر التمريض وأنواع التخصصات ذات جدوى في تحقيق أغراض النظام الصحي، وضمان توافر عدد كاٍف من الوظائف التدريبية بناء على احتياجات النظام الصحي وقدرته الاستيعابية. وينطوي إنشاء المستويات العليا في تعليم التمريض أو زيادة عددها -مثل برامج البكالوريوس أو الماجستير أو دكتوراه الفلسفة- على آثار هيكلية، مثل استحداث برامج تعليمية، وتزويدها بهيئة التدريس الملائمة، وضمان أن يزود كادر التمريض بهذا النوع من المسار التعليمي سيكون له دور محدد في النظام الصحي. الإطار 6.4 استخدام التكنولوجيا في تعليم التمريض وممارسته تؤدي التكنولوجيا دورا ًمتزايداً في كل من تعليم القوى العاملة في مجال التمريض وممارسته. ويمكن تسخير التكنولوجيا لإتاحة وسائل دعم اتخاذ القرارات السريرية، وإجراء التطبيب عن ُبعد من مقدم الخدمة إلى العميل، وتلقي التدريب والاستشارة من مقدم الخدمة إلى مقدم الخدمة (082) بطرق يمكن أن تعزز الإتاحة والتمكين من تقديم الرعاية عن ُبعد وتحسين تقديم خدمات الرعاية الصحية الأولية وتمكين المرضى. وينبغي أن يكون كادر التمريض مجهزا ًبالمحددات الرقمية للصحة وملما ًبها: وتشمل مستوى إلمامه بمبادئ التكنولوجيا الرقمية، وإتاحة استخدام المعدات التكنولوجية، والبنية التحتية للإنترنت، بما في ذلك النطاق العريض متى أتيح (182) وتعمل تقنيات الصحة الرقمية، سواء أكانت ذكاء اصطناعيا ًأم أشكالا ًأخرى من قبيل الواقع المعزز إلى جانب استخدام تقنيات الإنسان الآلي، بالفعل على إحداث تحول في التمريض ورعاية المرضى (282). والطب الشخصي وعلم الجينوم لديهما القدرة على تحسين رعاية المرضى (382). وإحدى أعظم الطاقات الكامنة في الصحة الرقمية هي فرص التعلم مدى الحياة. ويمكن أن تسمح تكنولوجيات من قبيل الذكاء الاصطناعي بإضفاء الطابع الشخصي على التعلم وجعله ملبيا ً للاحتياجات الخاصة ومواكبا ًلأحدث التطورات. وتشير الاستنتاجات المستخلصة من استعراض كوكرين المنهجي لخبرات العاملين الصحيين في مجال الرعاية الصحية الأولية إلى أن العاملين الصحيين، بمن فيهم كادر التمريض، أعربوا عن تقديرهم لفوائد استخدام تكنولوجيا الهاتف المحمول في تقديمهم الرعاية، لكنهم واجهوا تحديات كذلك (482). وشملت الفوائد المذكورة الاستمرار في الاتصال، وتولي مهام جديدة، وتحسين التنسيق وجودة الرعاية، وتحسين التواصل مع العملاء، والوصول إلى العملاء في المناطق التي يصعب الوصول إليها (482). في الوقت نفسه، أوضحت حسابات العاملين في مجال الصحة وجود تحديات متعددة ومعقدة، يمكن أن تكون شخصية (مثل ضعف الإلمام بمبادئ التكنولوجيا الرقمية)، أو ذات صلة بالعلاقات (تفضيل الاتصال وجها ًلوجه مع العملاء والزملاء)، أو مهنية (الشعور بأن مهاراتهم السريرية مهددة بأدوات الدعم السريري الرقمية)، أو ظرفية (عدم قدرة العملاء على تحمل تكلفة الهواتف المحمولة)، أو ذات صلة بالبنية التحتية (نقص الكهرباء) (482) وفي حين تقدم التطورات التكنولوجية العديد من الفوائد، تشير حسابات العاملين الصحيين المدرجة في هذا الاستعراض المنهجي إلى أن متخذي القرار في النظام الصحي يحتاجون إلى التفكير مليا ًفي كيفية تنفيذه في بيئاتهم من أجل تقليص التحديات التي يواجهها العاملون الصحيون، ومنهم أفراد كادر التمريض. 37الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض ينبغي للبلدان النظر في إنشاء آليات لزيادة التنوع . 741 الديموغرافي والجغرافي للطلاب في مدارس/ كليات التمريض. وقد يعني هذا التصدي للتحيزات التي تؤثر سلبًا على التمريض بوصفه خيارًا وظيفيًا للرجال أو الشباب أو فئة عرقية محددة، واستيعاب أولئك الذين يرغبون في دخول مجال التمريض بوصفه خيارًا وظيفيًا ثانيًا أو لاحقًا. وقد يتطلب الأمر في بعض السياقات تعزيز "ارتباط المسار الوظيفي بالريف" لتشجيع المدخلات المتوازنة جنسانيًا والتحاق عدد ملائم من الطلاب من المناطق والمجتمعات المحلية الريفية والنائية والمحرومة بأي شكل آخر بالبرامج. ويمكن أيضًا استخدام الدعم المالي المحدد الأهداف وآليات الحوافز لزيادة فرص التعليم الرسمي للأقليات والفئات المستضعفة والمحرومة، ولجذب أعضاء هيئة التدريس الذين يمثلون الفئات السكانية التي ينتمي إليها الطلاب والمجتمع. وتعد معايير الاعتماد التعليمي التي تعزز تدابير المساءلة الاجتماعية إحدى تلك الآليات. وينبغي للمؤسسات والجهات التنظيمية في مجال . 841 التعليم الصحي أن تعتمد مناهج قائمة على الكفاءة وأن تستفيد من التكنولوجيا المناسبة. وينبغي أن تتجلى الجودة في ممارسة التمريض في جميع مكونات المناهج الدراسية. وإضافة إلى المعرفة التقنية والمهارات الإجرائية للتدخلات السريرية الفردية، ينبغي أن يكون كادر التمريض مجهزًا للعمل في أفرقة متعددة التخصصات؛ لإظهار التعاطف والرحمة تجاه المرضى؛ ولاتخاذ القرارات تحت الضغط؛ وللحصول على الأدوات اللازمة لمواصلة التعلم المهني لعقود من الزمن. وينبغي أن تكون المناهج الدراسية متوافقة مع كل من نطاق ممارسة الطلاب الخريجين والاحتياجات الصحية للسكان. ويمكن أن يستكمل تقديم المحتوى التعليمي والتدريبي رقميًا الطرَق التقليدية على نحو يحقق الفائدة. ويتطلب نجاح هذه الجهود في مجال "التعلم الموزع" ضمان أن يحصل الطلاب على الحد الأدنى من الإلمام بمبادئ التكنولوجيا الصحية الرقمية في إطار تعليمهم، وأن تستعين المناهج الدراسية بالتعلم الرقمي وتعلم تقديم الخدمة الصحية عن ُبعد للحصول على الكفاءات المطلوبة إلى جانب الدعم والإشراف في التدريب السريري (582)، وأن تتوافر الموارد المؤسسية والبنية التحتية اللازمة للتمكين من سد الفجوة الرقمية (682). وينبغي للحكومات وأصحاب المصلحة إقامة شراكات . 941 بين القطاعات والاستفادة منها للمضي قدما ًفي تحقيق برامج عمل تعليم التمريض. ومن شأن التعاون مع الهيئات التنظيمية أن يسهل استعراض متطلبات الالتحاق ببرامج التمريض وتوافر الحد الأدنى من معايير التعليم لكادر التمريض (بالنظر إلى الأدوار المهنية الحالية والمستقبلية في النظام الصحي)، ويمكن أن يعزز مواءمة المعايير على المستوى الإقليمي. ومن شأن الحوار بين القطاعات من جهة مع هيئات الاعتماد من الجهة الأخرى أن يساعد في تحديد الآليات اللازمة لتعزيز جوانب المساءلة الاجتماعية للاعتماد، كأن ُيضمن إعطاء مؤسسات التعليم التمريضية الأولوية لإنتاج الخريجين القادرين على تقديم خدمات صحية جيدة، بدًلا من تحسين دخلهم المؤسسي ووضعهم من خلال الرسوم الدراسية والمنح الحكومية. ويمكن للوزارتين المختصتين (التعليم، الصحة) تحسين التنسيق الرسمي لتعزيز العلوم والتكنولوجيا باعتبارها أساسيات مهنة التمريض، وتسويق التمريض بوصفه مزيجًا من (العلوم، التكنولوجيا، الهندسة، الرياضيات)، ووضع آليات لاجتذاب مجموعة متنوعة من طلاب المدارس الثانوية إلى مجال التمريض. ويمكن أن تساعد الشراكات بين القطاعين العام والخاص على تحديد المواقع اللازمة لتقديم التدريب السريري في مرافق الرعاية الصحية الأولية؛ ويمكن أن يساعد التعاون مع برامج تعليم المهن الصحية الأخرى في جعل هذه الممارسات السريرية متعددة التخصصات. وينبغي أن تعزز مؤسسات تعليم التمريض قدرتها . 051 عن طريق معالجة أوجه القصور في أعداد أعضاء هيئة التدريس أو كفاءاتهم، والقيود المفروضة على البنية التحتية، وتوافر مواقع الممارسة السريرية المناسبة (انظر الإطار 6-5 الذي يتناول التزامات باكستان بشأن إنتاج مزيد من أفراد كادر التمريض). ومن أجل زيادة وظائف التدريب مع الحفاظ على الجودة في حالة التمريض في العالم عام 020247 الوقت نفسه، قد تكون هناك حاجة إلى الاستثمار في برامج تطوير قدرات أعضاء هيئة التدريس. وينبغي أن تزيد البلدان المرتفعة الدخل أو البلدان التي تعتمد على التوظيف على المستوى الدولي من إنتاج كادر التمريض محليًا ومن نشره على مراكز العمل. وينبغي أن تنظر البلدان في تطبيق أدوات التمويل . 151 ذات الصلة لتوسع نطاق جودة تعليم كادر التمريض (عند الحاجة) أو تعزيزه من أجل معالجة إخفاقات سوق العمالة الصحية. وتتمتع الآليات المالية بطاقات كامنة ضخمة كفيلة بزيادة تنوع الرصيد المتاح من الطلاب أو أعضاء هيئة التدريس، أو عدد المقاعد المتاحة في برامج التمريض، وتخفيف بعض القيود الحالية المفروضة على التدريب السريري. وتستخدم الإعانات المالية لبرامج التعليم التالي للتعليم الأساسي في بعض الأحيان لتعزيز سبل بلوغ مستويات أرفع في مجال ممارسة التمريض. ومع ذلك، يجب أن تكون الحكومات قادرة على اتخاذ قرارات مستنيرة بشأن تحديد ما إذا كان الاستثمار في دعم تعليم التمريض ذا مردودية ملائمة، وفي أي شروط، وبأي طرق، مع تحديد أولويات الموارد النادرة التي ُتوجَّ ه للاستثمارات التي يمكن أن تساهم مساهمة مباشرة في تحقيق غرضي العدالة والكفاءة (982). فعلى سبيل المثال، ينبغي أن يحدد تحليل سوق العمالة الصحية البيئات التي يكون إنتاج كادر التمريض فيها ناقصًا أو مفرطًا مقارنة باحتياجات النظام الصحي. وعند توثيق نقص الإنتاج المنهجي، يظهر مبرر تدخل الحكومة للتخفيف من العوائق غير الضرورية التي تحول دون الالتحاق، ولدعم التعليم السابق للخدمة إذا لزم الأمر، خاصة إذا ُمنحت الأولوية لفئة من الطلاب المحرومين، من أجل تمهيد مسارات التعليم المؤدية إلى مزاولة مهنة مفضلة في مرافق الرعاية الصحية الأولية، والحصول، في المقابل، على الحد الأدنى المضمون من الخدمة المقدم لتلك الفئة دون غيرها داخل القطاع العام (041). الإطار 6.5 جهود باكستان لزيادة القدرات في مجال تعليم التمريض تحاول باكستان معالجة النقص البالغ مليون عامل صحي. ففي عام 8102، أطلقت مبادرة تسخير الموارد البشرية تحقيقا ً للرؤية الصحية لعام 0302، التي تهدف إلى معالجة مزيج مهارات القوى العاملة الصحية والقوى العاملة في مجال التمريض. والتمريض، الذي ُيعتبر العمود الفقري للقطاع الصحي، ركيزة رئيسية من ركائز هذه الرؤية، حيث أصبح عام 9102 عام التمريض في باكستان، مما يبرز إسهامات التمريض في تحقيق تمتع السكان بالصحة (782). ولدى الإعلان عن عام التمريض، أعلن الرئيس ألفي عن إنشاء جامعة تمريض في إسلام أباد، تهدف إلى توفير التدريب لعدد يبلغ 000 52 طالب كل عام (782). ويخطط البلد لمضاعفة حجم قطاع التمريض في غضون عامين، للتغلب على النقص في عدد كادر التمريض على الصعيد الوطني. وقد وصف الدكتور نوشين حميد، الأمين البرلماني المعني بالخدمات الصحية الوطنية، النقص في عدد كادر التمريض بأنه عائق أمام تحقيق التغطية الصحية الشاملة، حيث إن ثمة حاجة إلى وجود أعداد كافية من أفراد كادر التمريض ذوي الأداء الجيد لتحقيق فعالية النظام صحي (882) 57الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض 6 3 2 ممارسة التمريض مستخلص النتائج تشير الاستنتاجات التي خلص إليها التقرير إلى . 251 أن حجم القوى العاملة في مجال التمريض أكبر مما أفادت به التقديرات السابقة، أي ما يقرب من 82 مليون في عام 8102، بما في ذلك ما لا يقل عن 96٪ من الأخصائيين و22٪ على الأقل من معاونيهم. ويعزى النمو، مقارنة بتقديرات عام 6102 السابقة الواردة في الاستراتيجية العالمية للموارد البشرية من أجل الصحة، في أجزاء تكاد تكون متساوية، إلى تحقيق تحسُّ ن كبير في توافر بيانات القوى العاملة في مجال التمريض وجودتها، وإلى النمو الفعلي في الرصيد. وحتى مع نمو الرصيد، يمثل التوزيع الجغرافي غير . 351 العادل للعاملين الصحيين، بما يشمل كادر التمريض، تحديًا على الصعيد العالمي. وقد انتهى هذا التقرير إلى أن ثمة اختلافات كبيرة في توزيع كادر التمريض بين مختلف البلدان والأقاليم وفي داخلها. وتشير الاستنتاجات التي خلص إليها كذلك إلى أن نسبة تبلغ ٪35 من البلدان المجيبة لديها أدوار ممارسة متقدمة في مجال التمريض. وتوجد هذه الأدوار بكثرة في البلدان ذات الكثافة المنخفضة للأطباء مقارنة بغيرها. وتسلط هذه المعلومة الضوء على مرونة وسرعة استجابة القوى العاملة في مجال التمريض مقارنة بوضع القوى العاملة الصحية الأوسع في البلدان. وقد يكون أفراد كادر التمريض هؤلاء في وضع جيد يمكِّنهم من تقديم الرعاية للفئات السكانية في المناطق الريفية والنائية، إذا كان مزيج المهارات الحالي يشير إلى أن هذه الخطوة من شأنها أن تزيد من الكفاءة. أمَّ ا داخل البلدان، فتشير البيانات إلى استمرار . 451 الحاجة إلى التركيز على معالجة سوء توزيع كادر التمريض القائم في المناطق الريفية مقابل القائم في المناطق الحضرية من أجل تحسين المساواة في الإتاحة. ويرتبط استبقاء العاملين الصحيين بمجموعة متنوعة من العوامل المعقدة والمترابطة من قبيل شروط العمل والسلامة المهنية ومستويات الأجور والحوافز غير النقدية. ومن المرجح أن يكون النجاح المطرد في تحسين استبقاء كادر التمريض بفضل التدخلات المخطط لها والمتسلسلة والمتعددة السياسات المصممة خصيصًا بما يتناسب مع السياق المحلي. ولا ينبغي دراسة الاستبقاء أو معالجته بمعزل عن سياق سائر سمات شروط عمل كادر التمريض ومعيشته. الخيارات السياساتية ينبغي للبلدان أن تمكن كادر التمريض من العمل بما . 551 يحقق أقصى استفادة من تعليمه وتدريبه (081) وينبغي أن يكون هذا الغرض جزءًا من الجهود الوطنية الأوسع نطاقًا الرامية إلى اعتماد نماذج الرعاية التي تصل بتقسيم المهام في أفرقة الرعاية الصحية الأولية المتكاملة إلى المستوى الأمثل (971). ويستلزم ذلك تعظيم مساهمة كادر التمريض في تعزيز الرعاية الصحية الأولية في المجالات ذات الأولوية (انظر الإطار 6-6 الذي يتناول توسيع نطاق إتاحة الخدمات الصحية المجتمعية في ُعمان). ويمكن أن تشمل الأساليب الممكنة أداء أدوار متقدمة في الممارسة، وتوسيع نطاق العيادات التي يتولى قيادتها كادر التمريض، واستحداث سلطة وصف الأدوية والعلاجات أو توسيع نطاقها، إلى جانب ما يناسب ذلك من التطور أو التعزيز اللازم في مجالي التعليم والتدريب. وينبغي أن يعمل أفراد كادر التمريض الحاصلون على مؤهلات اعتماد للممارسة المتقدمة في المرافق التي تعمل على تحسين إنتاجيتهم في توفير رعاية المرضى أو تولي المهام القيادية وإدارة الأطباء الآخرين. وينبغي دعم أفراد كادر التمريض الذين يؤدون أدوار الممارسة المتقدمة أو في العيادات التي يقودها كادر التمريض بالتوجيهات أو الشراكات التعاونية حسب الحاجة، وتزويدهم بالإمدادات والأدوية الكافية، وبالإرشادات الواضحة السريرية منها والمتعلقة بالمرافق اللازمة للممارسة، وإتاحة الموارد المطلوبة، ومنها المراجع والتكنولوجيا المناسبة المتاحة عبر الإنترنت. ويتطلب إدماج الإصلاحات المطلوبة في سياسات التعليم والصحة والعمل وغيرها من السياسات ذات الصلة أن تتوافر القدرة المؤسسية على التعاون والتنسيق الفعالين؛ والهياكل المؤسسية الداعمة والموارد المخصصة؛ والدعم السياساتي في مجالي القيادة حالة التمريض في العالم عام 020267 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض والإدارة؛ والإشراف الإداري الفعال؛ والثقافة التنظيمية الفعالة. ومن المهم أيضًا أن ُيطلع سائر مقدمي الرعاية الصحية والجمهور بدقة على أدوار كادر التمريض ووظائفه استنادًا إلى نطاق الممارسة والكفاءات. ينبغي للبلدان الوصول إلى المستوى الأمثل بالطرائق . 651 والآليات التي تستخدمها لنشر القوى العاملة في مجال التمريض على مراكز العمل وإدارتها. وُتعد الكفاءة والإنصاف والشفافية في التوظيف والنشر على مراكز العمل عناصر أساسية في برنامج العمل المتعلق بالعمل اللائق (61). وينبغي أن يتمتع راسمو السياسات والمديرون بإمكانية الاطلاع على المقاييس التي يمكن التعويل عليها والتي تقيِّم كفاءة عملية التوظيف وحسن توقيتها، مثل النسبة المئوية للخريجين الجدد الذين يعملون لمدة ثلاثة أشهر أو ستة أشهر أو سنة واحدة بعد الترخيص، ومتوسط الوقت المستغرق بين التخرج والترخيص، ومتوسط الوقت المستغرق بين الترخيص والتوظيف. فقد يكون انخفاض معدل توظيف الخريجين من أعراض تشبع سوق العمل، ولكن إذا ترافق ذلك مع فترات تأخر طويلة للغاية بين التخرج والحصول على ترخيص مزاولة المهنة والتوظيف، فإنه يمكن أن يشير، بدًلا من ذلك، إلى اتسام النظام الإداري بالجمود والعقبات البيروقراطية. وطرائق النشر على مراكز العمل لها أهمية كذلك: فما لم يكن القطاع العام قادرًا على ضمان استيعاب جميع المرشحين المؤهلين، يظل التوظيف التنافسي بعد الإعلان عن الشواغر وتقييم الإطار 6.6 توسيع نطاق إتاحة الخدمات الصحية المجتمعية في ُعمان تضرب ُعمان مثالاً على إعادة توجيه تعليم التمريض والقبالة والتأكيد على الكفاءات المتعلقة بالرعاية الصحية الأولية، التي كانت مكونا ًمن مكونات الدعوة إلى العمل لتعزيز القوى العاملة في مجال التمريض التي اعتمدتها الدورة السادسة والستون للجنة الإقليمية لشرق المتوسط (تشرين الأول/ أكتوبر 9102) (092) وقد شهدت ُعمان نموا ًسريعا ًفي عدد السكان ومأمول الُعمر. ومع ذلك، تأتي التحسينات في الوضع الاجتماعي الاقتصادي مصحوبًة بزيادة في عبء الاعتلالات المزمنة. وبغية معالجة هذه المشكلة الصحية للسكان، قررت الحكومة الاستثمار في كادر التمريض الصحي المجتمعي (192). ودشنت دائرة شؤون التمريض والقبالة بوزارة الصحة برنامج تدريب أثناء العمل مدته 61 أسبوعا،ً حيث ُجرب البرنامج لأول مرة في العاصمة مسقط، ثم امتد إلى محافظات أخرى. وُدمجت خدمات تمريض الصحة المجتمعية في هياكل الرعاية الصحية الأولية تماشيا ًمع الخدمات المقدمة في مراكز الصحة الأولية (292) وفي نهاية المطاف، تحول التدريب الذي استمر لمدة 61 أسبوعا ًإلى منح درجة البكالوريوس في التمريض مع التركيز على تمريض الصحة المجتمعية، ثم على دبلومة ما بعد التعليم الأساسي في تخصص تمريض الصحة المجتمعية (192) وساهم هذا البرنامج التخصصي في الحفاظ على توفير المعروض من كادر التمريض المؤهل للعمل في ميدان الصحة المجتمعية لتلبية احتياجات خدمة الرعاية الصحية الأولية في البلد. 77 كفاءات المرشحين حسب مبدأ الجدارة هو الطريقة التي ينبغي اختيارها (982). وكذلك ينبغي ربط فرص التقدم الوظيفي والترقية بالجدارة والقدرات، بدًلا من أن تستند بصفة أساسية إلى الأقدمية (عدد سنوات الخدمة). أمَّ ا فيما يتعلق بالفئات المهنية الأخرى، فينبغي أن تؤخذ في الحسبان حدود البرامج الإجبارية للنشر على مراكز العمل والتناوب عند النظر في هذه البرامج. وينبغي أن يعتمد نشر كادر التمريض على الخيارات والتفضيلات الوظيفية والتطوعية فيما يتعلق بمركز العمل، متى كان ذلك ممكنًا. والتوفيق بين تفضيلات كادر التمريض واحتياجات النظام الصحي، لاسيما فيما يتعلق بالإنصاف الجغرافي، قد يمثل تحديًا. وعندما تنشأ تجاذبات بين الجانبين، يكون من المستحسن وضع مجموعة من الاستراتيجيات ذات الأهمية التي يعزز بعضها بعضًا للنشر والاستبقاء في المناطق الريفية من منظور الفعالية وحقوق العمال على حد سواء (982). وينبغي للبلدان أن تتوقع على نحو صريح واستباقي . 751 التحديات التي ستصادفها في مجال استبقاء كادر التمريض ورسم السياسات المتعلقة بذلك. تشمل النهوج المسندة بالبينات الرامية إلى تعزيز الاستبقاء إتاحة فرص تطوير المهارات القيادية والتوجيه (392، 492)، ووضع جداول عمل مرنة، وتقديم حوافز غير نقدية، وتوفير التعلم مدى الحياة. ويمكن أن تؤدي برامج التدريب التالية للتخرج ذات الصبغة الرسمية التي ُتقدَّم إلى الخريجين الجدد قبل الالتحاق بالقوى العاملة إلى تحسين انتقالهم إلى مجال الممارسة والكفاءة السريرية والرضاء الوظيفي والتنشئة الاجتماعية والمهنية، وكل ذلك قد يؤثر على استبقاء أفراد كادر تمريض جديد في القوى العاملة (592). وتأثير برامج التدريب التالية للتخرج على دور الكفاءة والاستبقاء متشابه لأفراد كادر التمريض الجدد، سواء في المناطق الريفية أو في المناطق الحضرية (692). وينبغي رسم سياسات محددة لزيادة دور المرأة القيادي، والتصدي للتمييز بين الجنسين، ومنع التحرش الجنسي، الذي يرتبط، إضافًة إلى كونه انتهاكًا لكرامة العمال وحقوقهم، بزيادة معدل الخروج من الخدمة (221، 792، 892). 6 3 3 التنظيم مستخلص النتائج يؤدي تنظيم التمريض دورًا أساسيًا في حماية . 851 الجمهور وتمكين النظم الصحية من الاستجابة لاحتياجات المرضى والسكان المتغيرة. ويمكن أن يوفر أيضًا إطارًا للارتقاء بالمهنة (342، 992). وتشير الاستنتاجات التي خلص إليها هذا التقرير إلى أن 461 دولة عضوًا (68٪) لديها سلطة مسؤولة عن تنظيم تعليم التمريض وممارسته. ومع ذلك، تجب دراسة قوة وفعالية الأحكام التنظيمية الصادرة على مستوى كل بلد على حدة. فعلى سبيل المثال، أشارت ٪37 من البلدان إلى أن لديها متطلبات تنظيمية للتعلم مدى الحياة، لكن عددًا أقل (46٪) أشار إلى وجود أحكام تنظيمية تتطلب صدور ترخيص أو الخضوع لامتحان ُيقيِّم الملاءمة للممارسة. وللأحكام التنظيمية المهنية أهمية كذلك في الحفاظ . 951 على الرعاية الجيدة في سياق يتزايد فيه التنقل على المستوى الدولي، وضمان تمتع العاملين الصحيين الوافدين بالكفاءات التي تلبي احتياجات السكان، والقدرة على الممارسة دون المساس بالسلامة العامة. ويشهد الوقت الحالي تناميًا في الأنظمة الآنية العاملة عبر شبكة الإنترنت التي يمكن أن تسهل الاعتراف السريع sddoD nareiK © حالة التمريض في العالم عام 020287 بالمؤهلات وتوفر معلومات مصنفة عن حالة الترخيص الحالية والسجل المهني للممارس بوصفها أدوات مفيدة على المستوى الإقليمي، ويمكن أن تتطور حتى تصبح حلوًلا عالمية (861، 003-203). الخيارات السياساتية ينبغي للبلدان وضع الأحكام التنظيمية المنظمة . 061 للتمريض وتعزيز القائم منها لدعم التعليم والممارسة على نحو مأمون ومستدام وبجودة عالية. وقد يلزم إنشاُء السلطِة المسؤولِة عن تنظيم التمريض بموجب تشريع أولي جديد أو محدث يحدد دور ووظائف السلطة التنظيمية والأحكام والمعايير الرئيسية لتعليم التمريض وممارسته. ويتمثل أحد التحديات المتكررة في الحاجة إلى تحقيق التوازن الصحيح، أي ضمان أن تكون الأحكام التنظيمية أقل تقييدًا مع تحقيق منفعة الحماية العامة المطلوبة في الوقت نفسه (303-603). وينبغي للبلدان النظر في وضع اشتراطات التعلم مدى الحياة لضمان تعرض كادر التمريض في مختلف المستويات لفرص التعلم المناسبة لدورهم. وهناك تزايد في عقد امتحان الترخيص اللازم لتقييم الإلمام بالحد الأدنى من المعرفة الأولية من عدمه قبل السماح لأفراد كادر التمريض بممارسة مهام عملهم (552، 703). وبينما لاتزال ثمة حاجة إلى بينات قوية على الفعالية النسبية للنهوج المختلفة، فهناك توافُق آراٍء واسع النطاق على ضرورة أن يكون تقييم الكفاءة صحيحًا وعادًلا ومستقًلا ومستندًا إلى المعرفة والمهارات التي سيحتاج إليها كادر التمريض في مجموعة متنوعة من بيئات الممارسة. وينبغي أن تستثمر البلدان في قدرة النظم التنظيمية . 161 على تعزيز وتحسين جودة تعليم التمريض وممارسته. ويتمثل أحد الجوانب الرئيسية في التأكد من امتلاك الجهات التنظيمية سجلات محدثة قابلة للعمل المتبادل مع قواعد البيانات الأخرى في النظام الصحي والجهات التنظيمية الأخرى ومداومة إمساك تلك السجلات. وهناك طريقة لإمساك سجلات محدثة هي اشتراط إعادة التسجيل أو إعادة الحصول على الترخيص، وهي طريقة يمكن أن تكون أيضًا مفيدة في تحفيز التعلم مدى الحياة وكذلك إدرار الدخل للجهة التنظيمية. ويلزم أيضًا تقوية القدرة الفردية التي لدى الجهات التنظيمية المعنية بالتمريض. فالجهات التنظيمية المعنية بالتمريض، كما هو حال المهن الصحية الأخرى كذلك، قد تكون قد تلقت تدريبات رسمية قليلة أو لم تتلقَّ أيًا منها في مجال التنظيم المهني قبل اضطلاعها بهذا الدور. ويمكن للجهات التنظيمية أن تتعلم من تجربة البلدان الأخرى ومن الجهود المبذولة على المستوى الإقليمي التي نجحت في تعزيز الأطر التنظيمية (انظر الإطار 6-7 الذي يتناول الجمعية التعاونية التنظيمية الأفريقية لمهنة الصحة). 97الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض 6 3 4 العمل اللائق مستخلص النتائج ضمان شروط العمل اللائق أمر ذو أهمية وضرورة . 261 لجميع المهن الصحية، وإن كانت مهنة التمريض تواجه تحديات خاصة. والقوى العاملة في مجال التمريض بحكم طبيعتها، بوصفها قوى يغلب عليها العنصر النسائي وبالنظر إلى الموروث السلبي السائد في بعض السياقات الذي يعتبرها ذات دور تابع في العادة، أكثر عرضة لمواجهة التحيز بين الجنسين والتمييز في العمل. ويخضع كادر التمريض أيضًا للعمل ساعات طويلة، ويواجه خطر التعرض للاعتداءات في بعض الظروف، إلى جانب التحرش الجنسي والمعاملة غير العادلة اللذين يتعرض لهما العاملون المهاجرون. وقد أبلغت نسبة تبلغ 49% من البلدان بوجود أحكام تنظيمية تتناول ساعات العمل وشروطه، وأبلغت 19% بوجود نظم تتناول الحماية الاجتماعية، بينما أبلغت 98% بوجود نظم تتناول الحد الأدنى للأجور، رغم قلة المعلومات المتوافرة عن الكفاية والمستوى الفعلي لتنفيذ تلك السياسات. وأبلغ ما مجموعه 55 بلدًا (63٪)، معظمها في إقليمي جنوب شرق آسيا وشرق المتوسط، بتدابير تستهدف منع الاعتداءات على العاملين الصحيين. الخيارات السياساتية ينبغي للبلدان تنفيذ برنامج العمل في مجال العمل . 361 اللائق والاستثمار في تهيئة شروط العمل المواتية لكادر التمريض. وتشمل العناصر الأساسية الأجور الكافية، والحماية الاجتماعية، وشروط العمل العادلة، وساعات العمل المعقولة، والسلامة المهنية، والحوافز غير النقدية، وإتاحة فرص التقدم الوظيفي الشفافة والقائمة على الجدارة. وترتبط هذه الشروط ارتباطًا وثيقًا باستبقاء كادر التمريض وينبغي أن تنطبق على كادر التمريض بغضِّ النظر عن نوع جنس أفراده أو خلفيتهم الإطار 6.7 الجمعية التعاونية التنظيمية الأفريقية لمهنة الصحة أُنشئت الجمعية التعاونية التنظيمية الأفريقية لمهنة الصحة لمساعدة البلدان في تحديث الأحكام التنظيمية في مجالي التمريض والقبالة لتيسير اتباع النماذج المأمونة والمستدامة في رعاية المرضى المصابين بفيروس العوز المناعي البشري وعلاجهم. وتشارك في الجمعية التعاونية 71 بلدا،ً تضم معظم أعضاء كلية التمريض في شرق أفريقيا ووسطها وجنوبها (803) واجتمعت الجمعية مع المسؤول الحكومي عن التمريض، ورئيس الرابطة الوطنية للتمريض، وأحد رموز الأوساط الأكاديمية، وأمين سجل المجلس الوطني للتمريض والقبالة من كل بلد، وَدَعمْت تحديد الأولويات والتعاون في مواجهة التحديات التنظيمية المحددة على المستوى الوطني. وعملت أفرقة القيادة القطرية، التي أطلقت على نفسها "الرباعي"، معا ًعلى أولوياتها التنظيمية (من قبيل نطاق الممارسة الذي يضم المهام المتعلقة بفيروس العوز المناعي البشري ومتطلبات التطوير المهني المستمر لمحتوى فيروس العوز المناعي البشري) في الدورات السنوية. والتقى أعضاء الرباعي كثيرا ًبالزملاء في البلد وكذلك بالزملاء الإقليميين الذين يعملون على أولويات مماثلة. وقِيس التقدم المحرز بانتظام وبمقاييس متنوعة (903) وعلى مدار خمس سنوات (1102-6102) ُعززت الأحكام التنظيمية في مجالي التمريض والقبالة، وأبلغ الرباعي بحدوث زيادات كبيرة في مهارات القيادة والقدرة التنظيمية والتعاون بين المنظمات الوطنية المعنية بالتمريض والقبالة (013) ورغم أن الجمعية التعاونية كانت عبارة عن مبادرة تمولها الجهات المانحة، فقد أُضفي الطابع المؤسسي على الترتيبات المتمثلة في "الرباعي" في بلدان الجماعة الصحية لشرق أفريقيا ووسطها وجنوبها، وهي تؤدي دور الآلية المستمرة للارتقاء بالتمريض والقبالة من أجل معالجة الأولويات الصحية الوطنية. حالة التمريض في العالم عام 020208 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض الاجتماعية أو بلد أو إقليم منشئهم أو جماعتهم الإثنية أو لغتهم، وينبغي تنفيذها من خلال آليات مساءلة واضحة. وُتعد حقوق العاملين الصحيين، بما في ذلك الأجور المناسبة وشروط العمل الملائمة، من أكثر الأسباب شيوعًا للأعمال الاحتجاجية أو الإضرابات التي ينفذها العاملون الصحيون (انظر الإطار 6-8 الذي يتناول إضرابات العاملين الصحيين). ويجب على البلدان توفير الحماية والدعم لكادر . 461 التمريض المتضرر تضررا ًمباشرا ًمن الأزمات الإنسانية. وتحتاج وزارات الصحة ومنظمات التمريض المهنية والمنظمات غير الحكومية إلى التعاون مع السلطات والأطراف المعنية لضمان توفير الحماية والدعم لأفراد كادر التمريض الذين قد يقدمون الرعاية في ظل شح شديد في الموارد أو في ظروف بالغة القسوة (مثل مخيمات اللاجئين أو الملاجئ)، أو الذين قد يكونون جزءًا من السكان النازحين عبر الحدود ويقدمون الرعاية في ظل أحكام تنظيمية لا تعترف رسميًا بممارستهم المهنة. وسيساعد ذلك في ضمان أمن جميع العاملين الصحيين والمرافق الصحية في جميع البيئات، وخاصة للنساء، اللاتي قد يكنَّ أكثر عرضة للهجوم أو التحرش أثناء الأزمات. الإطار 6.8 إضرابات العاملين الصحيين في العديد من البلدان في جميع أنحاء العالم، يحق للعمال الإضراب قانونا،ً ويعتبر هذا على نطاق واسع حقا ًمن الحقوق المدنية (113). ومع ذلك، تتسم ممارسة العاملين الصحيين هذا الحق بالتعقيد لأن ذلك يؤدي إلى التعارض مع حقوق المرضى في الرعاية، ومع حقوق المواطنين في التغطية الصحية الشاملة، وقد يؤدي أو لا يؤدي إلى زيادة الوفيات (113-413). وعلى الرغم من ذلك، تحدث إضرابات العاملين الصحيين، بما في ذلك إضرابات كادر التمريض، في جميع أنحاء العالم، في البلدان المرتفعة الدخل والبلدان المتوسطة الدخل والبلدان المنخفضة الدخل (313، 413). وقد انتهى تحليل للإضرابات في البلدان المنخفضة الدخل إلى أن التقارير تفيد بلوغ إضرابات العاملين الصحيين 578 يوم عمل، في 32 بلدا ًمن البلدان المنخفضة الدخل، وذلك بين عامي 9002 و8102 (113). وذكرت الدراسة أن الإضرابات يمكن أن تستمر أياما ًأو شهورا،ً وقد تتكرر أيضا ًعلى مدار أشهر أو سنوات (113). وكانت العوامل السببية الرئيسية التي أدت إلى هذه الإضرابات هي الشكاوى المتعلقة بالأجور وتأخر المدفوعات، تليها الاحتجاجات على التنفيذ غير المرضي لاتفاق جرى التوصل إليه سلفا،ً أو ضد تصريف الشؤون والسياسات في القطاع الصحي، وكذلك الشكاوى المتعلقة بشروط العمل وقضايا الأمن. ويتطلب الحد من إضرابات العاملين في المجال الصحي اتباع النهوج المتعددة الأوجه والمتعددة القطاعات التي تشمل أصحاب المصالح المتعددين (113، 413، 513). وثمة حاجة إلى إجراء مزيد من البحث لفهم العوامل المسببة للحالات الفردية، وكذلك الأنماط السائدة في مختلف الأقاليم، وتحديد الجهات الفاعلة التي ينبغي إشراكها في الأمر للتوصل إلى حل إيجابي (113). ومع ذلك، من الواضح أن العمل المتعدد القطاعات، بدعم من القيادة السياسية، ضروري بين القطاعات الصحية والقطاعات الأخرى لمعالجة العوامل الكلية المرتبطة بإضرابات العاملين الصحيين (413). ولا غنى عن الاستثمار في شروط عمل لائقة بالعاملين الصحيين، حيث ُيضمن لهم توفير بيئة عمل آمنة وُممكِّ نة وفعالة، لإعمال الحق في التغطية الصحية الشاملة وحمايته (413) 18 6 3 5 نوع الجنس وحقوق المرأة مستخلص النتائج تتألف نسبة تبلغ 09٪ من القوى العاملة في مجال . 561 التمريض على مستوى العالم من النساء. ويؤدي المستوى العالي للفصل بين الجنسين في مجال التمريض إلى أنماط معقدة من الأجور: وفي العديد من البلدان هناك "فجوة في الأجور بين الجنسين"، على الرغم من أن البينات واردة، إلى حد كبير، من البلدان المرتفعة الدخل (12). والتنفيذ والرصد الفعالان لسياسات سد فجوة الأجور بين الجنسين ضروريان لتعزيز المساواة بين الجنسين بطريقة مقصودة داخل القوى العاملة الصحية، والتغلب على الإرث التاريخي الذي يقلل من أهمية عمل كادر التمريض، بصور منها التحيز الجنساني (121، 232). وقد انتهت التحليلات التي أجرتها منظمة الصحة العالمية إلى أن الرجال لايزالون يهيمنون على المناصب القيادية في مجال الصحة، حيث لا تشغل النساء سوى 52 في المائة من المناصب القيادية في مجال الصحة على الصعيد العالمي (12). ولم تتحدث دراسة تناولت العوائق التي تحول دون تولي المناصب القيادية وكذلك دور الميسرين في مجال التمريض، أجريت بتكليف من حملة التمريض الآن، عن وجود "سقف زجاجي" للنساء فحسب، بل إنها تحدثت أيضًا عن وجود "مصعد زجاجي" للرجال، الذين يضطلعون بعدد كبير من أدوار التمريض العليا على نحو غير متناسب (221). هذا مجرد مظهر من مظاهر الاختلالات العميقة بين الجنسين التي تتخلل النظم الصحية على جميع المستويات وتؤثر على جميع جوانب إدارة القوى العاملة في مجال التمريض. الخيارات السياساتية ينبغي للبلدان سد فجوة الأجور بين الجنسين التي . 661 تؤثر على كادر التمريض. ففي بعض البلدان، قد يكون الدافع وراء الأجر غير المنصف بين الجنسين هو ارتفاع مستويات الفصل المهني بين الجنسين في مجال التمريض مقارنة بالمهن الأخرى. ويمكن أن تبدأ معالجة ذلك بتحليل جداول الأجور الوطنية والالتزام بالتطبيق التدريجي لنظام أجور أكثر إنصافًا ومحايدة جنسانيًا بين العاملين الصحيين. ويجب أن تتضمن رسم سياسات سليمة وإعادة النظر في الترتيبات المالية فيما يتعلق بأجر العاملين الصحيين. ومع الاعتراف بضرورة تأثير قوى السوق على مستويات الأجور، ينبغي تطبيق السياسات والقوانين التي تسد الفجوة في الأجور بين الجنسين على أنها تخص القطاع الخاص كذلك. ويجب إدراج القيادة التمريضية في تقييم الإنصاف في المكافآت ووضع سياسات لمعالجة هذه المشكلة. وينبغي للبلدان إعطاء الأولوية للسياسات التي تتناول . 761 التحرش الجنسي والتمييز داخل مجال التمريض وبين القوى العاملة الصحية بوجه عام وتنفيذ تلك السياسات. وينبغي أن يشمل ذلك سياسة عدم التسامح مطلقًا إزاء العنف والتحرش اللفظي والجسدي والجنسي؛ والسياسات التي تخلق بيئات عمل لائقة للنساء، بما في ذلك ساعات العمل المرنة والقابلة للتنظيم التي تلبي الاحتياجات المتغيرة للممرضات؛ وفرص تطوير المهارات القيادية التي تراعي الفوارق بين الجنسين لصالح النساء في القوى العاملة في مجال التمريض. 6 4 بناء القدرات المؤسسية والمهارات القيادية من أجل تحقيق الفعالية في تصريف الشؤون مستخلص النتائج أبلغت أكثر من 08 بلدًا بوجود منصب قيادي . 861 للتمريض على المستوى الوطني مع تحمل شاغله مسؤولية تقديم مدخلات في القرارات السياساتية المتعلقة بالصحة والتمريض. وينبغي أن يعمل المسؤولون الحكوميون عن التمريض بوصفهم شركاء كاملي المشاركة مع القيادة المهنية الصحية الأخرى في اتخاذ القرارات الاستراتيجية التي تؤثر على تخطيط الخدمات الصحية وتقديم الرعاية وشروط العمل (613). وثمة حاجة إلى توافر قدرات في سوق العمل وإجراء تحليل للحيز المالي ورسم سياسة للقوى العاملة والتخطيط وتصريف الشؤون للوقوف على الأولويات ووضع الحلول المسندة بالبينات بغية تعزيز القدرة التعليمية، حالة التمريض في العالم عام 020228 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض egroeG-sgnilluM ecinaJ © وإيجاد فرص عمل لكادر التمريض واستبقائه. وتشير الاستنتاجات التي خلص إليها هذا التقرير إلى أنه من بين 67 بلدًا مجيبة، كان لدى 35٪ منها برامج وطنية لتطوير المهارات القيادية لكادر التمريض، رغم أن التوزيع كان غير متكافئ لأن غالبية البلدان التي أبلغت بهذه البرامج تقع في الإقليم الأفريقي وفي إقليم شرق المتوسط التابعين للمنظمة. تتطلب قدرات تصريف الشؤون اللازمة لرسم . 961 سياسات التمريض والصحة وتنفيذها على الوجه الصحيح أيضًا مؤسسات وآليات وسياسات وإجراءات تكفل النظر في أولويات القوى العاملة في مجال التمريض وتشكل جزءًا لا يتجزأ من الإجراءات الحكومية الأوسع نطاقًا في القطاع الصحي وخارجه. وقد أبرزت الاستنتاجات التي خلص إليها هذا التقرير أن منصب رئيس التمريض ووجود برامج تطوير المهارات القيادية لكادر التمريض مرتبطة بوجود بيئة تنظيمية أقوى للتمريض. ومع ذلك، لا يرتبط وجود منصب مسؤول التمريض بالضرورة بوجود برامج تطوير المهارات القيادية. وقد يكون هذا بسبب أن برامج المهارات القيادية غالبًا ما كان الباعث على إنشائها الرابطات المهنية إما بوصفها خدمة لأعضائها وإما بوصفها فرصة لإدرار الدخل. الخيارات السياساتية يجب تطوير المهارات القيادية التمريضية على . 071 المستويات القطري والإقليمي والعالمي. ويجب أن تتاح لكادر التمريض فرص لتطوير إمكاناتهم القيادية والمشاركة في محافل اتخاذ القرار. وينبغي النظر في كادر التمريض، على قدم المساواة مع غيره من كوادر المهن الصحية، بغية تعيينهم في مناصب قيادية داخل الحكومات الوطنية وحكومات الولايات، وكذلك داخل الهياكل التنظيمية المحلية وغيرها. وسيتطلب هذا الجهد تخصيص ميزانية خاصة لتطوير المهارات القيادية التمريضية. ويمكن إنشاء آليات منح الجوائز والتقدير في كل بلد على حدة للإعراب عن التقدير لمساهمات التمريض في النهوض بالتغطية الصحية الشاملة وبحيث تكون نماذج يحتذي بها كادر التمريض الأصغر سنًا (انظر الإطار 6-9 الذي يتناول برنامج الزمالة في مجال القيادة في إقليم غرب المحيط الهادئ). 38 ينبغي أن تضع محافل رسم السياسات على الصعيد . 171 الوطني منظور التمريض في اعتبارها لدى اتخاذ القرارات في النظام الصحي. وينبغي أن تضمن السياسات تمثيل كادر التمريض على جميع مستويات اتخاذ القرار وإعطاءهم مساحة للتأثير في قرارات النظام الصحي الرئيسية والمسائل السياساتية في مجال الصحة العمومية. وينبغي أيضًا أن تشمل عملية اتخاذ القرارات السريرية على مستوى السكان كادَر التمريض، مما يعني ضمنًا، على سبيل المثال، ضم كادر التمريض في أفرقة وضع المبادئ التوجيهية ولجان استعراضها كي تشمل المبادئ أبحاَث التمريض وكذلك رؤية متعمقة في جدوى التوصيات السريرية ومقبوليتها. 6 5 تحفيز الاستثمار لإيجاد وظائف في مجال التمريض مستخلص النتائج يعرض هذا التقرير بينات إضافية لإدراج تركيز . 271 أكبر على التمريض في إطار مبررات الاستثمار الأوسع نطاقًا في القوى العاملة الصحية لتحقيق التغطية الصحية الشاملة. وعلى الرغم من الاتجاه الإيجابي المسجل خلال السنوات القليلة الماضية، فما لم يزد إنتاج كادر التمريض واستيعابه زيادة كبيرة، فإن كثافة التمريض لن تتحسن إلا تحسنًا هامشيًا في معظم الأقاليم على مدار العقد المقبل، مع استمرار النقص الكبير القائم على الاحتياجات في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط، لاسيما في الإقليم الأفريقي وإقليمي جنوب شرق آسيا وشرق المتوسط. الإطار 6.9 برنامج الزمالة في مجال القيادة في إقليم غرب المحيط الهادئ تتحمل النظم الصحية في إقليم غرب المحيط الهادئ عبئا ًمزدوجا ًقوامه الأمراض غير السارية والأمراض السارية، وتواجه في الوقت نفسه تحديات اقتصادية واجتماعية وبيئية كبيرة. ويقدم الممرضون والممرضات نحو ٪87 من الرعاية في إقليم غرب المحيط الهادئ (713)، لذلك من المهم تمكينهم وتعليمهم إلى مستوى يمنحهم التأثير الذي يحتاجون إليه لتحسين الحصائل الصحية للمجتمع. ومع ذلك، يعاني إقليم غرب المحيط الهادئ عادة من نقص في برامج القيادة (813، 913)، بما يشمل قلة عدد البرامج الخاصة بالمهنيين الصحيين (023-223)، والبرامج الحالية لم توضع في سياقها الثقافي المطلوب (713، 323، 423) وفي الفترة من عام 9002 إلى عام 7102، نفذت جامعة سيدني للتكنولوجيا برنامجا ًللحصول على درجة الزمالة الأسترالية في مجالي القيادة والتوجيه في إطار من الشراكة مع تحالف رؤساء كادري التمريض والقبالة في جنوب المحيط الهادئ (813). وركز برنامج القيادة على الموارد البشرية الصحية والثقافات الجماعية والإرشاد التربوي وتنفيذ السياسات والروابط القائمة مع التغطية الصحية الشاملة. وقد َشِمل تقييم التأثير أكثر من 003 من أصحاب المصلحة والمشاركين في البرنامج من 41 بلدا ً(813) وتظهر النتائج الأولية أن ٪58 من المشاركين في نموذج القيادة قد حظوا بتطورات مهنية كبيرة وتولوا أدوارا ًمتقدمة في مجالي التمريض والقبالة. ونفذوا أيضا ًمشاريع في بلدانهم الأصلية في مجالات مثل التخطيط لتعاقب الموظفين والتطوير المهني والتنظيم والتدريب التنشيطي (913). ومن النتائج الرئيسية الأخرى أن هذه المهن ممثلة الآن في مؤتمرات القمة العالمية، وهو ما يؤثر على السياسات على المستويات العالمي والإقليمي والوطني (523). وحضر تسعة من مسؤولي التمريض والقبالة من برنامج القيادة جمعية الصحة العالمية الثانية والسبعين. وأصبح ستة منهم مسؤولين حكوميين عن التمريض في بلدانهم، في حين أصبح اثنان وزيَرْي صحة في بلديهما. حالة التمريض في العالم عام 020248 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض ستكون هناك حاجة إلى حوار السياسات بين . 371 القطاعات لتحديد موارد كافية في الميزانية والالتزام بها للاستثمار في التعليم والمهارات وإيجاد فرص العمل، وسياسات التوظيف والنشر على مركز العمل والاستبقاء، وبناء قدرات المؤسسات الوطنية ذات الصلة، من قبيل هيئات الترخيص والاعتماد. وتوسيع أسواق العمل الصحية ُيوِجد فرص عمل، خاصة للنساء. ويمكن أن ُيساعد توسيع نطاق فرص العمل في مجال التمريض في تعزيز مشاركة الإناث في القوى العاملة -التي تبلغ نسبتها 84٪ فقط على مستوى العالم، مقارنة بنسبة الرجال البالغة 57٪- وزيادة معدل توظيف الإناث (623، 723). والاستفادة من الاستثمار في إنشاء وظائف في مجال التمريض مسألة تدعمها بينات ضخمة تتحدث عن "المكاسب الثلاثية" - في مجالات الصحة والمساواة بين الجنسين والتنمية (12). الخيارات السياساتية ينبغي للبلدان تنسيق العمل المشترك بين القطاعات . 471 والتمويل المستدام للتمكين من زيادة الطلب الاقتصادي على إيجاد وظائف التمريض. ويمكن إنشاء الوظائف الجديدة المطلوبة في مجال التمريض البالغة 9.5 ملايين وظيفة (مع عدم التركيز إلا على تلك المطلوبة لسد الفجوات الحالية) في معظم البلدان بأموال محلية قائمة من خلال الإدارة الفعالة لتحقيق النمو في مخصصات الأجور. وينبغي للمخططين الوطنيين النظر في كفاءة الاستثمار في كادر التمريض مقارنة بغيره من الفئات المهنية وتحسين إنتاجية القوى العاملة في مجال التمريض الحالية والمستقبلية من خلال الحوافز ونظم الإدارة المناسبة. ويمكن للأموال العامة أن تفي بالتكاليف المتكررة للعاملين الصحيين في معظم البلدان المرتفعة الدخل والأخرى المتوسطة الدخل (بافتراض حدوث نمو مالي عادي والقدرة على تحديد الأولويات الصحية) (823). ويمكن لبعض البلدان المرتفعة الدخل والمتوسطة الدخل أن تسد النقص وتطلق العنان للطلب من خلال رفع القيود المفروضة على المعروض من العاملين الصحيين، مع تقليل الاعتماد المفرط على تنقل اليد العاملة الدولية والهجرة في الوقت نفسه. ينبغي أن يربط شركاء التنمية المساعدة الإنمائية . 571 الرسمية المقدمة لتعليم التمريض وفرص العمل في ذلك المجال بالقوى العاملة الصحية الوطنية واستراتيجيات القطاع الصحي. وستواجه بعض البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط تحديات تعوق توفير وظائف للتمريض بسبب عدم كفاية الحيز المالي. وتحقيق التواؤم والتنسيق في الدعم المقدم من الجهات المانحة والشركاء في التنمية من شأنهما توسيع نطاق uzimihS ihsoY/OHW © 58 التمويل المستدام اللازم لتعزيز القوى العاملة الصحية والاجتماعية مع ضمان إمكانية زيادة مخصصات الأجور واستدامتها لتسريع التقدم المحرز صوب تحقيق التغطية الصحية الشاملة (انظر الإطار 6-01 الذي يتناول الاستثمار في رأس المال البشري). ومتى كانت الموارد المحلية غير كافية على المديين المتوسط والطويل، كما هو الحال في البلدان المنخفضة الدخل وفي السياقات الهشة والمنكوبة بالنزاعات والضعيفة، ومتى سمحت ظروف تصريف الشؤون بذلك، يمكن النظر في إنشاء آليات من قبيل الترتيبات المؤسسية لتجميع الأموال. ينبغي للبلدان معالجة مسألة مقدار المكافآت التي . 671 ينبغي أن يحصل عليها كادر التمريض بالنظر إلى ظروف سوق العمالة المحلية والوطنية والدولية السائدة. وينبغي لراسمي السياسات والجهات التنظيمية، مثل الخدمة المدنية أو لجنة الخدمات الصحية، تجنب بعض المآزق النموذجية عن قصد. وقد يشمل ذلك الاستمرار في دفع مستويات أجور شديدة الانخفاض (وهو ما يمكن أن يؤدي إلى إلغاء التحفيز، والإفراط في تغيُّر العاملين واستراتيجيات المواجهة غير المشروعة)، أو شديدة الارتفاع (وهو ما يمكن أن يؤدي إلى تضخم الأجور وحدوث مشاكل في استدامة مخصصاتها)، أو إدامة الفوارق القائمة في الأجور بين الجنسين. ولطريقة دفع المكافآت أهمية كذلك: فعادة ما ُيدَفع لكادر التمريض دخل ثابت في شكل مرتب في معظم السياقات، ويكون الدخل الإطار 6.01 الاستثمار في رأس المال البشري بغية زيادة إتاحة خدمات الرعاية الصحية الأولية الجيدة، باعتبارها حجر الزاوية في تحقيق التغطية الصحية الشاملة، يلزم تخصيص استثمارات كبيرة للبنية التحتية (مثل المستشفيات والمراكز الصحية) ورأس المال البشري المرتبط بها (القوى العاملة الصحية، بما يشمل المعرفة والمهارات) (41، 823). ويركز عدد من مبادرات رأس المال البشري على مساعدة البلدان على تخصيص مزيد من الاستثمارات -مع مزيد من الفعالية- في شعوبها من أجل تحسين الحصائل في مجالات الصحة والتغذية والتعليم الجيد والمهارات. قطع البنك الدولي التزاما ًعلى نفسه باستثمار 51 مليار دولار أمريكي لدعم إصلاحات رأس المال البشري في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط، مع التركيز الخاص على أفريقيا؛ والتزمت 36 بلدا ًبأن تكون بلدانا ًتضم مشاريع في مجال رأس المال البشري. ويعزز صندوق النقد الدولي جميع البرامج من خلال مبادرة الإنفاق الاجتماعي بوصفها هدفا ًمن الأهداف الأساسية. وسيقدم مساعدة تقنية إضافية في مجالات الإنفاق الاجتماعي والحماية الاجتماعية والتعليم والصحة. وفي سياق التغطية الصحية الشاملة، يشترك بنك الاستثمار الأوروبي ومنظمة الصحة العالمية في برنامج عمل رأس المال البشري من خلال ابتكار أداة مالية تربط استثمارات بنك الاستثمار الأوروبي بالدعم المحدد الأهداف الموجه إلى التعليم والمهارات والوظائف في قطاع الصحة. وأنشأت منظمة التعاون والتنمية في الميدان الاقتصادي ومنظمة الصحة العالمية ومنظمة العمل الدولية الصناديق الاستئمانية المتعددة الشركاء التابعة للأمم المتحدة لتجميع الموارد اللازمة لتنفيذ التوصيات المقدمة من الهيئة الرفيعة المستوى المعنية بالعمالة في مجال الصحة والنمو الاقتصادي المتعلقة بالتعليم التحويلي والمهارات وإيجاد فرص العمل. حالة التمريض في العالم عام 020268 الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض المحصل من خلال الممارسة المزدوجة أقل أهمية مقارنة بالفئات المهنية الأخرى. وينبغي إيلاء الاهتمام لتجنب العيوب المعروفة للحوافز الإضافية التي ُتمنح في حالات أمراض أو برامج بعينها، حيث إنها تسبب الارتباك في الأولويات الوطنية ولا تميل إلى أن تكون ذات طبيعة مستدامة. وينبغي لراسمي السياسات النظر أيضًا في تماسك المكافآت في جميع المهن الصحية من أجل تجنب خلق مثبطات تثني عن اختيار مهنة التمريض، على سبيل المثال. وفي نهاية المطاف، ينبغي أن يحصل كادر التمريض على مكافآت بمستوى يجذبهم ويحقق استبقاءهم وتحفيزهم بما يكفي لتلبية احتياجات البلد. 6 6 برنامج عمل البحوث والبينات عرض هذا التقرير ذخيرة غير مسبوقة من البيانات . 771 ونظرة عامة على البينات البحثية المتوافرة عن القوى العاملة في مجال التمريض، وهو ما سمح بوضع الخيارات السياساتية كي تنظر فيها الدول الأعضاء وأصحاب المصلحة الآخرون. وفي الوقت نفسه، تأثر وضعها بالعديد من القيود في كل من البيانات والبينات المتوافرة عن الفعالية. وفيما يلي سرد للفجوات الرئيسية التي حددناها ويمكن اعتبارها جزءًا من جدول أعمال الأبحاث الاستشرافية. بينات التمريض الكمية وشبه الكمية. أحد . 871 الاستنتاجات التي خلص إليها تقرير حالة التمريض في العالم 0202 ليس مستمدًا من البيانات، بل إنه عن البيانات. فثمة فجوات كبيرة ومهمة في المعلومات اللازمة لفهم القوى العاملة في مجال التمريض بطريقة شاملة وإجراء تحليل سوق العمالة الصحية، لاسيما فيما يتعلق بالقدرة الإنتاجية والخروج من الخدمة ومستويات الأجور والاستيعاب في سوق العمالة الصحية. ويجب تعزيز أنظمة الدعم التي يقوم عليها جمع هذا النوع من البينات وتحليله واستخدامه. واستخدام الحسابات، الذي يعتمد على المشاركة القوية بين القطاعات، يمكن أن يدعم حوار السياسات واتخاذ القرارات المتعلقة بالاستثمارات المخططة والمستدامة اللازمة لتحفيز التقدم في المجالات الرئيسية للتمريض. البينات المتوافرة عن فعالية القوى العاملة في مجال . 971 التمريض في الرعاية الصحية الأولية والتغطية الصحية الشاملة. لخص هذا التقرير البينات المتوافرة عن مساهمة كادر التمريض في مختلف التدخلات السريرية ومجالات الصحة العمومية. وأقوى بينات مستمدة من استعراض منهجي شمل 81 تجربة عشوائية ذات أهداف محددة أظهرت فعالية التدخلات التي يقودها كادر التمريض عبر مجموعة من وظائف الرعاية الأولية (03). ومع ذلك، ُأجريت 71 من أصل 81 دراسة في البلدان المرتفعة الدخل، إلى جانب واحدة فقط واردة من بلد متوسط الدخل مع عدم ورود أي منها من البلدان المنخفضة الدخل. وُأجري أيضًا مزيد من استعراضات كوكرين وكامبل في مجالات سريرية أو برنامجية محددة، بما في ذلك العلاج المضاد للفيروسات القهقرية، والإقلاع عن تعاطي التبغ، والصحة النفسية، وفحص الاعتداءات الجنسية. ومن بين هذه الاستعراضات، لم يتشمل سوى واحد على تجارب عشوائية موجهة، في حين شملت التجارب الأخرى ُكًلا من الدراسات التجريبية وشبه التجريبية، بما في ذلك التجارب الموجهة (العشوائية أو غير العشوائية)، والموجهة قبل الدراسات وبعدها، ودراسات الأتراب (المحتملين أو بأثر رجعي)، ودراسات السلاسل الزمنية المتقطعة، وهو ما يمكن من عقد المقارنة بين التدخل والتوجيه (13، 33، 43). وقد ركز استعراض كامبيل على الممارسات السائدة في الولايات المتحدة والمملكة المتحدة، ومن ثم، اقتصر على دراسات واردة من تلك البلدان. وشمل الاستعراض المتعلق بالعلاج المضاد للفيروسات القهقرية دراسات واردة من أفريقيا فحسب. وكانت جميع الدراسات التي شملها الاستعراض وتتناول الإقلاع عن تعاطي التبغ واردة من بلدان مرتفعة الدخل، ومعظمها واردة من الولايات المتحدة. ولم يركز استعراض الصحة النفسية إلا على البلدان المنخفضة الدخل والأخرى المتوسطة الدخل، بما في ذلك سبع دراسات واردة من بلدان منخفضة الدخل و51 دراسة واردة من بلدان منخفضة الدخل وأخرى متوسطة الدخل (13، 33، 43). وتسلط النظرة العامة الضوء أيضًا على الفجوات المحددة في البينات المتعلقة بالفعالية، مثل فعالية التدخلات التمريضية إزاء المحددات الاجتماعية للصحة، بما في 78 ذلك تغيُّر المناخ، والتدخلات التمريضية في حالات الطوارئ المعقدة. الاستفادة من مختلف بيئات البحث ومنهجياته. . 081 لئن كانت استعراضات البينات المذكورة أعلاه ضرورية لإثبات فعالية التدخلات التمريضية، فإن تحديد الدراسات المشمولة يحد من قابليتها للتعميم وتطبيقها عالميًا. وعلاوة على ذلك، كثيرًا ما قارنت الاستقصاءات التجريبية وشبه التجريبية كادر التمريض بالمهنيين الصحيين الآخرين. وعلى الرغم من أن هذا قد يوفر رؤى مفيدة، فالطريقة غير مناسبة لتوضيح وفهم الطبيعة الجماعية للجهود والعمليات المترابطة اللازمة لإنجاح تقديم الرعاية الصحية الجيدة. وتوفر مجموعة واسعة من الدراسات، التي تضم الدراسات الأولية الكمية (التجريبية وغير التجريبية) والنوعية، واستعراضات الأساليب المختلطة، ووصف المجال، نظرة عامة أكثر شموًلا على قضايا سياسة التمريض في جميع أنحاء العالم (انظر الملحق المنشور على شبكة الإنترنت). ومع ذلك، أنتج معظم هذه البينات في مرافق البلدان المرتفعة الدخل (03، 923)، بما في ذلك تحديد أولويات البحوث (033). ويجب الاضطلاع بمزيد من العمل لدعم توثيق . 181 التدخلات التمريضية في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل ودعم علوم التمريض في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل، حتى يتسنى لأفراد كادر التمريض أنفسهم تولي زمام القيادة في خطط أبحاثهم بناء على خبرتهم التي اكتسبوها في العمل في تقديم الخدمات الصحية. ويقدم كادر التمريض بالفعل إسهامًا كبيرًا في علوم الرعاية الصحية، بما في ذلك تطوير أساليب بحثية مبتكرة واستخدام هذه الطرق لاستكشاف القضايا ذات الأهمية لتحسين الصحة العالمية (133). وقد أظهرت البحوث أن جودة البينات المتوافرة بشأن الاستراتيجيات الفعالة الرامية إلى تحسين ممارسات العاملين الصحيين في البلدان المنخفضة الدخل والأخرى المتوسطة الدخل uzimihS ihsoY/OHW © حالة التمريض في العالم عام 020288 جودة متدنية (233). ولذلك، يجب ألاَّ يركز الاستثمار في الأبحاث التمريضية على زيادة كمية المخرجات فحسب، بل أيضًا على زيادة جودة العلوم، حيث سيساهم ذلك في إثراء معرفتنا الشاملة بالقوى العاملة الصحية. البينات المتوافرة عما يلزم لتحسين دور التمريض . 281 من سياسات فعالة ودعم للنُّظم. أبرز هذا التقرير البينات المتوافرة عن فعالية الخيارات السياساتية اللازمة لتحسين مساهمة التمريض وأثره، بما في ذلك مجالات متنوعة مثل التعليم والتنظيم والنشر على مراكز العمل والممارسة والاستبقاء. وفي الوقت نفسه، كانت البينات المتوافرة عن المجالات الأخرى أقل قوة. فعلى سبيل المثال، يمكن تحسين فهم العائد على الاستثمارات في التمريض والقوى العاملة الصحية الأوسع نطاقًا وينبغي دراسته في مجموعة متنوعة من البيئات وسياقات السياسات، بوسائل منها الدراسات التي ُتجرى عن مردودية رعاية التمريض، وخاصة في مرافق الرعاية الصحية الأولية في المناطق المنخفضة والأخرى المتوسطة الدخل. وهناك أيضًا مجال لتعزيز البينات المتوافرة عن فعالية التدخلات السياساتية لاستبقاء كادر التمريض في بيئات الممارسة والنهوج التنظيمية ونهوج تصريف الشؤون اللازمة لتمكين كادر التمريض من استخدام كامل طاقته في تقديم خدمات الرعاية الصحية الأولية، والآليات الفعالة اللازمة لتنظيم التعليم والممارسة في القطاع الخاص. ومن شأن إجراء تقييم أكثر قوة للسياسات الرامية إلى معالجة الآثار السلبية للهجرة أن يتيح تصميمًا أفضل واستهدافًا أكثر واقعية للاستجابات السياساتية. وفي جميع هذه المجالات، ينبغي استخدام منظور جنساني واضح في التحليل. ونظرًا إلى أن معظم الدراسات التي اسُتعرضت لها أفق زمني قصير عادة، فقد تساعد الدراسات الطولية الطويلة الأجل في إيجاد مستوى أرفع من الثقة في مدى ملاءمة الاستنتاجات لظروف السياسات الواقعية. 98الاتجاهات المستقبلية لسياسات القوى العاملة في مجال التمريض © AKDN/Christopher Wilton-Steer 902020 ماع ملاعلا يف ضيرمتلا ةلاح الخلاصة أكد تقرير حالة التمريض في العالم لعام 0202 . 381 محورية كادر التمريض في إطار الأفرقة المتكاملة المكلفة بتقديم مساهمات حيوية صوب تحقيق التغطية الصحية الشاملة وغيرها من الأغراض الصحية الوطنية والعالمية. ويمثل كادر التمريض أكبر فئة مهنية، حيث ُقدِّر عدد أفراده في عام 8102 بنحو 82 مليون نسمة، وهو ما يمثل عنصرًا رئيسيًا في أنظمة الرعاية الصحية الأولية والنظم الصحية في البلدان أيًا كان مستوى التنمية الاجتماعية الاقتصادية فيها. والبيانات والبينات المجمعة في سبيل إعداد هذا . 481 التقرير أقوى الآن من أي وقت مضى. وقد أبلغ ما مجموعه 191 بلدًا برصيد القوى العاملة - حيث بلغ أعلى مستوى له على الإطلاق، وبحدوث زيادة بنسبة 35٪ مقارنة بأحدث ببيانات القوى العاملة الصحية الصادرة في عام 8102. وللمرة الأولى، زودت 08٪ من البلدان منظمة الصحة العالمية ببيانات وفقًا لما لا يقل عن 51 مؤشرًا تتعلق بالتمريض تغطي أبعادًا مختلفة من سياسة القوى العاملة. ويشير تحليل اتجاهات بيانات الرصيد إلى أن ثمة نقصًا قدره 9.5 ملايين ممرض وممرضة في عام 8102 يتركز تركزًا أساسيًا في الإقليم الأفريقي وإقليمي جنوب شرق آسيا وشرق المتوسط. ويدل هذا على حدوث تحسن في رصيد القوى العاملة في مجال التمريض في البلدان المتضررة من النقص، مقارنًة بالوضع المرجعي الذي حددته الاستراتيجية العالمية. ورغم علامات التقدم، أبرز التقرير كذلك المواضع . 581 الرئيسية التي تثير القلق. فتمشيًا مع التوقعات التي وردت في الاستراتيجية العالمية في عام 6102، سيكون من اللازم تسريع وتيرة التقدم المحرز في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط والإقليم الأفريقي وإقليم شرق المتوسط من أجل سد الفجوات الرئيسية. ومازال إقليم جنوب شرق آسيا يستأثر بأكبر نصيب من النقص في الأعداد المطلقة. ويواجه إقليم الأمريكتين والإقليم الأوروبي تهديدًا إضافيًا في ضوء تقدُّم قواهما العاملة في مجال التمريض في العمر. ويبدو أن العديد من البلدان المرتفعة الدخل في إقليم الأمريكتين والإقليم الأوروبي وإقليم شرق المتوسط يعتمد اعتمادًا مفرطًا على تنقل كادر التمريض على المستوى الدولي. الخلاصة 7 الفصل 19 uzimihS ihsoY/OHW © دعونا نغتنم هذه الفرصة لقطع الالتزام بجعل هذا العقد عقد عمل يبدأ بالاستثمار في التمريض من حيث التعليم والوظائف والمهارات القيادية. وينبغي للحكومات الوطنية، بدعم من شركائها . 681 المحليين والدوليين، عند الاقتضاء، أن تحفز على تسريع وتيرة الجهود المبذولة من أجل ما يلي وأن تتولى زمام قيادتها: بناء القدرات القيادية والإشرافية والإدارية للمضي قدمًا ببرامج العمل المتعلقة بالتعليم والصحة والعمل ونوع الجنس فيما يتصل بالقوى العاملة في مجال التمريض؛ تحسين عائد الاستثمارات الحالية في مجال التمريض من خلال اعتماد الخيارات السياساتية المطلوبة في القوى العاملة في مجال التمريض من حيث التعليم والعمل اللائق والنشر على مراكز العمل والممارسة والإنتاجية والتنظيم والاستبقاء؛ تخصيص استثمارات ضخمة في القوى العاملة الصحية، وفي كادر التمريض في هذا الإطار، والاستفادة منها لتحقيق حصائل التنمية المتعددة، بما في ذلك إيجاد فرص العمل والتمكين الجنساني وتمكين الشباب. وستتطلب ترجمة البينات الواردة في هذا التقرير . 781 والخيارات السياساتية الموصى بها فيه والتوجهات الاستراتيجية المبينة أعلاه إلى قرارات ملموسة في مجالي السياسات والاستثمار تنسيقا ًبين القطاعات الحكومية وتعاونا ًمع أكثر أصحاب المصلحة أهمية. وينبغي استخدام الاستنتاجات والبيانات المطروحة لإطلاق فرص إجراء حوار حول السياسات في البلدان التي تضم أهم أصحاب المصلحة. وينبغي الاستفادة من آليات حوار السياسات هذه لاستنباط القرارات المطلوبة من حيث اعتماد سياسات سليمة ومسترشدة بالبينات وتخصيص الاستثمارات بالمستويات الملائمة. عجارملا عجارملا 1. 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Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x)18(30398-x. عجارملا107 الملحق 1- ما تعريف الممرض؟ يقدم أفراد كادر التمريض مجموعة واسعة من الخدمات للأشخاص في جميع مرافق الرعاية الصحية، من المستشفيات المتخصصة إلى المراكز الصحية والمجتمعات المحلية. ويحمل هؤلاء الأفراد طائفة متنوعة من المسميات الوظيفية ويؤدون مختلف الأدوار ويسلكون مختلف المسارات التعليمية. وأكثر المسميات الوظيفية الستة شيوعًا في مجال التمريض هي الممرض/ الممرضة المسجلة، والممرض/ الممرضة، والممرض/ الممرضة المسجلة ذات أدوار الممارسة المتقدمة، والممرض/ الممرضة الُمماِرسة، والممرض/ الممرضة المساِعدة. ومع ذلك، قد يختلف دور الفرد في بلد ما عن دوره في بلد آخر، حتى لو كان يحمل المسمى الوظيفي نفسه. وهذا يجعل استخدام المسمى الوظيفي بوصفة أسلوبًا للتصنيف والتحليل على المستوى الدولي غير مناسب. ويهدف هذا التقرير إلى تقديم أفضل البيانات المتاحة والقابلة للمقارنة دوليًا عن القوى العاملة في مجال التمريض، على النحو الُمعرَّ ف في التصنيف الدولي الموحد للمهن 8002 الذي تعده منظمة العمل الدولية، وحسبما تبلغ به وتتحقق منه الدول الأعضاء في منظمة الصحة العالمية. وبغية المساعدة في تحقيق هذا الهدف، تستخدم حسابات القوى العاملة الصحية الوطنية نظام التصنيف الدولي لعام 8002 لتصنيف القوى العاملة الصحية. وقد ُطلب إلى البلدان تصنيف القوى العاملة في مجال التمريض بها إلى واحد من اثنين من رمزي التصنيف الدولي لعام 8002: أخصائي التمريض (الرمز 1222) ومعاون أخصائي التمريض (الرمز 1223). وتجدر الإشارة إلى أن هذا الفرع يتضمن معلومات عن أفراد كادر التمريض بوصفهم يشكلون فئة مهنية محددة أعلاه، ولكن تجدر الإشارة إلى أن "الرعاية التمريضية"، التي تضع أفراد كادر التمريض داخل نظام صحي متعدد التخصصات، تنطوي على العديد من المهن الأخرى غير المذكورة في هذا الفرع. فعلى سبيل المثال، يصنف التصنيف الدولي ونظام البلد الذي يتبع ذلك التصنيف "مساعد الممرض" على أنه مساعد رعاية صحية، وهي فئة دعم مهني أوسع نطاقًا.21 وتوفر إرشادات التصنيف الدولي وصفًا مفصًلا ينبغي بموجبه أن يدرج العاملون الصحيون تحت كل فئة (الإطار (أ)1-1). وبإيجاز، يتحمل أخصائيو التمريض المسؤولية عن تخطيط الرعاية التمريضية للمرضى وإدارتها، والعمل على نحو مستقل أو ضمن أفرقة مع الأطباء وغيرهم. ويوفر معاون أخصائي التمريض خدمة التمريض الأساسية والرعاية الشخصية، ويعمل عمومًا تحت إشراف الأخصائيين الطبيين أو أخصائيي التمريض أو غيرهم من الأخصائيين الصحيين أو بدعم منهم. ومع ذلك، في بعض البلدان، يتسم التمييز بين أخصائيي التمريض ومعاونيهم بعدم الوضوح. وكذلك، لا يتسم التمييز بين معاوني أخصائيي التمريض ومساعدي التمريض بالوضوح دائمًا. ولذلك، في هذه الحالات، كان على أصحاب المصلحة الوطنيين أن يقدروا الفرق. وقد ُنصحت البلدان بالنظر في كل من الأدوار والمسؤوليات ومدة التعليم السابق للخدمة عند تقرير ما إذا كان ينبغي تصنيف فئة مهنية على أنها فئة أخصائيين أو فئة معاونين، أو ليست من كادر التمريض على الإطلاق. فعلى سبيل المثال، القاعدة العامة هي أن يكون أخصائي التمريض قد أتم دورة تعليم سابقة للخدمة تستغرق ثلاث سنوات على الأقل. وفي حالة عدم قدرة أي بلد على تحديد الفئة التي يجب استخدامها، تتضمن حسابات القوى العاملة الصحية الوطنية خيار "ممرض/ ممرضة: ليس له تعريف آخر"، واختارت بعض البلدان وضع بعض القوى العاملة في مجال التمريض أو جميعها في هذه الفئة. وتقاِبل هذه الفئة إما أخصائيي التمريض وإما معاونيهم، ولكنها تستثني مساعدي التمريض الذين ينتمون إلى الفئة المهنية التي تضم مساعدي الرعاية الصحية، ولم يتناولها هذا التقرير بالتحليل. 21 /ocsi/tats/uaerub/hsilgne/cilbup/gro.oli.www//:sptth :snoitapuccO fo noitacfiissalC dradnatS lanoitanretnI OLI. حالة التمريض في العالم عام 0202801 الملحق -1 ملحوظة: ينبغي التمييز بين أخصائيي التمريض ومعاونيهم على أساس طبيعة العمل المنجز فيما يتعلق بالمهام المحددة أعلاه. والمؤهلات التي يحملها الأفراد أو السائدة في البلد ليست العامل الرئيسي في هذا التمييز، حيث يختلف التدريب الذي يحصل عليه كادر التمريض اختلافًا كبيرًا باختلاف البلدان وباختلاف الوقت الذي حصل عليه فيه داخل البلد الواحد. المصدر: مقتبس من التصنيف الدولي الموحد للمهن لعام 8002. الإطار (أ) 1.1 تعريفات التصنيف الدولي الموحد للمهن لأفراد كادر التمريض تشمل المهام المهنية لمعاون أخصائي التمريض ما يلي:تشمل المهام المهنية لأخصائي التمريض ما يلي: تخطيط الرعاية التمريضية للمرضى وتوفيرها وتقييمها تنسيق رعاية المرضى بالتشاور مع غيرهم من الأخصائيين الصحيين وضع وتنفيذ خطط الرعاية لعلاج المرضى بالتعاون مع غيرهم من الأخصائيين الصحيين تخطيط وتوفير الرعاية الشخصية والعلاجات والمعالجات، بما في ذلك إعطاء الأدوية ورصد الاستجابات للعلاج أو الرعاية تنظيف الجروح ووضع الضمادات رصد الألم والتململ لدى المرضى وتخفيف الألم باستخدام المعالجات، بما في ذلك الأدوية المسكنة للألم تخطيط برامج التثقيف الصحي والترقيات الصحية وأنشطة تعليم الممرضين والممرضات والمشاركة فيها الإجابة عن أسئلة المرضى والأسر وتقديم معلومات عن الوقاية من اعتلال الصحة والعلاج والرعاية الإشراف على عمل العاملين الصحيين الآخرين وتنسيقه إجراء البحوث على الممارسات والإجراءات المتصلة بالتمريض تقديم خدمات التمريض والرعاية الشخصية والعلاج والمشورة الصحية للمرضى وفقًا لخطط الرعاية التي وضعها الأخصائيون الصحيون إعطاء الأدوية وغيرها من العلاجات للمرضى، ورصد حالة المرضى واستجاباتهم للعلاج، وإحالة المرضى وأسرهم إلى أخصائي صحي للحصول على رعاية متخصصة حسب الحاجة تنظيف الجروح ووضع الضمادات تحديث المعلومات المتعلقة بحالة المرضى والعلاجات الواردة في نظم حفظ السجلات المساعدة في تخطيط رعاية المرضى الأفراد وإدارتها المساعدة في إعطاء علاج الإسعافات الأولية في حالات الطوارئ 901 الملحق 2- الأساليب المؤشرات المستخدمة في تقرير حالة التمريض في العالم لعام 0202 ُدعيت الدول الأعضاء في منظمة الصحة العالمية إلى أن تقدم، اعتبارًا من تموز/ يوليو 9102 إلى تشرين الثاني/ نوفمبر 9102، أحدث البيانات المتاحة عن القوى العاملة في مجال التمريض وفقًا لـ 63 مؤشرًا، هي 03 مؤشرًا من حسابات القوى العاملة الصحية الوطنية و6 مؤشرات محددة إضافية (انظر القائمة الواردة في الجدول (أ) 2-1). والمؤشرات الثلاثون ُمعرَّ فة في كتيب حسابات القوى العاملة الصحية الوطنية،31 الذي يعرض أيضًا تعريفات وبيانات وصفية تفصيلية عن كل مؤشر. عملية جمع البيانات حسابات القوى العاملة الصحية الوطنية عملية مستمرة تؤدي إلى تحسين تدريجي في توافر بيانات القوى العاملة الصحية وجودتها واستخدامها. في إطار هذه العملية، ُشجعت البلدان على تشكيل مجموعات عمل لأصحاب المصلحة المتعددين حول جميع الجوانب المتعلقة ببيانات القوى العاملة الصحية لإجراء التحقق الداخلي قبل تقديم البيانات؛ وقد ُنفذ ذلك في عدد كبير من البلدان. وأدى إعداد تقرير حالة التمريض في العالم لعام 0202 إلى تسريع هذا الجهد العالمي الرامي إلى تحسين رصد البيانات الموحدة والإبلاغ بها. وُطلب إلى البلدان تعيين مراكز الاتصال، التي أتيح لها دخول الحسابات عبر الإنترنت لإدخال البيانات أو التحقق من صحتها. وإضافة إلى ذلك، ُأدخلت سلفًا البيانات الخاصة ببلدان منظمة التعاون والتنمية في الميدان الاقتصادي المستقاة من استبيان جمع البيانات المشترك بين منظمة التعاون والتنمية والمكتب الإحصائي للاتحاد الأوروبي والمكتب الإقليمي لأوروبا التابع لمنظمة الصحة العالمية لتجنب ازدواجية جهود إبلاغ المنظمات الدولية، ونصحت مراكز الاتصال باستعراض البيانات والتحقق من صحتها. واستخرج عدد السكان لكل بلد وسنة من تقرير التوقعات السكانية في العالم، في نسخته المحققة لعام 9102، الذي أصدرته إدارة الشؤون الاقتصادية والاجتماعية التابعة للأمم المتحدة.41 وجمعت أيضًا بيانات إضافية عن مؤشرات تقييم تصريف الشؤون وبيئة السياسات من خلال أسئلة ثنائية الإجابة (نعم/ لا) عن وجود الآليات والعمليات ذات الصلة، وكذلك عن مدة التعليم والتدريب، من قواعد بيانات سيغما والمجلس الوطني لهيئات التمريض الحكومية51 لإكمال المعلومات المتعلقة بعدد صغير من البلدان. وبغية دعم عملية جمع البيانات، نظمت منظمة الصحة العالمية حلقات عملية إقليمية عن الحسابات في جميع الأقاليم الستة، وقدمت أدوات ومعلومات بعدة لغات. وإجماًلا، حضر أكثر من 052 ممثًلا من حوالي 08 بلدًا فعاليات بناء القدرات هذه. وُقدمت البيانات في الفترة بين تموز/ يوليو وتشرين الثاني/ نوفمبر 9102، وُأجريت عمليات تنقية البيانات وتحليلها بين تشرين الأول/ أكتوبر وكانون الأول/ ديسمبر 9102. ويستند هذا التقرير إلى مجموعة البيانات المستقاة من منصة الحسابات المتوافرة عبر الإنترنت حتى 71 كانون الأول/ ديسمبر 9102. وقد ُنِصحت مراكز الاتصال المعنية بالحسابات بإشراك قادة التمريض والجهات الوطنية صاحبة المصلحة الأخرى. ودعمت المكاتب القطرية والإقليمية التابعة لمنظمة الصحة العالمية عملية التنفيذ والإبلاغ المتعلقة بالحسابات، بما في ذلك جمع البيانات ذات الصلة والإبلاغ بها والتحقق من صحتها. البيانات المبلغ بها أبلغت 391 دولة، من الدول الأعضاء في منظمة الصحة العالمية البالغ عددها 491 دولة، ببيانات (حيث أبلغت 191 دولة منها بالرصيد) إما مباشرة من خلال منصة الحسابات وإما من خلال المكاتب الإقليمية وغيرها من العمليات الدولية مثل منظمة التعاون والتنمية في الميدان الاقتصادي والمكتب الإحصائي للاتحاد الأوروبي والمكتب الإقليمي لأوروبا التابع لمنظمة الصحة العالمية عن إحصاءات الرعاية الصحية غير النقدية. ويوضح الشكل (أ)2-1 أن ٪08 من البلدان قدمت بيانات من خلال ما لا يقل عن 51 من 63 مؤشرًا مختارًا، و٪32 من البلدان فعلت ذلك من خلال ما لا يقل عن 52 مؤشرًا. كانت الفجوات الرئيسية في البيانات تتعلق بالمؤشرات المتصلة بالأجور والإنفاق على تعليم التمريض والقضايا الأخرى المتعلقة بالتعليم. وفيما يخص المؤشرات المختارة، ُحددت مصادر بديلة لاستكمال بيانات الحسابات، مثل مدة التعليم والتدريب والأجور ومؤشرات القدرات. فعلى سبيل المثال، تدير الجمعية الدولية للتمريض (سيغما) قاعدة بيانات عن حالة تعليم التمريض على الصعيد العالمي، بما في ذلك المؤشرات المتعلقة بأجور 31 8102 ;noitazinagrO htlaeH dlroW :aveneG .ediug noitatnemelpmi :stnuoccA ecrofkroW htlaeH lanoitaN. 41 ,kroY weN .1 noisiver ,noitide enilno ,9102 stcepsorp noitalupop dlroW .noisiviD noitalupoP dna sriaffA laicoS dna cimonocE fo tnemtrapeD 9102 ;snoitaN detinU :aciremA fo setatS detinU. 51 بيانات سيغما المستخرجة من: secruoser-hcraeser/hcraeser/etavele-ecnavda/gro.gnisrunamgis.www//:sptth. واستخرجت بيانات المجلس الوطني لهيئات التمريض الحكومية من العنوان الإلكتروني التالي: mth.esabatad-gnisrun-lanoitan/gro.nbscn.www//:sptth. حالة التمريض في العالم عام 0202011 استمدت ثلاثون مؤشرًا من كتيب الحسابات وصممت ستة مؤشرات خصيصًا في سبيل إعداد هذا التقرير. اسم المؤشر (المختصر المستخدم في الحسابات) الرقم المستخدم في الحسابات معدل الإجابة حتى 71 كانون الأول/ ديسمبر 9102 رصيد القوى العاملة في مجال التمريض وتوزيعها 89%10-1كثافة كادر التمريض حسب نوع/ مستوى الفرد 13%20-1كثافة كادر التمريض على المستوى دون الوطني 55%30-1توزيع كادر التمريض حسب الفئة العمرية 86%40-1القوى العاملة من الممرضات 74%50-1توزيع كادر التمريض حسب ملكية المرفق 43%60-1توزيع كادر التمريض حسب نوع المرفق 53%70-1حصة أفراد كادر التمريض المولودين في الخارج 64%80-1حصة أفراد كادر التمريض المدربين بالخارج 88%10-2القائمة الرئيسية التي تضم المؤسسات التعليمية المعتمدةالتعليم والتدريب 65%20-2مدة التعليم والتدريب 21%30-2عدد طلبات التعليم والتدريب 01%50-2نسبة طلاب التمريض إلى المعلمين المؤهلين 78%10-3معايير مدة التعليم ومحتواهتنظيم التعليم والتدريب واعتمادهما 48%20-3آليات اعتماد المؤسسات التعليمية 08%60-3معايير التعليم المتعدد التخصصات 28%80-3التطوير المهني المستمر 7%50-4الإنفاق على تعليم التمريض لكل خريجماليات التعليم 41%10-5الخريجون الذين يبدؤون الممارسة في غضون سنة واحدةتدفقات سوق العمالة الصحية 54%20-5معدل التجديد بفضل الجهود المحلية 11%30-5معدل دخول أفراد كادر التمريض الأجانب 9%40-5معدل الخروج الطوعي من سوق العمالة الصحية 8%60-5معدل البطالة 6%20-6العاملون الصحيون المشتغلون بعقد بدوام جزئيسمات الوظيفة وشروط العمل 68%30-6أحكام تنظيمية لساعات العمل وشروطه 68%40-6أحكام تنظيمية للحد الأدنى للأجور 68%50-6أحكام تنظيمية للحماية الاجتماعية 08%90-6تدابير لمنع الاعتداءات على العاملين الصحيين 24%50-7مستوى الأجور والمرتبات على مستوى المبتدئينالإنفاق على القوى العاملة ومكافآتها 3%70-7الفجوة في الأجور بين الجنسين 97%60-8وجود أدوار تمريضية متقدمةتكوين مزيج المهارات حسب نماذج الرعاية مؤشرات محددة لتقرير حالة التمريض في العالم لعام 0202 48%–منصب كبير مسؤولي التمريض و/ أو القبالة في الحكومة 67%–برامج تطوير القيادة التمريضية 67%–الرابطة الوطنية للشباب والمبتدئين في مجال التمريض 89%–مجلس التمريض 86%–معايير مؤهلات هيئة التدريس 29%–امتحان اللياقة للممارسة الجدول (أ) 2.1 قائمة تضم 63 مؤشرا ًمستخدما ًلإعداد تقرير حالة التمريض في العالم لعام 0202 ملحوظة: للاطلاع على مزيد من المعلومات عن مؤشرات حسابات القوى العاملة الصحية الوطنية، تتوافر معلومات مفصلة مع البيانات الوصفية في كتيب الحسابات: /ne/koobdnah_awhn_feirb/stnemucod/hrh/tni.ohw.www//:sptth . والبيانات الوصفية الخاصة بالمؤشرات الستة الأخرى غير الخاصة بالحسابات متاحة عند طلبها بتوجيه رسالة إلى العنوان التالي: tni.ohw@0202NWOS. 111الملحق -2 المبتدئين ومدة البرنامج التعليمي لنحو 05 بلدًا إضافية. وفيما يخص مجموعة المؤشرات الثنائية ذات الصلة بسياسات ونظم ممارسة التمريض وتعليمه، اسُتخدم الأطلس التنظيمي العالمي لتحديد المكان الذي يشترط فيه الخضوع لامتحان قبل الحصول على الترخيص وأين توجد الهيئات التنظيمية. قدمت نسبة بلغت ٪38، من 191 بلدًا، بيانات عن عدد الموظفين اعتبارًا من عام 7102 أو عام 8102. وتمكنت بلدان أخرى من تقديم بيانات من السنوات السابقة (من عام 3102 إلى عام 6102) فحسب. وفي مثل هذه الحالات، ُقدر عدد العاملين في عام 8102 من خلال تطبيق كثافة أحدث الأعوام على عدد السكان في عام 8102. وفيما يخص أربعة بلدان لم ُيبلغ بعدد الموظفين فيها، طبقت الكثافة الإقليمية المقابلة على عدد سكانها في عام 8102. وتشير الحقيقة التي مفادها أن العديد من البلدان -خاصًة في غرب أفريقيا ووسطها ووسط آسيا- كانت غير قادرة على تقديم بيانات وفقًا لعدة مؤشرات إلى أن ثمة حاجة ماسة للغاية إلى مواصلة تعزيز الموارد البشرية في نظم المعلومات الصحية في هذه المناطق. ولا يعرض هذا التقرير جميع البيانات التي ُجِمعت: حيث إنه لم يحلل ويعرض سوى المؤشرات التي أبلغ عدد كبير من البلدان بالبيانات وفقًا لها. وسُتقدم بيانات إضافية تدريجيًا من خلال بوابة عامة تتيح الاطلاع على بيانات الحسابات. التقييم الُمركَّ ب لتنظيم التعليم وشروط العمل في الفرعين 4 5 و6 5 لئن كانت معظم التحليلات وصفية بحتة بحكم طبيعتها، حيث تركز تركيزًا أساسيًا على النسب المئوية، فقد استخدمت التقييمات المركبة لتلخيص مؤشرات تنظيم التعليم وشروط العمل. وفي كلا التقييمين، منح البلد نقطة واحدة لكل مؤشر كانت الإجابة عليه بـ «نعم»، و5.0 نقطة إذا كانت الإجابة «جزئيًا»، وصفر إذا كانت الإجابة بـ «لا»، ثم ُجِمعت الدرجات للتوصل إلى تقييم ُمركَّب. ومن ثم، كانت النتيجة القصوى الممكنة 9، وكان الحد الأدنى صفرًا. وفيما يخص المؤشرات التي تفتقر إلى المعلومات، اعُتبر المؤشر «لا»، ومن ثم، كانت نقاطه صفرًا. تحليل التناظر المتعدد لتنظيم التعليم وشروط العمل في الفرعين 4 5 و6 5 ُتظِهر المؤشرات المتعلقة بتنظيم التعليم وممارسته مستوى عاليًا من الارتباط: ففي حالة الإجابة على أحدها بـ «نعم»، من المحتمل أن يكون الرد على بعضها الآخر بـ «نعم». وبغية تحسين فهم هذه الأنماط، ُأجرى تحليل التناظر الشكل (أ)2.1 عدد المؤشرات المبلغ وفقا لها ًعالميا ًفي سبيل إعداد تقرير حالة التمريض في العالم لعام 0202 005000,4 000,3 000,2 000,1 0 +52 من 02 إلى 42 من 51 إلى 91 من 01 إلى 41 من 5 إلى 9 5 =< mk لم یبلغ عنھا لا ینطبق ملاحظة: يتضمن 03 مؤشرًا من مؤشرات حسابات القوى العاملة الصحية الوطنية وستة أسئلة عن القدرات. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. حالة التمريض في العالم عام 0202211 نوع التحليل: تحليل التناظر المتعدد للمتغيرات المتعلقة بتنظيم منظومة تعليم التمريض؛ والأقاليم معروضة في شكل متغيرات مستقلة. ويرد ملخص المتغيرات في هذا الرسم البياني: 2M-10: القائمة الرئيسية التي تضم مؤسسات التعليم المعتمدة؛ 3M-10: معايير مدة التعليم ومحتواه؛ 3M-20: آليات اعتماد المؤسسات التعليمية؛ 3M-60: معايير التعليم المتعدد التخصصات؛ 3M-80: التطوير المهني المستمر؛ 8M-60: الأدوار التمريضية المتقدمة؛ 2NN: امتحان اللياقة للممارسة؛ 3NN: معايير مؤهلات أعضاء هيئة التدريس. RFA = الإقليم الأفريقي؛ RMA = إقليم الأمريكتين؛ RAES = إقليم جنوب شرق آسيا؛ RUE = الإقليم الأوروبي؛ RME = إقليم شرق المتوسط؛ RPW = إقليم غرب المحيط الهادئ. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث البيانات المتاحة التي أبلغت بها البلدان بين عامي 3102 و8102 RAES RUE RMA RME RFA RPW � � � � � �- �- �- �- �- �- �-� � � � � � ��-�M-oN ��-�M-oN لا-2NNلا-10-3M لا-3NN لا-80-3M نعملا-60-3M نعم نعم نعم نعم نعم نعم %) .2 )1 2 ر ؤش الم المؤشر 1 )%7.97) الشكل (أ)2 2 ارتباط مؤشرات التعليم بتحليل التناظر المتعدد المتعدد، وهو ما أدى إلى أن تبسيط العلاقة بين العديد من المتغيرات في رسم بياني واحد ثنائي الأبعاد (الشكل (أ)2.2). وأتاح التحليل استخراج ُبعدين (المحورين (س) و(ص)). ويمكن تفسير «البعد» الأول (المحور (س)) على أنه عوامل مرتبطة بعدم وجود تنظيم على اليمين مقابل وجود تنظيم على اليسار. ويوضح البعد الأول ٪7.97 من التباين بين المتغيرات. ويمكن تفسير البعد الثاني (المحور (ص)) على أنه عدم وجود آليات اعتماد تجاه الجزء العلوي من المحور مقابل عدم وجود تنظيم تعليمي تجاه الجزء السفلي منه. ويوضح هذا البعد ٪1.2 من التباين بين المؤشرات. ويتضمن الرسم البياني أيضًا بيان الأقاليم لإبراز المؤشرات المرتبطة بها على نحو أوثق. وقد أكد التحليل أنه مع وجود أقاليم جنوب شرق آسيا وشرق المتوسط وغرب المحيط الهادئ على الجانب الأيمن من الرسم البياني، من المرجح أن ترتبط هذه الأقاليم بانخفاض مستوى تنظيم تعليم التمريض. وهناك ارتباط قوي بين مؤشرات شروط العمل، كما يتضح من تحليل التناظر المتعدد (الشكل (أ)3.2). وكان هناك مؤشران يدلان على وجود ارتباط قوي هما التدابير الرامية إلى منع الاعتداءات ووجود دور تمريضي متقدم: قد يشير هذا إلى أن كادر التمريض قد ُيمنح، في البيئات التي تتسم بمزيد من الخطورة، مستوى أعلى من الاستقلالية المهنية لمواصلة ضمان حصول المرضى على الرعاية في الظروف الصعبة. وقد ظهر في الإقليم الأوروبي نمط مختلف عن أنماط الأقاليم الأخرى، وهو ما يؤشر على اتخاذ عدد أقل من التدابير لمنع الاعتداءات على العاملين وقلة الأدوار التمريضية المتقدمة. الرصيد المتوقع بحلول عام 0302 بغية تقييم رصيد كادر التمريض بحلول عام 0302، ُأعدت ثلاثة سيناريوهات، على النحو التالي: السيناريو 1: الشيخوخة (تأثير وحيد • لشيخوخة القوى العاملة في مجال التمريض في العمر). اسَتخدم أحد التوقعات التوزيع العمري لكل بلد وفئة عمرية مستقرة تقل عن 53 عامًا، مع مراعاة تجديد ُعشر حجم هذه الفئة العمرية التي يبلغ عمرها أقل مستوى له. وقد َدَرس شيخوخة القوى العاملة التي تنتهي بتقاعد ُعشر حجم فئة كادر التمريض الذين تبلغ أعمارهم 55 عامًا أو أكثر. ولا يأخذ هذا السيناريو في اعتباره إحصائيات التخرج ويعتبر نسبة الفئة العمرية الأصغر ِسنًا ثابتة في السنوات القادمة. 311 السيناريو 2: التجديد. سيناريو • مشابه للشيخوخة الوارد في السيناريو 1، ولكن باستخدام أحدث معدل تخرج حسب الإقليم المحسوب في الفرع 5-5 الذي ُطبق عليه عامل تصحيح قدره 6.0، على افتراض أن ٪06 من الخريجين الجدد سيجدون وظيفة في القطاع الصحي، وذلك لتقليد الفرق بين التخرج والالتحاق بالقوى العاملة النشطة كما لوحظ في بلدان منظمة التعاون والتنمية في الميدان الاقتصادي. السيناريو 3: التجديد الُمعجَّ ل. • سيناريو مشابه للسيناريو 2 ولكن مع مراعاة تعجيل معدل التخرج والاستيعاب، مع زيادة عدد الخريجين سنويًا بحلول عام 0302، مع افتراض حدوث نمو بنسبة ٪05 من عام 8102 إلى عام 0302 في قدرة البلدان على التخريج (أي ما يعادل زيادة سنوية قدرها ٪44.3). ويفترض هذا السيناريو أيضًا استيعاب ٪06 في سوق العمالة الصحية. ومن خلال هذه السيناريوهات، ُحسبت الكثافة المتوقعة المقدرة لعام 0302 باستخدام التقديرات السكانية المسمدة من تقديرات التوقعات السكانية الصادرة عن الأمم المتحدة لعام 0302. وبغية تقييم تأثير السيناريو 3، اسُتخدمت عمليات محاكاة مختلفة مع التفاوت في الزيادة في الخريجين: زيادة بنسبة ٪52، وزيادة بنسبة ٪05، وزيادة بنسبة ٪001 (مضاعفة الإنتاج) (الشكل (أ)4.2). ويدل هذا على أن اختيار معدل نمو عدد خريجي التمريض لا يؤثر تأثيرًا كبيرًا على الرصيد المقدر بلوغه بحلول عام 0302، مع توقع بلوغ أرصدة كادر التمريض 0.83 مليونًا و7.93 مليونًا و8.24 مليونًا بمعدلات نمو إجمالية قدرها ٪52 و٪05 و٪001 على التوالي. تحذير يتعلق بتفسير التوقعات لاُبد من مراعاة العديد من القيود عند تفسير التوقعات. فيما يتعلق بتوافر البيانات، لم تتمكن . 1 جميع البلدان من الإبلاغ بالعمر، المستخدم في السيناريو 1، ومعدل التخرج، المستخدم في السيناريو 2. وأظهر التحليل نتائج متسقة للسيناريوهين 1و2، وهو ما يوفر الطمأنينة بشأن معدل دخول الخريجين الجدد إلى سوق العمل. اسُتخدمت افتراضات عديدة بشأن . 2 معدل خروج الأفراد الذين تبلغ أعمارهم 55 عامًا أو أكثر من الخدمة. وقد يختلف هذا الأمر نوع التحليل: تحليل تناظر متعدد للمتغيرات المتصلة بتنظيم شروط العمل؛ وتعرض الأقاليم في شكل متغيرات مستقلة. ويرد ملخص المتغير في هذا الرسم البياني: 6M-30: وجود أحكام تنظيمية لساعات العمل وظروفه؛ 6M-40: وجود أحكام تنظيمية للحد الأدنى للأجور؛ 6M-90: وجود تدابير لمنع الاعتداءات؛ 8M-60: وجود دور تمريضي متقدم؛ 1NN: وجود مجلس تمريض. RFA = الإقليم الأفريقي؛ RMA = إقليم الأمريكتين؛ RAES = إقليم جنوب شرق آسيا؛ RUE = الإقليم الأوروبي؛ RME = إقليم شرق المتوسط؛ RPW = إقليم غرب المحيط الهادئ. المصدر: حسابات القوى العاملة الصحية الوطنية، 9102. وأحدث البيانات المتاحة التي أبلغت عنها البلدان بين عامي 3102 و8102 الشكل (أ)2.3 ارتباط مؤشرات شروط العمل بتحليل التناظر المتعدد � �� �� � � � � �- �- �- �- �- �-� � � � � � � RAES RUE RMA RME RFA RPW لا-30-6M لا-40-6M لا-1NN لا-60-8M لا-90-6M نعم-90-6M نعم-60-8M نعم نعم نعم %) .2 )6 2 ر ؤش الم المؤشر 1 )1.08%) حالة التمريض في العالم عام 0202411 باختلاف الأقاليم وقد يكون مسببًا للتفاؤل، بالنظر إلى أن سن التقاعد ستصل إلى 56 عامًا. وكذلك، طبق التحليل معدًلا يبلغ 6.0 لإضافة الخريجين الذين بدؤوا في الممارسة، على أساس معدل الممارسة الذي حددته منظمة التعاون والتنمية إلى القوى العاملة في مجال التمريض الحاصلة على الترخيص. ومع ذلك، من المحتمل أن يختلف ذلك باختلاف الإقليم. وبغية اختبار تأثير جميع الافتراضات الضمنية للسيناريوهات من 1 إلى 3، ُأجريت سلسلة من تحليلات الحساسية. ولم تختلف النتائج إلا اختلافًا هامشيًا، وظلت النتائج دون تغيُّر إلى حد كبير. ولا تعكس التوقعات إلا الاتجاهات . 3 الحديثة وتوفر فهمًا واسع النطاق لمسار رصيد القوى العاملة في مجال التمريض. وسوف يحتاج ذلك إلى التنقيح في المستقبل مع توافر مزيد من البيانات. وإضافة إلى ذلك، لا تحل هذه التوقعات محل الاستنتاجات المستخلصة من النمذجة على المستوى الوطني، التي تأخذ في اعتبارها طائفة واسعة من مؤشرات القوى العاملة الصحية وغيرها من المؤشرات في جميع أنحاء سوق العمالة الصحية وكذلك الإحصاءات الاقتصادية الأكثر تفصيًلا، بما في ذلك الحيز المالي. تقدير النقص اتبع تقدير النقص في أفراد كادر التمريض طريقة مماثلة لتلك الموضحة في الاستراتيجية العالمية بشأن الموارد البشرية الصحية. ومع ذلك، لا يمكن، بسبب البيانات المحدَّثة، مقارنة قيم النقص مقارنًة مباشرًة بتلك المقدرة في الاستراتيجية العالمية. ويوضح التحليل أن التقدير في الاستراتيجية العالمية كان مبنيًا على أساس 201 بلد لديها رصيد متاح للفترة 9002-3102؛ واسُتخدمت بيانات قديمة أو مبتورة للبلدان المتبقية. وبناء على البيانات الحديثة المتاحة في سبيل إعداد تقرير حالة التمريض في العالم لعام 0202، كان لدى 471 بلدًا بيانات عن رصيد عام 3102 أو السنوات الخمس السابقة (بما في ذلك 031 بلدًا لديها بيانات عن عام 3102)، وُقدِّر الرصيد المنقح لعام 3102 بنحو 2.32 مليون ممرض وممرضة. ويعتمد رصيد عام 8102 على بيانات واردة من 191 بلدًا للفترة 3102-8102، بما في ذلك نسبة تبلغ ٪98 لديها بيانات عن عامي 7102 و8102. لذلك، يمكن اعتبار الرصيد المبلغ به في تقرير حالة التمريض في العالم لعام 0202 عن عام 8102 تقديرًا دقيقًا للغاية. وبغية تقدير النقص، قورنت كثافتي عامي 8102 و0302 بالقيمة المرجعية المستخدمة في الاستراتيجية العالمية. الشكل (أ)2.4 تطور رصيد كادر التمريض عالميا ً(بالملايين) في إطار سيناريو «العمل كالمعتاد» وثلاثة سيناريوهات «زيادة في إنتاج أفراد كادر التمريض الخريجين»، من عام 8102 إلى عام 0302 ملاحظة: يشمل «رصيد التمريض» الأخصائيين والمساعدين في مجال التمريض. رصید التمریض – استمرار التخرج 0.02 0.52 0.03 0.53 0.04 0.54 2302 0302 8202 6202 4202 2202 0202 8102 6102 ین لای لم با راد لأف ن ا م صید لر ي ا ص ف لنق ا رصید التمریض – %52 زیادة في التخرج رصید التمریض – %05 زیادة في التخرج رصید التمریض – %001 زیادة في التخرج عوامل التصحيح المستخدمة، الخاصة بالأقاليم هي: عامل الشيخوخة (ُعشر الفئة البالغ عمرها 55 سنة أو أكثر في عام 8102 التي تتقاعد كل سنة)، ومعدل التخرج المستمد من التحليل الذي أجري في الفرع 5-5 مصححا ًبنسبة 6 0 (معدل الممارسة الذي حددته منظمة التعاون والتنمية إلى المعدل الكادر الحاصل على الترخيص) لحساب الأنشطة التي تزاول خارج نطاق ممارسة التمريض. 511 الجدول (أ)2 2 تقديرات النقص في أفراد كادر التمريض (بالملايين) في البلدان التي تقل عن العتبة المحددة في الاستراتيجية العالمية حسب مستوى الدخل: 8102 و0302 (ثلاثة سيناريوهات) 8102 0302 فئة الدخل الشيخوخة واستقرار الفئة العمرية للشباب الشيخوخة والتخرج حتى السنوات الأخيرة الشيخوخة والتخرج بنسبة 05٪ بحلول عام 0302 62.145.108.143.1البلدان المنخفضة الدخل بلدان الشريحة الدنيا من الدخل المتوسط 45.118.244.319.3 بلدان الشريحة العليا من الدخل المتوسط 21.052.054.076.0 البلدان المرتفعة الدخل (تستخدم بوصفها مرجعًا، وكلها ذات كثافة أعلى من العتبة) –––– 29 206 496 519 5العالم ملاحظة: يشمل «العاملون في مجال التمريض» الأخصائيين والمساعدين في مجال التمريض. وبيانات فئات الدخل مستمدة من تصنيف البنك الدولي لعام 8102. وبعد ذلك، ُحوِّ ل هذا المعيار البالغ 54.4 أفراد من الأطباء وكادري التمريض والقبالة لكل 000 1 نسمة إلى قيمة مرجعية للتمريض. ففي البداية، طبقت حصة كادري التمريض القبالة الواردة في الاستراتيجية العالمية على هذا المعيار: فبالمعدلات البالغة 7.02 من أفراد كادري التمريض والقبالة لكل 000 01 نسمة و8.9 أطباء بشريين لكل 000 01 نسمة في عام 3102، يصحح المؤشر إلى 20.3 أفراد من كادري التمريض والقبالة لكل 000 1 نسمة (54.4 × (7.02/ (8.9 + 7.02))). وبعد ذلك، بغية حساب القيمة المرجعية لكادر التمريض فحسب، طبقت حصة كادر التمريض ضمن كادري التمريض والقبالة مجتِمَعين (7.09٪ من آخر سنة) على هذا المؤشر، مع إعطاء قيمة مرجعية قدرها 47.2 من أفراد كادر التمريض لكل 000 1 نسمة. ونظرا إلى أن كثافة القوى العاملة الصحية يعبر عنها لكل 000 01 نسمة، اسُتخدمت القيمة البالغة 4.72 من أفراد كادر التمريض لكل 000 01 نسمة بوصفها معيارًا. وقورنت هذه القيمة المرجعية بالكثافة التي لوحظت في عام 8102 والمتوقعة لعام 0302 في ظل السيناريوهات الثلاثة. وُقدِّر النقص المقدَّر بحلول عام 0302 حسب سيناريوهات التوقعات الثلاثة الموضحة أعلاه، التي توضح أن النقص لايزال مرتفعًا في البلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط في ظل كل سيناريو (الجدول (أ)2.2). التكلفة لكل خريج حددت مصادر متعددة متباينة لتكاليف كل خريج فيما يتعلق بالبلدان المنخفضة الدخل وبلدان الشريحة الدنيا من الدخل المتوسط، حيث يوجد معظم النقص. وتتراوح تلك التكاليف بين 081 5 دولارًا أمريكيًا في مدغشقر، و985 5 دولارًا أمريكيًا في تحليل البنك الدولي والجماعة الصحية لشرق أفريقيا ووسطها وجنوبها،61 و656 5 دولارًا أمريكيًا في موزمبيق، و497 91 دولارًا أمريكيًا في غانا.71 لذلك، ُأجريت حسابات التكاليف بسيناريو منخفض التكلفة قدره 000 5 دولار أمريكي لكل خريج، وسيناريو متوسط قدره 000 01 دولار أمريكي لكل خريج، وسيناريو مرتفع التكلفة قدره 000 02 دولار أمريكي لكل خريج. ولاحظ أن البيانات المتاحة عن هذه التكاليف وردت من بلدان أفريقية ولا يمكن تطبيقها على البلدان المرتفعة الدخل، التي تظهر البيانات المنشورة الارتفاع الشديد في تكلفة كل خريج بها. 61 ,sgnidnfi yranimilerp) acirfA nrehtuos dna ,lartnec ,tsae ni seirtnuoc 61 ni sisylana tekram ruobal esruN .MA azeM-aicraG ,CE ojuarA 0202 ;knaB dlroW :(CD) notgnihsaW .(dehsilbupnu. 71 ;knaB dlroW :(CD) notgnihsaW .anahG ni srekrow htlaeh fo noitacude pu gnilacS .A yejdA ,A noswaL ,J iwtnA ,S yetteyA ,SA rekerP ,AH uiceB 9002. حالة التمريض في العالم عام 0202611

ية ياد الق ت را ها الم و ف ظائ لو وا يم تعل ال في ر ما ستث الإ م عا م عال ال في ض ريــ تم ال لــة حا 02 02 الاستثمار في التعليم والوظائف والمهارات القيادية حالة التمريض 0202 في العالم بالتعاون مع:

投资发展教育、就业和领导力 状况 2020年 世界护理

状况 世界护理 2020年 投资发展教育、就业和领导力 2020年世界护理状况：投资发展教育、就业和领导力 [State of the world's nursing 2020: investing in education, jobs and leadership] ISBN 978-92-4-000488-7(网络版) ISBN 978-92-4-000489-4(印刷版) © 世界卫生组织 2020年 保留部分版权。本作品可在知识共享署名——非商业性使用——相同方式共享3.0政府间组织 (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.zh) 许可协议下 使用。 根据该许可协议条款，可为非商业目的复制、重新分发和改写本作品，但须按以下说明妥善引用。 在对本作品进行任何使用时，均不得暗示世卫组织认可任何特定组织、产品或服务。不允许使用世卫组 织的标识。如果改写本作品，则必须根据相同或同等的知识共享许可协议对改写后的作品发放许可。 如果对本作品进行翻译，则应与建议的引用格式一道添加下述免责声明：“本译文不由世界卫生组织 （世卫组织）翻译，世卫组织不对此译文的内容或准确性负责。原始英文版本为应遵守的正本”。 与许可协议下出现的争端有关的任何调解应根据世界知识产权组织调解规则进行 (http://www.wipo. int/amc/en/mediation/rules/)。 建议的引用格式。2020年世界护理状况：投资发展教育、就业和领导力 [State of the world's nursing 2020: investing in education, jobs and leadership]。日内瓦：世界卫生组织；2020年。许可协 议：CC BY-NC-SA 3.0 IGO。 在版编目（CIP）数据。在版编目数据可查阅 http://apps.who.int/iris。 销售、版权和许可。购买世卫组织出版物，参见 http://apps.who.int/bookorders。提交商业使用请 求和查询版权及许可情况，参见 http://www.who.int/about/licensing。 第三方材料。如果希望重新使用本作品中属于第三方的材料，如表格、图形或图像等，应自行决定 这种重新使用是否需要获得许可，并相应从版权所有方获取这一许可。因侵犯本作品中任何属于第三方 所有的内容而导致的索赔风险完全由使用者承担。 一般免责声明。本出版物采用的名称和陈述的材料并不代表世卫组织对任何国家、领地、城市或地 区或其当局的合法地位，或关于边界或分界线的规定有任何意见。地图上的虚线表示可能尚未完全达成 一致的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世卫组织所认可或推荐，或比其它未 提及的同类公司或产品更好。除差错和疏忽外，凡专利产品名称均冠以大写字母，以示区别。 世卫组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是，已出版材料的分发无任 何明确或含蓄的保证。解释和使用材料的责任取决于读者。世卫组织对于因使用这些材料造成的损失不 承担责任。 “感谢全民健康覆盖伙伴关系（比利时、欧洲联盟、法国、爱尔兰、日本、卢森堡、联合王国和世 卫组织）、德国和挪威为编制本文件提供了资金支持”。 封面图片 第一行(从左至右): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa 第二行(从左至右): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer 1第 章 2第 章 3第 章 4第 章 5第 章 前言 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii 联合主席寄语 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii 参与者和致谢 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 术语表 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x 执行概要 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 引言 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 护理工作与更广泛的人力和卫生重点事项 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 2 .1 卫生人力在实现2030年议程中的作用 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2 .2 护士是什么人？ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 目录 二十一世纪卫生系统中的护理职能 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 护理人力队伍证据和数据的现状 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 5 .1 护理人力队伍的人数、组成和分布 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5 .2 获得和使用护理人员队伍方面的公平性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 5 .3 护士的国际移徙与流动 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5 .4 护理教育与从业的监管 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5 .5 教育和护理人员的供应 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5 .6 从业：就业和工作条件的监管 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5 .7 管理与领导 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5 .8 评估实现2030年可持续发展目标成果的当前轨迹 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 扶持护理人员队伍的政策杠杆 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4 .1 职前教育和培训 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4 .2 人力的流入和流出 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4 .3 公平分布和效率 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 4 .4 监管 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3 .1 护理在实现全民健康覆盖中的作用 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3 .2 护理在应对突发事件、流行病和灾难中的作用 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3 .3 护理在实现人口健康和福祉方面的作用 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 护理人力政策的未来方向 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 6 .1 加强规划、监测和问责的证据基础 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 6 .2 流动性和移徙 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 6 .3 发展和支持护理人员队伍 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 6 .4 建设有效治理的机构能力和领导技能 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6 .5 促进投资以创造护理工作岗位 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 6 .6 研究和证据议程 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 结束语 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 参考文献 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 附件1 . 护士是什么人？ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 附件2 . 方法 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 网络附件。护理在21世纪卫生系统中的作用： https://apps.who.int/iris/bitstream/handle/10665/332852/9789240009196-chi.pdf 6第 章 7第 章 iii目录 目录 表 5.1 2018年按世卫组织区域分列的全球护士人数和每万人口的密度 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 表 5.2 2013年至2018年期间由于数据改善和实际增长而发生的护理人员总数变化 . . . . . . . . . . . . . . . . . . . . . . . . .34 表 5.3 按世卫组织区域分列的护士在卫生专业人员(医生、护士、助产士、牙医和药剂师)中的百分比 . . . . . . . . . .35 表 5.4 按世卫组织区域分列的女性护理人员百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 表 5.5 按收入组分列的护理人员密度 (2018年) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 表 5.6 按收入组分列的外国出生(或在外国接受培训)护理人员的百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 表 5.7 按世卫组织区域分列的报告称有护理教育和培训规定的答复国所占百分比 . . . . . . . . . . . . . . . . . . . . . . . . .46 表 5.8 按世卫组织区域和收入组分列的护理专业毕业生人数 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 表 5.9 按世卫组织区域分列的对是否具备护理工作条件规定做出答复的国家百分比 . . . . . . . . . . . . . . . . . . . . . . .52 表 5.10 领导和管理指标：按世卫组织区域分列的具备首席护理官职位和护理 领导能力发展规划的国家百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 表 5.11 按世卫组织区域分列的三种情景下2018年至2030年的护理人员总数 预计模拟 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 表 A2.1 用于《2020年世界护理状况》报告的36项指标列表 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 表 A2.2 按收入水平分列的低于《全球战略》阈值的国家护理人员短缺估计数 (以百万计)：2018年和2030年 (三种情景) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 专栏 专栏 3.1 护理服务有助于患者安全 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 专栏 3.2 护士主导的老年人社区护理模式 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 专栏 4.1 澳大利亚：让代表性不足的人群参与到护理人员队伍中 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 专栏 4.2 护理教育成本 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 专栏 4.3 解决护士教育师资短缺的问题 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 专栏 4.4 全球技能伙伴关系 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 专栏 4.5 高收入国家对护士的经济需求实例 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 专栏 4.6 波兰通过护士处方扩大获取途径 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 专栏 4.7 非洲区域的护理专家实例 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 专栏 4.8 农村留用指南 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 专栏 4.9 统一教育标准和执照考试的例子 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 专栏 5.1 国家内部的公平性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 专栏 6.1 苏格兰卫生人力市场分析 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 专栏 6.2 东部、中部和南部非洲卫生共同体：利用国家卫生人力账户指标报告 护理数据方面的国家合作 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 专栏 6.3 德国的移徙管理办法 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 专栏 6.4 护理教育和实践技术 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 专栏 6.5 巴基斯坦努力提高护士教育能力 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 专栏 6.6 阿曼扩大获得社区卫生服务 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 专栏 6.7 非洲卫生专业监管协作 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 专栏 6.8 卫生工作者罢工 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 专栏 6.9 西太平洋区域的领导力奖学金 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 专栏 6.10 投资发展人力资本 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 专栏 A1.1 ISCO关于护理人员的定义 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 iv 2020年世界护理状况 图 图 1. 每万人口中护理人员的密度 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii 图 2. 55岁以上护士和35岁以下护士的相对比例 (选定国家) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv 图 3. 按世卫组织区域和国家收入组分列护理人员总数的预计增长情况 (至2030年) . . . . . . . . . . . . . . . . . . . xv 图 4. 按世卫组织区域分列专业护理人员的平均受教育期限 (年) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvi 图 5. 具有工作条件监管规定的国家百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii 图 6. 按世卫组织区域分列女性和男性护理人员的百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 图 2.1 卫生人力资源全球战略:战略目标及与护理工作的相关性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 图 2.2 世卫组织各区域中不同护理职称的数量 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 图 3.1 护理工作对“三个十亿”目标的贡献 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 图 4.1 塑造卫生人力市场的公共政策杠杆 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 图 5.1 世卫组织国家卫生人力账户中提供的拥有人力数据的国家数量 (1990-2018年) . . . . . . . . . . . . . . . . . 32 图 5.2 按世卫组织区域分列的每个职业类别中护理人数的比例 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 图 5.3 按世卫组织区域分列的35岁以下和55岁以上的护理人员百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 图 5.4 55岁以上及35岁以下护士的相对比例 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 图 5.5 每万人口的护理人员密度 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 图 5.6 每万人口中护理人员密度的区域差异 (2018年) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 图 5.7 按收入组分列的每万人口的护理人员密度 (2018年) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 图 5.8 表示具有护理法规和标准的答复国百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 图 5.9 按国家显示的护理教育监管分数图 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 图 5.10 按世卫组织区域分列的专业护理人员平均受教育期限 (年) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 图 5.11 对工作条件有管制规定的国家所占百分比 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 图 5.12 工作条件规定评分图 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 图 5.13 按每万人口中医生的密度水平分列的设有高级护理职务的国家所占百分比 . . . . . . . . . . . . . . . . . . 54 图 5.14 政府首席护理官和护理领导能力规划与监管环境之间的关联 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 图 5.15 2030年每万人口的护理人员密度预测 (全球分布情况) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 图 5.16 按世卫组织区域和国家收入组分列的护理人员总数的预计增长 (至2030年) . . . . . . . . . . . . . . . . . . 59 图 5.17 2013年、2018年和2030年护理人员短缺估计情况 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 图 A2.1 为编写《2020年世界护理状况》报告在全球一级报告的指标数量 . . . . . . . . . . . . . . . . . . . . . . . . 100 图 A2.2 通过多重对应分析显示教育指标之间的相互关系 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 图 A2.3 通过多重对应分析显示工作条件指标之间的相互关系 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 图 A2.4 在“一切照旧”情景和三种“增加毕业护士人数”情景下、2018年至 2030年全球护理人员总数(以百万计)的演变情况 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 v目录 投资加强护理人员队伍 不仅可促进卫生相关可 持续发展目标（SDG）的各 项具体目标，还可促进与 教育（SDG4）、性别平等 （SDG5）、体面工作和经 济增长（SDG8）有关的 可持续发展目标。 封面图片 第一行（从左至右）：© Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa 第二行（从左至右）：© Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer ISBN 978-92-4-000333-0（网络版） ISBN 978-92-4-000334-7（印刷版） ©世界卫生组织 2020。 部分版权保留。作品署名-非商业性使用-相同方 式共享的政府间组织3.0版本适用于该作品 (CC-BY-NC-SA 3.0 IGO)。 世卫组织总干事 Tedros Ghebreyesus 世卫组织首席护士 Elisabeth Iro 国际护士理事会主席 Annette Kennedy “护理服务刻不容缓”运动联合主席 Sheila Tlou “护理服务刻不容缓” 运动联合主席 Nigel Crisp 可持续发展 目标 3 可持续发展 目标 4 可持续发展 目标 5 可持续发展 目标 8 前言 在世界各国对全民健康覆盖作出前所未有的政治承诺之时，我们迎来了这份 题为“2020年世界护理状况：投资发展教育、就业和领导力”的报告。与此同时， 我们的突发事件防范和应对能力正在接受考验，我们既要应对当前的 COVID-19 疫 情又要解决冲突造成的大规模人口流离失所问题。护士在所有这些情况中都必须提 供重要的护理服务。现在，世界比以往任何时候都更需要他们能够充分运用通过教 育和培训掌握的知识和能力。 这第一份《世界护理状况》报告揭示了许多护理人员队伍值得赞扬的方面。 为高级护理教育和强化专业职能提供机会，包括在政策层面，可以推动改善人口 健康。但与此同时，我们继续看到世界各地护士的分布仍存在巨大不平等、我们必 须解决这一问题。 2020年是国际护士和助产士年。这是一个契机，使我们可以利《2020用年世 界护理状况》报告中的证据，致力于落实一项议程以推动并持续向2030年目标进 展。为此，我们敦促各国政府和所有相关利益攸关方： • 投资大规模加速护理教育(包括师资、基础设施和学生)以响应全球需要、满足 国内需求、应对不断变化的技术和日益进步的综合卫生和社会护理模式； • 到2030年创造至少600万个新的护理工作岗位，主要是在低收入和中等收入 国家，以弥补预计的短缺，并纠正全球护士分布不公平的现象； • 加强护士的领导力，使其成为当前和未来的领导者，确保他们在卫生政策制定 和决策中发挥有影响力的作用，并促进提高卫生和社会护理系统的有效性。 所有国家都可以采取行动支持这一议程。大多数国家可以通过自己的资源完成 这些行动。对于需要国际社会援助的国家，我们必须将越来越多的人力资本投资用 于卫生和社会护理系统。这种投资还将推动各项可持续发展目标的进展，并在性别 平等、增强妇女经济权能和青年人就业方面产生效益。 让我们抓住这一契机，承诺开展十年行动，从投资发展护理教育、就业和领导 力开始。 vi 2020年世界护理状况 投资加强护理人员队伍 不仅可促进卫生相关可 持续发展目标（SDG）的各 项具体目标，还可促进与 教育（SDG4）、性别平等 （SDG5）、体面工作和经 济增长（SDG8）有关的 可持续发展目标。 封面图片 第一行（从左至右）：© Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa 第二行（从左至右）：© Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer ISBN 978-92-4-000333-0（网络版） ISBN 978-92-4-000334-7（印刷版） ©世界卫生组织 2020。 部分版权保留。作品署名-非商业性使用-相同方 式共享的政府间组织3.0版本适用于该作品 (CC-BY-NC-SA 3.0 IGO)。 世卫组织总干事 Tedros Ghebreyesus 世卫组织首席护士 Elisabeth Iro 国际护士理事会主席 Annette Kennedy “护理服务刻不容缓”运动联合主席 Sheila Tlou “护理服务刻不容缓” 运动联合主席 Nigel Crisp 可持续发展 目标 3 可持续发展 目标 4 可持续发展 目标 5 可持续发展 目标 8 前言 在世界各国对全民健康覆盖作出前所未有的政治承诺之时，我们迎来了这份 题为“2020年世界护理状况：投资发展教育、就业和领导力”的报告。与此同时， 我们的突发事件防范和应对能力正在接受考验，我们既要应对当前的 COVID-19 疫 情又要解决冲突造成的大规模人口流离失所问题。护士在所有这些情况中都必须提 供重要的护理服务。现在，世界比以往任何时候都更需要他们能够充分运用通过教 育和培训掌握的知识和能力。 这第一份《世界护理状况》报告揭示了许多护理人员队伍值得赞扬的方面。 为高级护理教育和强化专业职能提供机会，包括在政策层面，可以推动改善人口 健康。但与此同时，我们继续看到世界各地护士的分布仍存在巨大不平等、我们必 须解决这一问题。 2020年是国际护士和助产士年。这是一个契机，使我们可以利《2020用年世 界护理状况》报告中的证据，致力于落实一项议程以推动并持续向2030年目标进 展。为此，我们敦促各国政府和所有相关利益攸关方： • 投资大规模加速护理教育(包括师资、基础设施和学生)以响应全球需要、满足 国内需求、应对不断变化的技术和日益进步的综合卫生和社会护理模式； • 到2030年创造至少600万个新的护理工作岗位，主要是在低收入和中等收入 国家，以弥补预计的短缺，并纠正全球护士分布不公平的现象； • 加强护士的领导力，使其成为当前和未来的领导者，确保他们在卫生政策制定 和决策中发挥有影响力的作用，并促进提高卫生和社会护理系统的有效性。 所有国家都可以采取行动支持这一议程。大多数国家可以通过自己的资源完成 这些行动。对于需要国际社会援助的国家，我们必须将越来越多的人力资本投资用 于卫生和社会护理系统。这种投资还将推动各项可持续发展目标的进展，并在性别 平等、增强妇女经济权能和青年人就业方面产生效益。 让我们抓住这一契机，承诺开展十年行动，从投资发展护理教育、就业和领导 力开始。 vii前言 第七十二届世界卫生大会将2020年定为国际护士和助产士年，不仅是为了纪念弗洛伦斯· 南丁格尔诞辰200周年，也是为了表彰护士和助产士每天为全世界人民的健康与福祉做出的 贡献。 2020年世界卫生日将护士作为全球关注的焦点，我们借此机会荣幸地提交第一份《世界护 理状况》报告。该报告提供了全球护理人员队伍的最新证据和领先政策方案。此外，还提出了令 人信服的理由，说明应尽可能大量投资发展护理教育、就业和领导力，这是加强护理人员队伍 以实现可持续发展目标，改善全民健康和加强初级卫生保健人力，最终实现全民健康覆盖所必 需的。 《2020年世界护理状况》报告是国家层面出色合作的结果。在许多国家，由政府首席护理和 助产官员在教育部、劳动部和财政部提供的数据支持下，领导推动数据报告工作。护士教育者和 管理者分享并交叉验证了数据。全国护理协会和“护理服务刻不容缓”组织在报告数据和参与解 决报告所涉问题方面发挥了重要倡导作用。这些合作关系对于稳定常规报告护理状况至关重要， 并将有助于未来使报告更加充实。 我们迄今共同取得的成就令人惊叹。但还有远远更加重要的目标有待我们去实现。我们必 须利用国家、区域和全球数据以及国际护士和助产士年的机会，促进所有部门之间加紧对话与 合作，旨在加强人力以更好地提供初级保健并朝实现全民健康覆盖进展。我们必须促进和维持对 护理教育、就业和领导力的投资。 世界的健康需要所有国家作出承诺，支持并投资发展护理人员队伍。我们希望所有人都加入 这一行动呼吁。 世界卫生组织 卫生人力司 司长 James Campbell 国际护士理事会 首席执行官 Howard Catton 护理服务刻不容缓 后补联合主席 Mary Watkins 联合主席寄语 viii 2020年世界护理状况 指导委员会 联合主席：Howard Catton, Mary Watkins 成员：Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) 世界卫生组织 主要撰写人：Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell 行政支持：Beatrice Wamutitu, Elizabeth Tecson 参与者：Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez 证据审查的参与者 Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi-Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw 数据报告和分析的参与者 世卫组织谨感谢所有国家卫生人力账户联络点、政府首席护理和助产官、Novametrics 公司 (Martin Boyce, Andrea Nove) 以及其他协助数据报告和分析工作的人员 非洲区域 Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande 美洲区域 Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas- Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez 东南亚区域 Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen 欧洲区域 Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus 东地中海区域 Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob 西太平洋区域 Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou 编辑协调,设计和制作 感谢 Sharad Agarwal, Prographics Inc, John Dawson, 世卫组织翻译、出版和印 刷部门，约旦穆娜公主殿下，个人护士和伙伴机构对照片的支持。世卫组织还希望向 Salome Karwah表示特别敬意，她是利比里亚的一名护士，曾是埃博拉病毒感染的幸 存者，但因被拒绝医护而死于分娩并发症。 感谢JHPIEGO和约翰·霍普金斯大学护理学院为编写本报告协助进行了证据审查 和数据报告工作。Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson 参与者和致谢 ix参与者和致谢 人力市场是允许寻求(即需求)和提供 (即供应)人力服务的结构。工资和就业 条件(例如，适当的基础设施、支持性管 理、职业发展和职业晋升的机会)在决定 卫生工作者和雇主的选择方面发挥着作 用(1)。 需求指市场上提供的工作。需求是 一个卫生系统能够承担的卫生工作者数 量，以有资金的职位或对服务的经济需 求来衡量。需求与政府的卫生支出、 私人保险和自付费用相关(2)。 供应。卫生工作者的供应指愿意在 卫生保健部门工作的合格卫生工作者的 集合，随培训能力以及卫生工作者的净 移民、死亡和退休的变化而变化(2)。 需要是实现卫生系统服务提供目标 所需的卫生工作者人数。卫生人力市场 主要由供求关系决定，需要只是间接决 定因素(1)。 卫生人力市场对卫生保健工作者的 吸收能力是指卫生系统(包括公共和私 营部门)充分和有效利用现有(主要通过 教育和移徙产生的)合格卫生工作者的 能力。吸收能力受到将经济需求转化为 创造和填补空缺职位的效率和及时性的 影响。 职前教育指在受雇于某服务机构 之前，作为受雇佣的先决条件进行的正 式学习规划(3)。 发放执照是一个程序，证明一个人 能够在规定的实践范围内按照要求的标 准履行职能和任务，并授予执照以合 法授权其在既定管辖范围内从事某一 职业。 资格认证指根据提供教育所需的预 定标准对教育机构进行评价的过程。这 一过程的结果是证明教育规划的适宜性 以及教育机构在提供教育方面的能力。 授予证书是从业者在卫生保健机构 中或为卫生保健机构提供护理或服务的 资格的获得、验证和评估过程。证书是 执照发放、教育、培训、经验或其他资 格的书面证据(4)。 专业认证是一个自愿程序，通过此 程序，一个实体在核实一个人符合预先 确定的标准化标准之后，授予其一份在 认可和使用方面有时限的证书(5)。 术语表参考文献 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https://www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). 术语表 2020年世界护理状况x 以上图片来自: © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh 执行概要 2020年 xi 护士在实现全民健康覆盖和可持续发展目标 方面的核心作用 执行摘要 而且护理是卫生部门内最大 的职业群体，约占卫生专业 人员的 59% 护士对于实现“不落下任何人”的承诺及实现可持续发展目标的全球努力至关重要。 他们对与全民健康覆盖、精神卫生和非传染性疾病、突发事件防范和应对、患者安全以 及提供以人为本的综合护理等一系列卫生重点有关的国家和全球目标有重要贡献。 如果不以协调、持续的方式努力扩大护理人员的贡献并提升其在跨专业卫生团队中 的作用，就不可能实现任何全球卫生议程。要做到这一点，就需要采取政策干预措施，优 化护士的工作范围和领导作用，同时加快对护理教育、技能和就业岗位的投资，使之产 生最大的影响和效力。此类投资还将有助于实现可持续发展目标中有关教育、性别、体 面工作和包容性经济增长的具体目标。 《2020年世界护理状况报告》由世界卫生组织与国际护士理事会和“护理服务刻不 容缓”全球运动合作编写。该工作得到各国政府和更广泛伙伴的支持。报告令人信服地 说明全球护理人力队伍的价值。 © Shapecharge/Getty Images xii 2020年世界护理状况 2020年证据现状 护理人员队伍的规模和专业范围不断扩大。但这种扩大并不公平，不足以满足不断增 长的需求，并且使一些人口落后。 191个国家为报告提供了数据，创历史新高，比2018年提供数据的国家数量高53%。大 约80%的国家就15项或以上指标报告了数据。然而，有关教育能力、供资、薪资和卫生劳动 力市场流动的数据存在重大空白。这妨碍了进行卫生劳动力市场分析的能力，而这些分析 将为有关护理人力的政策和投资决策提供信息。 全球护理从业人员为2790万人，其中专业护士1930万人。也就是说，2013-2018年期间 总存量增加了470万，而且护理是卫生部门内最大的职业群体，约占卫生专业人员的59%。 总计2790万护理人员中专业护士为1930万人（69%），助理专业护士600万人（22%），非专 业护士260万人（9%）。 目前还没有一支与全民健康覆盖和可持续发展目标相称的全球护理人员队伍。占世界人 口一半的国家拥有全世界80%以上的护士。据估计，2016年全球护士短缺达660万，2018 年略微下降到590万。其中530万人（89%）的缺口集中在低收入和中低收入国家，这些国 家的护士人数增长几乎赶不上人口增长，护士占人口比例仅略有提高。图1显示了人口中 护理人员密度的巨大差异，非洲、东南亚和东地中海区域国家以及拉丁美洲一些国家的 差距最大。 图1. 2018年每1万人口中护理人员的密度 * 包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，世界卫生组织2019年。2013年至2018年期间的现有最新数据。 未报告不适用 0 1,000 2,000 3,000 4,000500 km < 10 10 到 19 20 到 29 30 到 39 40 到 49 50 到 74 75 到 99 100 + 3执行摘要 xiii 执行概要 为了在2030年前解决所有国家的短缺问题，护士毕业生总数平均每年需要增 加8%，同时提高雇用和留住这些毕业生的能力。如不增加的话，按目前的趋势，到 2030年，护士人数将达到3600万人，比预计需求短缺570万。短缺主要集中在非 洲、东南亚和东地中海区域。与此同时，美洲、欧洲和西太平洋区域一些国家仍将 面临本国定义的短缺问题。图3显示了按世卫组织区域和国家收入组分列的护士人 数预计增加情况。 图3. 按世卫组织区域和国家收入组分列护理人员总数的预计增长情况（至2030年） * 包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，世界卫生组织2019年。 EXECUTIVE SUMMARY 虽然模式还在演变，公平 分配和留住护士是几乎所 有国家都面临的挑战。 © ICAP/Sven Torfinn طسوتملا لخدلا نم ایلعلا ةحیرشلا %61 CHINESE 中等偏下收入 27% 中等偏上收入 61% 高收入 6% 低收入 6% 美洲 43% 欧洲 7% 非洲 6% 东地中海 4% 西太平洋 22% 东南亚 18% 按区域 按收入 部分地区卫生人力老龄化格局威胁着护理人员队伍的稳定。在全球范围内，护理人员 队伍相对年轻，但各区域之间存在差异。美洲和欧洲区域护理队伍的年龄结构偏老。刚入 行护士（35岁以下）相对即将退休人群（55岁及以上）的比例较低的国家将不得不增加毕 业生人数和加强留用措施，以维持获得卫生服务的机会。拥有年轻护理人员队伍的国家应 加强护理人员在全国的公平分布。如图2所示，接近退休的护士比例高于年轻护士的国家 （即绿线以上的国家）未来将面临维持护理人员队伍的挑战。 * 包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。2013年至2018年期间的现有最新数据。 图2. 55岁以上护士和35岁以下护士的相对比例（选定国家） 35岁以下护士的百分比 70% 60% 50% 40% 30% 20% 10% 0% 55 岁 以 上 护 士 的 百 分 比 60%0% 10% 20% 30% 40% 50% 70% 18个国家面临人力老龄化的风险 每个圆点代表一个国家 绿线表示即将退休的护士人数与年轻护士人数相等 5执行摘要4 2020年世界护理状况报告xiv 2020 为了在2030年前解决所有国家的短缺问题，护士毕业生总数平均每年需要增 加8%，同时提高雇用和留住这些毕业生的能力。如不增加的话，按目前的趋势，到 2030年，护士人数将达到3600万人，比预计需求短缺570万。短缺主要集中在非 洲、东南亚和东地中海区域。与此同时，美洲、欧洲和西太平洋区域一些国家仍将 面临本国定义的短缺问题。图3显示了按世卫组织区域和国家收入组分列的护士人 数预计增加情况。 图3. 按世卫组织区域和国家收入组分列护理人员总数的预计增长情况（至2030年） * 包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，世界卫生组织2019年。 EXECUTIVE SUMMARY 虽然模式还在演变，公平 分配和留住护士是几乎所 有国家都面临的挑战。 © ICAP/Sven Torfinn طسوتملا لخدلا نم ایلعلا ةحیرشلا %61 CHINESE 中等偏下收入 27% 中等偏上收入 61% 高收入 6% 低收入 6% 美洲 43% 欧洲 7% 非洲 6% 东地中海 4% 西太平洋 22% 东南亚 18% 按区域 按收入 部分地区卫生人力老龄化格局威胁着护理人员队伍的稳定。在全球范围内，护理人员 队伍相对年轻，但各区域之间存在差异。美洲和欧洲区域护理队伍的年龄结构偏老。刚入 行护士（35岁以下）相对即将退休人群（55岁及以上）的比例较低的国家将不得不增加毕 业生人数和加强留用措施，以维持获得卫生服务的机会。拥有年轻护理人员队伍的国家应 加强护理人员在全国的公平分布。如图2所示，接近退休的护士比例高于年轻护士的国家 （即绿线以上的国家）未来将面临维持护理人员队伍的挑战。 * 包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。2013年至2018年期间的现有最新数据。 图2. 55岁以上护士和35岁以下护士的相对比例（选定国家） 35岁以下护士的百分比 70% 60% 50% 40% 30% 20% 10% 0% 55 岁 以 上 护 士 的 百 分 比 60%0% 10% 20% 30% 40% 50% 70% 18个国家面临人力老龄化的风险 每个圆点代表一个国家 绿线表示即将退休的护士人数与年轻护士人数相等 5执行摘要4 2020年世界护理状况报告 xv执行概要 每八名护士中就有一名在其出生或受训的国家以外的地方从业。护理人员的国际流 动正在增加。虽然模式还在演变，公平分配和留住护士是几乎所有国家都面临的挑战。 不加管理的移徙可能加剧短缺，并导致不公平地获得卫生服务。不同区域的许多高收入 国家似乎过度依赖护理人员的国际流动，原因是毕业护士人数少或现有护理工作岗位相 比数量不足，而且卫生系统没有能力雇用新毕业的护士。 大多数国家（86%）都有负责规范护理的机构。将近三分之二（64%）的国家要求进 行从事护理行业前先进行能力评估，将近四分之三（73%）的国家要求护士不断发展专 业能力以便继续从业。然而，除一些次区域范围内的相互承认安排之外，护理教育和从 业的规定并不统一。在这个高度流动、以团队为基础和数字化的时代，监管机构面临的 挑战是确保护理教育和从业规定与时俱进，并维持最新的护理人员队伍登记簿。图5显 示了具有工作条件监管规定的报告国家比例。 护理仍然是一个高度性别化的职业，工作场所也存在相关偏见。大约90%的护理人 员是女性，但很少有卫生领域的领导职位由护士或妇女担任。有一些证据表明存在基 于性别的薪酬差距，以及工作环境中其他形式的基于性别的歧视。据报告，法律保护 （包括工作时长和工作条件、最低工资和社会保护）在大多数国家都已到位，但在不同 区域之间存在不平等。只有三分之一（37%）多一些国家报告说已采取措施防止卫生工 作者遭到攻击。 在115个答复国中，共有82个国家（71%）报告设有国家护理工作领导职位，负责指 导护理和卫生政策。78个国家（答复国的53%）存在国家护理领导力发展规划。政府首 席护理官（或同等职位）和护理领导规划的存在都与更强有力的护理监管环境有关。 图5. 具有工作条件监管规定的国家百分比 来源：国家卫生人力账户，世界卫生组织2019年。 关于工作时间和条件的规定 （142个答复国中133个报告“有”） 关于社会保护的规定 （137个答复国中125个报告“有”） 关于最低工资的规定 （134个答复国中119个报告“有”） 护理理事会 （164个答复国中141个报告“有”） 设有高级护理职务 （95个答复国中50个报告“有”） 防止袭击卫生工作者的措施 （55个答复国中20个报告“有”） 报告“有”的国家百分比 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 大多数国家（157个答复国中的152个；97%）报告说，护士教育的最低期限是三 年。绝大多数国家报告了教育内容和持续时间标准（91%）、认证机制（89%）、教师资 格国家标准（77%）和跨专业教育（67%）。然而，人们对这些政策和机制的有效性知 之甚少。此外，在护士的最低教育年限和培训水平方面仍然存在相当大的差异，同时 还存在诸如教员短缺、基础设施有限和临床安置岗位有无等能力制约因素。如图4所 示，全球护理教育的期限大多为三或四年。 共有78个国家（提供答复国 家的53%）报告有高级临床专科 护士。有强有力的证据表明，高级 临床专科护士可以增加农村社区 获得初级卫生保健的机会，并减 少城市弱势群体在获得保健方面 的不平等。如果能够赋能并支持 各级护士充分利用他们受到的教 育和培训，就能提供有效的初级 和预防性卫生保健。这和其它许 多卫生服务一样对实现全民健康 覆盖十分重要。 © Nazeer Al-Khatib/AFP via Getty 2 年 3 年 4 年 5 年 0% 20% 40% 60% 80% 100% 非洲 美洲 东南亚 欧洲 东地中海 西太平洋 世卫组织区域 全球 来源：99个国家的2019年国家卫生人力账户和58个国家的西格玛（sigma）数据库。2013年至2018年期间的现有最新数据。 图4. 按世卫组织区域分列护理专业人员的平均受教育期限（年） 7执行摘要6 2020年世界护理状况报告xvi 2020年世界护理状况 每八名护士中就有一名在其出生或受训的国家以外的地方从业。护理人员的国际流 动正在增加。虽然模式还在演变，公平分配和留住护士是几乎所有国家都面临的挑战。 不加管理的移徙可能加剧短缺，并导致不公平地获得卫生服务。不同区域的许多高收入 国家似乎过度依赖护理人员的国际流动，原因是毕业护士人数少或现有护理工作岗位相 比数量不足，而且卫生系统没有能力雇用新毕业的护士。 大多数国家（86%）都有负责规范护理的机构。将近三分之二（64%）的国家要求进 行从事护理行业前先进行能力评估，将近四分之三（73%）的国家要求护士不断发展专 业能力以便继续从业。然而，除一些次区域范围内的相互承认安排之外，护理教育和从 业的规定并不统一。在这个高度流动、以团队为基础和数字化的时代，监管机构面临的 挑战是确保护理教育和从业规定与时俱进，并维持最新的护理人员队伍登记簿。图5显 示了具有工作条件监管规定的报告国家比例。 护理仍然是一个高度性别化的职业，工作场所也存在相关偏见。大约90%的护理人 员是女性，但很少有卫生领域的领导职位由护士或妇女担任。有一些证据表明存在基 于性别的薪酬差距，以及工作环境中其他形式的基于性别的歧视。据报告，法律保护 （包括工作时长和工作条件、最低工资和社会保护）在大多数国家都已到位，但在不同 区域之间存在不平等。只有三分之一（37%）多一些国家报告说已采取措施防止卫生工 作者遭到攻击。 在115个答复国中，共有82个国家（71%）报告设有国家护理工作领导职位，负责指 导护理和卫生政策。78个国家（答复国的53%）存在国家护理领导力发展规划。政府首 席护理官（或同等职位）和护理领导规划的存在都与更强有力的护理监管环境有关。 图5. 具有工作条件监管规定的国家百分比 来源：国家卫生人力账户，世界卫生组织2019年。 关于工作时间和条件的规定 （142个答复国中133个报告“有”） 关于社会保护的规定 （137个答复国中125个报告“有”） 关于最低工资的规定 （134个答复国中119个报告“有”） 护理理事会 （164个答复国中141个报告“有”） 设有高级护理职务 （95个答复国中50个报告“有”） 防止袭击卫生工作者的措施 （55个答复国中20个报告“有”） 报告“有”的国家百分比 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 大多数国家（157个答复国中的152个；97%）报告说，护士教育的最低期限是三 年。绝大多数国家报告了教育内容和持续时间标准（91%）、认证机制（89%）、教师资 格国家标准（77%）和跨专业教育（67%）。然而，人们对这些政策和机制的有效性知 之甚少。此外，在护士的最低教育年限和培训水平方面仍然存在相当大的差异，同时 还存在诸如教员短缺、基础设施有限和临床安置岗位有无等能力制约因素。如图4所 示，全球护理教育的期限大多为三或四年。 共有78个国家（提供答复国 家的53%）报告有高级临床专科 护士。有强有力的证据表明，高级 临床专科护士可以增加农村社区 获得初级卫生保健的机会，并减 少城市弱势群体在获得保健方面 的不平等。如果能够赋能并支持 各级护士充分利用他们受到的教 育和培训，就能提供有效的初级 和预防性卫生保健。这和其它许 多卫生服务一样对实现全民健康 覆盖十分重要。 © Nazeer Al-Khatib/AFP via Getty 2 年 3 年 4 年 5 年 0% 20% 40% 60% 80% 100% 非洲 美洲 东南亚 欧洲 东地中海 西太平洋 世卫组织区域 全球 来源：99个国家的2019年国家卫生人力账户和58个国家的西格玛（sigma）数据库。2013年至2018年期间的现有最新数据。 图4. 按世卫组织区域分列护理专业人员的平均受教育期限（年） 7执行摘要6 2020年世界护理状况报告 xvii执行概要 受到护士短缺影响的国家将需要增加资金，以教育和雇用至少590万名 额外护士。据估计，低收入和中等收入国家对护理教育的额外投资在人均 10美元左右。还需要进一步投资推动雇用刚毕业的护士。在大多数国家，这 可以通过国内资金实现。相关行动包括审查和管理国家工资账单，并在一些 国家取消对护士供应的限制。在国内资源受到中长期限制的情况下，例如在 低收入国家和受冲突影响或脆弱的情况下，应考虑设立机构资金池等机制。 发展伙伴和国际供资机构可以提供帮助，将用于教育、就业、性别、卫生和技 能发展的人力资本投资转化为促进初级卫生保健和实现全民健康覆盖的国 家卫生人力战略。对护理人员队伍的投资也有助于推动创造就业，促进性别 平等和让青年参与进来。 护理人力政策的未来 方向 十大行动 1 © John W. Poole/NPR 8 2020年世界护理状况报告xviii 2020年世界护理状况 受到护士短缺影响的国家将需要增加资金，以教育和雇用至少590万名 额外护士。据估计，低收入和中等收入国家对护理教育的额外投资在人均 10美元左右。还需要进一步投资推动雇用刚毕业的护士。在大多数国家，这 可以通过国内资金实现。相关行动包括审查和管理国家工资账单，并在一些 国家取消对护士供应的限制。在国内资源受到中长期限制的情况下，例如在 低收入国家和受冲突影响或脆弱的情况下，应考虑设立机构资金池等机制。 发展伙伴和国际供资机构可以提供帮助，将用于教育、就业、性别、卫生和技 能发展的人力资本投资转化为促进初级卫生保健和实现全民健康覆盖的国 家卫生人力战略。对护理人员队伍的投资也有助于推动创造就业，促进性别 平等和让青年参与进来。 护理人力政策的未来 方向 十大行动 1 © John W. Poole/NPR 8 2020年世界护理状况报告 各国应加强卫生人力数据收集、分析和使用的能力。需要采取的行动包括加 快实施国家卫生人力账户，并利用卫生劳动力市场分析数据指导政策制定和投 资决策。整理护理数据需要各政府机构以及监管委员会、护理教育机构、卫生 服务提供者和专业协会等主要利益攸关方的参与。 必须对护士的流动和迁移进行有效监测，并以负责任且合乎伦理的方式加 以管理。需要采取的行动包括加强各国、招聘单位和国际利益攸关方执行世卫 组织《全球卫生人员国际招聘行为守则》。与监管机构、卫生人力信息系统、 雇主、政府部委和其他利益攸关方建立伙伴关系并开展协作，可以提高监测、 管理和规范国际护士流动的能力。过度依赖移徙护士的国家应该增加投资，促 进国内产生更多护士，争取实现更大程度的自给自足。因向外移徙而造成护理 人员过度流失的国家应考虑采取缓解措施和留用计划，如提高工资（和同工同 酬）及改善工作条件，创造职业发展机会，允许护士在其所受全面教育和培训 范围内开展工作。 护士教育和培训规划必须促进推动初级卫生保健和全民健康覆盖的护士 毕业。相关行动包括投资扩大护理教师队伍，提供临床安置场所，以及提供吸 引多样化学生群体的方案。护理应成为一种基于科学、技术、团队合作和卫生 公平的职业选择。政府的首席护士和其他国家利益攸关方可以牵头就适当的护 士入门和专科发展规划开展全国对话，以确保有充足的供应来满足卫生系统对 毕业生的需求。课程必须与国家卫生重点以及新出现的全球问题保持一致，使 护士能够在跨专业团队中有效工作，并最大限度地发挥毕业生在卫生技术方面 的能力。 对护理工作的领导和管理是加强护理人力的关键。行动包括在政府中设立 高级护士岗位，并支持其发挥作用，负责加强国家护理人员队伍并促进卫生政 策决定。政府首席护士应努力加强护理人力数据，并领导政策对话，以便就护 理人力投资作出循证决策。应设立或组织领导力培训计划，以培养年轻护士加 强领导能力。脆弱和受冲突影响的环境通常需要特别重视，以便（重新）建立体 制基础和个人能力，从而有效管理护理人员队伍。 2 3 4 5 9执行摘要 xix执行概要 规划者和监管者应优化护理实践的贡献。采取的行动包括确保初级卫生 保健团队里的护士全面开展工作。应酌情扩大以护士为主导的有效护理模 式，以满足人口卫生需求，改善初级卫生保健的获得，包括与非传染性疾病 有关的日益增长的需求以及卫生保健和社会护理的结合。工作场所政策必 须解决已知影响从业环境中护士保留率的问题；这包括利用数字卫生技术带 来的机会支持护士主导的护理模式和高级临床专科护士职能，其中考虑护 理人员队伍的老龄化模式。 政策制定者、雇主和监管机构应协调行动，支持体面工作。各国必须为护 理从业提供有利环境，以提高护理人力队伍的吸引力和积极性并改善其部 署和留用情况。必须优先考虑和落实适当的人员配备水平以及工作场所和职 业健康与安全，其中特别关注在脆弱和受冲突影响环境下工作的护士。薪酬 应该是公平和充足的，以吸引，留住和激励护士。此外，各国应该优先考虑和 执行解决和应对护理行业内的性骚扰、暴力和歧视问题的政策。 各国应有意识地制定对性别因素敏感的护理人力政策。相关行动包括在 卫生工作者中实施公平、不分性别的薪酬制度，并确保解决性别薪酬差异的 政策和法律也适用于私营部门。鉴于护理人员仍以女性为主的事实（图6）， 应当使考虑到性别因素的护理政策贯穿整个教育、从业、监管和领导职能； 政策考虑应该包括为妇女创造有利的工作环境，例如通过灵活和可管理的 工作时间适应护士作为妇女的不断变化需求，以及为护理工作队伍中的妇女 提供性别转换式领导力发展机会。 女性 男性 世卫组织区域 非洲 美洲 东南亚 欧洲 东地中海 西太平洋 0 20 40 60 80 100 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% 图6. 按世卫组织区域分列女性和男性护理人员的百分比 来源：国家卫生人力账户，世界卫生组织2019年。2013年至2018年期间的现有最新数据。 6 7 8 10 2020年世界护理状况报告xx 2020年世界护理状况 © Yoshinobu Oka via Sasakawa Health Foundation 专业护理法规必须现代化。相关行动包括统一护理教育和资格认证标 准，相互承认护理教育和专业资格证书，开发互操作系统使监管机构能够 方便快捷地核实护士资格证书和学科历史。监管框架（包括执业范围、初 步能力评估和持续专业发展要求）应有助于护士在充满活力的跨专业团队 中根据自己接受的全面教育和培训开展工作。 合作是关键。相关行动包括由卫生部和政府首席护士领导开展跨部门对 话及与其他相关部委（如教育、移民、财政、劳工）和公共和私营部门利益 攸关方进行接触。一个关键要素是加强有效公共政策管理的能力，使私营 部门的投资、教育能力和护士在提供卫生服务方面的职能得到优化并与公 共政策目标保持一致。专业护理协会、教育机构和教育工作者、护理监管 机构和工会、护理专业学生和青年团体、基层团体以及“现在关注护理”全 球运动都对强化护理工作促进实现人口卫生重点方面有宝贵贡献。 9 10 工作场所政策必须解决已知影响从业环境中护士保留率 的问题；这包括支持护士主导的护理模式和高级临床专科 护士职能。 本报告提供有关护理人力队伍的强有力数据和证据。需要这种情报 来支持政策对话和促进决策，以便促进投资于护理，从而加强初级卫生 保健，实现全民健康覆盖并朝可持续发展目标迈进。 尽管有取得进展的迹象，报告也强调了重点关注领域。非洲、东南亚 和东地中海区域许多低收入和中低收入国家需要加速取得进展，以弥补 主要差距。但是，中高收入和高收入国家不能自满，因为这些国家供应能 力有限，护理人员年龄结构较老，过度依赖国际招聘。这些因素共同威 胁到国家护理人员队伍需求的实现。 结论 投资发展教育、就业和领导力 © St Thomas’ Hospital, London 各国政府应在其国内和国际伙伴的支持下，促进和领导加快努力： 建设护理人员队伍的领导和管理能力，以推进相关教育、卫生、就业和性 别议程； 采用护理人员队伍的教育、体面工作、公平薪酬、部署、执业、生产率、 监管和保留等方面必要政策，优化目前在护理方面的投资回报； 加快和维持对护理教育、技能和就业的额外投资。 所需的投资将需要增加财政资源。如果获得投资，社会和经济方面的回 报体现在改善数十亿人的健康、创造数百万合格就业机会（特别是为妇女和 青年创造就业机会）以及加强全球卫生安全。投资护理教育、就业和领导力 的理由很清楚：相关利益攸关者必须承诺采取行动。 © St Thomas’ Hospital, London 各国政府应在其国内和国际伙伴的支持下，促进和领导加快努力： 建设护理人员队伍的领导和管理能力，以推进相关教育、卫生、就业和性 别议程； 采用护理人员队伍的教育、体面工作、公平薪酬、部署、执业、生产率、 监管和保留等方面必要政策，优化目前在护理方面的投资回报； 加快和维持对护理教育、技能和就业的额外投资。 所需的投资将需要增加财政资源。如果获得投资，社会和经济方面的回 报体现在改善数十亿人的健康、创造数百万合格就业机会（特别是为妇女和 青年创造就业机会）以及加强全球卫生安全。投资护理教育、就业和领导力 的理由很清楚：相关利益攸关者必须承诺采取行动。 © Carrie Tudor/The Union 1. 护理人员队伍由专业护理人员和护理辅助 人员1组成，是世界卫生部门中规模最大的 职业类别，也是实现人人享有卫生保健承 诺的跨专业卫生团队的基础。 2. 护士可以承担高级从业人员、临床医师、 领导者、决策者、研究人员、科学家和教 师的责任与职能，对卫生专业人员教育和 实践的有效运作至关重要。在护理职业的 勤勉、创新和启发下，人口的健康与福祉 已经并将继续得到有效改善。 3. 护理职业已经存在了几个世纪，自从200 年前被视为现代护理创始人的弗洛伦斯· 南丁格尔诞生以来，护理业已经有了极大 发展。19世纪出现了结构化教育、临床标 准和护士专业协会，逐渐提高了护理职业 的质量、能力和工作条件。20世纪，专业 化和自主权得到发展，同时为确保公共问 责和安全加强了专业监管(1)。1899年成 立了第一个国际卫生保健专业人员组织， 即国际护士理事会。目前，国际护士理事 会已经运作了121年，是一个由130多个国 家护士协会组成的联合会，代表全球2千 多万名护士(2)。 1 根据国际劳工组织的《国际标准职业分类》的定义(https://www.ilo.org/public/english/bureau/stat/isco/isco08/)。 4. 世界卫生组织(世卫组织)自其成立之初便 认识到护理和助产人员的巨大价值和贡 献(3)。多年来，护士和助产士为一些全 球重大卫生里程碑做出了贡献，包括消灭 天花、防治传染病以及在全球范围内大幅 降低孕产妇、新生儿和儿童死亡率和发病 率等(4,5)。他们的突出作用已得到世界卫 生大会的无比重视，在70多年时间里通过 了10项决议，旨在促进采用国际标准来教 育、雇用和保留护士和助产士，并将此纳 入更广泛的人力发展重点(3,6)。 5. 《2020年世界护理状况》报告由世卫组 织与国际护士理事会和“护理服务刻不容 缓”全球运动合作编写，探讨当代证据， 目的是为护理政策提供愿景和前瞻性议 程。随着世界卫生大会(7)将2020年定为 国际护士和助产士年，这份具有里程碑意 义的报告旨在提供信息，协助国家、区域 和全球在实现可持续发展目标的剩余十年 中针对护理人员队伍采取行动。 章节 引言 1 1引言 6. 该报告提供当前全球护理人员队伍的全 面、最新证据；评估与护理专业在实现卫 生目标中的作用有关的主要问题、挑战和 已知证据；并提供具体的政策方案来促进 护理专业，作为加强卫生人力队伍、初级 卫生保健和卫生系统的综合办法的一部 分。每个章节涉及的主题如下。 7. 世卫组织网站2上提供一个载有各国概况 的在线章节，列出了各国为本报告提供 的数据。 2 http://apps.who.int/nhwaportal © WHO/NOOR/Sebastian Liste 各章主题 第2章 护理工作与更广泛的人力和卫生重点事项 本章展示卫生人力对《2030年可持续发展议程》的贡献，特别是关于健康与福祉的可持续发展目标 3(8)。 第3章 二十一世纪卫生系统中的护理职能 本章概述护士在提供与世卫组织“三个十亿”目标有关的重点卫生干预措施方面的作用和贡献， “三个十亿”目标包括实现全民健康覆盖、应对突发卫生事件以及增进所有人的健康与福祉(9)。 第4章 扶持护理人员队伍的政策杠杆 本章描述了更广泛的卫生人力市场和人力政策杠杆以及治理决定因素，以便在国家和全球层面应对 护士为在医疗卫生机构和社区中充分发挥自身潜力所面临的挑战。 第5章 2020年护理人员队伍证据和数据的现状 本章概括分析了当前的护理人员队伍，包括与国家、区域和全球政策制定最相关的领域，即人员总 数、组成和分布；生产能力；教育、监管、实践、政策和治理环境；领导力；以及人力市场因素。 此外，还强调了通过护理工作帮助解决卫生工作者短缺问题(到2030年预计短缺1800万名卫生工 作者)方面的进展和挑战。 第6章 护理人力政策的未来方向 本章概述了一个前瞻性的议程，包括政策方案和针对会员国、教育机构、监管机构、专业协会、 发展伙伴、国际组织和其他利益攸关方的行动呼吁。 3引言 © Cecilie Arcurs/ Getty Image 4 2020年世界护理状况 2.1 卫生人力在实现2030年议程 中的作用 8. 2015年，世界迎来了联合国《2030年可 持续发展议程》，在对人类和地球至关重 要的领域提出了17项雄心勃勃且相互关 联的目标(8)。这些可持续发展目标(SDG) 包括消除贫困(SDG1)、实现所有人的健 康与福祉(SDG3)、确保包容和公平的教 育(SDG4)、实现性别平等(SDG5)以及促 进体面工作以及包容和可持续的经济增长 (SDG8)。 9. 世卫组织领导全球卫生界努力加快进展以 实现基于全民健康覆盖理念的可持续发展 目标3。逐步实现全民健康覆盖是所有联 合国会员国通过联合国大会《全民健康覆 盖问题高级别会议政治宣言》(10)和国际 议会联盟决议(11)等方式一致承诺的明确 目标。 3 阿斯塔纳初级卫生保健宣言：从阿拉木图迈向全民健康覆盖和可持续发展目标。 10. 初级卫生保健是全民健康覆盖的基石。 世界各国领导人为纪念1978年《阿拉木 图初级卫生保健宣言》发表40周年，发 表了《阿斯塔纳言》3(12)、坚定地将初 级卫生保健确立为实现全民健康覆盖的主 要途径。世卫组织已将可持续发展目标和 初级卫生保健理念纳入其《第十三个工作 总规划》的制定和实施当中，具体形式 为“三个十亿”目标，即：全民健康覆盖 受益人口新增10亿人，面对突发卫生事件 受到更好保护的人口新增10亿人，健康和 福祉得到改善的人口新增10亿人(9)。 11. 世卫组织2019年全球监测报告《初级卫 生保健迈向全民健康覆盖》发现了在改善 服务覆盖方面取得显著进展的证据，各国 越来越多地在其国家法律框架中为向全民 普及卫生服务和产品确立法定任务(13)。 然而，国家之间和国家内部的进展不均 衡，对最弱势群体的财政保护仍然是一 项挑战。薄弱的卫生系统和社会经济因素 正在阻碍进展；需要更好的数据和证据来 护理工作与更广泛的人力和 卫生重点事项 章节 2 5护理工作与更广泛的人力和卫生重点事项 确定投资重点和跟踪进展。目前有机会 从僵化的交付模式和角色转向更加敏捷、 可及和连贯的系统。 12. 据世卫组织估计，到2030年实现可持续发 展目标3中的卫生相关具体目标总共需要 投入3 .9万亿美元(10)。在12年时间里，这 笔投资40%以上将用于支付为解决预期短 缺(到2030年预计将短缺1800万名卫生工 作者)所需的卫生工作者的酬金、薪金和报 酬(14-16)。包含卫生人力教育和终身学习 所需额外投资在内的估计数据表明，平均 50%以上卫生相关投资将需要用于开发、 维持卫生人力并支付相应报酬。 13. 这项投资不是一项“花费”。与卫生人力 是需要控制的开销这一由来已久且错误的 观点(17,18)相反，2016年，联合国卫生 领域就业和经济增长高级别委员会(简 称“委员会”)公布了证据，表明卫生领 域的岗位和就业促进了经济增长，并提 高了其他部门的生产率(17,18)。对卫生 系统及其人力进行投资可极大地促进包 容性经济增长(SDG8)，特别是通过让妇 女和青年人就业并增强其权能(SDG5) (19,20)。女性占全球社会和卫生保健人 力的70%(21)，占护理和助产人力的近 90%(22,23)。 14. 委员会提出了对卫生和社会部门进行投资 的理由，并提供了一个框架，说明这种投 资如何能够扩大教育能力，以确保卫生工 作者的可持续供应，并转变他们的能力， 以满足需求，培养一支具备适当技能的卫 生人力队伍，在正确的地方从事体面的工 作，以更好地提供卫生服务，并保证人员 数量充足以避免出现预计的短缺1800万名 卫生工作者的情况。 15. 2017年，世卫组织会员国在世卫组织、 国际劳工组织(劳工组织)和经济合作与发 展组织(经合组织)的“致力于促进健康” 规划以及多伙伴信托基金框架内通过了 一项落实委员会建议的五年计划(15,17)。 世卫组织根据《卫生人力资源全球战略： 卫生人力2030》(图2 .1)(16)中概述的加强 卫生人力方法来实施这些建议。 16. 通过重新注重对卫生人力的投资需求， 有可能加快实现全民健康覆盖和实现可 持续发展目标3。为此必须全面理解和量 化供求与需要，并用来进行卫生人力市场 分析，为综合卫生人力战略和计划提供 参考。 17. 护理人员面临着所有卫生职业的共同 挑战，包括充足的人员、公平的分布和 留用、优质的教育、有效的监管、有利的 工作条件以及全民健康覆盖方面的质量和 效率(24-26)。然而，护理专业也面临一些 特定挑战，包括性别偏见、政策领导、监 管以及各种教育级别和职级(25)。清楚理 解这些问题和重点事项有助于采取适当的 政策和投资决定。 6 2020年世界护理状况 卫生人力资源全球战略：战略目标及与护理工作的相关性图2.1 护理方面的关键领 域包括：通过优化 护士在提供预防和 初 级 护 理 方 面 的 实践范围和作用， 最大限度提高护士 的贡献。 护 理 方 面 的 关 键 领 域 包括：积极管理护士移 徙问题，确保护理教育 的质量，以及在农村、 偏远或其他服务不足的 社区投资保留护士。 护理方面的关键领域包括 对 护 理 人 力 进 行 准 确 计 数或“盘点”，以及了解 必要信息，以便进行卫生 人力市场分析。用于监测 和问责的数据不仅需要政 府部委的参与，还需要护 理和跨部门利益攸关方的 参与。 护理方面的关键领 域包括让护理领导 者参与卫生决策和 发展护理领导力。 优 化 绩 效 、 质 量 、 生 产 率 、 实 效 、 技 能 组 合 、 留 用 策 略 ， 解 决 效 率 低 下 、 分 配 不 均 等 问 题 以 实 现 公 平 和全民健康覆盖 促进对卫生人力资源的 投资，以满足人口健康 需求，说明卫生人力市 场动态、教育政策、短 缺和分布不均问题。 加强人力资源数据，促 进卫生监测和问责。 建设机构能力，对卫 生人力资源进行有效 的公共政策管理、领 导和治理 战 略 目 标1 战 略 目 标 3 战 略 目 标 2 战略 目 标 4 7护理工作与更广泛的人力和卫生重点事项 2.2 护士是什么人？ 18. 这份报告旨在提供关于护理人员队伍的现 有最佳国际可比证据和数据。为此，有必 要明确“护士是什么人”。第3章和第4 章中汇总的证据代表了已出版文献中对护 理的广义解释。第5章介绍了专门为本报 告收集的数据和进行的分析，该术语专指 2008年《国际标准职业分类》(ISCO-08) 定义的两个职业类别：专业护士( ISCO 代码2221)和准专业护理人员(ISCO代码 3221)。 19. 各国根据自己决定符合这两种职业定义的 人员来报告数据；没有要求国家报告其他 职业类别(如助产士、护理助理或其他辅 助卫生工作者)的数据。一些国家将其一 些卫生工作者归类为“护士-助产士”， 这类人员拥有混合的教育途径和职能。由 于“护士-助产士”不属于国际分类的职 业组别，本报告仅包括国家归类为专业护 士或准专业护士的卫生工作者数据。关于 这些定义以及如何支持各国报告其护理人 员的更多信息，可以参阅第5章的方法描 述以及本报告的附件1。 20. 护理包括在各种环境中对各年龄人员、 家庭、群体和社区、患者或健康者的自 主和协作护理，包括促进健康、预防疾病 以及护理患者、残疾者和临终者(7,27)。 其他关键护理职能包括倡导、促进安全的 环境、参与患者和卫生服务管理、制定卫 生政策、教育和研究(27,28)。从三级医院 到偏远社区的卫生站，护士为所有医疗卫 生机构中的人们提供各种各样的卫生保健 服务。“护士”这一职称，不论其形式， 均应表明一个人符合从事护理工作的法 律、教育和行政要求。 21. 取得“护士”职称的教育途径各种各样。 完成初级护理课程后，通常还可接受高等 教育和专业教育，并由此获得不同的职称 和职能。结果是形成各种护理职称、职能 和能力，甚至在同一个国家内部也是如 此。任何一个国家中的多样性在区域一级 会被放大，而在全球一级评估时则会更进 © AKDN/Christopher Wilton-Steer 一步(图2 .2)。全球监管图集(29)中的数据 显示，全世界至少有144种不同的护士职 称需要执照考试，包括专科和高级实践职 称。这反映了护士类型数量的范围，从东 南亚区域的10种不同职称到美洲和欧洲区 域的30多种不等。 22. 护士的职能从一个国家到另一个国家可能 有所不同。这突出表明制定国际标准化定 义的重要性，以便支持关于护士定义的讨 论，帮助理解护理职能，并计划卫生服务 以优化护士的贡献，促进实现关于人口健 康的目标。 世卫组织各区域中不同护理职称的数量图2.2 欧洲 世卫组织区域 东地中海美洲 东南亚非洲 世 卫 组 织 各 区 域 国 家 中 不 同 职 称 的 数 量 0 5 10 15 20 25 30 35 31 19 32 11 20 10 西太平洋 注：数字表示每个区域需要考试的护理职称，按区域分列。 来源：美国联邦护理委员会全国理事会全球监管图集(29)。 9护理工作与更广泛的人力和卫生重点事项 10 2020年世界护理状况 23. 本章汇总了当代证据基础(详见网页附 录)，内容涉及护士在促进可持续发展目 标3方面的作用和责任，更具体地说， 涉及世卫组织“增进健康、维护世界安全 和为弱势人群服务”的使命及其《工作总 规划》的“三个十亿”目标。 3.1 护理在实现全民健康覆盖中的作用 24. Cochrane协作网的一项综述表明，护士 能够有效地为传染性和非传染性疾病提供 广泛的初级卫生保健服务，包括能对某些 病症进行临床决策，以及提供卫生保健教 育和预防服务(30)。综述还表明，在某些 环境和适当的情况下，以护理为主导的初 级保健服务可以带来类似的或有时甚至更 好的患者健康结果，以及比其他护理提供 模式更高的患者满意度；而且护士对患者 的诊查时间可能也更长(30)。Cochrane 协作网的其他一些综述显示，护士可在艾 滋病治疗的开始和后续跟进中发挥有效作 用(31)、，而戒烟方面的护理干预则可提 高戒烟的可能性(32)。Cochrane协作网的 另一项综述表明，包括护士在内的非专科 卫生工作者可以改善一般抑郁症和围产期 抑郁症、创伤后应激障碍和酒精使用障碍 的结果，以及痴呆症患者和照护者的结果 (33)。Campbell协作网的一项系统综述表 明，负责性侵犯检查的护士或法医护士检 查员在对性侵犯进行法医检查和记录方面 同样有效，这些护士可以提供性传播感染 和怀孕预防措施，这种护理具有良好的资 金效益(34)。 二十一世纪卫生系统 中的护理职能 章节 3 11二十一世纪卫生系统中的护理职能 25. 护士在确保护理质量和患者安全、预防 和控制感染以及对抗抗微生物药物耐药性 方面具有重要作用(35)。这可通过履行多 种职能来实现，包括监测患者的临床恶化 情况、发现错误和险兆(36)、实施感染预 防干预措施、监测控制措施和提供指导 (37)，以及确保保持水、环境卫生和手部 卫生方面的良好做法(38)在诸如COVID-19 这样的疫情中，手部卫生、身体距离和表 面消毒是遏制疾病的核心，护士发挥感染 预防和控制作用至关重要 (专栏3 .1)。 26. 此外，有详细记录表明，护士历来在预 防、治疗和控制传染性疾病方面具有促进 作用(4,49)。例如，护士主导进行的干预 可以提高疫苗接种率(50)。护士一直在全 球范围内积极参与结核病的管理和预防， 并能有效参与临床和非临床任务，如健康 促进和社会心理支持(51-54)、自愿实施男 性医学包皮环切术(55-61)以及制定和实施 艾滋病毒暴露前预防规划等(62)。护士还 可通过社区教育、大规模化学预防、识别 和诊断疾病病例、确定疾病流行程度、筛 查和确认由社区卫生工作者识别和转诊的 疑似病例、分发药物、进行某些类型的手 术(例如沙眼手术)以及向患者提供关于疾 病管理的知识(例如淋巴水肿自我护理)来 有效地参与抗击被忽视的热带病(63)。在 非洲若干地区，护士还通过培训、指导和 监督社区卫生工作者来提高传染病护理的 质量(63-65)。 27. 护士在健康促进、健康素养和非传染性 疾病管理方面也发挥着至关重要的作用 (66-72)。有了正确的知识、技能、机会 和财政支持，他们就具备独特的能力， 可作为从业者、健康教练、代言人以及患 者和家庭的知识中介在生命全程中有效发 专栏 3.1 护理服务有助于患者安全 低收入和中等收入国家每年有800多万人因医护质量差而死亡(39)。护士可以通过预防不良事 件来提高医护质量和患者安全，但这需要他们能够在强大的团队和良好的工作环境中发挥最佳能 力。护士在确保患者安全方面发挥着至关重要的作用，可通过监控患者的临床恶化情况、发现错误 和险兆、了解护理流程和某些系统固有的弱点，以及采取许多其他措施来确保患者获得高质量的医 护(36)。护士和医生因高工作量、长途旅行和不良人际关系而精疲力竭是导致患者安全恶化的因素 (40)，而如果工作环境良好，护士人力配备得当并能对技能混合型团队进行教育，则可促使缩短住 院时间、降低不良事件(如肺炎、胃炎、上消化道出血、压疮和导管相关尿路感染等)的发生率并降 低总体死亡率 (41-48)。 12 2020年世界护理状况 © WHO/Tania Habjouqa 挥作用(73)。护士在非传染性疾病护理和 预防方面的效用已在一系列非传染性疾 病任务中反复得到证明(66-72)，这些任 务包括对多种非传染性疾病，如高血压、 心血管疾病、糖尿病、精神疾患、神经疾 病、呼吸道疾病和癌症等进行筛查并提供 初级卫生保健服务(70)。在执行这些任务 过程中，护士改善了健康结果，例如降低 了血压，降低了抑郁评分，并为心力衰竭 或糖尿病患者提供了同等护理(30,70)。 护士还可促使改变行为，例如提高对药物 的利用，由护士治疗的患者更有可能保持 随访(30,70)。对护理教育和从业范围适当 定向可使卫生保健团队中的护士发挥更大 作用，并可能有助于将非传染性疾病纳入 初级保健(74,75)。虽然在很多环境中都可 能应当扩大护士的作用，但在专科医生短 缺的情况下，这尤其有可能增进卫生公平 性(73,76)。 28. 护士可促进贯穿生命全程的护理服务。 护士与助产士、产科医生和其他专科医生 合作，为育龄妇女提供产前、产时和产后 护理(77)。具有新生儿护理专业技能的新 生儿护士能够在其他新生儿专家的支持 下，有效地提供特殊支持和及时、高质量 的住院护理。在大多数国家，护士是为儿 童和青少年提供护理的学校卫生服务骨干 力量(78-81)。护士提供各种各样的性和 生殖卫生服务；例如，他们可安全有效地 提供口服和注射避孕药、植入物和宫内节 育器(82)。证据还表明，护士能有效地进 行宫颈癌筛查并为育龄及以上妇女提供艾 滋病服务(83,84)。向适龄青少年及其父 母或照护者提供信息和进行宣传是护士为 扩大人乳头瘤病毒疫苗接种服务发挥的核 心作用之一(83,85,86)。护士在为老年人 提供护理方面也具有核心作用，并可协助 提供综合护理，从而为老年人带来更好的 结果(专栏3 .2)(87)。作为姑息治疗的主要 提供者，护士能够使临终者感受到尊严和 同情。 13二十一世纪卫生系统中的护理职能 专栏 3.2 护士主导的老年人社区护理模式 在日本“超级老龄化”社会状况的推动下，世川卫生纪念基金于2014年开始实施一项规划， 使护士能够建立和运营基于社区的家庭护理服务中心(88)。这些中心是社区的卫生中枢，护士从这 些中心提供服务，使老年人能够有尊严地在家中生活，并提高社区居民的生活质量。世川卫生纪念 基金还支持一个网络，以加强各中心之间的合作，收集数据，并倡导建立基于社区的家庭护理服务 中心(89)。 一项为期八个月的老年人护理和家庭护理课程帮助护士做好准备，以便能进行身体状况评估， 满足社区居民的初级卫生保健需求，并帮助家人在家中提供姑息治疗和临终关怀。额外的课程侧重 于创业、管理和商业计划，以发展和经营家庭护理中心(89)。 截至2019年3月，67名护士完成了该课程，其中56余名护士在日本23个地区经营家庭护理服务 中心。这些中心的工作人员平均70%是护士，30%是其他专业人员，说明采取了跨专业协作方法来 满足社区及家庭的初级卫生保健需求。作为一个网络，这些中心平均每月接诊 25 000人次。家庭成 员协助提供临终关怀有助于降低与住院和医疗程序相关的医疗费用(90)。 14 2020年世界护理状况 3.2 护理在应对突发事件、流行病和灾 难中的作用 29. 护士能参与护理临床紧急情况(如事故或 心脏病发作)，预防和应对流行病疫情， 以及应对灾难和人道主义危机。护士通常 是患者在医疗机构看到的第一个卫生人 员；他们的作用可能因环境而异，但通常 包括分诊、早期识别威胁生命的症状、施 行药物治疗、采取救生程序和早期转诊。 30. 护士在应对威胁全球健康的流行病的团队 中发挥了关键作用，例如2003年的严重急 性呼吸综合征(SARS)(91)、2015年的中 东呼吸综合征冠状病毒(MERS-CoV)疫情 (92)、2016年的寨卡病毒病(93,94)、2014 年的埃博拉病毒病(95 ,96)和始于2019 年的COVID-19疫情。护士和其他卫生工 作者可通过世卫组织紧急医疗队举措接受 培训，以加强本国应对未来灾难和突发事 件的能力(97)。这对提高因灾难和冲突而 变得更加脆弱的卫生系统的抵御能力可能 尤为重要(98)。 31. 在受脆弱性和冲突影响的环境中，包括 护士在内的卫生工作者面临着许多个人和 职业挑战，如可能遭绑架，不得不面对同 事的死亡、对自己死亡的恐惧、工作量 的增加、工作复杂性的提高(例如，不得 不处理枪伤)以及道德和职业标准的败坏 等问题(99)。尽管条件如此，但护士和其 他卫生工作者在面对这些挑战时表现出了 韧性和决心，并继续提供基本服务(99)。 冲突环境中或照料难民人口的护士在支 持下，能够成功地治疗一系列不同的 病症，如肺结核(100)和其他呼吸道感染、 龋齿和创伤后应激障碍等(101)。 © National Health Commission of the People's Republic of China 15二十一世纪卫生系统中的护理职能 © WHO/Yoshi Shimizu 3.3 护理在实现人口健康和福祉方面的作用 32. 改善人口的健康与福祉需要护士和其他卫 生工作者解决健康问题的社会决定因素， 并由此推动实现可持续发展目标。目前 一些领域出现了新证据，例如可通过促 进洗手、营养和环境卫生来预防腹泻疾病 (102,103)，证明了护理在解决健康问题 的社会决定因素方面的有效性(4)。护士 可能跻身于应对气候变化影响的一线人员 之列(104-106)，这将包括努力加强穷人 和易受气候相关事件影响人群的抵御力， 以及降低腹泻病、疟疾、非洲锥虫病、 利什曼病、血吸虫病、肠道线虫感染和登 革热等气候敏感性疾病的死亡率。 33. 促进改善和维持人口健康取决于两方面， 一是要通过公平实现全民健康覆盖来确保 年轻人的健康，二是要确保年轻人身体健 康并愿意将可持续发展工作延续到下一 代。护士了解并能够采取必要的方法来响 应年轻人的期望（包括值得信赖、不作评 判和以客户为中心）；满足他们的条件； 并保证及时响应其需求(107-110)。 34. 护士在对妇女构成特殊挑战的领域， 如计划生育和流产护理方面显示了积极 作用(111,112)。优化她们在提供这些服务 中的作用可以使许多妇女更好地获得生殖 卫生保健。护士在一些人生重要事件中 (例如，产前和产后期间(113)和乳腺癌等) 为妇女提供社会支持以促进孕产妇保健， 同时是确保妇女在卫生服务机构的护理中 受到尊重的关键(114,115)。护士对打击基 于性别的暴力也至关重要：关于筛查亲密 伴侣暴力的研究指出，护士和助产士是最 经常(分别为45%和24%)进行现场鉴定的 卫生专业人员(116)。在结束本章时，图 3 .1总结了护理工作对“三个十亿”目标 的贡献。 图3.1 护士 是多学科团队的一部分 突发事件、 流行病和灾难 . 为临床紧急情况 提供护理 . 应对流行病、 灾难和人道主义危机 . 识别危险病症并 采取救生程序 全民健康覆盖 . 初级保健的一线提供者 . 预防和治疗各种传染性和非传染性疾病 . 提供从出生到死亡的生命全程护理 健康与福祉 . 通过合作行动解决健康 问题的社会决定因素 . 应对和处理气候变化 的影响 . 确保包括妇女和青少 年在内的弱势群体 获得服务 护理工作对“三个十亿”目标的贡献 17二十一世纪卫生系统中的护理职能 © WHO/ Yoshi Shimizu 18 2020年世界护理状况 35. 如前一章所述，优化护理专业的贡献需要 有利的政策和实践环境。可以利用世卫组 织卫生人力市场框架(117)(图4 .1)，从公 共政策角度分析影响护理人力的可得性、 分布、能力、有利工作环境和绩效的许多 因素。 36. 基于这一框架，本报告考虑了体现护 理方面卫生人力政策论述特点的四个方 面，巩固了来自同行评审文献的证据基 础，这些文献涉及(a)职前教育和培训； (b)人力流入和流出；(c)公平分布和效 率；(d)监管(包括私营部门)。框架中还提 到了影响卫生人力市场的社会、经济和人 口因素。本报告详细讨论了其中一些因素 （性别偏见、国家收入水平），而其他因 素，如人口趋势（老龄化、增长模式）和 气候变化，应在设计和实施相关护理人员 政策时，在国家层面更直接地加以考虑。 4.1 职前教育和培训 37. 护理教育的目的是培养一支在数量、质 量和分布方面都能满足人口健康需要的护 理人员队伍。因此，护理教育机构的学生 招纳和输出应符合卫生部门的需要和吸收 能力。卫生、教育、劳动和财政部门之间 定期进行对话和协调有助于确保避免不匹 配现象。 38. 注册和完成护士教育课程的学生人数首 先会受到人口基础教育水平和注册护理 课程的教育先决条件的影响(118,119)。 护理课程的注册受课程地点、费用、可容 纳人数、临床附属机构和所提供的护理教 育水平的影响。这些当中每一项反过来又 受到负责完成课程任务和目标的合格教师 数量，以及临床教育的基础设施和能力的 影响(120)。Squires等人报告说，卫生系 章节 扶持护理人员队伍的 政策杠杆 4 19扶持护理人员队伍的政策杠杆 统吸纳卫生工作者的能力(按人口计的医 院床位)和对女性的赋权等“宏观”因素 也会影响特定国家对护士的培养(121)。 39. 性别问题会影响护理专业学生的入学，从 而影响护士的人员供应。护理工作在社会 和经济中受到低估，限制了护士参与决策 和成为卫生保健系统领导者的机会(22,23, 122)，这可能会破坏招聘合格申请人参加 护理教育规划的努力。将照护工作视为女 性责任的偏见以及各种社会性别规范使得 招收男生成为一项持续挑战：女性接受护 理教育可能被认为是一种向上的流动，但 对于男性则可能并非如此(123-125)。此 外，女性在其他职业类别中的机会可能会 受到文化或制度限制，使护理教育成为女 性进入卫生保健事业的唯一或最明显的途 径，而不是面向有抱负的任何性别卫生工 作者的一种宝贵选择。 40. 在一些环境中，某些种族、民族或其他 弱势群体在护理教育中的代表性可能不足 ( 12 6 ) 。 这 可 能 会 对 护 士 与 其 所 服 务 的 社 区 之 间 的 文 化 契 合 产 生 负 面 影 响 。 尽 管 整 个 护 理 职 业 越 来 越 重 视 确保在教育和培训中纳入文化能力， 但 仍 需 要 做 出 更 大 努 力 ， 从 代 表 性 不 足 的 人 群 中 选 拔 和 招 聘 更 多 学 生 (专栏4 .1)。 41. 护士学校和培训规划的地点也会影响合 格申请人的数量。护理教育规划主要位 影响卫生人力市场的公共政策杠杆图4.1 教育部门 人力市场动态 Economy, population and broader societal drivers 培养政策 � 基础设施和材料政策 � 入学政策 � 学生选拔政策 � 教职人员政策 处理分布不均和效率低下问 题的政策 � 提高生产率和绩效的政策 � 改善技能组合的政策 � 在服务不足地区留用卫生工作者 的政策 处理人员流入和流出的政策 � 处理移入和移出人口问题的政策 � 吸引失业卫生工作者的政策 � 促使卫生工作者返回卫生保健部门的政策 监管私营部门的政策 � 管理从事多项职务的政策 � 提高培训质量的政策 � 强化服务提供的政策的政策 * Supply of qualified health and social - willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors 来源: 改编自Sousa A、 Scheffler RM、 Nyoni J、 Boerma T。 A comprehensive health labour market framework for universal health coverage。 «世界卫生组织简报»2013；91：892–4。 全 民 健 康 覆 盖 国外 中 学 卫生领域的培训 其他领域的培训 合格卫生工作者 人才库* 就业 失业 退出人力队伍 卫生保健部门** 其他部门 能提供优质服 务并可被接受 的卫生人力 教育部门 人力市场动态 中学 卫生领域的 培训 其他领域的 培训 合格卫生工作 者人才库 移徙 国外 就业 退出人力队伍 卫生保健部门 能提供优质服务 并可被接受的 卫生人力 全民健康 覆盖 培养政策 • 基础设施和材料政策 • 入学政策 • 学生选拔政策 • 教职人员政策 其他部门 处理人员流入和流出的政策 • 处理移入和移出人口问题的政策 • 吸引失业卫生工作者的政策 • 促使卫生工作者返回卫生保健部门的政策 处理分布不均和效率低下问题的政策 • 提高生产率和绩效的政策 • 改善技能组合的政策 • 在服务不足地区留用卫生工作者的政策 监管私营部门的政策 • 管理从事多项职务的政策 • 提高培训质量的政策 • 强化服务提供的政策 来源：改编自Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage。 《世界卫生组织简报》2013;91:892–4. 20 2020年世界护理状况 于有大学和医院的城市中心，大大减少 了农村和偏远地区潜在学生的教育选择 (129)随着越来越重视卫生人力的地域 分布和培训机构的社会责任，一些规划 正在将农村培训场所纳入在内，或积极 招募和支持来自在高等教育中历来代表 性不足社区的学生。在线远程教育规 划与适当的临床教育机会相结合，可以 为农村地区的潜在学生提供有效的方案 (130)；虽然应持续注意监控和保持教育 质量，不过这种方法在某些环境中，有可 能提高护理专业学生的多样性(131)。 42. 费用(包括学费和生活费)会影响学生参加 或完成护理教育规划的能力。虽然护理教 育的费用差异很大(专栏4 .2)，但公共规划 可得到更多补贴，往往比依赖学生学费和 私人捐款的私人规划便宜。生活费用，加 上全日制学习时收入低或无收入，增加了 个人的学习成本。不同国家有不同的资助 计划，其中可能包括面向代表性不足群体 的学生或毕业后愿意在服务不足地区从业 的学生的方案或激励措施。 43. 初级教育规划各种各样，培养具有不同资 格和专业职能的护士，但都必须符合护理 专业和护理协会的分类标准(ISCO-08)。 初级规划可以培养证书级、文凭级和 (学士)学位级的护士；初级护理课程的学 术要求各不相同，可以完成九年级以下课 程并于17岁开始证书课程，也可完成中 学(十二年级)外加两年大学教育然后进入 学位课程(135,136)。虽然规划和入学要 求的多样性可以使更多的人进入该职业， 但雇主往往无法根据教育水平来区分从业 职务，造成了供应系统与雇主之间的不匹 专栏 4.1 澳大利亚：让代表性不足的人群参与到护理人员队伍中 在澳大利亚，土著澳大利亚人一直要求由土著从业人员提供更多护理服务，以便不仅能增加他 们获得护理的机会，而且能获得文化上安全的护理(127)。然而，解决办法并不像增加土著和原住 民学生和托雷斯海峡岛民学生的人数那样简单，而是要确保解决这些学生面临的各种挑战，例如 创造一个有利的环境，提供土著护士师资，在课程中嵌入土著内容，以及解决学生的经济需求等 (127,128)。 专栏 4.2 护理教育成本 据估计，全球每年在护理和助产教育方面的支出为272亿美元(132)。虽然护士和助产士占全球 卫生人力一半以上，但护理和助产教育支出仅约占全球卫生工作者教育支出的四分之一。据2010年 公布的估计数据显示，全球护理专业毕业生的平均成本为5万美元，从中国平均每位护士3000美元 到北美超过10万美元不等(132)。这种差异可归因于公共和私营部门在资助、拥有和管理教育机构 中所占的比例，因为国家内部和国家之间资助护理教育的模式各不相同(133)。推动护理教育成本变 化的另一个因素是同时存在各种不同的资格等级，而且教育规划的期限和预认证也各式各样(134)。 需要更多更好的关于护理和助产专业毕业生以及教育和培训成本的数据来指导投资，以便到2030年 能弥补预计的短缺。 21扶持护理人员队伍的政策杠杆 配，前者在培养多面手，而后者则在专科 或差异化护理背景下构建其服务。 44. 世界各地一些国家对其相当一部分护理 人员进行证书和文凭级别的教育，通常是 在独立培训机构进行，注重以任务为主的 临床技能(137)。大学学位(学士)教育通常 包括一些额外课程，涉及领导力、病例管 理以及影响不同住院和门诊环境中的健 康结果和患者结果的社会经济因素；有 时也包括涉及研究工作的课程。这些课 程还强调“批判性思维技能”，这有助 于进行更高级的临床判断和提高护理服务 的安全性。研究结果表明，在更多有学位 的护士护理下，患者死亡几率降低，且住 院时间较短，支付的医疗保健费用也更低 (46,138,139)。不过，大多数显示患者结 果因有学位的护士而得到改善的研究是在 医院中进行的，在门诊和社区环境中并未 出现同样的情况，这限制了研究结果的普 遍性(140)。此外，另有证据表明，有学士 学位的护士在其工作场所可能没有充分使 用他们的知识和技能(141)。 45. 护士也可以攻读学士后专科学位或者专业 或高级实践的硕士学位，或者可以获得护 理博士学位，或以实践为主的护理实践博 士学位，或者以研究为导向的哲学博士学 位(142)。提高专业护士的学历将需要使不 同层次的课程相互衔接，这些课程建立在 先前学习的基础上并为其提供学分(143)。 在对有学位的护士存在需求的国家，对现 有护理证书进行“过渡”或“升级”的教 育规划可能是一种重要的职业发展机制， 并可给个人带来高回报率。值得注意的 是，硕士或博士水平的大学后教育需要先 培养学士级别的护士，而这反之也可影响 初级护理课程的师资数量和质量。 46. 护理教育的一个关键但往往具有挑战性 的部分是确保学生有足够的时间接触临 床实践环境。在临床实习期间，学生应用 并整合在教育环境中学习的批判性思维、 临床评估和护理能力。临床教学人员需要 提供适当的监督和进行临床技能评估。 由于许多护理课程位于城市地区，因此在 农村或偏远机构提供合适的临床经验可能 具有挑战性。这种实习有助于学生最终决 定在哪里执业(144)。一些在线或远程课程 已证明提高了农村和偏远临床机构的可及 性，这些机构以前与“实体”教育机构没 有关联(145,146)。另外，远程卫生保健技 术和模拟实验室可以在初级保健中提供适 当和互补的临床经验(147-150)。应当对在 线远程教育课程进行监测，并使其达到与 其他教育机构相同的认证和质量标准。 47. 许多国家出现了私立卫生教育机构大幅增 加现象，其中非营利和营利性兼有(151, 152)。后者往往牵涉更高的学费，并且可 能受制于不同的监管机构规定和认证要求 (152)。它们可能与卫生和教育的公共政策 目标脱节，因此可能不总是与人口健康重 点相一致，尤其是如果目的是为不断增长 的国际卫生人力市场培养护士。若没有质 量保证机制，则课程的内容和授课方式便 可能不符合国家标准，包括必须的临床经 验，培养出来的毕业生将不具备提供安全 优质护理服务的知识、技能或行为(153)。 不附属于医院或学术医疗中心的私立学校 的激增会对现有的临床实习点造成压力， 并令人质疑其提供的培训质量。 48. 护士教育最大的挑战之一是招聘和保留足 够数量的合格护士(19,20,154)。这些挑 战包括他们的就业环境(教育机构与临床 机构)，这可能涉及薪金差异和受保护的 教学时间。美国护理学院协会的一份报告 提议合并护士学院的教育和临床实践职务 (联合职称)，以提高护理教育中临床护理 专家的地位、报酬和参与度(155)。其他策 略包括建立学术-临床伙伴关系，在这种 关系中，临床医师接受学术培训以便能够 在临床环境中教导学生，此外还包括激励 学生继续深造的措施，如减免学费和提供 额外的培训机会。这些伙伴关系的成功往 往依赖于临床实习点能否为临床护理专家 提供足够的自由时间，使其能在现场监督 或与学生互动。专栏4 .3提供了国家内部 和国家之间的例子。 22 2020年世界护理状况 49. 硕士和博士级别师资的短缺是建立高等护 理教育课程的一个障碍，尤其是在关于认 证或批准的标准中对教育者提出明确要求 的情况下。缺乏受过博士水平培训的师资 也影响了该职业的必要研究能力，难以开 发证据为实践提供参考并在学术和卫生保 健部门发挥领导作用(20,154,160)。 50. 在所有卫生保健学科中，护理经证明最能 利用跨专业教育(161)。这种教育方法也受 到护理专业学生的重视，他们认为这有助 于他们实现跨专业的协作能力(149,162)。 此外，将不同学科的教育人员整合到护理 教学中，有可能将其他学科的专业知识引 入护士教育，并可能提高护士在基于团队 的病患护理中所必须具备的能力(163)。 目前，高收入国家比低收入和中等收入国 家更多地采用这种教学方法(159)，但技术 使用的日益增加，甚至在低资源环境中也 是如此，为加强跨学科学习创造了真正的 机会(162)。 4.2 人力的流入和流出 51. 在职护士的数量(或护理人力“总数”)取 决于许多因素。“流入”包括从国内护理 课程毕业并开始执业的护士、从其他国家 移民过来的护士以及那些重返岗位的护 士。“流出”包括未能在国内卫生部门就 业的护士毕业生、选择在卫生部门以外工 作的护士、退休人员和移居国外的人员。 52. 卫生工作者流入卫生人力市场的一个基本 决定因素是国家创造有资金支持的就业 岗位(无论是在公共部门还是在私营部门) 的经济能力，或者通过提供卫生服务获得 收入的机会。因此，创造就业机会与国家 的社会经济水平直接相关，同时，在此 范围内，还与公共部门决策者对投资于卫 生部门，特别是投资于卫生人力的重视程 度有关。影响需求的其他因素包括人口 变化，如人口老龄化；疾病概况不断演 变，如慢性病和多种疾病并存情况增多； 护士大量离职或其他卫生专业人员短缺； 专栏 4.3 解决护士教育师资短缺的问题 护士教育师资短缺问题是全球各地都面临的挑战，可以通过更多的合作方法，如跨机构，甚至 跨国家共享资源(156)来缓解。 在泰国，由中华医学基金会(157)资助在清迈大学开展的高等护理教育发展规划是增加有学历证 书的护理教育人员的一种合作方法。该规划始于1994年，重点是培养有硕士和博士学位的护理教育 师资，以便在中国各地越来越多的本科护理教育规划中任教。该规划随后扩大了其在东亚和东南亚 10个国家的影响，使护士教育规划得以扩展，并在整个区域相互承认护士证书(157)。 在美国，退伍军人事务部护理学术伙伴关系规划为在伙伴学术机构任教的护理专家的薪金和培 训提供资金，以增加准备好满足紧急和初级保健环境中退伍军人独特卫生保健需求的毕业生人数 (158人)。 在卢旺达，通过持续教育，注重先进的教学方法和课程开发等，加强了护理教育人员的能力 (159)。这一举措得到了一个国际学术伙伴关系的支持，认识到该规划必须由卢旺达自主管理，并有 必要通过合作来践行文化谦逊态度(159)。 23扶持护理人员队伍的政策杠杆 医疗卫生机构增多，例如建造医院或医 院改变雇用政策等；或法规变化，如以 护士对患者比率为标准配置人员等(140, 164)。可能减少对护士需求的因素包括采 用新技术后减少了对住院治疗或由护理人 员提供护理的需求、人员留用率高、生产 率提高(例如，通过使用循证做法或增加 技术使用)，以及将护士的职能委派给另 一职业类别(164)。 53. 护理人力的国际流动在日益增加，对各 国的卫生工作者队伍产生了重大影响。护 士移徙的原因包括寻求获取更好的工作、 薪金、工作条件、卫生基础设施、诊所或 医院资源以及教育机会。除了这些吸引因 素之外，目的地国对家庭签证申请的规定 也可能是移民的一个诱因。推动因素包括 缺乏工作机会，工作条件和服务条件恶劣 以及来源国局势不安全等。来自在国外工 作护士的汇款可以成为家庭收入的重要 来源，并对一些来源国的经济作出相当大 的贡献。各种政策解决方案，如国家间协 议(双边协议)等，必须对来源国和目的地 国都有利，且符合世卫组织《全球卫生人 员国际招聘行为守则》(165)关于支持和保 障的政策规定(见关于全球技能伙伴关系 的专栏4 .4)。 54. 在2011年至2016年的五年时间里，在经 合组织国家工作的外国培训护士人数增 加了20%，超过了医生，达到近55万人 (168)。这一数据的大幅提高表明传统上确 认的“来源国”和“目的地国”模糊不清 (169)。虽然高收入国家对护士的经济需求 仍然很高(例见专栏4 .5)，但正在出现从亚 洲、非洲和加勒比向其他区域和国家(如 向海湾国家)移徙的模式(170)，以及同一 区域内国家之间的南南移徙模式。 专栏 4 .4 全球技能伙伴关系 2018年12月，152个联合国会员国通过了《安全、有序和正常移民全球契约》，促进以综合办 法解决国际移民问题。《全球契约》的一个核心宗旨是建立全球技能伙伴关系，这是一种双边协 议，通过使对工作者的供求与原籍国有针对性的教育相匹配来利用移民机会(166)。这种伙伴关系 形式旨在将移民带来的压力转化为来源国和目的地国共同公平分享的切实利益，这符合世卫组织 《全球行为守则》的原则。 通过这样一项协议，目的地国同意在移徙之前提供技术和资金，在原籍国培训具有目标技能的 潜在移民，而原籍国同意提供这种培训，并同时也获得对非移民培训的支持(166)。作为这种伙伴 关系的一部分，护士可以接受”本国发展”和”出国发展”培训，选择本国发展的护士接受适合原 籍国需要的技能培训，而选择出国发展的护士则为在目的地国工作做准备。根据每个伙伴的需要， 这种伙伴关系可能不限于单一职业。(联合王国国家卫生服务体系的)英格兰健康教育机构和牙买加 政府之间的伙伴关系旨在加强牙买加的专科护理人员队伍。牙买加护士在联合王国医院接受为期 两年的重症护理培训，然后返回牙买加过渡为护理专家。与此同时，联合王国的护士将在牙买加居 留一段时间，支持加强卫生系统的活动，包括提供服务、提高质量和培训。该交流计划已于2019年 启动。 国际移民组织在全球有类似项目，通过一系列促进有效管理卫生工作者移徙、原籍国卫生系统 能力建设以及海外侨民技能和知识转让的规划，将原籍国和目的地国联系起来(167)。该组织通过与 各国政府和其他利益攸关方合作来实施这些项目。国际移民组织是世卫组织的一个主要合作伙伴， 支持世卫组织的《全球行为守则》以及相关政策和世界卫生大会决议(167)。 24 2020年世界护理状况 4.3 公平分布和效率 55. 一旦进入卫生部门，护士会在一系列的 公共和私人卫生服务提供点被雇用(175- 178)。关于护士在不同类型设施中的分布 以及设施的所有权没有系统记录。然而， 与初级保健环境相比，护士可能更喜欢在 医院和急诊环境中工作，在某些情况下， 护士选择在私营部门工作，因为薪酬比公 共设施更高(175,177)。 56. 护理模式应努力在综合初级卫生保健团队 中实现最佳技能组合(179)，允许护士充 分发挥从其护理教育中学到的知识和能力 (180,181)。护士是综合护理团队的基石， 通常领导提供护理服务并承担更广泛的实 践任务，包括与社区卫生工作者协作和对 其进行监督(182-193)。允许护士充分发挥 其教育和经验所得可以提高工作满意度以 及患者对护理的满意度(194)。促进因素包 括开展初级卫生保健培训、制定标准化实 践指南或常规，以及建立跟踪患者护理结 果的数据系统(195,196)。 57. 许多国家将处方作为专业或注册护士实 践范围的一部分(197,198)。护士处方权 专栏 4 .5 高收入国家对护士的经济需求实例 人口、流行病学和卫生政策的转变表明，高收入国家对护士的需求日益增长。这方面例 子包括： • 英国健康基金会估计，到2024年，每年至少需要从国外招聘5000名护士(171)。 • 在日本，颁布了一项新的签证计划，旨在吸引多达24 .5万名外国工作者，包括6万名护理助 手(172)。 • 德国政府报告在老年人和病人护理方面约有36 000个职位空缺(173)，表示需要从国外招聘 (174)。 专栏 4 .6 波兰通过护士处方扩大获取途径 波兰的国家卫生重点事项之一是改善社区一级对慢性病的管理，增加在初级卫生保健机构获得 治疗和药物的机会。围绕护理教育和监管机制采取的政策决定有效地扩大了护士在卫生保健系统中 的职能，并增加了患者获得卫生服务的机会(205)。 2016年，准许拥有特定资格的护士有权在特定条件下开处药物。为了让即将毕业的护士为这一 职能做好准备，每个初级护理和助产教育规划都纳入了处方课程，并且法规允许所有获得护理学士 学位的护士开具预定清单中的药物(206)。与此平行，一项关于发展护理和助产学的新国家战略为护 士的不同职能和专业能力引入了组织标准，并改善了工作条件。 自2016年以来，10 287 名护士和 4799 名助产士完成了培训，有能力开具处方。截至2018年12 月，护士和助产士独立开具了2538份处方，并授权延续了363 288份已有的处方。 25扶持护理人员队伍的政策杠杆 可限于法规或专业监管框架(199)中规定 的特定群体或用药时间表。在另一些情 况中，则针对人群的重点健康事项开处 药物，这些重点可能包括撒哈拉以南非 洲艾滋病高负担国家的一线抗逆转录病 毒治疗、抗微生物药物耐药性或应对慢 性病等(200-202)(见关于波兰处方权的专 栏4 .6)。此外，护士在鼓励遵医嘱用药、 监控处方决定和减少处方错误方面也发挥 着重要作用(203,204)。 58. 确立高级实践注册护士职务是为了增加 服务不足和偏远地区人口的获取机会， 并解决初级保健环境中人员不足的问题 (192,207)。最常见的高级实践护士类型 是开业护士，其临床范围包括有权自主 安排诊断检测、作出诊断以及开具治疗 和药物处方(207)。此类型通常需要专业 组织的认证和硕士水平教育(208)。在少 数高收入国家，尽管关于成本效益的数 据有限(208-210)，但有确凿证据表明， 开业护士和高级实践护士经过充分培训 后，在提供优质护理、增加护理获取机 会和提高患者对护理的满意度方面很有 成效(208,209)。在其他国家，护理硕 士和开业护士的数量也在增加(159,211- 214)，不过影响教育准备以及认证或执照 发放的法规差异很大(192)。关于高级实 践护士职务定义和相关能力的认识也因国 家而异(192,215)，不过国家经验表明高 级实践护士职务增加了护士职业的吸引力 (211,214)。培养的学士级别护士如果具有 护理特定患者群体的专业知识，即使没有 获得高级实践护士执照，也可有资格被认 证为护理专家(见专栏4 .7关于护理专家的 实例)。 59. 农村和城市地区卫生人力地理分布不均是 一个普遍挑战。各国在多个领域(教育、 监管、金融和专业)采取各种政策措施， 试图在农村或偏远地区公平部署和留用 卫生工作者(217)(见关于农村留用问题的 专栏4 .8)。鉴于解决这一多层面问题需要 多管齐下的方法，了解各种干预措施的影 响是在不同实践环境和地区推广和共享此 类策略的关键(144)。在一项国家研究中， 发现一些额外措施对农村护理提供者很 重要，尤其是公平性、透明度、卫生部卫 专栏 4 .7 非洲区域的护理专家实例 东部和南部非洲有越来越多的政府正在投资确立儿童健康护理专家职务，作为降低儿童死亡率 战略的一部分。儿童健康护理专家应是注册护士，接受过基础后培训，并由此获得儿科护理专家或 儿童健康护士的额外资格认可。 最常见的途径是在完成基础培训(即高级护理文凭或护理学士学位)后，通过为期12个月的学习 获得儿科护理研究生文凭，从而得到专科化。由此产生的职称和证书因国家而异，典型的一些表述 包括注册儿科护理专家或儿科专业护士。 该区域约有3650名注册儿科护士，其中肯尼亚、马拉维、乌干达和赞比亚约有750名，南非有 2900名(216)。每年大约有205名儿科护理专家从12个不同的教育规划(大部分在南非)毕业。另有三 个规划(分别在博茨瓦纳、坦桑尼亚联合共和国和津巴布韦)正在制定当中(216)。 该区域很少有国家信息系统按护士专业分类。儿科护理人力观察站支持国家制定计划以优化技 能组合，满足该区域儿童的特殊健康需要。自2015年以来，研究人员、护理教育者和其他利益攸关 方一直在合作，以了解和报告东部和南部非洲儿科护理人员队伍的作用。 26 2020年世界护理状况 生人力资源管理的可预测性以及就业状况 (长期工相对于合同工)(218)。在中等收入 和高收入国家进行的研究发现，组织承 诺以及护士管理人员的大力支持关系到 护士能否留在农村从业(219,220)。从交 通不便的社区招募护理学生，如果他们之 后能回到其社区工作，可能会提高留用率 (146,221)。 60. 将护士保留在其从业环境中可能是一项挑 战。护士的更替是市场作用的必然结果， 对卫生保健机构、患者和护士本身都有积 极和消极两方面影响(220,222)。例如，适 度的更替率有利于职业能力发展和组织协 调，例如，护士离职去某个组织或卫生系 统中追求职业发展(223)。另一方面，辞 职和更替几乎总会给组织带来费用问题， 并可能对患者的护理产生负面影响。 61. 组织和个人因素都会影响护士离开或留在 给定工作岗位的意愿。个人因素包括个人 或家庭生活或健康方面的变化、教育目 标、工作压力、对工作不满意，或相反， 感到决策可以增强权能(224,225)。影响留 任的组织因素包括工作环境、工作关系、 工作条件、薪金、管理风格和有效监督 (226)。在对澳大利亚、埃及、伊朗伊斯 兰共和国、约旦和菲律宾等国进行的研究 中发现，在医院环境(227-229)和农村环境 (219,220)中，临床管理者的领导风格和组 织文化可能直接影响护士的工作满意度和 更替率，并可能影响护理质量。 4 请注意，目前在对这些指南进行更新。 体面工作 62. 根据劳工组织，体面工作“涉及生产性 就业机会，提供公平收入、安全的工作场 所和家庭的社会保障，为个人发展和社 会融合带来更美好的前景，使人们能够 自由表达关切，并为影响其生活及男女 机会平等和待遇的问题进行组织并参与 决策”(230)。在护理职业背景下，体面 工作议程面临的典型挑战包括性别平等问 题、袭击风险、过长的工作时间和对移民 护士的不公平待遇。 63. 女护士与卫生人力中的其他女性相比，在 工作中面临更多的障碍(21,231)。其中包 括对妇女的照护责任的偏见、社会性别规 范、性别偏见和陈规定型观念，所有这些 都削弱了护士获得良好工作条件、获得公 平薪酬和平等待遇、参与决策和成为卫生 保健领域领导者的能力(21,22,122)。世卫 组织2019年题为《女性提供服务，男性提 供领导》的报告发现，在女性占多数的工 作中，往往存在更大的歧视负担：据一个 环境中的护士报告，她们当中36%没有受 到其上级的尊重，同时32%的护士表示希 望能听取或倾听其意见(21)。这些障碍损 害了女性卫生工作者的福祉和生计，并限 制了性别平等方面的进展(21)。性别歧视 也对护理产生直接影响，因为对护士的机 构支持和尊重可提高护理质量(232)。工 作场所的性骚扰是所有女性卫生工作者， 包括护士(25%)(233)和助产士(37%)(21) 面临的一个问题。 专栏 4 .8 农村留用指南 在许多国家，为农村和偏远地区吸引、招聘和留用护理人员越来越受到关注。2010年，世卫组 织提出通过改善留用条件加强向边远和农村地区普及卫生工作者的全球政策建议 4 (217)。 这些建议涵盖四个主要干预领域：教育、法规、财政激励以及个人和专业支持。尽管针对农村 护理的研究正在增加，但仍非常有限。这方面证据主要来自高收入国家(特别是澳大利亚、加拿大 和美国)，而且表明财政激励、个人和专业支持以及更快的卫生职业发展道路会影响农村地区护士的 留用。 27扶持护理人员队伍的政策杠杆 64. 在某些环境中，护士和卫生工作者有被袭 击的危险。在2019年1月1日至2020年1月 1日期间，世卫组织通过其袭击医疗机构 事件监测系统记录了1005起袭击医疗机构 事件，在面临复杂紧急情况的11个国家的 卫生保健工作者和患者中造成198人死亡 和626人受伤(234)。 65. 卫生服务提供必须持续灵活响应患者的需 求，以致工作时间长且不规律，造成了特 别的挑战，对护士本身和患者都有潜在的 负面影响(前者会精疲力竭，后者则面临 医疗错误增加导致的风险)(235)。劳工组 织1977年《护理人员公约》(第149号)要 求签署方确保护士享有与其他工作者同等 的工作时间，并对加班、不方便的工作时 间和轮班工作进行管理和补偿。 66. 移民护士也面临着没有体面工作条件的特 殊风险。移民护士和少数民族护士比目的 地国或多数民族的护士(236)更容易遭受 工伤和歧视。据报告，歧视是移民和少数 民族护士健康受损的主要原因(236)。然 而，本国缺乏体面工作机会也可能是推动 护士移民的一个因素(237-240)。 专栏 4 .9 统一教育标准和执照考试的例子 1972年，加勒比共同体各领土成立了区域护理机构，最初的任务是建立合格教育工作者共享人 才库，以缓解对毕业护士进行能力评估的瓶颈(252)。当分析表明整个分区域的护理教育课程目标、 内容和教学方法相似时，各国同意从1990年开始对护士进行单一和共同的考试。区域护理机构负责 协调考试，以共同商定的注册护士执业能力为基础，并由每个国家的首席或首要护理官员、护士导 师和护理委员会以及该分区域的大学教育工作者(257)共同管理。该考试有助于护理教育的标准化和 改进，以及注册护士在该分区域各国之间的互用和流动。 在欧洲联盟，1970年代末颁布了一系列部门指令，开始努力统一多样和复杂的护理学位结构 和课程大纲，并随着2005年的修订(第36号指令)和随后的更新(第55号指令)(253,254)加快了速度。 这些变化，加上《博洛尼亚协定》(1999年)，促使形成了学士、硕士和博士三期教育结构，所有学 科的学历都得到了统一(258)。 28 2020年世界护理状况 4.4 监管 67. 监管通过制定和执行有关行为、教育和实 践的标准来保护公众。监管也能使护理提 供者受益，并有助于提高公共和私营部门 护理教育(241,242)和实践的质量。监管机 构还在日益生成和维护卫生人力数据和证 据(243)：过去15年中，生成的跨多个学 科的监管研究证据显著增加，其中护理领 域的证据最多(244,245)。 68. 教育监管可以包括制定护理教育方面的 国家标准，由护理监管机构批准护理教育 和培训规划，以及由外部机构对各教育机 构进行资格认证。资格认证指根据教育提 供标准对机构进行评估，可激励机构培养 毕业生，从而提高人口卫生服务的质量、 公平性、相关性和有效性(246)。然而， 标准和资格认证周期必须跟上卫生保健科 学和交付模式的变化，并且对于机构来说 可以负担或不增加费用。有必要执行标准 来补救规划缺陷，或者作为一种极端但有 时是必要的措施，中止达不到可接受标准 的规划。2013年在17个撒哈拉以南非洲 国家进行的一项研究发现，对护理教育认 证有严格的法律规定；然而，在培养该地 区大多数护士的规划中，认证水平较低， 并且公共规划的认证水平高于私人规划 (247)。在某些情况下，私营部门对认证结 果提出质疑，理由是做出决定的人员存有 利益冲突；因此，政府正在改变决策机构 的组成，以增加非专业成员的参与(248)。 69. 在各国内部，资格认证可能因规划类型而 异(249)。在一些国家，政府机构建立和 监督公立大学，只有私立机构需要得到资 格认证；在其他地方，如果政府不要求， 私人机构可能根本不需要获得认证。资格 认证可以由法律直接规定，也可以做出间 接规定，要求申请加入或注册护理委员会 或参加执照考试的毕业生必须毕业于护理 委员会批准或由适当组织认证的规划。 70. 大多数护理教育标准规定了最低临床学时 数和最低能力，以确保课程内容的完整性 和广度。护理教育的标准通常是某个司法 管辖区(例如，某个国家、州或其他必须 维护一套特定法律或规则的地区)所特定 的，可能会影响护理毕业生的流动。达 成相互承认协议和统一的教育要求正在不 断提高从业人员的标准化和安全高效的流 动性。这方面例子包括美国护士执照契 约(250,251)、加勒比地区护士注册考试 (252)、欧洲联盟专业指令(253,254)、东 南亚国家联盟协议(255)和跨塔斯曼协议 (256)等。专栏4 .9介绍了统一教育标准和 执照考试的实例。 71. 就个体护士而言，职业监管涉及(a)确立 对初始承认“护士”头衔的要求(即注 册或注册并有执照)，这可能包括执照 考试；(b)对重新加入、注册或考照提出 要求，其中可能包括要求持续专业发展； (c)确定护士的从业范围以及行为和道德守 则；以及(d)协助对护士进行调查和采取 可能的纪律处分(259)。监管机构也日益 有义务和责任维持对在职护理人员登记 簿的更新。 72. 60%以上国家通过执照考试来执行一个 最低水平，评估护理毕业生的初始知识 或“就业能力”，然后授予他们执业资 格(29)。另一种评估初始就业能力的方法 是客观的结构化临床考试，试图在模拟临 床环境中直接观察能力；然而，这在管理 方面可能很昂贵且需要大量人力(260- 262)。关于是否应该对重新发照、重新进 入该职业或对外国培训的护士适用就业能 力考核，目前尚有争议。 29扶持护理人员队伍的政策杠杆 © WHO/Sergey Volkov 30 2020年世界护理状况 护理人力队伍证据和 数据的现状 章节 73. 本章根据国家卫生人力账户方法并基于 一套标准化指标和一个数据报告程序，报 告了190多个国家的护理人力队伍数据。 这是世卫组织历史上的第一次。 74. 收集了关于护理人员的数量、组成、分 布、教育和培训、技能、管理、监管、经 费和领导的数据5。总共收集并分析了30 多项指标的数据。数据收集工作包括卫生 部、劳动和教育部等其他部委、卫生观测 站的人力资源部门、国家公共卫生机构、 护理专业组织、政府护理和助产服务最高 主管官员以及其他国家、区域和国际组织 等各利益攸关方。数据通过统一的数据 定义和报告系统(国家卫生人力账户平台) 收集，该平台被用作会员国报告、监测和 使用其卫生人力资源数据的在线资源库。 详细方法见附件2。 5 使用国际劳工组织对护理人力队伍的定义：见附件1。 5 75. 分析的重点是当前的护理人力队伍， 但本章的最后部分考虑了在不同假设下 护理人力队伍的未来可能情景，以便评 估在实现世卫组织《卫生人力资源全球 战略：人力2030》中概述的目标方面以 及与2030年可持续发展目标和全民健康 覆盖议程相关的进展(16)。 31护理人力队伍证据和数据的现状 76. 报告护理人员总数的国家数量是空前的， 代表了有史以来最全面和最新的护理人力 队伍数据(图5 .1)。鉴于指定2020年为国际 护士和助产士年所产生的势头，与其他职 业相比，2013-2018年期间的护理信息尤 其增多了。不仅在信息数量方面，而且在 报告的及时性方面，近年来关于卫生人力 总数的数据都有所增加，大多数国家都报 告了可持续发展目标指标3.c.1中包括的五 个职业(医生、护理和助产人员、牙医、 药剂师)最近五年内的数据。由于能够获 得实际数据和追溯数据，以前的估计就可 以追溯更新，并且可以解决先前分析和报 告的数据局限性。 77. 在本报告中使用的36项护理人力队伍指 标中(见附件2表A2 .1)，几乎所有世卫组织 会员国都能够报告其护理人员总数数据， 大多数还能报告其他主要指标，例如年龄 分布、性别组成和培训时间。大约80%的 国家提供了至少15项指标的数据，而23% 的国家提供了至少25项指标的数据。本章 报告了会员国答复率很高的选定指标(完 整列表载于附件2)。 有牙科人员数据的国家 有护理和助产人员数据 的国家 有制药人员数据的国家 有内科医生 数据的国家 国 家 数 量 160 140 120 100 80 60 40 20 0 191个国家有最新数据 83%为2017年或2018年的数据 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 注：(a关于最近五年，收集了191个国家的护理人员总数数据。最新的数据点可能涉及不同的年份；大多数国家(83%)提供了2017年或2018年的人员数据。 (b)提供和报告数据的滞后时间可以解释近年来的明显下行趋势；预计2014-2018年将有更多数据点可用，从而会保持护理人员总数数据呈积极的上升趋势。 来源：国家卫生人力账户，2019年。 世卫组织国家卫生人力账户中提供的拥有人力数据的国家数量 (1990-2018年)图5.1 32 2020年世界护理状况 5.1 护理人力队伍的人数、组成和分布 5.1.2 全球和区域的护士总数 78. 191个国家的数据表明，全球公立和私立 部门的护理人员总数约为2800万(表5 .1)。 这意味着全球每万人口拥有36 .9名护士。 但是，这一全球数字掩盖了区域内部和区 域之间的巨大差异6。 79. 尽管美洲区域和非洲区域的人口数相近， 但美洲区域的护士人数几乎是非洲区域 的10倍，每万人口分别有83 .4和8 .7名 护士。东地中海和东南亚区域的护士密度 为倒数第二和第三(分别为每万人口15 .6和 16 .5名护士)，但仍然是在非洲区域观察到 的护士密度的近两倍。 6 见关于公平性的第5 .2节。 80. 全球约81%的护士在三个区域(美洲、 欧洲和西太平洋区域)工作，这些区域合 计占世界人口的51%。 81. 在将2018年2790万名护士的总估计数 与《卫生人力资源全球战略》中的估计 数进行比较时(该战略使用2013年数据得 出2070万名护士和助产士(其中1880万名 为护士)的估计)，需要谨慎地进行解释。 护士人数从2013年到2018年增多的部分 原因是由于数据可得性的提高(涉及440万 名护士)，而实际增加的人数估计为470万 名护士(表5 .2)，而实际增加的人数估计为 360万是专业护士(假设专业人员与准专业 人员的比例保持不变)(图5 .2)。 5.1.1 主要调查结果 191个国家的数据表明，2018年全球护理人员总数约为2800万，主要是专业护士(69%)。 即使考虑到数据可得性和数据质量有所提高，2013年至2018年全球护理人员总数实际增加了 470万。 在具有可用数据的172个国家中，专业和准专业护士约占卫生专业人员(医生、护理人员、 助产士、牙医、药剂师)的59%。 全球每10名护士中有9名是女性，但区域差异很大：在非洲区域，男女比例为1:3。在13个国 家中，男护士人数超过女护士。 区域内的分布也存在很大差异。在美洲区域，每10名护士中有超过8名在三个国家(巴西、加拿 大和美国)工作，而这些国家只占人口的57%。在非洲和东地中海区域，不同国家护士相对于 人口的密度相差100倍。 预计未来十年，全球将有六分之一的护士退休；在美洲区域，这一百分比明显更高(24%)， 从而在人员补充方面构成了进一步的挑战。 33护理人力队伍证据和数据的现状 82. 因此，2018年报告的2790万名护士总数突 出了两个不同方面的积极趋势： • 护理人力数据的提供有所改善，因此 可以更好地解释和重新评估先前的 分析； • 全球护理人员总数出现实际增长， 反映了人力市场对这一职业群体的需 求不断增长以及会员国对该领域的 投资。 83. 将拥有数据的172个国家的护理人员总数 与医生、助产士、牙医和药剂师的总数进 行比较时，护士平均占卫生专业人员的 59%，具体占比从东地中海区域的49%到 西太平洋区域的68%有所不同(表5 .3)。 世卫组织区域 报告人数的 国家数/总数 护理人员人数a (百万)(%) 每万人口的 密度 非洲 44/47 0 .9 (3%) 8 .7 美洲 35/35 8 .4 (30%) 83 .4 东南亚 11/11 3 .3 (12%) 16 .5 欧洲 53/53 7 .3 (26%) 79 .3 东地中海 21/21 1 .1 (4%) 15 .6 西太平洋 27/27 6 .9 (25%) 36 .0 全球 191/194 27.9 (100%) 36.9 a 包括专业护理人员和准专业护理人员。 注：没有喀麦隆、科摩罗和南苏丹的护士总数数据。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新密度。对于在2013年至2017年期间报告人数的国家，为了使所有 国家按2018年进行标准化，通过将其现有最新密度应用于2018年的人口来报告人数。 从联合国经济和社会事务部2019年《世界人口展望》修订版中提取了用于计算密度值的每个国家和年份的人口规模(263)。 表5.1 2018年按世卫组织区域分列的全球护士人数和每万人口的密度 2013年的护理人员总数 2018年的护理人员总数 由于实际 人员 总数增加 而发生的变 化(百万)来源 2009–2013年 拥有数据的 国家数 人员总数 (百万) 2013–2018年 拥有数据的 国家数 人员总数 (百万) 《卫生人力资源全球战略》(2016年)的估计 102 18 .8a 《2020年世界护理状况》报告的估计 174 23 .2 191 27 .9 4.7 由于数据改善而发生的变化(百万) 4.4 a 原出版物包括助产士：2070万护士和助产士。按护士占比校正后，相当于1880万名护士。 来源：国家卫生人力账户，2019年。 表5.2 2013年至2018年期间由于数据改善和实际增长而发生的护理人员总数变化 34 2020年世界护理状况 84. 有66个国家能够报告至少10种职业的近期 卫生人员数量；与所有这些可能的卫生工 作者相比，护理人员总数占卫生人力的比 例在40％至50％之间。 5.1.3 组成 85. 在全球2790万名护士中，有1930万(69%) 被归为专业护士( ISCO代码为2221)， 而600万(22%)被归为准专业护士(ISCO代 码为3221)。余下260万(9%)未被分类， 从而表明在国家数据系统和《国际标准职 业分类》系统之间的一致性方面可能存在 挑战。这些护士是专业护理人员或护理辅 助人员，而且此类别不包括护理助手或卫 生保健助理人员。如图5 .2所示，不同护理 人员类别的相对比例因区域而异。 世卫组织区域 护士总数a与可持续发展目标3.c.1中卫生专业人员的总数相比 进行报告的国家数/总数 护士平均占比 非洲 45/47 66% 美洲 24/35 56% 东南亚 11/11 53% 欧洲 50/53 57% 东地中海 20/21 49% 西太平洋 22/27 68% 全球 172/194 59% a 包括专业护理人员和准专业护理人员。 注：可持续发展目标指标3.c.1是用于评估可持续发展目标3.c进度的指标。 来源：国家卫生人力账户，2019年。 表5.3 按世卫组织区域分列的护士在卫生专业人员 (医生、护士、助产士、牙医和药剂师) 中的百 35护理人力队伍证据和数据的现状 5.1.4 护理人员统计：性别和年龄分布 性别分布 86. 需要将性别观点纳入卫生人力战略的主 流，以确保在卫生人力规划和管理中采取 对性别因素敏感的循证方法。长期以来， 由于各种原因，包括缺乏用于国家规划 以及区域和全球比较的高质量数据，人们 一直忽略了护理人员的性别组成和年龄 问题。在194个世卫组织会员国中，有132 个提供了按性别分类的数据，并有106个 提供了关于年龄的数据。在这132个国家 中，十分之九的护士(89%)为女性，但区 域差异很大。妇女在护理工作中所占的比 例在西太平洋区域最高(95%)，在非洲区 域最低(76%)。据13个国家报告，男护士 多于女护士(表5 .4)。 7 在本文中称为年轻护士。 年龄分布 87. 鉴于人口和人力队伍老龄化的全球模 式，有必要在预测中考虑人力队伍的年龄 结构。在许多国家，计划人员依赖于标准 退休年龄，但由于不同职业、性别和职位 级别的实际退休年龄不同，这种方法存 在局限性。106个国家的年龄分布数据被 用来说明护理人员统计的当前趋势。总体 而言，现有信息表明护理人力队伍相对 较年轻：38%的护士年龄在35岁以下7； 相比之下，年龄在55岁以上的人占17% (据认为，他们将在未来10年内退休)(图 5 .3)。然而，区域差异很大：在东地中海 区域，年轻护士与即将退休护士的比例 为14:1；相比之下，在美洲，这一比例为 1 .2:1，在欧洲和非洲为1 .9:1，因此表明 接替人群规模要小得多。 非洲 美洲 东南亚 欧洲 东地中海 西太平洋 全球 占护理人员总数的% 专业护士 准专业护士 未进一步界定的护士世卫组织区域 0% 20% 40% 60% 80% 100% 按世卫组织区域分列的每个职业类别中护理人数的比例图5.2 36 2020年世界护理状况 世卫组织区域 进行报告的国家数/总数 女性% 男性% 非洲 30/47 76% 24% 美洲 26/35 87% 13% 东南亚 9/11 89% 11% 欧洲 32/53 89% 11% 东地中海 11/21 78% 22% 西太平洋 24/27 95% 5% 全球 132/194 89% 11% 注：“护理人员”包括专业护理人员和准专业护理人员。 来源： 国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人数。 按世卫组织区域分列的女性护理人员百分比表5.4 非洲 (n=20) 美洲 (n=25) 东南亚 (n=8) 欧洲 (n=30) 东地中海 (n=5) 西太平洋 (n=18) ＜35岁 ≥55岁 0% 20% 40%80% 60% 40% 20% 世卫组织区域 全球 (n=106) 注：“护理人员”包括专业护理人员和准专业护理人员。 按世卫组织区域分列的35岁以下和55岁以上的护理人员百分比图5.3 37护理人力队伍证据和数据的现状 注：“护理人员队伍”包括106个国家按年龄分列数据的专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人数。 35岁以下护士的百分比 70% 60% 50% 40% 30% 20% 10% 0% 55 岁 以 上 护 士 的 百 分 比 60%0% 10% 20% 30% 40% 50% 70% 18个国家面临着 人力老龄化的风险 每个点代表一个国家 绿线表示人力队伍中即将退休的护士人数与年轻护士的人数相等 图5.4 55岁以上及35岁以下护士的相对比例 88. 由于全球17%的护士年龄在55岁或以上并 因此预计将在未来10年内退休，所以在未 来10年中，必须培养和雇用470万新护士 才能维持现状。为了跟上人口增长的步伐 并消除护理人员的短缺，将需要做出更大 的努力(见第5 .8节)。 89. 为了说明护理人力队伍的老龄化，图5 .4 报告了护理人力队伍中较年轻人员与较年 长人员的比例。虽然有若干国家的年轻 护士比例很高，但有些国家勉强处于平衡 状态(年龄小于35岁与超过55岁的护士比 例相似，如图5 .4中的绿线所示)，还有18 个国家(拥有可得数据国家的六分之一)面 临着特别具有挑战性的局面，即人力队伍 老龄化，年轻护士的数量少于即将退休的 护士。 38 2020年世界护理状况 90. 要实现全民健康覆盖，就需要解决在获得 和使用卫生人力方面的人口、地域和技能 差异。 5.2.2 各区域的公平性 91. 图5 .5显示了全球每万人口的护理人员 密度差异，其中最大的差距集中在非洲、 东南亚和东地中海区域以及拉丁美洲的一 些国家。 5.2.3 区域内护理人员数量方面的公平性 92. 图5 .6显示了区域内护士密度的差异： 每个点代表一个国家。各区域的护理 人员密度存在显著差异，但东地中海区 域的差距最大，最高与最低密度的比例 为121:1；非洲区域的差异比例为100:1。 此外，美洲区域一些大国家的护理人员密 度很高，而大多数其它国家的密度相对 较低：该区域87%的护士位于占人口约 57%的巴西、加拿大和美国。在欧洲区 域，密度差距较小，为10:1。非洲区域的 国家聚集在该列的下端，表明只有少数 非洲国家的护士密度高于每万人口25名 护士。在东南亚和东地中海区域也观察 到类似的模式。密度差异在很大程度上由 收入水平决定，低收入国家的护士密度为 每万人口9 .1名护士，而高收入国家的护 士密度为每万人口107 .7名护士(表5 .5和 图5 .7)。 5.2 获得和使用护理人员队伍方面的公平性 5.2.1 主要调查结果 占世界人口51%的美洲、欧洲和西太平洋区域有全世界约81%的护士。 护士密度低的国家大多在非洲、东南亚和东地中海区域以及拉丁美洲的部分地区。 全球护理人员数量方面不平等现象的主要原因是收入，低收入国家的护士密度为每万人口9 .1 名护士，而高收入国家的护士密度为每万人口107 .7名。 各国内部存在巨大差异：在35个按城乡地区分列数据的国家中，36%的护士部署在农村地区， 而在那里居住的人口为49%。在有可用数据的76个国家中，有75%的护士受雇于公立部门， 其余25%在私立部门。 39护理人力队伍证据和数据的现状 图5.5 2018年每万人口的护理人员密度 注：“护理人员”包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。2013年至2018年期间的现有最新数据。 未报告不适用 0 1,000 2,000 3,000 4,000500 公里 10人以下 10至19人 20至29人 30至39人 40至49人 50至74人 75至99人 100至49人以上 0 50 100 150 200 最高:最低密度比率 100:1 22:1 18:1 10:1 12:1 33:1 世卫组织区域 非洲 东地中海欧洲美洲 东南亚 西太平洋 每 万 人 口 护 士 人 数 注：“护理人员”包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人数。 图5.6 每万人口中护理人员密度的区域差异(2018年) 40 2020年世界护理状况 收入水平 低收入 中等偏下收入 中等偏上收入 高收入 0 50 100 150 200 每 万 人 口 护 士 人 数 注：“护理人员”包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人数。收入组别取自截至2018年的世界银行分类。 图5.7 每万人口中护理人员密度的区域差异(2018年) 93. 在考虑截至2018年12月联合国发展政 策委员会归类为最不发达的46个国家 时，护理人员的密度为每万人口中6 .4名 护士，这是所有其他国家平均水平的六 分之一，而且远低于低收入国家的平均 水平。根据脆弱国家指数，这些国家中 的绝大多数也被视为弱势国家(“严重警 告”或“警报”类别)8。专栏5 .1提供了关 于国家内部公平性的更多信息。 8 脆弱国家指数得分超过80的国家。来源：https://fragilestatesindex.org/。 41护理人力队伍证据和数据的现状 收入组 进行报告的国家 数/总数 每万人口的密度 最高与最低之间 的比率总体 低 高 低收入 30/31 9 .1 0 .6 42 .0 68:1 中等偏下收入 44/46 16 .7 1 .8 104 .6 57:1 中等偏上收入 60/60 35 .6 5 .0 124 .2 25:1 高收入 57/57 107 .7 19 .4 196 .1 10:1 全球 191/194 36.9 0.6 196.1 319:1 注：“护理人员”包括专业护理人员和准专业护理人员。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人员总数。 关于库克群岛和纽埃，未进行收入类别分类。因此，它们被归类为中等偏上收入国家，与同一地区的其它国家类似。收入组别取自截至 2018年的世界银行分类。 按收入组分列的护理人员密度 (2018年)表5.5 专栏 5 .1 国家内部的公平性 农村地区的护理服务 就公平获得服务而言，国家内部护理人员的分布同样重要。总共35个国家(主要在拉丁美洲和 非洲)9 提供了关于农村地区护理人员比例的数据。在这些国家中，平均约有36%的护士在农村地区 工作，而居住在农村地区的人口则为50%。 公立和私立部门的护理服务 在国家内部，不平等现象的另一个潜在起因是公立部门与私立部门之间的人力分配。在提供数 据的76个国家中，平均75%的护士在公立部门工作，而且各区域之间的差异相对较小。 9 9 安提瓜和巴布达、伯利兹、巴西、文莱达鲁萨兰国、柬埔寨、厄瓜多尔、埃及、萨尔瓦多、斯威士兰、冈比亚、加纳、几内亚比绍、圭亚那、洪都拉斯、冰岛、 肯尼亚、老挝人民民主共和国、马达加斯加、马绍尔群岛、蒙古、缅甸、巴基斯坦、巴拉圭、秘鲁、萨摩亚、塞尔维亚、塞拉利昂、斯里兰卡、塔吉克斯坦、 泰国、东帝汶、乌干达、坦桑尼亚联合共和国、乌拉圭、委内瑞拉（玻利瓦尔共和国）。 42 2020年世界护理状况 5.3.1 主要调查结果 根据来自86个国家的数据，八分之一(13%)的护士是在其当前就业的国家之外的另一个国家出 生或接受培训的。 在做出答复的国家中，高收入国家非常依赖在外国出生的护士；据报告，那里有15 .2%的护士 是在外国出生的或在外国接受培训的。 尽管在数据的获得方面有所改善，但关于迁徙和流动的数据仍不足以全面评估迁徙模式的复 杂性。 5.3 护士的国际移徙与流动 5.3.2 主要调查结果 94. 近几十年来，人口、流行病学、财政和 卫生政策趋势加快了卫生工作者的国际 流动，并且这种流动预计还将增加(18)。 世界卫生大会于2010年通过的《世卫组织 全球卫生人员国际招聘行为守则》是加强 国际卫生工作者流动中道德管理的重要国 际法律文书。 95. 长期以来，人们认识到并讨论了卫生工 作者从低收入国家向高收入国家的转移 以及相关的挑战。但是，用于决策的数 据主要限于特定的高收入国家。近期在 获得数据方面的改进，尤其是通过国家 卫生人力账户系统，表明原籍国（全球 南方）和目的地国（全球北方）之间的 区别不像以前想象的那么明显。 96. 截至2018年，总共有86个国家通过国家 卫生人力账户和经济合作与发展组织、欧 盟统计局和世卫组织欧洲区域办事处的报 告系统提供了关于在外国出生或在外国接 受培训的护士比例的数据，以此作为移民 现象规模的代用指标(表5 .6)。在进行报告 的国家中，每八名护士中就有一名(13%) 是在其目前就业的国家之外的另一个国家 出生或接受培训的。将这一比额应用于护 理人员总数，估计全球有370万名在外国 出生或接受培训的护士。在外国出生或接 受培训的护理人员主要分布在高收入国 家，所占比例为15 .2%，而在其他收入组 别的国家所占比例不到2%。 43护理人力队伍证据和数据的现状 收入组 进行报告的国家数/总数 在外国出生或接受培训的护士百分比 低收入 3/31 NR 中等偏下收入 18/46 0 .4% 中等偏上收入 27/60 0 .7% 高收入 38/57 15 .2% 全球 86/194 13.2% 注：“护理人员”包括专业护理人员和准专业护理人员。对无法提供有关在外国出生百分比数据的30个国家，“在外国接受培训”被用作代用指标。 来源：国家卫生人力账户，2019年。国家在2013年至2018年期间报告的现有最新人员总数。收入组别取自截至2018年的世界银行分类。 NR = 由于国家数量少，因此未报告。 按收入组分列的外国出生(或在外国接受培训)护理人员的百分比表5.6 © Ian Miles-Flashpoint Pictures/Alamy 44 2020年世界护理状况 5.4.1 主要调查结果 几乎所有国家都对护理教育监管指标进行了报告，有超过50％的国家对9项相关指标均做出了 肯定的答复。 据报告，在非洲、美洲和欧洲区域，监管机制和程序到位的程度很高。 与教育的领导和管理相比，对教育内容的监管(例如期限和内容的标准或者教育机构的认证 机制)的关注更多。 护理教育体系的监管在欧洲区域似乎更为充分，而在东南亚、东地中海和西太平洋区域则较为 欠缺，特别是在就业能力考核和教师资格标准方面。 5.4 护理教育与从业的监管 5.4.2 结果分析 97. 《卫生人力资源全球战略：卫生人力 2030》包括2020年的一个里程碑，即各 国应建立卫生人力教育的监管和认证机 制。本节概述了与护理教育和培训监管有 关的9项自我报告的指标(图5 .8)。 98. 绝大多数国家报告说具备护理教育期限和 内容的标准、教育机构的认证机制以及获 得认证的教育机构的总清单(分别占做出 答复国家的91%、89%和81%)。在做出 答复的国家中，有77%报告说具有教师 资格标准，而73%说具有持续专业发展 系统。做出答复的国家中约有三分之二制 定了跨专业教育标准、就业能力考核以及 全国待办证学生协会(分别为67%、64% 和62%)。在做出答复的95个国家中， 有53%报告说具有高级实践护士职称。 但是，这些监管程序或系统的存在并不一 定意味着它们可以正常运行。 99. 表5 .7列出了关于世卫组织不同区域教 育和培训管理机制和系统的数据。非洲、 美洲和欧洲区域的国家比其它区域的国家 更多地报告说具有教育法规。在东地中 海区域，各国报告说有更多的就业能力 考核，并且设有高级护理职务。与其它区 域的国家相比，东南亚区域只有少数国家 报告称有继续专业发展系统、全国待办证 学生协会或跨专业教育标准。这些区域差 异可能在一定程度上反映了对这些指标有 不同的解释。 45护理人力队伍证据和数据的现状 世卫组织区域 获得认可的教 育机构总清单 教育期限和 内容 标准 教育机构的 认证 机制 跨专业教育 标准 持续专业发展 设有高级护理 职务 就业能力考核 教师资格标准 全国待办证 学生 协会 非洲 91% 100% 90% 81% 68% 74% 68% 78% 66% 美洲 77% 91% 94% 49% 71% 55% 57% 75% 91% 东南亚 69% 85% 78% 60% 61% 75% 72% 64% 38% 欧洲 85% 94% 98% 87% 91% 30% 64% 94% 67% 东地中海 80% 80% 70% 20% 50% 50% 70% 80% 30% 西太平洋 70% 77% 78% 52% 63% 52% 56% 71% 35% 全球 81% 91% 89% 67% 73% 53% 64% 77% 62% 来源：2019年国家卫生人力账户，以及《2020年世界护理状况》中关于最后三个因素的具体指标。国家在2013年至2018年期间报告的现有最新数据。 按世卫组织区域分列的报告称有护理教育和培训规定的答复国所占百分比表5.7 0% 20% 40% 60% 80% 100% 教育期限和内容的标准 （169个答复国中154个回答“是”） 教育机构的认证机制 （165个答复国中147个回答“是”） 获认证的教育机构总清单 （146个答复国中118个回答“是”） 教师资格标准 （99个答复国中76个报告“有”） 持续专业发展 （132个答复国中96个回答“是”） 跨专业教育标准 （99个答复国中66个回答“是”） 就业能力考核 （114个答复国中73个回答“是”） 全国待办证学生协会 （89个答复国中55回答“是”） 设有高级护理职务 （95个答复国中50个回答“是”） 回答“是”的国家百分比 91% 53% 62% 64% 67% 73% 77% 81% 89% 图5.8 表示具有护理法规和标准的答复国百分比 46 2020年世界护理状况 按国家显示的护理教育监管分数图图5.9 4分及以下 5分 6分 7分 8分 9分 未报告不适用 0 1,000 2,000 3,000 4,000500 公里 注：结合关于教育能力的问题，原始分数0-9。 来源：国家卫生人力账户，2019年。 100. 这9项指标的数据用于得出每个国家的综 合“教育和从业监管”评分(见附件2)。 每项指标的评分从0(无)到1(有)，部分具 备为0 .5；答案缺失被视为0。然后将这些 分数相加，总和最高为9。由于分析间接 认为指标答案缺失得到的分数为0，因此 进行了敏感性分析，以探讨对缺失分值进 行不同分类的影响，但这并没有改变对 结果的解释。图5 .9进一步证实了这一发 现，即本报告中所报告的监管机制情况表 明，北美、西欧和撒哈拉以南非洲的教育 监管环境相对较强。 47护理人力队伍证据和数据的现状 5.5 教育和护理人员的供应 5.5.2 教育渠道 101. 为了满足当前和预期的卫生系统需求并满 足国家和次国家级的需求，需要在教育和 培训上进行大量投资。 102. 为了评估教育渠道的能力，要求各国提供 现有最近年份的护理专业毕业生人数。共 有88个国家对该指标进行了报告，其中近 半数(41个国家)在欧洲。因此，解释表5 .8 中的“总计”数字时应格外谨慎，因为数 据受到东南亚和欧洲数据的影响，不能代 表其他区域的情况。 103. 类似于与护士密度的关联，收入水平是每 10万人口中毕业生人数增多的一个因素。 104. 根据现有数据进行模拟并应用于世界 人口，每10万人口中22 .6名毕业生的总体 密度每年估计将产生172万名护理专业毕业 生。这种分析应被视为纯粹的例证，建立 在每个区域少数国家(欧洲区域除外)的基 础之上。但是，这些数据虽然覆盖范围有 限，但在毕业生与护理人员总数的比例方 面并未显示有巨大差异。此外，将这些估 计的人员总数结果与35岁以下年龄组(大约 为前10年内开始就业的人力队伍)的比额进 行了比较。使用这一较年轻类别的十分之 一作为每年进入人力市场的人员总数的代 理指标，将相当于106万的人力总数，而目 前估计的毕业生为170万。由于并非所有工 作者都被雇用，大致情况似乎是合理的。 5.5.1 主要调查结果 共有88个国家 (主要来自东南亚和欧洲) 报告了每年护理人力队伍毕业生人数的数据。 护士密度最低的区域(非洲、东地中海和东南亚区域)的毕业率也最低(分别为每10万人口7 .7、 7 .1和12 .2)。 相对于其人口，美洲区域的毕业生人数是非洲和东地中海区域的10倍。 在报告数据的国家中，非洲和西太平洋区域的护理专业教育平均期限在大约75%的国家为2至 3年，而在美洲、东南亚和东地中海区域半数以上的国家中为4至5年。 48 2020年世界护理状况 进行报告的国家 数/总数 每100名在职护士中的护理专业毕业生平均数 每10万人口的毕 业生人数按世卫组织区域分列 总体 低 高 非洲 14/47 8 .8 2 .8 23 .7 7 .7 美洲 14/35 9 .8 0 .8 30 .8 81 .2 东南亚 8/11 7 .5 3 .9 13.8 12 .2 欧洲 41/53 4 .0 1 .0 31 .9 31 .9 东地中海 5/21 4 .6 0 .6 16 .5 7 .1 西太平洋 6/27 5 .7 3 .4 12 .0 20 .6 按收入组分列 低收入 8/31 13 .8 4 .1 31 .9 10 .4 中等偏下收入 15/46 7 .7 2 .8 13 .8 12 .8 中等偏上收入 26/60 6 .4 0 .6 30 .8 22 .7 高收入 40/57 3 .6 1 .5 7 .6 38 .7 总计 88/194 6.2 0.6 31.9 22.6 来源：国家卫生人力账户，2019年。收入组别取自截至2018年的世界银行分类。 表5.8 按世卫组织区域和收入组分列的护理专业毕业生人数 © WHO/Yoshi Shimizu 49护理人力队伍证据和数据的现状 5.5.3 职前教育的期限 105. 从各种来源获得了157个国家的入职前护理 教育课程期限的数据。少数国家，主要在 非洲、东地中海和西太平洋区域，有为期 两年的课程，而所有区域的大多数国家有 为期三年或四年的课程；为期五年的课程 在各区域都很罕见(图5 .10)。在非洲和西太 平洋区域，大约四分之三的国家有为期三 年的课程；在东南亚区域，将近四分之三 的国家有为期四年的课程。 106. 在扩大护理从业范围的时代，必须考虑 职前教育之后的护理教育以及通过直接入 职途径(具有明确的前提条件)入职的各种 情况。对职前教育课程期限的报告受这 些固有局限性的影响，从而制约了所提供 的数据描述全球范围内多样化护士教育 (尤其是对高级实践护士而言)的能力。 按世卫组织区域分列的专业护理人员平均受教育期限(年)图5.10 2年 3年 4年 5年 0% 20% 40% 60% 80% 100% 非洲 美洲 东南亚 欧洲 东地中海 西太平洋 世卫组织区域 全球 来源：2019年国家卫生人力账户(99个国家)和西格玛(sigma)数据库(58个国家)。国家在2013年至2018年期间报告的现有最新数据。 50 2020年世界护理状况 5.6.1 主要调查结果 非洲、美洲、欧洲和东地中海区域报告说，在较高程度上存在与护士工作条件有关的监管 机制。 一些国家(主要在东南亚和西太平洋区域，但也包括非洲区域和南美)报告的此类法规水平 较低。 略超过三分之一的国家(37%)报告说已采取措施防止对卫生工作者的袭击，主要是在东南亚和 东地中海区域。 在医生密度较低的国家，具有高级护理职务的情况更加常(在95个答复国中占53%)，从而表明 护士更多的职业自主权可能是一种旨在缓解医生短缺的政策措施。 5.6 就业和工作条件的监管 5.6.2 结果分析 107. 就业特征和工作条件是就业吸引力、 绩效和生产率以及留住卫生人力的主要驱 动因素。《卫生人力资源全球战略：卫生 人力2030》呼吁维护“所有卫生工作者 的人身、就业和专业权利，包括安全体面 的工作环境以及免受各种歧视，强迫和暴 力的侵害”。为了评估这一方面，审视了 与监管就业特征和工作条件有关的六项指 标(图5 .11)。应当指出的是，三项指标(关 于工作时间和条件的规定、护理委员会、 设有高级护理职务)专门针对护理工作； 其余指标适用于整个卫生人力队伍，包括 护士。 108. 在做出答复的国家中，有80%以上报告 说对工作时间和条件、社会保护和最低工 资进行监管，并设有护理委员会或同等机 构；但是，在做出答复的国家中，设有高 级护理职务的国家较少(53%)。关于是否 有防止袭击卫生工作者的措施，共有55个 国家做出了答复，而其中只有略多于三分 之一(37%)表示已采取此类措施。 51护理人力队伍证据和数据的现状 关于工作时间和条件的规定 （142个答复国中133个回答“是”） 社会保护规定 （137个答复国中125个回答“是”） 最低工资规定 （134个答复国中119个回答“是”） 护理理事会 （164个答复国中141个回答“是”） 设有高级护理职务 （95个答复国中50回答“是”） 防止袭击卫生工作者的措施 （55个答复国中20个回答“是”） 回答“是”的国家百分比 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 来源：国家卫生人力账户，2019年。 图5.11 对工作条件有监管规定的国家所占百分比 世卫组织区域 关于工作 时间和工作条 件的规定 最低工资 规定 社会保护 规定 防止袭击 卫生工作者的 措施 设有高级 护理职务 护理委员会 非洲 90% 90% 85% 41% 74% 78% 美洲 97% 85% 94% 37% 55% 91% 东南亚 75% 50% 50% 67% 50% 80% 欧洲 98% 92% 100% 26% 30% 96% 东地中海 85% 100% 92% 73% 75% 85% 西太平洋 100% 86% 57% 30% 52% 78% 全球 94% 89% 91% 37% 53% 86% 来源：2019年国家卫生人力账户，以及《2020年世界护理状况》中关于最后一个因素的具体指标。国家在2013年至2018年期间报告的现有最新数据。 按世卫组织区域分列的对是否具备护理工作条件规定做出答复的国家百分比表5.9 工作条件规定评分图图5.12 1分或无分 2 3 4 5 6 未报告不适用 0 1,000 2,000 3,000 4,000500 公里 注：结合关于工作条件能力的问题，原始分数0-6 来源：国家卫生人力账户，2019年。 52 2020年世界护理状况 109. 表5 .9表明，据东地中海区域的国家报 告说，本报告所检查的护士就业规定水平 较高：超过70%的国家对所有六项指标都 做出了肯定的答复。只有东南亚和东地中 海区域的大多数国家报告说已采取措施防 止对卫生工作者的袭击，这可能反映了这 两个区域中此类袭击的发生率相对较高10。 非洲、美洲和欧洲区域对追踪的大多数指 标也做出了肯定的报告；但是，做出答复 的欧洲国家中只有30%报告说设有高级护 理职务，26%报告称已采取措施防止袭击 卫生工作者。 10 袭击医疗机构事件监测系统：https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx。 110. 西太平洋区域很大一部分国家报告说对工 作时间和条件以及最低工资有规定，并设 有护理委员会或同等机构。但是，它们报 告说其他三种监管机制的存在水平较低。 东南亚区域对评估监管环境的指标报告的 肯定答复率最低，尽管该区域有半数国家 对六项指标分别做出了肯定的答复。如第 5 .4节所述，这些区域差异可能在一定程 度上反映了对这些指标含义的不同理解， 以及各区域的不同报告率。收集的数据未 提供关于法规是否适当或相关规定实施水 平的信息。 工作条件规定评分图图5.12 1分或无分 2 3 4 5 6 未报告不适用 0 1,000 2,000 3,000 4,000500 公里 注：结合关于工作条件能力的问题，原始分数0-6 来源：国家卫生人力账户，2019年。 53护理人力队伍证据和数据的现状 图5.13 按每万人口中医生的密度水平分 列的设有高级护理职务的国家所 占百分比 每万人口医生密度 设 有 高 级 护 理 职 务 的 国 家 百 分 比 80% 60% 40% 20% 0% 5人以下 5-19人 20人以上 65% 59% 43% 来源：国家卫生人力账户，2019年。 © AKDN/Christopher Wilton-Steer 111. 使用与第5 .4节中使用的方法类似的方法 以及附件2中描述的方法，这六个指标的 数据被用来得出每个国家的综合“工作条 件规定”评分。图5 .12强调了以下发现： 与第5 .4节中对教育系统的分析一样， 据报告称，北美、撒哈拉以南非洲和欧 洲区域的监管环境相对较有力。 112. 如图5 .13所示，在医生密度较低的国 家中，高级护理职务更为常见。 54 2020年世界护理状况 5.7 管理与领导 5.7.2 结果分析 113. 护理专业的未来发展需要强大的护理领导 和管理能力(264,265)。使用了《2020年 世界护理状况》的两项指标来评估护理领 导和管理状况：在国家政府中是否设立了 政府首席护理官职位，以及是否有用于发 展护理领导、研究或政策素养技能的由国 家支持的规划(分别有115个和76个国家做 出了答复)。 114. 在115个做出答复的国家中，有71%报告 称具有政府首席护理官职位，占比范围 从东地中海区域的54%到欧洲区域的86% (表5 .10)。较少的国家(在76个做出答复的 国家中占53%)报告称具有护理领导能力发 展规划，占比范围从东南亚区域的40%到 非洲区域的64%。 115. 报告的强有力监管环境与报告的护理领 导和管理环境之间存在显著的相关性。 图5 .14显示，平均而言，具备政府首席护 理官和护理领导能力规划的国家在护士 工作条件监管和护理教育监管方面得分 更高。 116. 尽管具备政府首席护理官职位和护理领 导能力发展规划都与强大的监管环境相 关联，但领导能力规划的关联性略高于政 府首席护理官的关联性。换句话说，在国 家政府内部设立高级别的护理职务并不一 定会产生诸如启动领导能力规划等行动： 事实上，拥有政府首席护理官的国家中有 37%没有领导能力发展规划。 5.7.1 主要调查结果 在115个和76个答复国中，分别有71%报告有政府首席护理官或助产士职位，53%报告有护理 领导能力发展规划。 具备政府首席护理官职位和护理领导能力规划，都与更强大的护理监管环境相关。 但是，政府首席护理官的职位和领导能力规划都与护士人数增长率的提高无关。 55护理人力队伍证据和数据的现状 117. 为了检验关于护理方面的领导和管理是否 也会转化为更多投资(例如，体现为加速护 理院校毕业和随后为解决护士短缺而招募 人员)的假设，将具有领导和管理措施的国 家中的毕业生比例与没有这些措施的国家 中的毕业生比例进行了比较。没有发现统 计学方面的显著关联，因此表明强有力的 护理领导能力和管理并不一定会转化为护 理院校毕业生的加速增多。 首席护理官职位 护理领导能力发展规划 世卫组织区域 做出答复的 国家数/总数 “是”的百分比 做出答复的 国家数/总数 “是”的百分比 非洲 26/47 60% 28/47 64% 美洲 26/35 79% 16/35 46% 东南亚 6/11 60% 4/11 40% 欧洲 30/53 86% 10/53 56% 东地中海 7/21 54% 8/21 62% 西太平洋 20/27 74% 10/27 43% 全球 115/194 71% 76/194 53% 来源：《2020年世界护理状况》(2019年)中的具体指标。国家在2013年至2018年期间报告的现有最新数据。 领导和管理指标：按世卫组织区域分列的具备首席护理官职位和护理领导能力发展 规划的国家百分比 表5.10 0 2 4 6 无政府首席护理官 政府首席护理官 0 2 4 6 8 10 无领导能力规划 领导能力规划 0 2 4 6 8 10 无政府首席护理官 政府首席护理官 0 2 4 6 8 10 无领导能力规划 领导能力规划 政府首席护理官 护 理 工 作 条 件 评 分 领导能力规划 护 理 工 作 条 件 评 分 护 理 工 作 条 件 评 分 护 理 工 作 条 件 评 分 工作条件 教育监管 P = 0.008 (Kruskal-Wallis 检验) P = 0.007 (Kruskal-Wallis 检验) P < 0.001 (Kruskal-Wallis 检验) P < 0.001 (Kruskal-Wallis 检验) 政府首席护理官 领导能力规划 来源：国家卫生人力账户，2019年。 图5.14 政府首席护理官和护理领导能力规划与监管环境之间的关联 56 2020年世界护理状况 5.8.1 主要调查结果 我们将2018年数据与《卫生人力资源全球战略》中规定的基准值进行比较，估计短缺590万名 护士；缺口主要(89%)集中在低收入和中等偏下收入国家。 如果所有国家都保持其护士毕业人数的当前水平，则护士人数预计将从2018年的近2800万增 加到2030年的约3600万；但是，这一预计增长的70%将发生在中等偏上收入和高收入国家， 而不是在缺口最大的国家。 考虑到预计的人口增长和护理人员的老龄化，非洲、东南亚和东地中海区域预计将在2030年 保持不变，其密度低于每万人口25名护士。预计非洲区域的密度也只会略有改善。 要解决低密度国家中护理人员短缺的问题，需要从2018年到2030年使平均每年的毕业生人数 增加8 .8%(范围：0 .2-13 .4%)，并使吸收能力提高到至少70%。 在受影响的低收入和中等偏下收入国家提升护士的教育水平以弥补缺口，2018-2030年期间的 成本可能约为人均10美元。 5.8 评估实现2030年可持续发展目标成果的当前轨迹 118. 为了实现与卫生相关的可持续发展目标， 世卫组织会员国将需要培养足够的护士， 以便(a)补充人力以避免减员(例如，由于 死亡、移民或退休而造成的减员)；(b)满 足由于人口增长和老龄化以及不断变化的 卫生保健需求而在世界许多地方出现的更 多需求；(c)消除现有的全球缺口。 5.8.2 到2030年的护理人员总数和密度预测 119. 考虑到当前的护理人数、估计的退休率 (基于护理人力队伍的年龄分布)、人口增 长以及对人力市场新增人员的假设，为每 个国家制定了基本的“存量和流量”模型 (关于各情景的说明，见附件2)。根据当 前趋势，护理人员总数预计将从2018年的 2790万增加到2030年的3590万。 120. 到2030年，护理人员总数的增长将集中 在高收入国家，而低收入国家的增长将 非常有限(图5 .15)。据预计，2018年记录 的差异(见5 .2节)将在很大程度上持续到 2030年。 57护理人力队伍证据和数据的现状 2030年每万人口的护理人员密度预测 (全球分布情况)图5.15 0 1,100 2,200 3,300 4,400550 公里 10人以下 10至19人 20至29人 30至39人 40至49人 50至74人 75至99人 100至49人以上 未报告不适用 注：“护理人员”包括专业护理人员和准专业护理人员。 121. 预计人员总数的增长轨迹不足以完全满足 需求，特别是在非洲区域，因为该区域的 预计人口增长率为34%。此外，预计东地 中海区域护理人员总数只会略有增加(表 5 .11)。 122. 根据分析中所用因素的现有数据和数据 质量，使用不同的假设和情景进行了 预测。附件2中讨论了可能的局限性。 123. 相反，预计美洲、东南亚和西太平洋区域 的护理人员总数将显著增多。按收入水平 分组进行考虑时，人员总数的增加预计将 有88%出现在中等收入国家中(图5 .16)。 5.8.3 护理人员短缺 124. 据世卫组织2016年的《卫生人力资源全 球战略》估计，到2030年，在密度低于 每千人口4 .45名医生、护士和助产士基准 的国家中，全球缺口将达760万护士和助 产士；该阈值不包括大多数高收入国家。 采用相同的方法和基准值，但使用更近 期的数据，估计2018年的护士缺口为590 万，到2030年的缺口为570万。2018年 (数字上)缺口最大的国家包括孟加拉国、 印度、印度尼西亚、尼日利亚和巴基斯 坦。收入水平与护理人员短缺密切相关 (附件2，表A2 .2)，因此2018年的缺口有 89%集中在低收入和中等偏下收入国家。 58 2020年世界护理状况 ENGLISH 中等偏下收入 27% 中等偏上收入 61% 高收入 6% 低收入 6% 美洲 43% 欧洲 7% 非洲 6% 东地中海 4% 西太平洋 22% 东南亚 18% 注：收入组别取自截至2018年的世界银行分类。 图5.16 按世卫组织区域和国家收入组分列的护理人员总数的预计增长 (至2030年) 按收入按区域 2018年观察到的 人员总数(百万) 到2030年预计的人员总数(百万) 世卫组织区域 情景1： 老龄化以及 稳定的 年轻年龄组 情景2： 老龄化以及 最近数年的 毕业人数 情景3： 老龄化以及 毕业人数到2030年增 长50％ 非洲 0 .9 1 .2 1 .5 2 .0 美洲 8 .4 9 .2 12 .4 17 .7 东南亚 3.3 4 .7 5 .0 6 .1 欧洲 7 .3 8 .6 8 .0 10 .4 东地中海 1 .1 1 .9 1 .5 1 .7 西太平洋 6 .9 10 .3 9 .0 11 .2 全球 27.9 35.9 37.4 49.3 按世卫组织区域分列的三种情景下2018年至2030年的护理人员总数预计模拟表5.11 59护理人力队伍证据和数据的现状 125. 通过更正先前的估计值以仅显示护士的短 缺(即不包括助产士)并考虑数据的改善， 可以将该估计值与2016年《全球战略》 的调查结果进行比较(图5 .17)。 126. 估计的缺口考虑到《全球战略》中使用 的基准值。因此，高于基准的所有国家 均不包括在此估算之内。这并不是说高于 基准的国家没有出现护士短缺的情况。 实际上，根据国家确定的服务提供目标和 卫生系统配置，大多数国家确实遇到了严 重短缺的情况。对于这些国家，应进行专 门的短缺估算。这些国家采用的方法应 考虑人口和人力老龄化、流行病学模式的 变化、实施的留用策略以及其他人力市场 动态。例如，根据国家定义的人口需求和 卫生系统要求进行的分析表明，到2030 年，31个高收入经合组织国家中的护士 短缺可能会达到320万(266)。除其他外， 在日本(到2025年，缺27万名护理人员) (267)、德国(到2030年，约缺50万名卫生 工作者，尤其是老年人护理人员和护士) (268)和英国(到2030年，缺10 .8万多名护 士)(269)，对护士的未来短缺也报告了类 似的估计。 注：通过将每年每个国家的护理人员总数与基准密度进行比较来估算缺口。 来源：《卫生人力资源全球战略》(2016年)和全球级报告《2020年世界护理状况》。 如果保持当前趋势、 《2020年世界护理状况》对2030年护理缺口的估计与《全球战略》的估计相符(前者为570万名护士，后者为560万)。 图5.17 2013年、2018年和2030年护理人员短缺估计情况 卫生人力资源全球战略 (2016年) 2020年世界护理状况 应用的校正系数： 1 使用最新的比例数据(护士占护士+助产士总人数的90%)，从《卫生人力资源全球战略》的护士和助产士总人数中除去助产士的比例 2 为改进数据进行校正，由此提高总人数估计值，并减少短缺：2018年，2780万总人数中有440万名护士，这一数据对比《卫生人力资 源全球战略》中的数据得到了改进。 9百万护士和助产士 820万护士 760万护士和助产士 690万护士 对2030年短缺 的一致估算 1 只对护士进行校正 2 为改进数据进行校正 570万护士590万护士 660万护士 2013 2018 2030 560万护士 60 2020年世界护理状况 5.8.4 到2030年解决护理人员短缺问题所需的人 员增量和成本 127. 在不同的假设下，估计了完全解决2030 年的短缺问题所需增加的毕业人数和工作 岗位。 • 按照目前的趋势，每年的毕业生人 数将需要平均增加大约10%(范围从 1 .5%到14 .9%)。 • 如果提高了人力市场对护理专业毕业 生的吸收能力，那么人力市场对毕业 生的吸收率以70%计算，弥补缺口所 需的毕业生年均增长率将为8 .8%(范 围从0 .2%到13 .4%)。 • 在人力市场吸收能力进一步提高的情 况下(占毕业生的80%)，解决2030年 护理缺口所需的毕业生年均增长率为 8 .1%(从0 .03%到12 .2%)。 128. 用每个国家从2018年至2030年的新增 护士人数(根据80%的毕业生就业的情况 预计)乘以培训护士的平均费用，可以估 算到2030年消除短缺所需的投资(270)。 根据低收入和中等偏下收入国家教育成 本方面已发表的文献和灰色文献，对每 名护士的平均培训成本使用了三种不同 的假设：5000美元、10 000美元和20 000 美元(271)。培训更多护士以消除短缺所 需的投资分别为人均5 .2美元、10 .5美元和 21美元11。考虑到分析对所作假设的敏感 性和证据的匮乏，采用人均约10美元的估 计数中间值进行直观模拟是合理的。 11 所引用的数字是在护士短缺国家中一次性支付的投资，覆盖所有毕业生的 培训。 61护理人力队伍证据和数据的现状 © WHO/Yoshi Shimizu 62 2020年世界护理状况 129. 在现有框架和已发表文献(第2、3、4章) 及护理人力现状分析(第5章)基础上，本报 告提出证据，令人信服地说明需要在更广 泛卫生人力和卫生系统政策范围内彻底改 变护理人力队伍的教育、部署、管理和支 持方式。 130. 这样做将需要庞大投资，但会产生更大的 社会和经济回报，包括改善数亿人的健康 状况，创造数百万合格就业机会(特别是 为妇女和青年创造就业机会)，以及加强 全球卫生安全。 131. 利用这一潜力需要地方、国家和全球各级 不同部门共同努力。本章内容首先是从全 球讨论中得出的主要结论和为本报告整理 的具体证据。然后在此基础上，本章概述 需要采取哪些行动刺激可持续投资、建设 机构能力和促进政策行动，支持发展符合 目的和有就业能力的护理人员队伍。 132. 这些政策选择既针对会员国也针对其他 利益攸关方。各国应根据其卫生系统的目 标、基本条件和执行能力逐个考虑是否适 用和相关。 6.1 加强规划、监测和问责的证据基础 结果综述 133. 《2020年世界护理状况》报告提供最全面 的全球护理专项数据和证据。80%的国家 报告了至少15项指标。数据上的差距表明 各国卫生人力信息系统的能力各不相同， 也意味着存在集中注意力推进相关工作的 宝贵机会。 134. 关于现有护理人员总数和年龄构成等指标 的数据最多(分别有191个和132个国家提 供)，但报告有关教育、筹资和卫生人力 市场流动指标的国家要少得多，妨碍了进 行全面卫生人力市场分析的能力。例如， 只知道人员总数数据而不能从数量上了 解培养能力、空缺率、失业和减员情况， 可能使决策者不确定是否应该扩大培养或 人数已经足够。决策者和计划制定者应当 知道，教育部门培养人员和卫生人力市场 吸纳这些人员之间是否均衡匹配，或者是 否会导致任何形式的不平衡(即人力短缺 或失业)(关于苏格兰卫生人力市场分析， 见专栏6 .1)。 护理人力政策的未来方向 章节 6 63护理人力政策的未来方向 135. 影响各国提供数据和报告这些指标的能力 的因素包括卫生部、劳动部、教育部和财 政部之间的协调程度，以及与其他利益攸 关方(如专业协会、理事会和教育机构)的 接触。 政策方案 136. 各国应加快实施国家卫生人力账户，包括 按分解数据报告护理人员队伍情况。特别 紧迫的是解决进行国家卫生人力市场分析 所需基本数据要素方面存在的缺口。这应 通过加强和建设卫生信息系统人力资源能 力的全面努力来实现(273)。由于全球各国 正努力实施国家卫生人力账户并承诺实现 数据来源多样化，因而可以描述全球护理 人员队伍的状况。卫生信息系统人力资源 的机构能力建设可能需要建立常设机制， 召集包括护理领域领导人在内的利益攸 关方，建立明确的数据整理和交流机制， 讨论数据的可得性、质量和挑战，并实施 可互操作的数据系统。不同部门和利益攸 关方之间的协调也可提供机会，正式确定 数据收集和分享的政治任务，并开展部门 间政策对话，将数据转化为有意义的政策 变化。各国应利用强化的护理和卫生人力 数据并将其纳入卫生人力市场分析，以指 导国家一级的政策和投资决策(关于护理领 导小组利用国家卫生人力账户指标进行护 理人力市场分析，见专栏6 .2)。 6.2 流动性和移徙 结果综述 137. 约有370万名护士(八分之一)在其出生或 接受护士培训的国家以外的地方从事护理 工作。调查结果表明，护士的国际流动性 很高，因为国内护士产量低的国家高度依 赖这种移徙。来自高收入国家(据报有15% 以上的护士在国外出生或在国外受到培训) 的需求可以吸引来自低收入国家的最合格 护士，并加深有害于人口健康的质量和分 布差距(关于德国移徙管理办法、见专栏 6 .3)。 138. 非常高的外移人数(如果不是因有意将护 理人力输出海外的政策所致)可以理解为 国内劳动条件缺乏吸引力的征兆。因此， 政策规定应侧重于处理根本原因(改善工 作环境、支持系统和薪酬)，而不是孤立 地处理移徙现象。同样，培养护士的过程 必须实现两方面的适当平衡，一是培养护 士在当地工作和参与初级卫生保健所需的 技能和能力，二是学生有意愿学习使他们 能够扩大获得收入的机会并转移到更专业 化或全球性的专业环境下工作的技能。 专栏 6 .1 苏格兰卫生人力市场分析 2019年12月，苏格兰政府发布苏格兰综合卫生和社会保健人力计划(272)。该计划的愿景是让人 们呆在家里而不是住院。但实施该计划需要增加地区护士的人数。 苏格兰政府使用来自国民卫生服务体系信息服务部的数据对额外需要多少护理专业学生进行建 模。政府还考虑了其他卫生领域职业的供应和短缺情况，包括短缺如何影响需要提供的服务以及如 何解决这一问题。 与护理和助产专业学生录取参考小组及其他利益攸关方共享了相关数据和调查结论。这种对话 促使政府决定采取积极主动方式培训地区护士，增加对地区护士教育和培训的投资，并考虑什么样 的人员配备能够允许在职护士接受这种教育和培训。 这是政府首次尝试在国家一级以综合方式解决卫生和社会人力问题，并从单一职业规划转向多 学科团队护理规划。 64 2020年世界护理状况 专栏 6 .2 东部、中部和南部非洲卫生共同体：利用国家卫生人力账 户指标报告护理数据方面的国家合作 东部、中部和南部非洲卫生共同体是一个政府间卫生组织，旨在培育和促进区域卫生合作 (274)。护士短缺在该区域很常见。恶劣工作条件和很高工作量导致护士缺乏进入人力市场的动力和 大量外迁。教育系统往往支离破碎，师资力量和监管能力不足，导致培训足够多技能熟练护士的能 力有限。 世界银行集团与国际护士理事会和东部、中部和南部非洲护理学院合作进行了一项研究，评估 护理人力和教育市场。研究目的是评估这些系统面临的挑战，并确定通过有针对性的公共和私人投 资在该地区扩大护理教育的政策。研究人员考察了面对治理和监管挑战的护士人力市场如何调节教 育系统和卫生系统之间的互动。他们收集了世卫组织拟定的国家卫生人力账户指标(273)数据以及在 区域磋商确定的其他定性数据。协调研究数据报告的国家小组是国家护理领导“四人组”，世卫组 织在数据审查过程中提供了额外支持(另见第6 .3 .3节)。 结果显示，该区域市场不平衡，护士供求严重失调。过去10年来，护士供应的增长速度快于人 口增长；但与此同时，通常由于招聘效率低下或工作条件差，许多国家公共部门对护士的吸纳率较 低，还存在基于需要的严重短缺。根据预测分析，2019年至2039年间，有效需求将增长33%，但仍 有超过22万名公共和私营部门无法或不愿雇用的护士。相比之下，基于需要的护士短缺估计到2030 年将达到84 .1万名，使当前护理人力市场的不平衡进一步扩大。 该研究的结论是，增加护士供应以推动东部、中部和南部非洲国家实现可持续发展目标，需要 扩大护理教育，提高护理学校的质量(包括实施质量保证机制)，并增加将护士纳入当地和区域人力 市场所需的资源。可以对物质和人力资源、护理治理、监管以及数据和分析能力进行充分投资， 使各国能够监测投资影响，从而促进该项工作。 专栏 6 .3 德国的移徙管理办法 2018年11月9日，德国议会通过了《护理加强法案》，其目的是提高医院和养老院员工和护 理人员的卫生保健和长期护理的吸引力(275)。改善这些设施的人员配备是新政府卫生政策的核心。 多年来，医疗保健和长期护理服务一直受到护士严重短缺的困扰，医院和养老院普遍人手不足。由 于退休和不满而离开卫生服务的专业人员多于职业培训毕业后进入人力队伍的人数。此外，一般 认为，工作人员不足导致工作条件恶化和护理质量差。根据2012年的预测，到2030年，德国护理 人员队伍将出现26。3至50万人的短缺(276)。为减少工作人员短缺，德国采取了多管齐下的策略， 包括扩大教育规模、创造新的护理工作岗位和优化对移民卫生工作者(如来自中欧和东南欧的护士) 的国际招聘(277)。对于最后这一要素，德国已采取措施，利用机会促进与来源国一道从国际卫生工 作者流动中获益，包括通过技术合作和双边协议在来源国创造培训和投资机会(168)。 65护理人力政策的未来方向 139. 随着护士移徙人数的大量增加，对公共 保护采取单一管辖区解决办法的典型做 法是不够的，改革后的制度需要提供和加 强区域和全球解决办法(245,278,279)。 此外，由于许多国家同时是原籍国和目的 地国，因此必须更好地了解人员流动模 式，以便有效管理人员流动，并规划未来 卫生人力需求。然而，只有86个会员国报 告了其工作人员中外国出生或外国培训的 护士所占百分比，而这是世卫组织《全球 卫生人员国际招聘行为守则》设想的基本 报告要求之一。 政策方案 140. 各国和监管机构应加强执行有关卫生人员 (包括护理人员)国际流动的规定.目的地管 辖区的监管机构需要确定护士的准备、资 格和纪律履历符合所需的执照、教育和道 德标准及行为守则、以利于公众保护。通 过统一关于进入护理规划的要求及获得和 保持护理证书所需的教育内容等方式加强 监管模式可以促进流动性。一些区域已有 关于相互承认护理专业资格的协议、可能 为今后达成更广泛协议提供基础。 141. 各国和国际利益攸关方应加强执行世卫组 织《全球行为守则》。有效监测、管理和 规范护理人员国际流动可能需要进行能力 建设、利用伙伴关系以及开展监管机构、 卫生人力信息系统、雇主、政府部委和其 他利益攸关方(如专业协会)之间的协作。 因护理人员向外移徙而遭受过度流失的国 家应考虑采取缓解措施，例如改善工资(和 薪资公平)和工作条件，确保体面工作，并 在必要时执行量身定制的留用计划。 6.3 发展和支持护理人员队伍 6.3.1 教育 结果综述 142. 本报告的调查结果表明培养护理毕业生 的情况复杂。欧洲和东地中海区域及高收 入国家的毕业生占现有存量的比例最低。 除非中等偏上收入国家能够增加产量， 否则数据表明，高收入国家可能继续依赖 国际招聘，这可能加剧现有的短缺，并引 发相关的准入和公平问题。 143. 在世界不同区域，护理教育和培训规划的 持续时间差异很大。然而，绝大多数国家 (169个答复国家中的154个)报告了教育和 培训的内容和期限标准。在制定这些标准 时，关键的考虑因素包括这些标准是否帮 助教育工作者向学生提供满足人口健康需 求所需的能力，包括为初级和预防保健服 务、灾难、突发事件和冲突作准备、掌握 领导技能和适当使用技术(关于护理教育 和实践技术，见专栏6 .4)。 144. 大多数国家(89%)还报告有教育机构认证 机制和经认证机构的总清单。对大多数 国家来说，这表明有机会侧重于加强核 证的关键领域，包括高效和负担得起的 模式，并确保各项规划对人民健康重点 有意义且社会能够问责。健全的认证机 制可涵盖内容、课程、学生临床经验、 教师资格和跨专业学习。我们的调查结果 表明，67%的答复国有跨专业学习标准， 但在一些地区，这个比例还不到一半， 甚至低至20%。 145. 要确保卫生人力队伍具有代表性，也就 是其构成与所服务人口的构成相一致， 就需要参加和完成护理规划的人员具有多 样性。本报告的调查结果表明，护理人 员仍以女性为主，尤其是在美国和西太平 洋区域。培养适当的护理人员队伍不仅需 要增加不同学生群体的入学率，还需要解 决结构和组织方面的挑战，这些挑战要么 将一些学生排除在护理行业之外(例如， 完成中等教育)，要么使他们无法完成学 业(例如，费用过高)(126)。一些国家存在 职业性别隔离和护理地位低下现象，也会 影响到对护理规划的需求。要使护理成为 一个有吸引力的职业选择，必须解决这些 挑战，特别是在美洲这样毕业生占人口比 例最低的地区。 66 2020年世界护理状况 政策方案 146. 各国应确保护理教育和培训规划使护士 具备提供优质、以人为本的综合服务的能 力。一个重点问题是严格评估护理专业的 技能组合，决定护士的级别和专业类型是 否符合卫生系统需求，并确保根据卫生系 统的需要和吸纳能力提供足够数量的培训 员额。创造或增加更高层次的护理教育(例 如，学士或硕士课程，或哲学博士课程)具 有结构性影响，例如制定新的教育规划， 为其配备适当教员，并确保这种教育途径 的护士在卫生系统中发挥明确作用。 147. 各国应考虑建立机制，增加护理学校学 生的人口和地理多样性。这可能意味着要 消除那些对男性、年轻人或特定民族选择 护理工作产生负面影响的偏见，并满足那 些希望将护理行业作为备选职业的人。 在某些情况下，可能需要建立一个“农村 管道”，以促进性别均衡的招生，并培养 适量来自农村、偏远和其他服务不足地区 和社区的学生。还可以利用有针对性的财 政支持和激励机制，增加少数群体、弱势 群体及处境不利群体接受正规教育的机 会，并吸引反映学生和社区人口构成的教 职人员。加强社会问责措施的认证标准就 是这样一种机制。 148. 卫生教育机构和监管机构应采用以能力 为基础的课程，并利用适当的技术。整个 课程中均应体现护理实践的质量。除涉及 临床干预措施的技术知识和程序技能外， 护士还应该：具备在跨专业团队中工作 的能力；能够向病人表现出同理心和同 情心；能够在压力下作出决定；获得在几 十年职业生涯中不断学习的工具。课程应 与毕业生的执业范围和人口健康需求相 匹配。以数字方式提供教育和培训内容， 可以有效地补充传统方法。这种“分布 式学习”的努力要取得成功，就需要确 专栏 6 .4 护理教育和实践技术 技术在护理人员的教育和实践中发挥着越来越大的作用。可以利用技术来获得临床决策支 持，提供服务提供者和客户之间的远程医疗，以及接受服务提供者之间的培训和咨询(280)，从而 便利服务获取，实现远程护理，改善初级保健服务的提供并赋权患者。护士应具备并熟悉健康问 题的数字决定因素，包括他们的数字素养、获得技术设备的机会及互联网基础设施(包括可用的宽 带)(281)。 数字卫生保健技术，无论是人工智能还是增强现实和机器人等其他形式，已经在改变护理工 作和对患者的照护(282)。个性化医学和基因组学有潜力推动更好地定制患者护理服务(283)。数字 卫生保健的最大潜力之一在于终身学习机会。人工智能等技术可以让学习更有针对性、更相关和 最新。 有关初级卫生保健中卫生工作者使用移动卫生保健技术经验的Cochrane系统综述显示，包括 护士在内的卫生工作者已经意识到在提供保健服务时使用移动技术的好处，但也遇到了挑战(284)。 他们谈到的益处包括彼此之间可以联系得更加紧密，承担新的任务，更好地相互协调和提高护理质 量，改善与客户的沟通，以及为偏远地区客户提供服务(284)。同时，卫生工作者也谈到多种复杂的 挑战，比如个人面临的挑战(如数字素养差)，涉及人际关系的挑战(偏好与客户和同事面对面接触)、 专业方面的挑战(感觉他们的临床技能受到数字临床支持工具的威胁)、与社会背景有关的挑战(客户 买不起手机)或基础设施方面的挑战(电力短缺)(284)。虽然技术进步带来许多好处，但该系统综述中 包括的卫生工作者的陈述表明，卫生系统决策者需要仔细考虑如何根据本国本地情况实施，以便最 大限度地减少包括护士在内的卫生工作者面临的挑战。 67护理人力政策的未来方向 保学生在教育过程中获得最低水平的数 字卫生素养，课程设计利用相关的数字 和远程保健学习确保学生获得必要的能 力，并为临床培训提供支持和监督(285)， 以及建立弥合数字鸿沟所需的体制和基础 设施资源(286)。 149. 各国政府和利益攸关方应发展和利用部 门间伙伴关系和合作，以推进护理教育 议程。与监管机构合作可促进(根据当前 和今后在卫生系统中的专业作用)审查护 理规划的入门要求和护士的最低教育标 准，并可促进区域一级标准的统一。与 认证机构开展部门间对话有助于确定推 进认证的社会问责方面的机制，例如， 确保护理教育机构优先培养能够提供高 质量卫生服务的毕业生，而不是优先 考虑通过学费和政府赠款获得收入和地 位。相关职能部委(教育、卫生)可加强正 式协调，促进以科学和技术作为护理专 业的基础，将护理作为STEM(科学、技 术、工程、数学)学科推广，并建立机制 吸引各类中学生学习护理。政府与社会资 本合作项目可以帮助在初级卫生保健环境 中寻找临床培训场所；参与其他卫生职业 教育规划有助于使这些临床实习课程具有 跨专业性。 150. 护理教育机构应加强其能力，解决教员人 数或能力不足、基础设施受限和提供适当 临床实践场所的问题(关于巴基斯坦承诺 培养更多护士，见专栏6 .5)。为了在保证 质量的同时增加培训职位，可能需要对教 师发展计划进行投资。高收入国家或依靠 国际招聘的国家应增加护士的国内生产和 部署。 151. 各国应考虑运用相关融资杠杆，(必要 时)扩大护理教育或提高其质量，以解 决卫生人力市场失灵的问题。金融机 制有很大潜力来增加学生的多样性， 扩大教师人才库或增加护理课程的学 位数量，并解决目前临床培训方面的 一 些 限 制 。 为 基 础 教 育 之 后 相 关 规 划提供财政补贴的做法有时被用来促进进 入更高级别的护理实践。但是，各国政府 必须能够就如下问题作出知情决定：补贴 护理教育的投资是否以及在何种情况下和 以何种方式具有成本效益，从而将稀缺资 源优先用于可直接促进公平和效率目标的 投资(289)。例如，卫生人力市场分析应查 明在哪些环境下与卫生系统的需求相比护 士生产不足或生产过剩。如果存在系统性 的生产不足，政府有理由采取干预措施， 放宽不必要的准入壁垒，并在必要时补贴 职前教育，特别是优先考虑处境不利的学 生群体，以促进其通过教育途径在初级卫 生保健领域获得优先职业，并作为交换在 公共部门服务满规定时间(140)。 6.3.2 护理实践 结果综述 152. 报告的调查结果表明，护理人力队伍的 人数超过以前的估计，2018年达到将近 2800万人，其中至少69%是专业护士，至 专栏 6 .5 巴基斯坦努力提高护士教育能力 巴基斯坦正试图解决短缺100万卫生工作者的问题。2018 年，为解决卫生人力技能组合和护 理人力问题，巴发布《2030年人力资源促进卫生健康愿景》。护理被视为卫生部门的支柱，是这 一愿景的关键。巴政府确定2019年为护理年，强调护理对人口健康的贡献(287)。启动护理年时， 阿尔维总统宣布将在伊斯兰堡建立一所护理大学，其目标是每年向25 000名学生提供培训(287)。 该国计划在两年内将护理部门的规模扩大一倍，以解决全国护士短缺的问题。负责国家卫生服务的 议会秘书 Nausheen Hamid 博士称，护士短缺是实现全民健康覆盖的一个障碍，而全民健康覆盖 需要足够数量表现良好的护士(288)。 68 2020年世界护理状况 少22%是准专业护士。与2016年《卫生人 力资源全球战略》中的估计数相比，增长 的原因在于护理人力资源数据的可用性和 质量得到大幅改善以及人力总数出现实际 增长，这两者贡献的比例大致一样。 153. 即便人力总数增加了，包括护士在内的卫 生工作者的不公平地域分布仍是一个普遍 挑战。本报告发现，在国家和区域之间以 及国家和区域内部，护士的分布存在显著 差异。报告的调查结果进一步表明，53% 的答复国设有高级实践护士职务。该职务 在医生密度低的国家更为常见。这突出表 明护理人力队伍面对国家更广泛卫生人力 状况时十分灵活且反应灵敏。如果现有技 能组合表明相关措施将提高效率，这些护 士可以很好地为农村和偏远地区人口提供 护理。 154. 数据表明，各国内部仍然需要重点解决城 乡地区护士分布不均的问题，以改善获得 护士服务的公平性。卫生工作者的留用涉 及各种复杂且相互关联的因素，如工作条 件、职业安全、薪酬水平和非金钱奖励。 要在提高护士留用率方面持续取得成功， 可能需要根据本地情况认真规划、有序实 施多种政策干预措施。不应脱离护士工作 和生活条件的其他特点来研究或处理留用 问题。 政策方案 155. 各国应使护士能够按照其所受教育和培 训充分开展工作(180)。这一目标应成为 更广泛国家努力的一部分，推动采用优 化初级卫生保健综合团队任务分工的保健 模式(179)。这需要最大限度地提高护士 的贡献，以加强重点领域的初级卫生保健 (关于阿曼扩大获得社区卫生服务，见专 栏6 .6)。可能的办法包括设置高级实践护 士职务，扩大护士领导的诊所，发展或扩 大处方权，同时相应地发展或加强所需教 育和培训。有高级实践护士证书的护士所 在的岗位应当能够优化他们在患者护理或 领导和管理其他临床人员方面的生产率。 应酌情支持具有高级实践护士职务或在 护士领导的诊所中发挥作用的护士，包括 让他们能够得到辅导或合作伙伴的支持， 获得足够物资和药品，有关于其从业的明 确临床和设施指南，并有机会获得所需 资源，包括在线参考材料和适当技术。在 相关的教育、卫生、劳动和其他政策方 面进行必要的改革，需要具备进行有效 协作和协调的机构能力、支持性的体制结 构和专门资源、领导和政治意愿、有效的 管理监督以及有效的组织文化。同样重要 的是，要根据从业范围和能力向其他卫生 保健服务提供者和公众准确传达护士的作 用和职能。 156. 各国应优化有效部署和管理护理人员队 伍的模式和机制。雇用和部署的效率、 公平和透明度是体面工作议程的关键要 素(16)。决策者和管理人员应能够利用可 靠指标评估就业过程的效率和及时性， 例如在获得执照三个月、六个月或一年 后就业的应届毕业生所占比例，从毕业 到获得执照的平均时间，以及从获得执 照到就业的平均时间。毕业生就业率低 可能是因为人力市场饱和，但如果伴随 着毕业、获得执照和就业之间过长的滞 后时间，则可能意味着行政系统僵化和 官僚主义障碍。部署方式也很重要：除 非公共部门能够保证吸收所有合格候选 人，否则在公布空缺后进行竞争性招聘 和对候选人能力进行客观评估仍然是首 选方式(289)。职业发展和晋升机会也应 该与业绩和能力挂钩，而不是主要基于 资历(服务年限)。至于其他职业类别， 在审议这些计划时应考虑到强制部署和 轮岗计划的局限性。只要有可能，护士 的部署应以自愿职业选择和对工作地点 的偏好为基础。调和护士的偏好与卫生 系统的需要，特别是在促进地域公平方 面，可能会颇具挑战性。当两者之间出 现紧张关系时，从有效性和工人权利的 角度来看，最好确定一系列相互关联、 相互促进的农村部署和留用策略(289)。 157. 各国应明确和积极主动地预测护士留用 方面的挑战并制定相关政策。有助于留住 护士的循证方法包括提供机会促进发展领 导力、获得辅导(293,294)、享受灵活的 69护理人力政策的未来方向 时间安排、得到非金钱奖励和终身学习。 为进入人力市场的应届毕业生做出正式 导师安排，可以促进他们向执业、临床 能力、工作满意度和职业社会化的过渡， 所有这些都可能影响新护士在这个队伍 里的去留(295)。导师式培训对城乡新护 士胜任职责和留用的影响类似(296)。 应制定具体政策，提高妇女在领导层中的 作用，解决性别歧视问题，防止性骚扰； 这些不仅是对工人尊严和权利的侵犯， 还与不断增加的减员有关有关(122,297, 298)。 6.3.3 监管 结果综述 158. 对护理领域进行监管至关重要，可保护公 众并增强卫生系统应对患者和人口需求变 化的权能。此外，还可以提供促进专业发 展的框架(243,299)。本报告的调查结果 表明，164个会员国(86%)有负责监管护 理教育和实践的主管部门。但是，所发布 条例的力度和效力必须针对具体国家具体 分析。例如，73%的国家表示对终身学习 专栏 6 .6 阿曼扩大获得社区卫生服务 阿曼是调整护理和助产教育方向并强调初级保健能力的范例。这两者是东地中海区域委员会第 六十六届会议(2019年10月)通过的加强护理人力队伍行动呼吁的组成部分(290)。 阿曼经历了人口和预期寿命的快速增长。但是，社会经济状况的改善伴随着慢性病负担的增加。 为解决这一人口健康问题，政府决定投资促进社区卫生护士的发展(291)。卫生部护理和助产司启动 了为期16周的在职培训规划。该规划首先在首都马斯喀特试行，然后推广到其他省份。社区卫生护 理服务被纳入初级卫生保健架构，与初级保健中心提供的服务相一致(292)。 最终，为期16周的培训发展成为侧重社区健康护理的护理学士学位，然后又发展为社区健康护理 专业的更高级文凭(291)。这一专业规划有助于维持合格社区保健护士的供应，以满足该国的初级保 健服务需求。 © Kieran Dodds 有监管要求，有执照或执业考试等监管要 求的国家比例更低一些(64%)。 159. 在国际专业人员流动性不断增加的情 况下，专业监管对于保持优质护理也很 重要。它确保新晋卫生工作者有能力满足 人口的需要，也有能力在不损害公共安 全的情况下开展工作。基于网络的实时 系统有助于加快证书的确认，并提供关于 从业人员目前执照状况和专业历史的整 理信息。这些系统正在成为区域一级的 有用工具，有可能发展成为全球解决方案 (168,300-302)。 政策方案 160. 各国应发展和加强护理监管，以支持安 全、可持续、高质量的教育和实践。 可能需要新立或更新基本法规，以确立 70 2020年世界护理状况 监管部门的作用和职能以及护理教育和 实践的关键规定和标准，从而建立护理 监管权威。一个反复出现的挑战是需要 在确保监管的限制性最小和实现保护公 众的预期效益之间取得适当平衡(303- 306 )。各国应该考虑明确对终身学习 的要求，以确保各个层次的护士都能接 触到适合自己角色的学习机会。在允许 护士执业之前，通过执照考试评估最低 初 步 知 识 水 平 的 做 法 越 来 越 普 遍 (255,307)。虽然仍然需要更有力的证据 来证明不同方法的相对有效性，但广泛 的共识是，能力评估必须有效、公平、 独立，并以护士在各种实践环境中所需 的知识和技能为基础。 161. 各国应投资建设监管系统的能力、以加强 和提高护理教育和实践的质量。一个关键 方面是确保监管机构拥有并维护可与卫生 系统和其他监管机构的其他数据库互操作 的实时登记簿。保持最新登记的一个方 法是要求重新登记或重新发放执照，这也 有助于激励终身学习，并为监管机构创造 收入。护理监管者的个人能力也需要加 强。护士监管者，和其他典型卫生领域职 业一样，在承担该角色前可能很少或根本 没有接受有关专业监管的正式培训。监管 机构可以借鉴其他国家和区域一级成功加 强监管框架的经验(关于非洲卫生专业监 管协作，见专栏6 .7)。 6.3.4 体面工作 结果综述 162. 确保体面的工作条件对所有卫生领域职业 都有意义且必要，但护理专业面临着特殊 挑战。护理人员队伍本身是一支以女性为 主的人力队伍，且在某些国家和地区传 统上一直处于从属地位，因而更容易在工 作中面临性别偏见和歧视。护士们还常常 需要长时间工作，在某些情况下面临遭到 攻击的风险、性骚扰和针对移民工人的不 公平待遇。94%的国家报告存在关于工作 时间和条件的法规，91%的国家报告存在 关于社会保护的法规，89%的国家报告存 在关于最低工资的法规，不过我们对这些 政策是否适足和实际执行水平知之甚少。 共有55个国家(36%)报告有防止袭击卫生 工作者的措施，这些国家大多位于东南亚 和东地中海区域。 政策方案 163. 各国应实施体面工作议程，并投资于为 护士创造有利的工作条件。基本要素包括 专栏 6 .7 非洲卫生专业监管协作 创建非洲卫生专业监管协作机制是为了帮助各国更新有关护理和助产的法规，以促进安全、 可持续、由护士主导的艾滋病患者护理和治疗模式。这项合作涉及17个国家，包括东部、中部和南 部非洲护理学院的大部分成员 (308)。 非洲卫生专业监管协作机制召集来自各个国家的政府首席护士、全国护理协会主席、学术界领袖 及全国护理和助产理事会注册官，并支持就各国确定的监管挑战确定优先次序并开展合作。自称为 “四人组”的国家领导小组按年度就重点监管事项(例如，包括艾滋病毒任务在内的从业范围、涉及 艾滋病毒内容的持续专业发展要求)开展合作。四人小组经常在国内会面，也经常与从事类似工作的 地区同事会面。相关进展得到定期测量，且采用不同测量方法 (309)。 在五年的时间里(2011-2016年)，护理和助产法规得到加强。根据四人组的报告，他们的领导技 能和组织能力得到很大提高而且在国家护理和助产组织之间开展了合作(310)。虽然非洲卫生专业 监管协作是一项由捐助者资助的倡议，但“四人组”的做法已在东部、中部和南部非洲国家制度化， 是利用护理和助产工作处理国家卫生重点的持续机制。 71护理人力政策的未来方向 适足薪酬、社会保护、公平的工作条件、 合理的工作时间、职业安全、非金钱奖励 以及透明和择优晋升机会。这些条件与护 士的留用密切相关，应适用于所有护士， 而不论其性别、社会背景、来源国家或 地区、族裔群体或语言，并应通过明确的 问责机制加以执行。卫生工作者的权利， 包括适当工资和适足工作条件，是卫生工 作者采取行业行动或罢工的一些最常见原 因(关于卫生工作者罢工，见专栏6 .8)。 164. 各国必须保护和支持受到人道主义危机 直接影响的护士。卫生部、专业护理组织 和非政府组织需要与有关当局和有关各方 接触，确保保护和支持那些可能在资源严 重不足或条件恶劣的情况下(如难民营或 庇护所)提供护理的护士，或者那些可能 成为跨界流离失所人口的一部分并在没有 正式承认其从业资格的管辖区提供护理的 护士。这将有助于确保所有环境中所有卫 生工作者和卫生设施的安全，特别是妇女 的安全，因为她们在危机期间可能面临遭 到攻击或骚扰的更大风险。 6.3.5 性别与妇女权利 结果综述 165. 全球大约90%的护理人员是妇女。护理 领域的高度性别隔离导致复杂的薪酬模 式：尽管证据主要来自高收入国家，确实 许多国家存在着“性别薪酬差距”(21)。 需要有效实施和监测两性工资差距政策， 有意识地促进卫生人力队伍内的性别 平等，克服历史遗留的低估护士工作的 问题，包括性别偏见造成的低估(121, 232)。世卫组织的分析发现，卫生领导 职位继续由男性占主导地位，全球卫生领 域只有25%的领导职位由妇女担任(21)。 “护理服务刻不容缓”运动委托进行了一 项关于护理领域领导力的障碍和促进因 素的研究。研究报告不仅描述了妇女面 对的“玻璃天花板”，还描述了男性乘 坐“玻璃直升梯”，不成比例地过多占据 护理领域的高级职位(122)。这正是深层次 性别不平衡的最明显表现，这种不平衡渗 透到卫生系统各个层级，影响到护理人力 管理的各个方面。 政策方案 166. 各国应解决影响女护士的性别薪酬差距 问题。在一些国家，两性薪酬不平等的原 因可能是护理工作与其他职业相比存在 专栏 6 .8 卫生工作者罢工 在全球许多国家，工人依法有权罢工，这被广泛认为是一项公民权利(311)。然而，卫生工作 者行使这一权利的情势较为复杂，因为这会与患者获得护理的权利和公民享受全民健康覆盖的权 利形成冲突，并可能导致死亡率上升(311-314)。不过，全世界各地高、中、低收入国家都还是会 发生卫生工作者罢工，包括护士罢工(313,314)。对低收入国家罢工的分析发现，2009年至2018年 期间报告在23个低收入国家卫生工作者罢工了875个工作日(311)。根据该研究，罢工可能持续数 天或数月，也可能在数月或数年时间内反复发生(311)。导致这些罢工的主要原因是对薪酬和拖欠 工资不满，其次是抗议以前达成的协议执行情况不令人满意，或抗议卫生部门的治理和政策，以及 对工作条件和安全问题的投诉。减少卫生工作者罢工需要采取多利益攸关方、多方面和多部门方法 (311,314,315)。需要进行更多研究来了解个案中的因果关系、各个区域的罢工模式，以及应该让哪 些行为者参与进来以达成积极的解决方案(311)。但是，显然需要在政治领导支持下，在卫生和其 他部门之间采取多部门行动，处理与卫生工作者罢工有关的上游因素(314)。投资促进卫生工作者 享有体面的工作条件，确保他们有安全、有利、有效的工作环境，对于实现和保护全民健康覆盖权 利至关重要(314)。 72 2020年世界护理状况 © Janice Mullings-George 严重的职业性别隔离。要解决这一问题， 首先可以分析国家薪级表，并承诺逐步在 卫生工作者中实行更公平和不分性别的薪 酬制度。它必须包括健全的政策和重新考 虑有关卫生工作者薪酬的财政安排。虽然 认识到需要市场力量来影响薪酬水平，但 解决两性薪酬差距的政策和法律也应酌情 适用于私营部门。在评估薪酬公平和制定 解决这一问题的政策时，必须让护理领域 的领导者参与进来。 167. 各国应该优先考虑和执行政策，解决护理 和整个卫生人力中的性骚扰和歧视问题。 这应当包括对暴力及口头、身体和性骚扰 的零容忍政策；为妇女创造体面工作环境 的政策，包括适应女护士不断变化需求的 灵活和可管理的工作时间；以及为护士队 伍中的妇女提供对性别问题有敏感认识的 领导能力发展机会。 6.4 建设有效治理的机构能力和领导 技能 结果综述 168. 80多个国家报告说，在国家一级设立了护 理领导职位，负责为与卫生和护理有关的 政策决定提供意见。政府首席护士应作为 全面合作伙伴与其他卫生专业领导一道作 出影响卫生服务规划、服务交付和工作条 件的战略决策(316)。需要有人力市场和 财政空间分析、人力政策、规划和治理方 面的能力，以确定优先事项并制定循证解 决办法，从而加强教育能力，创造就业机 会和留住护士。本报告的调查结果表明， 在76个答复国中，53%制定了护士领导能 力发展国家规划，不过其分布并不均等， 因为报告有此类规划的大多数国家在世卫 组织非洲和东地中海区域。 169. 健全的设计和实施护理和卫生政策的治 理能力还需要机构、机制、政策和程序， 以确保护理人员队伍的优先事项得到考虑 并纳入卫生部门内外更广泛的政府行动。 本报告的调查结果强调指出，首席护士职 位和护士领导力发展规划存在与否与更加 强有力的护理监管环境相关。然而，首席 护士的存在并不一定与领导力规划的存在 有关。这可能是因为领导力规划往往由专 业协会推动，是为其成员提供的服务或作 为创收机会。 政策方案 170. 必须在国家、区域和全球层面发展护士领 导能力。护士必须有机会发展其领导潜力 和参与决策论坛。在任命国家和省级政府 以及地方和其他组织机构的领导职务时， 应该考虑到护士与其他卫生专业人员的同 等地位。这项工作将需要专门为发展护理 领导力预算拨款。可以建立以国家为基础 的奖励和表彰机制，以表彰护理人员对推 进全民健康覆盖的贡献和在年轻护士面前 的榜样作用(关于西太平洋区域领导力奖 学金规划，见专栏6 .9)。 73护理人力政策的未来方向 171. 国家决策论坛应在卫生系统决策中考虑护 理视角。政策应确保护士在各级决策中都 有代表，并在影响重要卫生系统决定和公 共卫生政策事项方面发声。护士也应该被 纳入人口层面的临床决策，这意味着， 例如，让护士加入指南编写小组和指南审 查小组，以反映关于临床建议可行性和可 接受性的护理科研和见解。 6.5 促进投资以创造护理工作岗 结果综述 172. 本报告提供了更多证据，说明在推动更广 泛卫生人力投资以实现全民健康覆盖过程 中应更加注重护理。尽管过去几年出现了 积极趋势，但除非护士的生产和吸纳大幅 度增加，否则今后十年大多数区域的护士 密度只会略有改善。低收入和中等偏下收 入国家，特别是非洲、东南亚和东地中海 区域，持续存在基于需要的大量短缺。 173. 将需要进行部门间政策对话，以确定并 承诺提供充足预算资源，用于对教育、 技能和创造就业机会、征聘、部署和保留 政策以及有关国家机构（如执照和认证机 构）的能力建设进行投资。扩大卫生人力 市场可创造就业机会，特别是为妇女创造 就业机会。扩大护理工作有助于提高女性 劳动力的参与率(全球女性劳动力参与率 仅为48%，而男性为75%)和女性就业率 (326,327)。大量证据表明，投资创造护理 工作机会有“三重回报”：健康、性别平 等和发展(21)。 政策方案 174. 各国应协调部门间行动和可持续供资， 以扩大经济需求，创造更多护理工作 机会。在大多数国家，通过有效管理工 资增长，可以利用现有国内资金创造出 来所需的590万个新护理工作岗位(仅关 注填补当前缺口所需的工作岗位)。国家 规划制定者应考虑护理投资相对于其他 职业群体的效率，并通过适当的激励和 管理制度优化当前和未来护理人员队伍 的生产率。公共资金可以支付大多数高 收入和中等收入国家卫生工作者的经常 性费用(假定财政增长正常并有能力优先 考虑卫生问题)(328)。一些高收入和中等 专栏 6 .9 西太平洋区域的领导力奖学金 西太平洋区域各国卫生系统正在管理非传染性疾病和传染病的双重负担，同时也面临重大 经济、社会和环境挑战。在西太平洋区域，护士提供大约78%的护理(317)，因此至关重要的是赋 予护士权能，并对其进行教育，使其具备改善社区健康结果所需的影响力。然而，西太平洋区域传 统上缺乏领导力规划(318,19)，包括针对卫生专业人员的领导力规划也不多(320-322)，现有规划也 没有根据文化背景调整(317,323,324)。 从2009年到2017年，悉尼科技大学与南太平洋首席护理和助产官联盟(318)合作开展了一项澳大 利亚奖学金领导力和辅导规划。领导力规划的重点是卫生人力资源、集体文化、教学辅导、政策执 行以及与全民健康覆盖的联系。来自14个国家的300多个利益攸关方和规划参与者参加了影响评估 (318)。 初步调查结果显示，85%的领导力项目参与者都有重大职业发展，并在护理和助产领域担任高 级职务。他们还在本国实施继任规划、专业发展、监管和进修培训等领域的项目(319)。另一个主要 发现是，这些专业的代表现在出现在全球峰会上，影响着全球、区域和国家层面的政策(325)。领导 力规划的九名护理和助产官员出席了第七十二届世界卫生大会。六名已经成为所在国家的政府首席 护士，两名是本国卫生部长。 74 2020年世界护理状况 收入国家可以通过取消对卫生工作者供 应的限制来解决短缺问题和释放需求， 同时减少对国际劳工流动和移民的过度 依赖。 175. 发展伙伴应使护理教育和就业方面的官 方发展援助与国家卫生人力和卫生部门战 略保持一致。由于财政空间不足，一些低 收入和中等偏下收入国家在创造护理工作 机会方面将面临挑战。统一和协调捐助方 和发展伙伴的支持可以扩大可持续供资， 促进加强卫生和社会工作人员队伍，同时 确保工资账单可以扩大和持续，从而加 快实现全民健康覆盖(关于投资发展人力 资本，见专栏6 .10)。如果估计中长期国 内资源不足，例如在低收入国家和脆弱、 受冲突影响和不利环境中，在治理条件允 许的情况下，可以考虑资金池机构安排等 机制。 176. 各国应结合当地、国家和国际上普遍的 人力市场状况处理护士应获得多少报酬的 问题。政策制定者和监管机构，如公务员 制度或卫生服务委员会，应该有意避免一 些典型的陷阱。这些措施可能包括将薪酬 水平维持在过低水平(这可能导致员工失 去工作动力、人员过度流动和采取非法对 策)、过高水平(这可能导致工资膨胀和工 资账单的可持续性问题)，或使男女工资 差距长期存在。薪酬方式也很重要：在大 多数情况下，护士通常以薪金形式获得 固定收入，从事多项职务带来的收入少于 其他职业类别。应注意避免已知的针对具 体疾病或规划的补充奖励办法的弊端，因 为这些办法扭曲国家重点，而且往往不可 持续。政策制定者还应考虑卫生领域各专 业薪酬的一致性，以避免制造不利于选择 护理职业的因素。最终，护士的薪酬水平 应足以吸引、保留和激励他们满足国家的 需要。 6.6 研究和证据议程 177. 本报告提供前所未有的大量数据，并概述 关于护理人员队伍的研究证据，从而可以 © WHO/Yoshi Shimizu 拟定政策方案，供会员国和其他利益攸关 方审议。同时，报告的撰写受到数据和有 效性证据方面的若干限制。下文报告了我 们查明的主要差距，可将其视为前瞻性研 究议程的一部分。 178. 专门针对护理的定量和半定量证据。 《2020年世界护理状况》报告中最重要 的一个调查结论不是来自数据，而是关于 数据。现有信息还不足以全面了解护理人 员队伍和进行卫生人力市场分析，尚有 巨大而重要的差距，特别是在培养能力、 75护理人力政策的未来方向 专栏 6 .10 投资发展人力资本 为增加获得优质初级卫生保健服务的机会，作为实现全民健康覆盖的基石，需要对基础设施 (例如医院和卫生中心)和相关人力资本(卫生人力，包括知识和技能)进行大量投资(14,328)。一些人 力资本计划的重点是帮助各国对本国人民进行更多、更有效的投资，以改善健康、营养、优质教育 和技能方面的结果。 • 世界银行承诺投资150亿美元支持低收入和中等偏下收入国家的人力资本改革，其中特别关注 非洲；63个国家已经签约加入人力资本项目。 • 国际货币基金组织正在加强所有以社会支出倡议为核心目标的规划。它们将在社会支出、社会保 护、教育和卫生领域提供额外的技术援助。 • 在全民健康覆盖的背景下，欧洲投资银行和世卫组织正在结成人力资本议程伙伴关系，共同开 发一种金融工具，将欧洲投资银行的投资与对卫生部门教育、技能和就业的有针对性支持联系 起来。 • 经合组织、世卫组织和劳工组织设立了联合国多伙伴信托基金，汇集资源落实联合国卫生领域就 业和经济增长高级别委员会提出的与转型教育、技能和创造就业有关的建议。 © WHO/Yoshi Shimizu 76 2020年世界护理状况 自然减员、工资水平和卫生人力市场吸 纳方面。需要加强支持这类证据的整理、 分析和使用的系统。国家卫生人力账户有 赖于强有力的跨部门参与。使用该账户可 以支持有关计划的可持续投资的政策对话 和决策，从而促进在关键的护理领域取得 进展。 179. 初级卫生保健和全民健康覆盖中护理人 力有效性的证据。本报告总结护士在不同 的临床干预和公共卫生领域所做贡献的 证据。最强有力的证据来自于一项系统综 述，该综述涵盖18项显示了护士主导的 干预措施在一系列初级保健职能中的有效 性的随机对照试验(30)。不过，18项研究 中有17项是在高收入国家进行的，只有 一项来自中等收入国家，没有一项来自低 收入国家。针对具体的临床或规划领域进 行了进一步Cochrane和Campbell综述， 包括抗逆转录病毒疗法、戒烟、精神卫 生和性侵害研究。其中一份综述仅包括 随机对照试验，而其他综述则包括实验 和准实验研究，包括对照试验(随机或非 随机)、对照研究前后、队列研究(前瞻 性或回顾性)和中断时间序列研究，从而 对干预措施和对照措施进行对比(31,33, 34)。Campbell综述的重点是美国和联合 王国的做法，因此仅限于这些国家开展的 研究。有关抗逆转录病毒疗法的综述只包 括来自非洲的研究。戒烟问题综述所涵盖 的研究都来自高收入国家，主要是美国。 精神卫生综述只关注低收入和中等收入国 家，包括来自低收入国家的7项研究及中 等偏下收入国家的15项研究(31,33,34)。 概览还强调在有效性证据方面存在的具体 差距，例如针对包括气候变化在内的健 康问题的社会决定因素的护理干预措施， 以及复杂突发事件下的护理干预措施。 180. 利用不同的研究设置和方法。虽然上 述证据审查对于确定护理干预措施的有 效性必不可少，每项综述所包含研究 的设置限制其可归纳性和全球适用性。 此外，最典型的实验和准实验调查会将 护士与其他卫生专业人员对比。虽然这 可能提供有益的见解，但这种方法不适 于说明和充分理解成功提供高质量卫生 保健所需努力和相互关联进程的性质是以 团队为基础。一个更广泛的研究范围， 包括定量(实验性和非实验性)和定性的 初级研究，混合方法评价及实地说明， 提供有关全球护理政策问题的更全面概述 (见网页附录)。然而，这些证据大多产生 于高收入国家(30,329)，包括产生的研究 重点(330)。 181. 需要做更多的工作，以支持低收入和中 等收入国家记录采取的护理干预措，并支 持它们发展护理科学，以便护士们根据自 己在提供卫生服务方面的工作经验推动自 己的研究议程。护士们已经为卫生保健科 学做出了重大贡献，包括开发创新的研究 方法和使用这些方法来调查对改善全球 健康具有重要意义的问题(331)。研究表 明，有关低收入和中等收入国家改善卫生 工作者做法的有效策略的证据质量较低 (332)。因此，对护理研究的投资不仅要 注重增加产出数量，还要注重提高科学质 量，因为这将有助于我们的总体卫生人力 知识。 182. 有关有效政策和制度支持优化护理角色的 证据。这份报告强调有关政策选择对优化 护理工作的贡献和影响的有效性的证据， 包括教育、监管、部署、实践和留用等多 个领域。与此同时，其他领域的证据则不 那么有力。例如，投资护理和更广泛卫生 人力的回报或可得到更好的理解，并应在 各种环境和政策背景下进行研究，包括研 究护理的成本效益，特别是在低收入和中 等收入国家的初级保健环境中。以下方面 还有加强证据的空间：政策干预措施对于 在实践环境中留住护士的有效性，使护士 能够在提供初级保健服务方面充分发挥作 用的监管和治理方法，以及规范私营部门 教育和实践的有效机制。对旨在应对移徙 不利影响的政策进行更缜密的评价，将有 助于更好地设计和更切合实际地确定应对 政策的目标。在所有这些领域，应在分析 中明确采用性别角度。由于大多数经过审 查的研究通常时间较短，较长期的纵向研 究可能有助于提高人们对研究结果于现实 政策环境的相关性的信心。 77护理人力政策的未来方向 © AKDN/Christopher Wilton-Steer 78 2020年世界护理状况 183. 《2020年世界护理状况》报告强调了 护士作为综合团队的一部分在大力促进 全民健康覆盖和其他国家及全球卫生目 标方面的核心作用。护士是规模最大的 职业类别，2018年的总人数估计约为 2800万，是各种社会经济发展水平国家初 级卫生保健和卫生系统的核心要素。 184. 为本报告整理的数据和证据比以往任何时 候都更加充分。共有191个国家报告了人 力总数，创下历史新高，比2018年发布的 卫生人力数据增加了53%。80%的国家首 次向世卫组织提供了至少15项护理指标的 数据，涵盖不同的人力政策层面。对总人 数数据趋势的分析表明，2018年护士短缺 590万人，主要集中在非洲、东南亚和东 地中海区域。这说明，与全球战略确定的 基线情况相比，受短缺影响的国家的护理 人力总数有所改善。 185. 尽管有取得进展的迹象，但报告也强调了 令人关切的一些关键领域。根据2016年 全球战略所作预测，低收入国家和中等偏 下收入国家以及非洲和东地中海区域需要 加快进展，以弥补关键差距。绝对数字的 最大缺口仍然在东南亚区域。美洲和欧洲 区域因为护理人力的老龄化而面临额外的 威胁。美洲、欧洲和东地中海区域的一些 高收入国家似乎过度依赖护理人员的国际 流动。 结束语 章节 7 79结束语 186. 各国政府应在其国内和国际伙伴的适当支 持下，促进并领导加快努力，以便： • 培养护理人员的领导、维护和管理能 力，以推进相关的教育、卫生、就业 和性别议程； • 通过在教育、体面工作、部署、实 践、生产力、监管和留用护理人力方 面采纳必要的政策方案，优化当前对 护理领域投资的回报； • 对卫生人力，包括对其中的护士进行 大量投资，并利用他们实现多种发展 成果，包括创造就业、实现性别平等 和增强青年人的权能等。 187. 要将本报告陈述的证据、建议的政策方案 和上述战略方向转化为具体的政策和投资 决定，需要在政府各部门之间进行协调并 与最重要的利益攸关方合作。应当利用提 出的调查结果和数据来促使在国家开展有 最重要利益攸关方参与的政策对话，并应 利用这些政策对话机制，就合理的循证政 策和适当的投资水平做出必要决定。 © WHO/Yoshi Shimizu 让我们抓住这一契机， 承诺开展十年行动， 从投资发展护理 教育、就业和领导力开始。 参考文献 1. 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Lancet Global Health. 2018;6:e1163–75. doi:10.1016/ s2214-109x(18)30398-x. 95参考文献 附件1. 护士是什么人？ 12 国际劳工组织《国际标准职业分类》：https://www.ilo.org/public/english/bureau/stat/isco/ . 从 专 科 医 院 到 卫 生 站 和 社区，护士在各种卫生保健环 境中为人们提供多种多样的 服务。护士拥有各种不同的 职称、职能和教育途径。六种 最常见的护理职称是注册护 士、护士、有照实践护士、高 级实践注册护士、开业护士和 护理助理。然而，护士的职能 从一个国家到另一个国家可能 有所不同，即使他们的职称 相同。因此，在国际上使用职 称作为分类和分析的方法是不 当的。 本报告旨在提供根据国际 劳工组织2008年《国际标准 职业分类》(ISCO-08)定义， 由世卫组织会员国报告和验 证的现有最佳国际可比护理 人力数据。为了帮助实现这 一目标，国家卫生人力账户 使用 ISCO-08系统对卫生人 力进行了分类。各国按要求 将其护理人员分别归入两个 主要的 ISCO -08代码，即： 专业护士( ISCO代码 2221 ) 和准专业护理人员( ISCO代 码 3221 )。须注意的是，本 节将护理人员作为上面界定 的一个职业类别进行报告， 但“护理服务”将护理人员纳 入多学科卫生系统，这便涉及 本节未描述的其他几种职业。 例如，ISCO分类和遵循ISCO 的国家系统会将“护士助手” 归类为卫生保健助理，一个更 广泛的支持性职业类别12。 ISCO指南详细描述了每一 类别应包括哪些卫生工作者(专 栏A1 .1)。总体而言，专业护士 负责患者护理的计划和管理， 可自主工作或与医生及其他 人员一起工作。准专业护理人 员负责提供基本护理和个人照 护，通常在医疗、护理或其他 卫生专业人员的监督或支持下 工作。 然而，在一些国家，专业 护士和准专业护士之间的区别 是模糊的。同样，准专业护士 和护士助手之间的区别也不总 是很清楚。因此，在这些情况 下，需要国家利益攸关方做出 判断。建议各国在决定是否将 一个职业群体归类为专业人员 或准专业人员或根本不归类为 护士时，既要考虑职能和责 任，又要考虑职前教育的持续 时间。例如，一般来说，专业 护士必须完成至少三年的职前 教育课程。如果一个国家不能 决定使用哪一个类别，国家卫 生人力账户包括一个“护士： 未进一步界定”的选项，一些 国家选择将其部分或全部护理 人员纳入这一类别。这一类别 对应于专业护理人员或准专 业护理人员，但不包括护理助 手，后者属于卫生保健助理 职业类别，本报告不对其进行 分析。 96 2020年世界护理状况 专业护理人员的任务包括： 准专业护理人员的任务包括： • 为患者计划、提供和评价护理服务 • 与其他卫生专业人员协商，协调对患者的护理 • 与其他卫生专业人员合作，制定和实施针对患者 治疗的护理计划 • 计划和提供个人照护、治疗和疗法，包括施用药 物和监测对治疗或护理的反应 • 清洗伤口和敷药 • 监测患者的疼痛和不适，并使用包括止痛药在内 的疗法缓解疼痛 • 计划和参与健康教育规划、健康促进和护士教 育活动 • 回答患者和家属的问题，提供关于预防疾病、 治疗和护理的信息 • 监督和协调其他卫生工作者的工作 • 开展关于护理实践和程序的研究 • 根据卫生专业人员制定的护理计划，为患者提供 护理、个人照护、治疗和健康建议 • 对患者进行药物治疗和其他治疗，监测患者的病 情和对治疗的反应，并根据需要将患者及其家人 转介给卫生专业人员进行专门护理 • 清洗伤口和敷药 • 更新病历保存系统中关于患者状况和治疗的信息 • 协助计划和管理个体患者的护理 • 在紧急情况中协助提供急救治疗 ISCO关于护理人员的定义专栏A1.1 注：专业护士和准专业护士之间的区别应基于与上述任务相关的工作性质。个人持有的资格或在国内占主导地位的资格并不是做出这种区分的主 要因素，因为护士的培训安排在各国之间差异很大，而且随着时间的推移在国家内部也有所不同。 来源：改编自ISCO-08。 97附件1 附件2. 方法 《2020年世界护理状况》报告 中使用的指标 世 卫 组 织 会 员 国 应 邀 在 2019年7月至2019年11月期间根 据36项指标(30项国家卫生人力 账户指标和6项特定附加指标) 提交了护理人员队伍的最新数 据(见表A2 .1中的列表)。《国 家卫生人力账户手册》13 对这 30个指标进行了界定，并为每 个指标提供了详细的定义和元 数据。 数据收集过程 国家卫生人力账户是一个 持续进程，卫生人力数据的可 得性、质量和使用都在逐步提 高。作为这一进程的一部分， 鼓励各国就所有与卫生人力数 据相关的方面建立多利益攸关 方工作组，以便在提交数据之 前进行内部验证；许多国家都 这样做了。《2020年世界护 理状况》报告的编写加快了这 一旨在改善标准化数据监测和 报告的全球努力。各国按要求 指定了联络点，联络点可以进 入国家卫生人力账户在线平台 以输入或验证数据。此外，通 过经合组织、欧统局和世卫组 织欧洲区域办事处的联合数据 收集问卷获得的经合组织国家 数据已预先填充，以避免向 国际组织重复报告，并建议联 络点审查和验证这些数据。每 个国家每年的人口规模摘自联 合国经济和社会事务部《世界 人口展望》2019年修订本14。 此外，还从西格玛(Sigma)数 据库和美国联邦护理委员会全 国理事会数据库15收集了额外 数据，涉及评估治理和政策环 境的指标(通过二元问题(是/否) 了解有无相关机制和程序)和教 13 国家卫生人力账户：实施指南。日内瓦：世界卫生组织；2018年。 14 经济和社会事务部和人口司。《2019年世界人口展望》，在线版，修订版1。美利坚合众国纽约：联合国；2019年。 15 西格玛(Sigma)数据取自：https://www.sigmanursing.org/advance-elevate/research/research-resources。美国联邦护理委员会全国理事会的数据取自： https://www.ncsbn.org/national-nursing-database.htm。 育与培训的期限，以补充少数 国家的信息。 为了支持数据收集，世卫 组织在所有六个区域举办了区 域国家卫生人力账户研讨会， 并以若干种语言提供了工具和 信息。总共有来自大约80个国 家的250多名代表参加了这些 能力建设活动。2019年7月至 11月期间提交了数据，2019年 10月至12月进行了数据清洗和 分析。本报告以国家卫生人力 账户在线平台截至2019年12月 17日的数据集为基础。 建议国家卫生人力账户联 络点让护理领导者和其他国家 利益攸关方参与进来。世卫组 织国家和区域办事处支持国 家卫生人力账户的实施和报告 进程，包括收集、报告和验证 相关数据。 报告的数据 在 世 卫 组 织 1 9 4 个 会 员 国中，有193个直接通过国家卫 生人力账户平台或通过区域办 事处和其他国际程序，如经合 组织、欧统局和世卫组织欧洲 区域办事处联合收集非货币卫 生保健统计数据的程序，报告 了数据(191个会员国报告了人 力总数)。图A2 .1显示80%的国 家提供了36个选定指标中至少 15个指标的数据，23%的国家 提供了至少25个指标的数据。 主要数据缺口是与工资、 护理教育支出和其他教育相关 问题有关的指标。对于选定的 指标，已确定了补充国家卫生 人力账户数据的替代来源， 如教育和培训期限、工资和能 力指标。例如，国际护理荣誉 学会西格玛(Sigma)管理着一 个关于全球护理教育状况的数 据库，包括大约另外50个国家 的初级工资和教育规划期限的 指标。关于与护理实践和教育 的政策和法规有关的一组二元 指标，利用全球监管图集来确 定哪里需要执照考试以及哪里 存在监管机构。 在191个国家中，83%提供 了2017年或2018年的护理人员 数量数据。其他国家只能提供 前些年(2013年至2016年)的数 据。在这种情况下，估算2018 年人数时对2018年的人口应用 了现有最近一年的密度。对于 四个未报告人数的国家，对其 2018年人口应用了相应的区域 密度。 许多国家，尤其是西非和 中非以及中亚国家，无法提供 若干指标的数据，这一事实表 明，迫切需要继续加强这些区 域卫生信息系统的人力资源。 本报告并未列报收集的所 有数据：仅分析和列报了拥 有大量国家报告的统计数据的 指标。将通过一个方便获取国 家卫生人力账户数据的公共门 户网站逐步提供更多的数据。 对第5.4和第5.6节中教育监管和 工作条件的综合评分 虽然大多数分析本质上是 纯描述性的，主要侧重于百 分比，而对教育和工作条件 监管方面的指标则使用了综合 分数。在对这两方面的指标 计分时，国家每次对指标回 答“是”可得1分，如果回答 为“部分”，得0 .5分，如果回 答为“否”，得0分，然后将分 数相加、确定一个综合分数。 因此，最高可能得分为9分， 98 2020年世界护理状况 30项指标源自《国家卫生人力账户手册》，6项指标系为本报告专门制定。 指标名称(国家卫生人力账户) 国家卫生人力 账户编号 截至2019年 12月17日的答 复率 护士人员总数和分布 按护士类型/级别划分的护士密度 1-01 98% 次国家级护士密度 1-02 31% 按年龄组划分的护士分布 1-03 55% 女护士人力资源 1-04 68% 按设施所有权划分的护士分布 1-05 47% 按设施类型划分的护士分布 1-06 34% 外国出生护士的比例 1-07 35% 接受外国培训的护士比例 1-08 46% 教育和培训 获认证的教育机构总清单 2-01 88% 教育和培训期限 2-02 56% 教育和培训申请数量 2-03 12% 护理专业学生与合格师资的比例 2-05 10% 教育和培训监管及资格认证 教育期限和内容的标准 3-01 87% 教育机构的认证机制 3-02 84% 跨专业教育标准 3-06 80% 持续专业发展 3-08 82% 教育经费 护理教育毕业生人均支出 4-05 7% 卫生人力市场流动 毕业生一年内开始从业 5-01 14% 通过国内努力实现的人员补充率 5-02 45% 外籍护士进入比率 5-03 11% 自愿退出卫生人力市场的比率 5-04 9% 失业率 5-06 8% 就业特点、工作条件 持兼职合同的卫生工作者 6-02 6% 关于工作时间和条件的规定 6-03 86% 最低工资规定 6-04 86% 社会保护规定 6-05 86% 防止袭击卫生工作者的措施 6-09 80% 护理人员的支出和薪酬 初级工资和薪金 7-05 42% 基于性别的工资差距 7-07 3% 各种护理模式的技能组合 设有高级护理职务 8-06 79% 《2020年世界护理状况》特定附加 指标 政府首席护理和/或助产官员职位 – 84% 护理领导能力发展规划 – 76% 全国年轻和新护士协会 – 76% 护理委员会 – 98% 教师资格标准 – 68% 就业能力考核 – 92% 用于《2020年世界护理状况》报告的36项指标列表表A2.1 注：关于国家卫生人力账户指标的进一步信息，具有元数据的详细信息见《国家卫生人力账户手册》：https://www.who.int/hrh/documents/ brief_nhwa_handbook/en/。 六个不属于国家卫生人力账户的附加指标的元数据可向SOWN2020@who.int索取。 99附件2 最低为0分。对于缺失信息的指 标，答复被视为“否”，得分 为0。 对第5.4和第5.6节中教育监管 和工作条件的多重对应分析 关于教育和从业监管的指 标显示出高度相关性：如果一 个指标得到的回答为“是”， 那么其他一些指标得到回答很 可能也为“是”。为了更好地 理解这种模式，进行了多重对 应分析，由此简化了单一二 维图(图A2 .2)中许多变量之间 的相关性。这种分析能够提取 两个维度(x轴和y轴)的变量。 第一个“维度”(x轴)上的系 数右侧代表缺乏监管，左侧代 表存在监管。第一个维度表明 变量之间存在79 .7%的差异。 第二个维度(y轴)向上代表缺少 资格认证机制，而向下代表缺 少教育监管。这个维度表明指 标之间存在2 .1%的差异。该图 还标有一些区域，以突出显示 它们与哪些指标更紧密相关。 分析证实，东南亚区域、东地 中海区域和西太平洋区域位于 图的右侧，说明这些区域更可 能存在护理教育监管水平较低 问题。 多重对应分析证明，工作 条件指标之间有很强的相关性 (图A2 .3)。两个显示出很强相 关性的指标是防止袭击卫生工 作者的措施和设有高级护理职 务：这可能表明，在更危险的 环境中，护士可能被授予更高 水平的专业自主权，以便在具 有挑战性的环境中继续确保对 患者的护理。欧洲区域显示出 与其他区域不同的模式，表明 防止袭击卫生工作者的措施 较少，高级护理职务也较少。 到2030年的预计人员总数 为了评估到2030年的护士 总数，设想了三种情景，如下 所示。 • 情景1 :老龄化。 (护理人 力老龄化的单一影响)。 这项预测使用了每个国家 的年龄分布和35岁以下 的稳定年龄组，并考虑补 充这一最低年龄组的十分 之一。该情景考虑了人力 老龄化问题，假定55岁及 以上护士群体十分之一将 退休。这种情景没有考虑 毕业统计数据，并认为年 轻年龄组的比例在未来几 年保持不变。 • 情景2:人员补充。该情景 具有与情景1相同的老龄 化问题，但使用第5 .5节中 按区域计算的最新毕业率 (适用的校正系数为0 .6)， 并假设60%的新毕业生将 在卫生部门就业，由此模 拟在经合组织国家中看到 的毕业与加入在职人员队 伍之间的差异。 • 情景3:加速人员补充。该 情景与情景2类似，但考 虑加快毕业和吸收率，到 2030年每年增加毕业生 人数，具体假设是从2018 年到2030年各国毕业能力 增长50%(相当于每年增 长3 .44%)。该情景还假设 为编写《2020年世界护理状况》报告在全球一级报告的指标数量图A2.1 0 1,000 2,000 3,000 4,000500 公里 5个以下 5至9个 10至14个 15至19个 20至24个 25个以上 未报告不适用 注：包括30项国家卫生人力账户指标和六个能力问题。 来源：国家卫生人力账户，2019年。 100 2020年世界护理状况 60%的毕业生会进入卫生 人力市场。 根据这些情景，使用联合 国2030年人口展望估计中的人 口估计数估算了2030年的预计 密度。 为了评估情景3的影响， 对毕业生数量的各种增加情况 进行了模拟:增加25%、增加 50%和增加100%(即人数加倍) (图A2 .4)。结果表明对护理专 业毕业生人数增长率的选择不 会对2030年的估计总人数产生 重大影响，如果总增长率分别 为25%、50%和100%，预计 护士总人数将分别达到3800 万、3970万和4280万。 解释预测时的注意事项 解释预测时需要考虑几个限 制因素。 1. 涉及数据的可得性，并非 所有国家都能报告用于情景1的 年龄数据和用于情景2的毕业 率数据。分析显示情景1和情景 2的结果一致、因此为新毕业 生进入人力市场的比率提供了 保证。 2. 对55岁及以上人员的自然 减员率使用了几个假设。这可 能因区域而异，并可能是乐观 的，因为退休年龄将提高到65 岁。同样，根据经合组织的从 业护士与持有执照的护理人员 之间的比率，该分析采用了0 .6 这一比率来增加开始从业的毕 业生数量。不过，这可能因区 域而异。为了检验情景1-3的所 有基本假设的影响，进行了一 系列敏感性分析。结果仅略有 不同，结论基本保持不变。 3. 预测仅反映了最近的趋势， 并提供了对护理人员总数量轨 迹的宽泛理解。这将需要在未 来获得更多数据后进行修订。 此外，这些预测并不能取代从 国家一级建模得出的结论， 国家一级建模会考虑到整个卫 生人力市场中范围更广的卫 生人力和其他指标，以及更详 细的经济统计数据，包括财政 空间。 估算短缺 对护理人员短缺的估算采 用了一种类似于《卫生人力资 源全球战略》中描述的方法。 然而，由于数据更新，短缺值 无法直接与《全球战略》中的 估计值进行比较。 分析表明，《全球战略》中 的估计以2009-2013年期间拥 有总人数数据的102个国家为 基础，其余国家使用了较旧的 或推定的数据。根据《2020年 世界护理状况》报告获得的最 图A2.2 通过多重对应分析显示教育指标之间的相互关系 SEAR EUR AMR EMR AFR WPR 维度1 (79.7%) 维 度 2 (2 .1 % ) 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes 分析类型：对护理教育体系监管变量的多重对应分析；区域显示为独立变量。 本图中涵括的变量：M2-01：获认证的教育机构总清单；M3-01：教育期限和内容的标准；M3-02：教育机构的认证机制；M3-06：跨专业教育标准； M3-08：持续专业发展；NN2：就业能力考核；NN3：教师资格标准。 AFR = 非洲区域；AMR = 美洲区域；SEAR = 东南亚区域；EUR = 欧洲区域；EMR = 东地中海区域；WPR = 西太平洋区域。 来源：国家卫生人力账户，2019年。2013年至2018年期间各国报告的现有最新数据。 101附件2 新数据，174个国家有2013年 或之前五年的总人数数据(其中 130个国家有2013年的数据)， 经订正的2013年总人数估计为 2320万名护士。2018年的总人 数以191个国家2013-2018年的 数据为依据，其中89%有2017 年和2018年的数据。因此，可 以说2018年《2020年世界护理 状况》报告中提供的总人数是 一个非常可靠的估计值。 为了估算短缺，将2018年 和2030年的密度与《卫生人 力资源全球战略》中使用的基 准值进行了比较。然后将每千 人中有4 .45名医生、护士和助 产士的基准转换成护理人力基 准值。 • 首先，将《全球战略》中 护士和助产士的比例适用 于这一基准：根据 2013 年每万人中有20 .7名护士 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009. 和 助 产 士 以 及 每 万 人 中 有9 .8名医生，将基准修 正为每千人中有3 .02名护 士和助产士(4 .45x(20 .7 / (9 .8+20 .7))。 • 然后，为了仅计算护士的 基准值，将护士在护士和 助产士总人数中所占比例 (最近一年为90 .7%)应用 于该基准，得出了每千人 2 .74名护士的基准值。 • 由于卫生人力的密度以每 万人表示，所以将每万人 27 .4名护士用作基准值。 • 之后将该基准值与2018年 观察到的密度进行比较， 并在三种情景下预测2030 年的密度。 根据上述三种预测情景， 对到2030年的短缺进行了估 算，结果表明在每种情景下， 低收入和中等偏下收入国家的 短缺率都很高(表A2 .2)。 每个毕业生的成本 在 短 缺 最 严 重 的 低 收 入 和中等偏下收入国家、每个毕 业生的费用来源多种多样。这 些费用的数额从马达加斯加的 5180美元、世界银行ECSA(东 部、中部和南部非洲)分析16得 出的5589美元、莫桑比克的 5656 美元到加纳的 19 794 美 元17各不相等。因此、计算成 本时使用了低、中、高三种假 设，分别是：每个毕业生 5000 美元费用、个毕业生 10 000 美 元费用和每个毕业生 20 000 美 元费用。请注意，关于这些费 用的现有数据来自非洲国家， 不能转用于高收入国家，因为 高收入国家公布的数据显示每 个毕业生的费用远高于此。 图A2.3 通过多重对应分析显示工作条件指标之间的相互关系 0 12 10 8 6 4 2 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes 维度1 (80.1%) 维 度 2 (2 .6 % ) 分析类型：对工作条件的监管变量的多重对应分析；区域显示为独立变量。 本本图中涵括的变量：M6-03：关于工作时间和条件的规定；M6-04：最低工资规定；M6-09：防止袭击的措施；M8-06：设有高级护理职务； NN1：设有护理委员会。 AFR = 非洲区域；AMR = 美洲区域；SEAR = 东南亚区域；EUR = 欧洲区域；EMR = 东地中海区域；WPR = 西太平洋区域。 来源：国家卫生人力账户，2019年。2013年至2018年期间各国报告的现有最新数据。 102 2020年世界护理状况 在“一切照旧”情景和三种“增加毕业护士人数”情景下，2018年至2030年全球护理 人员总数(以百万计)的演变情况 图A2.4 护理人员总数- 毕业生常量 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 护 理 人 员 总 数 （ 以 百 万 计 ） 护理人员总数- 毕业生增加25% 护理人员总数- 毕业生增加50% 护理人员总数- 毕业生增加100% 注：“护理人员总数”包括专业护理人员和准专业护理人员。 针对特定区域使用的校正系数包括老龄化系数(2018年55岁及以上年龄组每年有十分之一退休)，此外用0 .6这一系数(即经合组织从业者与有执照者 之间的比率)对第5 .5节分析中的毕业率进行了校正，以考虑护理实践以外的活动。 收入组 2018年 2030年 老龄化 以及稳定的 年轻年龄组 老龄化 以及最近数年的毕 业人数 老龄化 以及毕业人数 到2030年 增加50% 低收入 1 .34 1 .80 1 .54 1 .26 中等偏下收入 3 .91 3 .44 2 .81 1 .54 中等偏上收入 0 .67 0 .45 0 .25 0 .12 高收入(用作参考、所有国家的密度都 高于阈值) – – – – 全球 5.91 5.69 4.60 2.92 按收入水平分列的低于《全球战略》阈值的国家护理人员短缺估计数(以百万计)： 2018年和2030年 (三种情景) 表A2.2 注：“护理人员”包括专业护理人员和准专业护理人员。收入组别来自世界银行截至2018年的分类。 103附件2

合作组织：

Contents iii CONTENTS FOREWORD ........................................................................................................................................ vii Message from the Co-Chairs ............................................................................................................ viii Contributors and acknowledgements ................................................................................................ ix Glossary ............................................................................................................................................... x EXECUTIVE SUMMARY ....................................................................................................................... xii Introduction ................................................................................................................... 1 Nursing in a context of broader workforce and health priorities ..................................... 5 2.1 Role of the health workforce in achieving the 2030 Agenda ................................................... 5 2.2 Who is a nurse? ........................................................................................................................ 8 Nursing roles in 21st-century health systems ................................................................ 11 3.1 Role of nursing in achieving universal health coverage ......................................................... 11 3.2 Role of nursing in dealing with emergencies, epidemics and disasters ................................. 15 3.3 Role of nursing in achieving population health and well-being ............................................. 16 Policy levers to enable the nursing workforce ............................................................... 19 4.1 Pre-service education and training ......................................................................................... 19 4.2 Workforce inflows and outflows ............................................................................................ 25 4.3 Equitable distribution and efficiency ...................................................................................... 27 4.4 Regulation .............................................................................................................................. 32 Current status of evidence and data on the nursing workforce ..................................... 35 5.1 Nursing workforce availability, composition and distribution ............................................... 37 5.2 Equity in availability of and access to the nursing workforce ................................................ 43 5.3 International nurse migration and mobility ........................................................................... 47 5.4 Regulation of nursing education and practice ........................................................................ 49 5.5 Education and nursing workforce supply ............................................................................... 52 5.6 Regulation of employment and working conditions .............................................................. 56 5.7 Governance and leadership .................................................................................................... 61 5.8 Assessing the current trajectory towards 2030 SDG outcomes ............................................. 64 Future directions for nursing workforce policy ............................................................. 70 6.1 Strengthening the evidence base for planning, monitoring and accountability .................... 71 6.2 Mobility and migration ........................................................................................................... 72 6.3 Developing and supporting the nursing workforce ................................................................ 75 6.4 Building institutional capacity and leadership skills for effective governance ....................... 85 6.5 Catalysing investment for the creation of nursing jobs .......................................................... 87 6.6 Research and evidence agenda .............................................................................................. 90 CONCLUSION ................................................................................................................ 94 References ......................................................................................................................................... 96 Annex 1 . Who is a nurse? ............................................................................................................... 111 Annex 2 . Methods........................................................................................................................... 113 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 iv Tables Table 5. 1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 .................................. 38 Table 5. 2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 ........................... 38 Table 5. 3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region .......................................................................................................................... 39 Table 5. 4 Percentage of female nursing personnel, by WHO region .............................................................................. 41 Table 5. 5 Density of nursing personnel per income group (2018) .................................................................................. 46 Table 5. 6 Percentage of nursing personnel foreign born (or foreign trained) per income group................................... 48 Table 5. 7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region ..................................................................................................................................................... 50 Table 5. 8 Production of graduate nurses, by WHO region and income group................................................................ 53 Table 5. 9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region ............................................................................................................................................................... 57 Table 5. 10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region ....................................................................... 62 Table 5. 11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region ............................................................................................................................................................... 66 Table A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report .................................................. 114 Table A2. 2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) ............................................................................................. 121 Boxes Box 3. 1 Nursing contribution to patient safety ............................................................................................................... 12 Box 3. 2 Nurse-led model of community care for ageing populations ............................................................................. 14 Box 4. 1 Australia: engaging underrepresented populations in the nursing workforce .......................................... 21 Box 4. 2 Cost of nursing education ................................................................................................................................ 22 Box 4. 3 Addressing the shortage of nurse educators ................................................................................................... 24 Box 4. 4 Global skills partnerships ................................................................................................................................. 26 Box 4. 5 Examples of economic demand for nurses in high-income countries ............................................................. 27 Box 4. 6 Expanding access via nurse prescribing in Poland ........................................................................................... 28 Box 4. 7 Example of a specialist nursing role in the African Region .............................................................................. 29 Box 4. 8 Rural retention guidelines ................................................................................................................................ 31 Box 4. 9 Examples of harmonization of education standards and licensure examination ............................................ 33 Box 5. 1 Equity within countries ....................................................................................................................................... 46 Box 6. 1 Scotland health labour market analysis ............................................................................................................ 71 Box 6. 2 East, Central and Southern African Health Community: national collaboration on nursing data reporting using NHWA indicators ..................................................................................................................................... 73 Box 6. 3 Germany’s approach to managing migration ................................................................................................... 74 Box 6. 4 Technology in nursing education and practice ................................................................................................. 76 Box 6. 5 Pakistan efforts to increase nurse education capacity ..................................................................................... 78 Box 6. 6 Expanding access to community health services in Oman ............................................................................... 80 Box 6. 7 African Health Profession Regulatory Collaborative ......................................................................................... 83 Box 6. 8 Health worker strikes ........................................................................................................................................ 84 Box 6. 9 Leadership fellowship in the Western Pacific Region ....................................................................................... 87 Box 6. 10 Investing in human capital ............................................................................................................................... 89 Box A1. 1 ISCO definitions of nursing personnel .............................................................................................................. 112 Contents v Figures Figure 1 Density of nursing personnel per 10 000 population in 2018 .......................................................................xiii Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) ..................... xiv Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group..................... xv Figure 4 Average duration (years) of education for nursing professionals, by WHO region ...................................... xvi Figure 5 Percentage of countries with regulatory provisions on working conditions ............................................... xvii Figure 6 Percentage of female and male nursing personnel, by WHO region ............................................................. xx Figure 2. 1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing ................ 7 Figure 2. 2 Number of distinct nursing titles within each WHO region ............................................................................ 9 Figure 3. 1 Nursing contribution to the triple billion targets .......................................................................................... 17 Figure 4. 1 Public policy levers to shape health labour markets .................................................................................... 20 Figure 5. 1 Number of countries with workforce data available in the WHO NHWA (1990–2018) ............................... 36 Figure 5. 2 Proportion of nursing headcount within each occupation group, by WHO region ...................................... 40 Figure 5. 3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region .................... 41 Figure 5. 4 Relative proportions of nurses aged over 55 years and below 35 years ...................................................... 42 Figure 5. 5 Density of nursing personnel per 10 000 population in 2018 ....................................................................... 44 Figure 5. 6 Regional disparities in density of nursing personnel per 10 000 population (2018) .................................... 44 Figure 5. 7 Density of nursing personnel per 10 000 population by income group (2018) ............................................ 45 Figure 5. 8 Percentage of responding countries indicating existence of nursing regulations and standards ................ 50 Figure 5. 9 Map of nursing education regulation scores, by country ............................................................................. 51 Figure 5. 10 Average duration (years) of education for nursing professionals, by WHO region ...................................... 55 Figure 5. 11 Percentage of countries with regulatory provisions on working conditions ................................................ 57 Figure 5. 12 Percentage of countries with regulatory provisions on working conditions ................................................ 58 Figure 5. 13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population ..................................................................................................................................................... 59 Figure 5. 14 Association between GCNO and nursing leadership programme and the regulatory environment ............ 63 Figure 5. 15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) ..................... 65 Figure 5. 16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group.................... 66 Figure 5. 17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 ....................................................... 67 Figure A2. 1 Number of indicators reported globally for the State of the world’s nursing 2020 report ........................ 115 Figure A2. 2 Correlation of education indicators with a multiple correspondence analysis .......................................... 117 Figure A2. 3 Correlation of working condition indicators with a multiple correspondence analysis ............................. 119 Figure A2. 4 Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 .......................................................................... 120 vi State of the world’s nursing 2020 간호에 대한 투자는 보건의료관련 지속가능한개발목표(SDG)에 기여할 뿐만 아니라, 교육(SDG 4), 젠더(SDG 5), 좋은일자리와 경제성장 (SDG 8)에도 기여할 것입니다. Tedros Ghebreyesus Director-General, WHO Elisabeth Iro Chief Nursing Officer, WHO Annette Kennedy President International Council of Nurses Sheila Tlou Co-Chair, Nursing Now Nigel Crisp Co-Chair, Nursing Now Foreword vii 서문 SDG 3 『세계 간호 현황 보고서 2020년: 간호교육, 일자리, 리더십에 대한 투자』 는 전세계적으로 보편적 건강보장에 대한 정치적 결의가 유례없이 강한 시점에서 출간되었습니다. 동시에, 우리의 응급상황 준비와 대처 능력은 현재의 COVID-19 사태와 분쟁으로 인한 대규모 인구 이동에 의해 시험받고 있습니다. 이제, 그 어느때보다도, 세계는 간호사들이 그들의 교육과 훈련의 성과를 최대한 발휘하여 일하기를 바라고 있습니다. 이 최초의 『세계 간호 현황 보고서』는 간호인력에 대해 기릴만한 것이 많이 있음을 보여주고 있습니다. 상급 간호교육에 대한 기회 확대와 정책 입안 등을 포함하여 향상된 전문적 역할은 대중 보건의 개선을 추진할 수 있습니다. 한편, 전세계적으로 계속되고 있는 간호사 분배/수급의 불균형은 우리가 반드시 다루어야 할 과제입니다. 2020년은 세계 간호사와 조산사의 해입니다. 이는 『세계 간호 현황 보고서 2020년』 이 증거한 사실을 활용하여 2030년을 향한 발전을 추진하고 지탱해 나갈 과제에 전념할 수 있는 기회인 것입니다. 이러한 목표를 위하여, 우리는 각국 정부와 모든 관련된 이해당사자들에게 다음의 행동들을 취할 것을 추구하는 바입니다. • 간호교육 (교수진, 인프라, 학생)의 획기적인 발전를 위해 투자하십시오. 그렇게 함으로써 전세계적 필요에 대처하고, 국내 수요를 충족하며, 변화하는 기술과 발전하는 건강·사회 통합 케어 모델 (models of integrated heath and social care)에 대응할 수 있을 것입니다 • 특히 중·저 소득국가들에서는, 2030년까지는 적어도 600만의 신규 간호사직을 창출하십시오. 그렇게 함으로써 예상되는 간호인력의 부족을 메꾸고, 전세계적인 간호인력의 불공평한 분배를 시정할 수 있을 것입니다. • 현재와 미래의 간호사 리더십을 강화하십시오. 그렇게 함으로써 보건 정책 형성과 의사결정에 있어서 간호사의 영향력을 보장할 수 있고 효과적인 건강·사회 통합 케어 시스템에 기여할 수 있을 것입니다 모든 나라들은 이러한 과제를 지원하는 행동을 취할 수 있습니다. 대부분의 나라들은 그러한 행동들을 국내 자원을 가지고 취할 수 있습니다. 국제사회의 도움을 필요로 하는 나라들을 위해서는, 우리는 인적자본 투자의 증가하는 분량을 건강·사회 케어 경제에 할당해야 할 것입니다. 그러한 투자는 지속가능한 발전 목표들 (SDGs)의 진전을 촉진할 것이며, 양성 평등, 여성의 경제력 향상, 청년 고용 같은 투자수익을 거둘 수 있을 것입니다. 이 기회에, 우리 다같이 간호교육· 일자리· 리더십에 투자하기로부터 시작되는 행동의 10년에 결의를 다집시다. SDG 4 SDG 5 SDG 8 viii State of the world’s nursing 2020 회장단 메세지 제 72차 세계보건총회는 2020년을 세계 간호사와 조산사의 해로 지정하였는데, 이는 나이팅게일 탄생 200주년을 기념할 뿐만 아니라 간호사와 조산사들이 전세계 인류의 건강과 복지에 매일 공헌하고 있음을 인지하기 위함입니다. COVID-19 대유행 사태로 간호사들이 전세계의 주목을 받고 있는 가운데, 세계 보건의 날에 처음으로 『세계 간호 현황 보고서』를 증정하게 된 것을 영광스럽게 생각합니다. 본 보고서는 전세계 간호인력에 대한 최신의 증거 사실과 신예의 정책 제안들을 제공하고 있습니다. 또한, 본 보고서는 간호교육·일자리·리더십에 상당히 많은 그러나 가능한 투자가 필요함을 역설하고 있는 바, 이는 지속가능한 발전 목표들 (SDGs)의 달성을 위한 간호인력의 보강을 위해서, 모든이들의 건강개선을 위해서, 그리고 우리의 목표인 보편적 건강보장으로 가기 위한 일차진료 인력의 보강을 위해서 필요한 투자인 것입니다. 『세계 간호 현황 보고서 2020년』은 각 국가 차원의 주목할만한 협조의 결과물입니다. 많은 나라들에서, 데이타 보고 작업은 각 정부내 간호사 및 조산사 출신의 부서장들에 의해 주도되었고, 이들은 교육, 노동, 재정 부처들로부터 데이타 제공 지원을 받았습니다. 간호대학 교수진과 간호관리 담당관들은 데이타를 공유하고 상호검증하였습니다. 국가 간호협회들과 Nursing Now 그룹들은 본 보고서에서 다루어 질 이슈들에 대하여 보고하고 참여하는 적극적 역할을 하였습니다. 이러한 공조관계는 간호 현황에 대한 튼실하고 정례적인 보고에 매우 중요하며, 향후 보다 보강된 보고를 용이하게 할 것입니다. 우리가 함께 이룩한 것은 인상적입니다. 그러나 우리가 아직 이룩하지 못한 것이 훨씬 더 중요합니다. 우리는 국가적 ·지역적·세계적 데이타의 출간과 세계 간호사와 조산사의 해를 계기로 삼아, 더 나은 일차진료 제공과 보편적 건강보장을 진전시키기 위한 간호인력 보강에 대하여 보다 긴밀한 대화와 협력을 증진하여야겠습니다. 우리는 간호교육·직업·리더십에 대한 투자를 촉진하고 유지해 나가야합니다. 인류의 건강을 위해서는 모든 나라들이 간호인력에 대한 지원과 투자를 하겠다는 결의가 요구됩니다. 우리는 당신이 이러한 행동의 부름에 동참하기를 희망합니다. James Campbell Director Health Workforce Department World Health Organization Howard Catton Chief Executive Officer International Council of Nurses Mary Watkins Alternate Co-Chair Nursing Now Contributors and acknowledgements ix Contributors and acknowledgements STEERING COMMITTEE Co-Chairs: Howard Catton, Mary Watkins Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WORLD HEALTH ORGANIZATION Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Administrative support: Beatrice Wamutitu, Elizabeth Tecson Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah- Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Ö zge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez CONTRIBUTORS TO EVIDENCE REVIEW Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw CONTRIBUTORS TO DATA REPORTING WHO wishes to acknowledge all National Health Workforce Accounts focal points, government chief nursing and midwifery officers, and others who contributed to the data reporting process to produce this report. African Region Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean- Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande Region of the Americas Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose- Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez South-East Asia Region Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S. Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira- Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen European Region Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus Eastern Mediterranean Region Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob Western Pacific Region Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou EDITORIAL COORDINATION, DESIGN AND PRODUCTION Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for translation, publications and print. Her Royal Highness Princess Muna of Jordan, individual nurses and partner agencies are acknowledged for their support to the photos. WHO wishes to pay a special tribute to Salome Karwah, a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth complications when refused care. JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING are acknowledged for contributing to the evidence review and data reporting processes to develop this report. Peter Johnson, Nancy Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy Roberton, Elizabeth Thompson x State of the world’s nursing 2020 Glossary The labour market is the structure that allows labour services to be sought (i.e. demand) and offered (i.e. supply). Wages and conditions of employment (for example, adequate infrastructure, supportive management, opportunities for professional development and career progression) play a role determining the choices made by health workers and employers (1). Demand refers to the jobs being offered on the market. Demand is the number of health workers that a health system can support in terms of funded positions or economic demand for services. It is correlated with the expenditure on health by the government, private insurance, and out-of-pocket payments (2). Supply. The supply of health workers refers to the pool of qualified health workers willing to work in the health care sector. It is a function of the training capacity and the net migration, deaths, and retirements of health workers (2). Need is the number of health workers required to attain the service delivery objectives of a health system. Health labour markets are primarily shaped by supply and demand and only indirectly by need (1). The absorption capacity for health care workers by the health labour market refers to the ability of the health system (which includes both the public and the private sector) to fully and productively employ the pool of available qualified health workers (mainly generated through education and immigration). The absorption capacity is influenced by the efficiency and timeliness of translating economic demand into creating and filling job openings. Pre-service education refers to a formal learning programme that takes place prior to and as a prerequisite for employment in a service setting (3). Licensing refers to the process of certifying that an individual can perform the roles and tasks within a defined scope of practice to the required standard and conferring a licence to legally authorize them to exercise a certain profession within a given jurisdiction. Accreditation refers to the process of evaluation of education institutions against predefined standards required for the delivery of education. The outcome of the process is the certification of the suitability of education programmes and of the competence of education institutions in the delivery of education. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications (4). Professional certification is the voluntary process by which an entity grants a time- limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria (5). REFERENCES FOR GLOSSARY 1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter? Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794. 2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6. 3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https:// www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty- resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020). xi Above images: © AKDN/Christopher Wilton-Steer, © WHO/ Yoshi Shimizu, © WHO/Conor Ashleigh 보고서 개요 Executive summary xii 보고서 개요 보편적 건강보장과 지속가능한 발전 목표 달성을 위한 간호사의 역할 간호사(Nurses)는 “모두가 함께 가는 세상”(Leaving no one behind)이라는 공약과 지속가능한 발전 목표(Sustainable Development Goals, SDGs)를 이행하는데 핵심적 역할을 하고 있습니다. 간호사는 국내외 의료분야에서 우선순위를 차지하는 중요한 과제들, 예를 들어 보편적 건강보장, 정신질환과 비감염성 질환 케어, 응급상황에 대한 대비와 대처, 환자의 안전, 그리고 환자 중심의 통합케어를 달성하는데 있어서 중추적 역할을 하고 있습니다. 간호인력(Nursing workforce)의 보건의료팀 내 역할을 극대화하기 위한 지속적인 노력을 하지 않으면 어떠한 건강과제도 실현될 수 없습니다. 이를 실천하기 위해서는 간호사의 업무범위와 리더십을 구축하고, 교육·기술·업무에 대한 투자 확대를 통해 영향력과 효과를 극대화할 수 있는 정책적 개입이 필요합니다. 그러한 투자는 교육, 젠더(Gender), 좋은 일자리(Decent work), 포괄적 경제성장과 관련된 SDGs 목표 달성에 기여할 것입니다. 설득력 있는 연구조사 결과를 통해 전 세계적인 간호인력의 가치와 중요성에 대해 잘 보여주는 ‘세계 간호 현황보고서 2020’(The State of the world’s nursing 2020 이하 본 보고서)은 WHO(세계보건기구)가 국제간호협의회(The International Council of Nurses, ICN)와 세계 Nursing Now 캠페인과 협력하여 작성하였으며 각국 정부와 여러 관련 단체와 기관에서 이를 지원하였습니다. © Shapecharge/Getty Images 간호는 의료분야에서 가장 많은 부분을 차지하는 직업군으로 보건의료 인력의 약 59%를 차지합니다. Executive summary xiii 2020년 간호 현황 간호인력(Nursing workforce)은 규모와 전문직 범위(Professional scope)가 계속 확대되고 있습니다. 그러나 그러한 확대가 모두에게 공평하지 않고, 증가되는 수요를 충족시키기에 충분하지 않아 아직도 혜택을 받지 못하는 지역이 존재합니다. 191개국이 본 보고서를 위한 데이터를 제공하였는데, 이는 지금까지 가장 많고 2018년 보고서에 사용된 데이터 비해 53% 증가하였습니다. 약 80%의 참여국들이 15개 혹은 그 이상의 지표에 대해 보고하였습니다. 그러나 간호교육 역량, 재정(Financing), 간호사의 급여, 보건의료 인력시장의 흐름에 관한 데이터는 상당히 부족합니다. 이로 인해 간호인력 정책 (Nursing workforce policy)과 투자를 결정하는 데 중요한 보건의료고용 시장(Health labour market) 분석에 어려움을 겪고 있습니다. 전 세계 간호인력은 2천790만 명으로, 그 중 1천930만 명은 전문직 간호사(Professional nurses)입니다. 이는 2013년부터 2018년간 총 470만 명이 증가하였으며, 간호직종이 보건의료분야에서 가장 많은 부분을 차지하는 직업군으로서 전체 보건의료 인력의 약 59%를 차지하고 있다는 것을 알 수 있습니다. 2천790만 명의 간호인력을 세분하면 전문직 간호사(Professional nurses) 1천930만 명(69%), 준 전문직 간호사(Associate professional nurses) 6백만 명(22%), 기타 분류되지 않은 간호직(Not classified either way) 2백6십만 명(9%)을 포함하고 있습니다. 현재의 간호인력은 보편적 건강보장과 SDGs 목표를 성취하기에는 아직 부족합니다. 간호사의 80% 이상이 전 세계 인구의 절반을 차지하는 국가들에서 일하고 있습니다. 2016년 6천600만 명으로 추정되었던 간호사 부족현상은 2018년 소폭 감소하여 5천900백만 명이었습니다. 이 부족한 인력 중 약 5천300만 명(89%)는 중·저 소득국가에 집중되어 있는데, 이들 국가에서 간호사의 증가는 인구증가에 간신히 보조를 맞추고 있어 인구대비 간호사 비율은 미미하게 개선될 뿐입니다. Figure 1은 인구 1만 명 당 간호인력(Nursing personnel)의 밀도의 다양함을 보여주고 있는데, 큰 격차는 아프리카의 국가들, 동남아시아 및 지중해 동부지역, 그리고 라틴아메리카의 몇몇 나라들에서 나타나고 있습니다. Figure 1 Density of nursing personnel per 10 000 population in 2018 *Includes nursing professionals and associates. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018. km not applicable not reported 10 to 19 <10 30 to 39 20 to 29 40 to 49 75 to 99 50 to 74 100+ xiv State of the world’s nursing 2020 일부 지역의 보건의료 인력(Health workforce)의 고령화로 인해 간호인력의 수급의 안정성이 흔들리고 있습니다. 세계적으로 간호인력의 연령은 상대적으로 젊은 편에 속하나, 북남미와 유럽에서 간호인력의 고령화와 더불어 지역 간 불균형이 발생하고 있습니다. 은퇴 연령에 이른 간호사(55세 이상)의 비율에 비해 경력이 짧은 간호사(35세 이하) 비율이 낮은 국가는 보건의료서비스 공급수준을 유지하기 위해 간호사 양성 및 기존 간호인력 보유방안을 강화해야 할 것입니다. 간호인력의 연령이 젊은 국가는 간호인력을 전국적으로 고르게 배치해야 할 것입니다. Figure 2에 보이는 젊은 연령대보다 정년에 가까운 연령대의 간호사 비율이 높은 국가들은(녹색 선 위쪽에 위치한 국가들) 앞으로 보건의료서비스의 공급수준을 유지하기 어려워질 것입니다. Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries) ● Each dot represents a country / Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. 18 countries at risk of an ageing workforce Percentage of nurses less than 35 years *Includes nursing professionals and nursing associate professionals. Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. P e rc e n ta g e o f n u rs e s a g e d 5 5 + y e a rs xiv State of the world’s nursing 2020 Executive summary xv 간호사 부족을 해소하려면 2030년까지 모든 국가에서 간호학과 전체 졸업생의 수를 매년 평균 8%까지 늘려야하며, 더불어 이들 졸업생들을 고용하고 계속 간호현장에서 일하게 해야 할 것입니다. 이러한 증가 없이 현 추세대로 가면 2030년에는 전체 간호사의 수가 3천600만 명이 되나, 예상 수요에 기반하여 570만 명의 간호사가 부족할 것으로 예상되며, 특히 아프리카, 동남아시아, 지중해 동부 지역에서 심할 것으로 예상됩니다. 마찬가지로, 북남미와 유럽, 태평양 서부지역 일부 국가들 또한 간호사 부족으로 인한 국가적 문제에 봉착하게 될 것입니다. Figure 3은 2030년까지, WHO 지역별 및 국민소득별 간호사의 예상 증가율을 보여줍니다. Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group EXE © *Includes nursing professionals and nursing associate professionals. 변화의 유형은 다르지만, 간호사의 공평한 분배와 보유는 거의 보편적인 난제입니다. Americas Eastern Mediterranean Africa Europe South-East Asia Western Pacific High income Low income Lower middle income Upper middle income Executive summary xv xvi State of the world’s nursing 2020 Figure 4 Average duration (years) of education for nursing professionals, by WHO region WHO REGION 2 years 3 years 4 years 5 years 0% 20% 40% 60% 80% 100% Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. 대다수 국가(참여국 157개국 중 152개국, 98%)에서 간호사 교육 기간이 최소 3년 과정(Programme)이라고 보고하였습니다. 이들 국가는 교육내용과 교육기간의 표준화(91%), 인증제도(89%), 교원자격의 표준화(77%), 전문직간 교육(Interprofessional education) (67%) 체제를 갖추고 있다고 보고했습니다. 그러나 이러한 정책과 체제가 얼마나 실효성이 있는지에 대한 검증은 아직 미흡합니다. 더 나아가 간호사에 대한 최소한의 교육(Minimum education)과 훈련수준(Training levels)에 대해서는 아직도 상당한 편차가 있으며, 아울러 교원 부족, 인프라 부족, 임상 실습 장소의 부족과 같은 문제점들이 있습니다. Figure 4는 전 세계적으로 간호교육기간이 대부분 3년에서 4년 과정임을 보여줍니다. 총 78개국(참여국 53%)에서 전문간호사 역할(Advanced practice roles nurse)이 있다고 보고하였습니다. 전문간호사(Advanced practice nurses)는 지방에서 일차보건의료에 대한 접근을 활성화하고, 도시지역의 취약집단에 대한 의료서비스를 확대하여 의료불균형 문제를 해소하는데 역할을 할 수 있을 것으로 보입니다. 모든 간호직종 종사자(Nurses at all levels)들이 직업적 역량을 최대로 발휘할 수 있도록 지원 및 보장을 받는다면 보편적 건강보장을 실현하기 위한 많은 의료서비스 중 일차보건의료(Primary health care)와 예방의학 차원의 서비스를 효과적으로 제공할 수 있을 것입니다. 간호사 8명 중 1명은 자신이 태어나거나 교육받은 나라가 아닌 외국에서 간호직을 수행하고 있습니다. Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Global Executive summary xvii 간호인력의 국제이동이 점점 증가하고 있습니다. 간호사의 국제이동 현상이 증가하면서 간호사의 분배와 이직률 증가는 어느 국가든 처한 문제입니다. 무분별한 이민으로 인해 간호사 부족은 심화되고 의료서비스 불균형 문제가 생기게 됩니다. 많은 고소득 국가들은 간호학과 졸업생의 수가 적거나, 기존 또는 신규 간호사(New graduate nurses)로 충원되어야 할 간호직을 채우지 못하기 때문에 해외유입 간호인력에 지나치게 의존하는 듯 보입니다. 많은 국가(86%)에서 간호관련 규정(Regulation of nursing)을 담당하는 기관이 존재합니다. 거의 2/3에 달하는 국가(64%)에서 간호실무에 들어가기 위한 초기 역량평가를 필수로 하고 있으며, 거의 3/4에 달하는 국가(73%)에서 간호실무를 지속하기 위해 보수교육을(Continued professional development)요구하고 있습니다. 그러나 간호교육과 실무에 대한 규정은 몇 개의 지역차원의 상호인정 조항 외에는 조정되지 않고 있는 실정입니다. 각국의 관리 당국은 매우 유동적이고 팀 기반으로 일하는 디지털 시대에 맞게 간호교육과정과 임상 실무 관련 규정을 업데이트하고, 간호인력의 등록명부(Registry)를 최신상태로 유지해야 합니다. Figure 5 는 노동환경과 근무 조건에 관한 규정을 갖춘 국가의 비율을 보여줍니다. 간호직은 아직도 여성에 치우쳐 있고, 직장내 그와 관련된 편견들이 존재하고 있습니다. 90% 가량의 간호인력이 여성으로 구성되어 있으나 간호사 또는 여성이 리더의 위치까지 오르는 경우는 드문 실정입니다. 또한 성별에 따른 임금 격차와 근무지에서 성차별 관행이 존재합니다. 대부분의 국가는 간호사의 근무시간과 근무조건, 최저임금, 사회보장과 같은 법적인 보호 조치를 취하고 있으나, 모든 지역에서 동등하게 이루어지고 있지는 않습니다. 겨우 1/3 남짓의 국가들(37%)에서 보건의료 인력에 대한 폭행을 방지하는 법적 보호 수단을 갖추고 있을 뿐입니다. 115개국 중 82개국(71%)에서 간호 관련 정책 업무를 맡고 책임지는 국가 간호정책국 관리자 직위 (National nursing leadership position)가 있습니다. 정부 차원의 간호 리더십 프로그램(Natoinal Nursing leadership program)은 78개국(참여국의 53%)에서 운영 중이었습니다. 정부 간호정책 수석직위(Chief nursing officer, CNO)와 리더십개발프로그램의 운영은 더 엄격한 간호 관련 규제 환경과 관련이 있습니다. Percentage of countries reporting yes Source: National Health Workforce Accounts, World Health Organization 2019. Regulation on working hours and conditions (133 yes out of 142) Regulation on social protection (125 yes out of 137) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Executive summary xvii Figure 5 Percentage of countries with regulatory provisions on working conditions xviii State of the world’s nursing 2020 10대 주요 과제 간호인력 정책이 나아가야 할 방향 ohn W. Poole/NPR ⓒ John W. Poole/NPR Executive summary xix 간호사 부족을 겪고 있는 국가는 최소 590만 명의 간호사를 양성하고 추가 고용하기 위해 자금을 늘려야 할 것입니다. 간호교육에 대한 추가 투자는 중·저소득 국가들의 경우 1인당 10달러 범위에 있는 것으로 추정됩니다. 이들 국가에서는 간호대학 졸업생을 고용하기 위해 추가 투자가 필요할 것입니다. 대부분의 국가에서 국내 자금으로 이 비용을 충당할 수 있을 것으로 보입니다. 국가의 임금체계를 검토하고 관리해야 하며, 몇몇 국가에서는 간호인력 수급 제한을 해제해야 합니다. 국내 자원이 중·장기적으로 제약되어 있는 국가들의 경우, 예를 들면 저소득국가와 분쟁이나 취약한 상황에 놓여 있는 국가들은, 관련 기관 차원에서 자금을 모으는 방법을 모색해야 합니다. 개발협력자와 국제금융기관은 교육, 고용, 양성 평등, 건강과 기술개발을 위한 인적자본 투자를 국가 보건의료 인력 확충전략에 이전함으로써 일차보건의료 활성화와 보편적 건강보장을 성취하는 데 도움을 줄 수 있습니다. 또한 간호인력 확충을 위한 투자는 일자리 창출, 양성 평등(Gender equity), 젊은이들의 사회참여라는 면에서도 도움이 됩니다. xx State of the world’s nursing 2020 국가는 보건의료 인력에 대한 데이터를 수집, 분석 및 활용하는 역량을 강화해야 합니다. 국가는 ‘국가 보건의료 인력 백서’ (National Health Workforce Accounts)를 구축하고 증강하여야 하며, 그 데이타를 활용하여 보건의료 인력시장을 분석하여 정책개발과 투자결정에 지침으로 삼아야 할 것입니다. 간호 관련 데이터 수집분석에는 정부 부처들의 참여와 주요 이해당사자인 규정 위원회, 간호교육기관, 진료기관, 전문 협회들의 참여가 요구됩니다. 간호사의 해외 이주와 이동을 효과적으로 모니터링해야 하며 책임있고 윤리적으로 관리해야 합니다. 국가, 채용담당자, 국제적 이해당사자들은 WHO가 제정한 국제 보건의료 인력 채용에 관한 업무의 글로벌 규정(Global Code of Practice on the International Recruitment of Health Personnel)을 준수해야 합니다. 규제 기관, 보건의료 인력 정보시스템, 고용주, 정부 부처, 그리고 이해 당사자간의 파트너십과 협력을 통하여 간호사의 국제이동을 모니터링하고, 관리하고 규제하는 능력을 제고할 수 있습니다. 이주 간호사(Migrant nurses)에 지나치게 의존해오던 국가는 자국의 간호사 양성에 투자하여 자급할 수 있도록 해야 합니다. 간호사들의 해외 이주로 간호인력 부족이 심각한 국가는 임금인상(그리고 동등임금)과 근무조건 개선, 전문직 발전의 기회(Professional development opportunities)의 창출, 그들의 교육과 훈련의 성과를 최대로 발휘하도록 하는 등의 완화 조치 (Mitigating measures)와 보유/이직률 감소 방안 (Retention packeages)을 모색해야 할 것입니다. 간호리더십과 거버넌스는 간호인력 강화를 위해 매우 중요합니다. 간호인력 강화와 의료정책을 결정하는 간호정책수석(CNO)의 위상을 강화해야 합니다. 간호정책수석은 간호 관련 자료 수집을 강화하고 간호인력 분야에 대해 근거에 기초한 투자를 결정하는 정책에 관한 논의를 끌어내야 하는데 최선을 다해야 합니다. 간호사 리더십 프로그램을 구성해야 하고 젊은 간호사들이 참여하도록 해야 합니다. 취약하거나 분쟁에 휘말린 국가는 특히 간호의 제도적 기초를 마련하고 간호인력 양성과 관리에 특히 집중해야 합니다. 간호사 교육(Nurse education)과 훈련 프로그램(Trainig programmes)은 일차보건의료와 보편적 건강보장을 주도하는 간호사를 양성해야 합니다. 간호대학 교원양성, 임상실습장소 확보, 타 전공 학생들을 유치할만한 교육과정을 개발하는 데 투자해야 합니다. 간호(Nursing)는 과학과 기술, 팀워크 그리고 인류 공통의 건강 평등권을 바탕으로 발전해야 하는 직종입니다. 간호정책수석(CNO)과 그 외 정부 관계자는 졸업자에 대한 국가 건강 시스템의 수요를 충족하기 위해 간호사를 위한 적합한 입문 및 전문과정 개설에 대한 국가적 논의를 끌어낼 수 있습니다. 교육과정은 새로이 발생하는 국제문제에 대처할 뿐 아니라 국내 의료 관련 우선 과제를 해결하는 데 있어 간호사들이 여러 의료직종으로 구성된 팀 안에서 효과적으로 일할 수 있게 준비시키며 발전하는 의료기술 속도에 맞춰 경쟁력을 갖춰나가도록 구성되어야 합니다. 2 3 5 xxⅰ State of the world’s nursing 2020 정책 입안자와 규제 당국은 간호 실무(Nursing practice)가 기여하는 바를 최대화해야 합니다. 이를 위해 일차보건의료팀에서 일하는 간호사들이 그들의 직무범위의 최대 한도까지 일할 수 있도록 보장해주어야 합니다. 간호사 주도 케어 모델(Nurse-led models of care)은 비전염성 질환(만성질환)의 케어와 의료 사회복지의 통합에 대해 점점 높아지는 요구와 관련된 국민의 건강요구를 적절히 충족시키고 일차보건의료의 접근성 향상을 위해 확대되어야 합니다. 근무환경에 대한 정책으로 간호사의 이직률에 영향을 미치는 문제들을 반드시 해결하도록 해야 합니다. 즉 간호사 주도 케어 모델을 실행하기 위해 필요한 지원, 전문간호사제, 디지털 의료기술 발전으로 인해 생기는 여러 기회의 활용, 간호인력 고령화를 고려해서 정책을 세우도록 해야 합니다. 정책입안자와 고용주, 규제 당국은 좋은 일자리를 만들어나가기 위해 서로 협동해야 합니다. 국가는 간호사가 기꺼이 일하고자 하는 환경을 만들어야 하며, 이직률을 낮추고, 인력을 적절하게 배치하고, 간호인력을 양성해야 합니다. 의료팀의 구성과 근무환경, 직업 관련 안전을 최우선으로 보장해야 하며, 특히 취약하고 분쟁에 휘말린 지역에서 일하는 간호사에게 임금을 지급할 수 있도록 노력해야 합니다. 임금은 공정하게 지급해야 하며 간호사 이직률을 감소시키고, 새로운 인력을 모이게 하고, 일할 동기를 부여할 만큼 적절한 수준이어야 합니다. 또한 각국 정부는 직장 내 성희롱, 폭력과 차별행위를 근절하기 위한 정책 수립을 최우선시해야 합니다. 정부는 성인지적(Gender-sensitive) 간호인력 정책을 입안해야 합니다. 동등하고 평등한 임금체계를 수립해야 하며 공공 의료기관뿐만 아니라 민영 의료기관에도 존재하는 성별 임금 격차문제를 해결하는 정책과 관련 규제를 마련하도록 해야 합니다. 간호교육, 간호직무수행, 관련 규제, 간호사리더십에 관한 정책을 수립하는 데 있어서, 여전히 간호인력 대다수가 여성인 점을 또한 염두에 두면서 성 평등을 지향하는 방향으로 나아가야 합니다 (Figure 6). 간호 관련 성 평등 정책은 여성을 위한 근무환경 개선, 예를 들면 여성간호사의 근무시간을 유연하게 조절할 수 있도록 해야 하며, 간호 분야에서 일하는 여성에게도 리더십 개발 기회가 주어져야 합니다. Figure 6 Percentage of female and male nursing personnel, by WHO region Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018. 6 7 8 Americas Eastern Mediterranean Africa Europe South-East Asia Western Pacific WHO REGION Females Males 근무환경을 개선하는 정책은 간호사의 이직률을 낮추기 위한 우선 과제를 해결하는 방향으로 세워야 합니다. 간호사 주도 케어 모델을 지원하고 전문간호 역할에 필요한 지원이 필요합니다. 간호 관련 규정은 시대에 맞게 개정되어야 합니다. 간호교육과정을 균형 있게 개정하고 자격조건을 부여하여 자격증을 취득하려면 그에 상응하는 교육을 이수하도록 해야 합니다. 이와 더불어 간호교육과정 이수 여부와 취득한 자격증을 확인할 수 있는 호환 시스템을 개발하여 관계 당국이 신속하고 용이하게 확인할 수 있도록 해야 합니다. 간호직무의 범위를 설정하고, 최초 역량평가 제도와 지속적인 전문직 개발을 위한 교육 이수를 의무화하는 일련의 규제방침을 세워, 역동적으로 협력하는 의료팀 내에서 간호사가 본연의 업무를 수행할 수 있도록 해야 합니다. 협력이 가장 중요한 요소입니다. 간호정책수석과 보건복지부처가 대화와 협력을 이끌어야 하며, 그 외 관련 부처(교육, 이민, 재정, 노동관련 부처)와 공공과 민영부문 관계자의 협의를 도출해야 합니다. 중요한 점은 정부의 공공정책 검증을 강화하여 민영 의료분야에 투자를 늘리고, 간호교육 역량을 강화하며, 의료서비스 지원에 있어 간호사의 역할을 확대하는 등 공공정책 목표를 성취하는 것입니다. 간호협회, 교육기관, 교수진, 관련 당국, 간호노동조합, 간호학과 학생, 풀뿌리 시민단체, Nursing Now와 같은 국제적 캠페인 등은 공공 보건 우선 과제를 해결하기 위해 노력하는 의료진 내 간호사의 역할을 확대하는데 공헌할 수 있습니다. © Yoshinobu Oka via Sasakawa Health Foundation 9 10 결론 교육, 일자리, 리더십에 대한 투자 본 보고서는 간호인력에 대한 신뢰성 있는 자료를 수집하여 현 상황에 대해 분석하고 있습니다. 정책 수립을 위한 대화의 필요성을 지지하고 간호 분야에 대한 투자를 확대하여 일차보건의료를 활성화하고, 보편적 건강보장을 성취하여 SDGs 목표를 향해 한 걸음씩 나아가도록 하려는 것이 본 보고서의 목적입니다. 본 보고서는 간호 분야에 개선되고 발전하는 부분을 확인했음에도 불구하고 우려되는 부분을 또한 강조했습니다. 아프리카대륙과 동남아시아지역, 지중해 동부지역 저중소득 국가들은 벌어진 격차를 줄이기 위해 더 큰 노력을 기울여야 할 것입니다. 그러나 중상위 소득 국가들 또한 성취감에 취해 안이하게 생각해서는 안 됩니다. 이들 국가는 간호인력 수급 부족 현상에 시달리고 있으며 기존 간호인력의 고령화가 진행되어 해외 간호인력에 지나치게 의존하여 필요한 간호인력을 충당하기 어려운 상태에 이르고 있기 때문입니다. 각국 정부는 관계부처와 국제파트너의 지원으로 다음과 같은 노력을 기울여야 합니다: 간호 리더십, 경영관리 역량을 향상해 관련 교육 분야, 보건, 고용 창출, 성 평등 과제를 해결하도록 노력해야 합니다; 간호교육, 좋은 일자리 창출, 공정한 임금, 인력배치, 업무수행, 생산성, 규제, 인력 유지를 위해 필요한 정책을 채택하여 간호 분야에 대한 투자수익을 극대화해야 합니다; 간호교육 분야와 기술, 고용 창출에 적극적으로 투자해야 합니다 필요한 투자를 하려는 재정자원이 필요할 것입니다. 이와 같은 노력이 성공한다면 사회경제적 관점에서 수십억 인구의 건강증진, 수백만의 자격을 갖춘 고용의 기회, 특히 여성과 젊은이들의 고용 창출, 세계보건향상 등의 막대한 이익이 발생할 것입니다. 간호교육 분야와 고용 창출, 지도자양성에 대한 투자는 명백히 필요합니다. 관련 이해당사자들은 이제 행동에 나서야 합니다. © St Thomas’ Hospital, London 서론 1. 간호인력은 전문직 간호사(Nursing professional)와 간호보조인력(Nursing associates)을 포함하며, 단일 의료직종 중 가장 큰 부분을 차지하며 모든 사람들의 건강(Health for all)을 위해 일하는 전문직간 의료팀(Interprofessional health teams)의 핵심요소라고 볼 수 있습니다. 2. 간호사의 전문간호사(Advanced practitioners), 임상가(Clinicians), 지도자, 정책가, 연구자, 과학자, 교수로서의 책임과 역할은 의료전문가의 교육과 실천의 효과적인 기능에 중추적인 역할을 합니다. 인류건강과 안녕의 향상은 간호직의 근면함, 혁신적 사고, 영감 등을 통해 실현되었고, 앞으로도 중요한 역할을 하게 될 것입니다. 3. 간호사라는 직업은 수백 년 동안 존재했고 200년 전 현대적 의미의 간호사 개념을 정립한 플로렌스 나이팅게일이 활동한 이후 더욱 진화했습니다. 1800년대 간호교육이 조직화하고, 임상 기준(clinical standards)이 세워지며 간호사협회가 생기는 등 근무 조건이 개선되고 간호직의 질적 수준이 높아지고 경쟁력이 생기기 시작되었습니다. 1900년대에 간호직이 전문화되었으며 자율성도 생기게 되었으며 이에 따른 공적 책임과 국민 안전을 위해 더욱 강력한 법적 규제가 생겨났습니다(1). 1899년에 설립된 건강관리전문가를 위한 최초의 국제기구는 국제간호협의회(The International Council of Nurse, ICN)였습니다. 현재 121년 역사의 국제간호협의회는 130개국 이상 간호사 협회의 연합으로 전 세계 2천만 명의 간호사를 대표합니다. 4. 세게보건기구(WHO)는 창립 첫 해부터 간호사와 조산사의 엄청난 가치와 공헌을 인지했습니다(3). 수년동안 간호사와 조산사는 천연두 퇴치, 전염병과 싸움, 산모와 신생아, 아동 사망률의 급격한 감소 등, 국제적으로 중요한 보건 문제 해결에 기여했습니다(4, 5). CHAPTER 이들의 두드러진 역할은 세계보건기구가 70년 이상 10개 결의안을 채택하여 광범위한 인력개발 우선순위의 일환으로 간호사와 조산사를 교육, 고용 및 유지하도록 장려한 국제표준채택을 촉진하였습니다(3,6) 5. 세계 간호 현황 보고서 2020은 WHO가 국제간호협의회, 국제 Nursing Now 캠페인과 협력하여 작성하였으며 간호 관련 정책 수립을 위해 필요한 비전과 미래지향적 계획을 세우기 위한 바탕으로 현 상황을 살펴보고자 합니다. 세계보건총회가 2020년을 세계 간호사과 조산사의 해로 정한 것을 기념하여(7) 작성된 본 보고서는 지난 10년간 국가별, 지역별, 세계적으로 SDGs 목표를 성취하기 위하는 과정에서 간호 관련 활동과 현황에 관해 서술하고자 합니다. 6. 본 보고서는 전세계 간호 현황에 대해 최신 데이터를 포괄적으로 수집하였습니다. 주요 이슈와 당면과제, 건강증진에 있어 간호사의 역할과 관련된 데이터를 포함합니다. 그리고 보건의료 인력 강화와 일차보건의료 활성화, 의료체계 발전과 관련하여 간호사의 위상을 증진하는 정책들을 제시하고자 합니다. 7. WHO 웹사이트에서 국가별 간호 현황과 관련된 데이터를 열람할 수 있습니다. 2 http://apps.who.int/nhwaportal. © WHO/NOOR/Sebastian Liste Introduction 3 각 챕터 별 주제 CHAPTER 2 건강 우선순위와 보건의료 인력에서의 간호 제2장은 2030 지속가능한 개발 안건(2030 Agenda for Sustainable Development) 중 특히 SDG 3 (건강과 안녕)를 위한 보건의료 인력의 기여에 관해 기술하고 있습니다(8). CHAPTER 3 21세기 보건의료 체계에서 간호의 역할 제3장에서는 보편적 건강보장을 성취하고 응급 의료문제를 해결하며 모두의 건강과 안녕을 향상시키기 위해 WHO가 제시한 ‘30억’(Triple billion) 목표 달성과 관련한 건강 우선순위 과제를 수행하는 데 있어 간호사의 역할과 기여에 대해 간략히 소개하고 있습니다(9). CHAPTER 4 간호인력 관련 정책 제4장에서는 의료기관과 지역사회에서 자신의 잠재력을 최대한 발휘하여 일하는 간호사의 도전을 위한 국내 및 세계 보건의료 인력시장 확대, 인력 정책 강화와 거버넌스 결정 요인을 설명하고 있습니다. CHAPTER 5 간호인력 현황 제5장에서는 국가, 지역 및 글로벌 정책 개발과 밀접한 영역으로 간호인력 보유량, 구성, 배치(즉 간호인력 양성 능력, 간호교육, 관련 규정, 간호실무, 간호정책, 관리환경, 리더십과 보건의료 인력시장 관련 요인)에 관한 간호인력 현황을 개괄적으로 분석하여 제공합니다. 또한 2030년까지 약 1천800만 명의 보건의료 인력 부족이 예상되는 문제를 해결하기 위한 과정과 도전을 제시하고 있습니다. CHAPTER 6 간호인력 정책이 나아가야 할 방향 제6장은 간호인력 정책이 나아가야 할 방향과 회원국, 교육기관, 규제 기관, 간호협회, 개발 협력파트너, 국제조직과 그 외 이해관계자를 향한 행동 요청에 대해 개략적으로 설명하고 있습니다. 4 State of the world’s nursing 2020 Nursing in a context of broader workforce and health priorities 5 건강 우선순위와 보건의료 인력에서의 간호 2.1 2030 목표를 달성하기 위한 보건 인력의 역할 8. 2015년 UN은 지속가능한 발전목표(SDGs)라는 명제를 내걸고 2030년까지 17개의 목표를 인류애와 지구를 보호하는데 매우 중요한 영역에서 설정했습니다(8). SDGs에는 빈곤퇴치(SDG 1), 만인의 건강과 안녕달성(건강한 삶 확보)(SDG 3), 포괄적이고 평등한 교육보장(모두에게 평생 교육의 기회 증진)(SDG 4), 양성평등 달성(SDG 5), 양질의 일자리 창출과 포용적이고 지속가능한 경제성장(SDG 8) 등이 포함됩니다. 9. WHO는 보편적 건강보장에 근거를 둔 SDG 3 목표를 성취하기 위해 전 세계 의료 관련 기관과 의료진을 선도합니다. 보편적 건강보장을 이룩하는 것은 모든 UN 회원국이 만장일치로 고위급 회의에서 제안한 보편적 건강보장에 대한 정책선언(10)과 국제의회 연합의 결의문(11)에서 명시적으로 표현하고 있습니다. 10. 일차보건의료는 보편적 건강보장을 실현하기 위한 초석이라고 볼 수 있습니다. 세계지도자들은 1978년 일차 보건의료에 관해 보장한 알마-아타 결의(Alma-Ata Declaration)를 제정한 기념으로 카자흐스탄 아스타나에서 일차 보건의료 보장에 관한 의지를 재천명했습니다(Astana Declaration3). (12) WHO는 13차 총회에서 수립한 전략계획에서 ‘30억(triple billion)’이라는 제명 하에 SDG와 일차 보건의료를 중요하게 다루었습니다. “30억”이라는 목표는 다음과 같습니다: 보편적 건강보장의 혜택을 받는 인구 10억과 건강과 관련된 위급상황에서 더욱 나은 보호를 받는 인구 10억, 더 나은 건강과 안녕을 누리는 인구 10억을 뜻합니다(9). 11. 2019년 보편적 건강보장의 실현 여정의 일차보건 의료(Primary health care on the road to universal health coverage)라는 제목하에 WHO가 발행한 보고서에 의하면 보편적 건강보장을 법적 의무로 명시하는 국가의 수가 늘어나면서 건강보장의 범위가 괄목할만하게 확장되었다고 보고하고 있습니다(13). 그러나 이러한 발전상황은 불균형하게 이루어지고 있어, 대부분의 취약계층은 의료보장을 위한 재정적 지원을 받지 못하고 있는 상황입니다. 부실한 의료체계와 사회경제적 요인들이 장애물이 되고 있습니다. CHAPTER 6 State of the world’s nursing 2020 . 어떤 분야에 먼저 투자해야 할 것인지 밝히기 위해 좀 더 확실한 데이터와 증거를 수집해야 합니다. 경직된 의료체계를 무너뜨리고 신속하고 접근 가능한, 조응(照應)하는 의료체계를 구축할 기회가 있습니다. 12. WHO는 2030년까지 SDG 3 목표를 성취하려면 3.9조 달러가 필요하다고 추산합니다. 12년 이상의 기간동안 이 투자금의 40% 이상은 2030년까지 보건의료 인력 부족분 1천800만 명을 충당하는데 소요되는 보수, 월급 등의 경비로 사용될 것입니다. 또한 보건의료 인력의 교육과 직업훈련 요구에 필요한 추가적인 투자금을 포함한 추산은 건강과 관련한 투자의 평균 50% 이상이 보건 의료인력 양성과 임금 지급, 인력 유지에 쓰일 것이라고 예상됩니다. 13. 보건의료 인력은 그 비용을 절감해야 한다는 오랫동안 존재했던 잘못된 관념과 달리(17, 18), 2016년 보건의료 인력 채용과 경제발전에 관한 유엔 고위급회담(이하 ‘유엔회담’)에서 발행한 보고서에 의하면 건강관련 직업과 채용은 경제발전을 촉진하고 다른 분야의 생산성을 증진한다는 결과가 발표되었습니다(17, 18). 의료체계와 보건의료 인력 확충에 투자하는 것은, 특히 여성 인력을 고용하여 여권신장에도 기여하게 되고(SDG 5) 젊은 연령층의 경제력이 발전함으로써 궁극적으로 경제발전(SDG 8)에 도움이 됩니다(19, 20). 전 세계적으로 사회복지, 보건의료 인력(Social and health care workforce)에 여성이 차지하는 비율은 70%에 이르며(21), 이들 여성의 거의 90%가 간호사와 조산사로 활동하고 있습니다(22.23). 14. 유엔회담은 보건분야와 사회복지 분야에 대한 투자의 필요성에 대한 이유를 설명합니다. 즉 교육투자를 확대하면 보건의료 인력의 지속적인 공급이 가능하게 되며, 보다 나은 의료서비스를 제공하기 위한 기술적 역량을 갖춘 보건의료 인력을 양성할 수 있습니다. 또한 앞으로 부족한 보건의료 인력 1천800만 명을 충당하기에 충분한 인력을 확보할 수 있게 됩니다. 15. 2017년 유엔회담의 권고안을 실행하기 위해 WHO 회원국은 Working for Health programme, 다자 협력 신탁기금 (Multi-Partner Trust Fund), 국제노동기구(ILO), 경제협력개발기구(OECD)와 협력하여 5개년 계획을 수립하였습니다(15, 17). WHO는 권고안을 실행하는 데 있어 세계 보건의료 인적자원 활용 전략 2030 (Global Strategy on Human Resources for Health: Workforce 2030) (Figure 2.1)에 제시된 보건의료 인력 강화 방법과 같은 방식으로 진행하고 있습니다(16). 16. 보편적 건강보장의 실현과 SDG 3 목표를 성취하기 위해서는 보건의료 인력 분야에 투자를 강화해야 합니다. 이를 위해서는 공급, 수요 및 요구에 대한 통합적인 이해와 정량화하여 보건의료 인력시장을 분석하는 데 사용해야 합니다. 이를 통해 통합적인 보건의료 인력 전략과 계획을 수립할 수 있습니다. 17. 간호인력은 직무를 수행하는데 필요한 적정수준의 인원, 적절한 인력배치와 인원 수준 유지, 양질의 교육, 효과적인 규제, 근무환경, 보편적 건강을 보장하는 보건의료 인력의 효율성 등과 같은 모든 의료 관련 직종이 공통으로 겪는 어려움에 직면하고 있습니다(24-26). 그러나 간호직에 관련된 특정한 어려움, 즉 성 편견(Gender bias), 간호 관련 정책 수립에 있어 리더십의 부재, 규제와 관리, 다양한 수준의 간호교육과 직무수행에 대한 문제가 있습니다(25). 이러한 문제를 확실히 이해하고 우선순위를 정하는 것은 간호 관련 정책 수립을 용이하게 하고 어떤 부분에 투자할 것인가를 결정하는 데 도움이 됩니다. Nursing in a context of broader workforce and health priorities 7 Figure 2. 1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing Key areas for nursing include maximizing the contributions of nurses via an optimized scope of practice and nurses’ roles in providing preventive and primary care. Key areas for nursing include positively managing nurse migration, ensuring the quality of nursing education, and investing in the retention of nurses in rural, remote, or otherwise underserved communities. Key areas for nursing include engaging nursing leaders in health policy-making and the development of nursing leadership. Key areas for nursing include having an accurate count or “stock” of the nursing workforce and understanding the requisite information with which to conduct a health labour market analysis. Data for monitoring and accountability requires the engagement not just of government ministries, but also nursing and intersectoral stakeholders. Optimize the performance, quality, productivity, effectiveness, skill mix, retention, address inefficiencies, maldistribution for equity, universal health coverage. Catalyse investment in human resources for health aligned to address population health needs, account for health labour market dynamics, education policies, shortages and maldistribution. Build the capacity of institutions for effective public policy stewardship, leadership, and governance on human resources for health. Strengthen data for human resources for health monitoring and accountability. 2.2 간호사는 어떤 직업입니까? 18. 본 보고서는 가장 최신의 신뢰할만한 데이터를 활용하여 전 세계 간호인력 현황을 분석 보고하는 것을 목적으로 작성되었습니다. 이를 위해 먼저 “간호사”직업에 대한 개념을 확실히 해야 할 필요가 있습니다. 3장과 4장에서 그동안 발표되었던 연구 결과를 바탕으로 근거를 통합하여 넓은 의미의 간호개념을 제시하였습니다. 5장에서는 이 보고서에서 사용한 데이터와 분석방법에 대해 실었습니다. 2008년 국제표준 직업군 분류(ISCO-08)에 의하면 간호사라는 용어는 특히 2개의 직업군, 전문직 간호사(ISCO code 2221, Professional nurse)와 준 전문직 간호사(ISCO code 3221, Nursing associate professional)를 일컫는 데 사용됩니다. 19. 이들 2개의 직업군과 관련된 데이터를 수집하였으며 다른 직업군(예를 들어 조산사와 간호조무사, 그 외 의료보조직 등) 은 여기에서 제외했습니다. 몇몇 국가에서는 하이브리드교육과정을 마친 의료직 종사자를 “간호사-조산사(Nurse-midwives)”로 분류하기도 합니다. “간호사-조산사”는 국제표준직업군으로 분류되어있지 않기 때문에, 전문직 간호사 및 준 전문직 간호사를 직업군으로 분류한 국가의 데이터만 취합했습니다. 직업군에 대한 정의와 각국 간호인력에 관한 데이터 수집이 이루어진 방식에 대한 보다 자세한 내용은 5장과 부록(Annex 1)에 수록되어 있습니다. © AKDN/Christopher Wilton-Steer Nursing in a context of broader workforce and health priorities 9 20. 간호(Nursing)에 대한 정의는 다음과 같이 내릴 수 있습니다. 가족과 단체, 지역사회에 속한 모든 연령층의 질병이 있거나 건강한 개인을 모든 세팅에서 자율적이며 동시에 협력적으로 케어하는 행위입니다. 간호는 건강증진과 질병 예방, 질병의 치료, 장애인 케어 서비스, 호스피스(완화의료) 행위를 모두 포함합니다(7, 27). 간호의 또 다른 중요한 역할은 의료정책 수립과 교육, 연구에 참여하여 안전한 환경을 조성하고, 환자 관리와 원활한 의료서비스 개선에 이바지하는 것입니다(27, 28). 간호사는 3차 의료기관에서부터 도서지역 보건소에 이르는 모든 보건의료현장에서 광범위한 건강서비스를 제공합니다. “간호사”라는 직업은 직무를 수행하는 데 있어 법적, 교육적, 행정적 요건을 충족하는 자를 의미합니다. 21. 간호사라는 이름으로 직무를 수행하는데 요구되는 교육과정은 다양한 형태로 존재합니다. 입문 간호교육프로그램(Entry level nursing programme)을 마친 후에는 상위과정(Higher education)을 거쳐 전문자격(Specialist qualifications)을 취득할 수 있으며, 이후 직함과 역할에 차이가 발생합니다. 한 국가 내에서도 간호직명과 업무는 세분화될 수 있습니다. 간호사 면허국 협의회(NCSB)에서 발생한 세계간호면허관련 규정지도에 따르면 전문간호사면허를 포함하여 면허시험을 필요로 하는 간호관련자격(혹은 면허)이 전 세계에 최소한 144개 이상 존재합니다. 이는 동남아시아 지역의 10개 직함(Titles)과 미주와 유럽지역의 30개 이상의 세분화된 간호사 유형이 해당합니다. 22. 간호사의 역할은 국가마다 다를 수 있습니다. 세계 공공보건이라는 목적을 성취하기 위해 간호사의 직업을 정의하고, 역할 범위를 규정하여 간호사의 역량을 최대화하기 위해서는 국제 표준 정의를 내리는 것이 매우 중요합니다. Figure 2. 2 Number of distinct nursing titles within each WHO region WHO region Note: Numbers indicate nursing titles requiring an examination in each country, grouped by region. Source: NCSBN Global Regulatory Atlas (29). Americas Africa South-East Asia Europe Eastern Mediterranean Western Pacific N u m b e r o f d is ti n c t ti tl e s i n c o u n tr ie s i n e a c h W H O r e g io n 10 State of the world’s nursing 2020 © WHO/Atul Loke Nursing roles in 21st-century health systems 11 21세기 보건의료 체계에서 간호의 역할 23. 제3장에서는 SDG 3 목표, 보다 구체적으로는 WHO가 제정한 “건강하고 안전한 세상. 약한 사람이 보호받는 세상” 캠페인과 일반계획(General Programme of Work)의 ‘30억’ 프로젝트에 기반한 목표를 성취하기 위해 간호사의 역할과 책임에 관한 최신 데이터를 수록하였습니다. (자세한 사항은 본 보고서의 부록 온라인 버전에서 확인할 수 있습니다) 3.1 보편적 건강보장을 성취하기 위한 간호사의 역할 24. 코크란 리뷰(Cochrane review)에 따르면, 간호사는 환자의 상태에 따른 임상 결정뿐 아니라 건강 증진 교육과 질병 예방 활동에 이르는 광범위한 의료활동을 통해 일차보건의료를 활성화하는 데 지대한 역할을 하는 것으로 평가되었습니다(30). 특정 조건과 적절한 의료환경에서 간호사 주도 일차보건의료 서비스는 환자 치료와 만족도 면에서 기존의 의료현장과 비슷하거나 오히려 나은 수준의 결과를 이루어내는 것으로 나타났는데, 이는 아마도 간호사가 환자 면담에 더 많은 시간을 할애하고 있기 때문으로 보입니다(30). 또 다른 코크란 리뷰에서 간호사가 HIV 치료와 추적관찰에 효과적으로 대응하며(31), 금연 클리닉에서 간호사의 중재로 인해 금연율이 높아지는 것으로 보고되었습니다(32). 일반 간호사를 포함한 비 전문 보건의료 인력(Non- specialist health workers)이 일반적인 우울증과 산전 후 우울증, 외상 후 스트레스 증후군(Post-traumatic stress disorder), 알코올중독, 치매 환자 케어 결과가 더 좋은 것으로 나타났습니다(33). 캠벨리뷰(Campbell systematic review)에 의하면 성폭력 검사 전담 간호사 혹은 법의학 간호사는 성폭력 검사를 효과적으로 진행하고 있으며, 이들 간호사가 성병 검사와 원치 않는 임신 예방 조치에도 대응할 수 있을 것으로 보고했습니다. 이로 인해 또한 의료비용 절감의 효과를 볼 수 있다고 합니다(34). CHAPTER 12 State of the world’s nursing 2020 25. 간호사는 의료 서비스의 질적 수준을 높이고 환자의 안전을 보장하며 감염을 예방 및 통제를 합니다. 또한 의료현장에서 흔히 발생하는 항생제내성균의 확산을 막는데도 크게 기여하고 있습니다(35). 이는 환자의 상태가 악화하는지 계속 모니터링하고, 오류나 근접오류(Error and Near misses)를 찾아내거나 예방하고(36), 감염의 확산을 막는 예방조치와 이에 관한 멘토링(37), 식수와 위생관리에 이르는 다방면의 활약에 의해 이루어집니다(38). COVID-19 같은 감염병 확산을 저지하기 위해 손씻기, 사회적 거리 두기, 살균이 아주 중요한 상황에 감염 예방과 관리에서 간호사는 핵심적 역할을 합니다(Box 3.1). 26. 과거부터 현재까지 감염성 질병의 예방과 치료, 관리, 통제에 대한 간호사의 역사적 공헌도 관련 문헌에 매우 잘 기록 되어있습니다(4, 49). 예를 들어, 간호사 주도 케어 (Nurse-led interventions) 방식으로 백신 접종률을 크게 높일 수 있습니다(50). 간호사는 전 세계적으로 결핵예방과 치료에 적극적으로 관여해왔으며 임상적 임무뿐 아니라 건강증진과 정신보건과 같은 비임상적 임무도 수행합니다(51-54). 또한 HIV 예방을 위한 자발적 포경수술(VMMC)운동(55, 61), HIV 예방계획의 수립과 실행에도 역시 깊이 관여해 왔습니다(62). 간호사는 또한 소외된 열대성 질환 치료와 예방에도 효과적으로 관여할 수 있습니다. 이를 위해 지역사회 교육, 예방 차원에서 항생제와 같은 의약품 처방, 진료와 진단, 질병의 확산 정도 추정, 지역 의료기관에서 질병이 의심되어 이관된 환자의 진단, 스크리닝, 약품 관리, 트라코마(Chlamydia tramomatis에 의한 만성적인 각결막염)와 같은 특정 질환에 연관된 외과적 처치, 림프 부종을 관리하는 법과 같은 자가치료법 등을 교육하는 등 간호사의 역할 범위는 매우 광범위합니다(63). 또한 아프리카 전역의 여러 환경에서 간호사는 지역사회 보건의료 인력의 훈련, 멘토링 및 감독을 통해 전염성 질병관리의 질 향상에 기여합니다(63-65). Box 3. 1 환자의 생명을 보호하는 간호사 해마다 저∙중소득 국가에서 8백만 명 이상이 질적으로 낮은 수준의 의료서비스로 인해 사망합니다(39). 간호사는 의료서비스의 질적 수준을 높이고 위해사건(adverse events)을 예방하여 환자의 생명을 보호하는 데 기여할 수 있습니다. 이를 위해 의료현장에서 간호사가 역량을 최대한 발휘하도록 경쟁력 있는 의료진을 구성하고 근무환경을 개선해야 합니다. 간호사는 환자의 생명을 보호하는 중요한 역할을 맡고 있습니다. 이를 위해 환자의 상태를 지속해서 모니터링하고, 오류나 근접오류(Error and Near misses)를 찾아내거나 예방하고, 치료과정을 정확히 이해하고 보완해야 할 점을 파악하고 있어야 하는 등 환자에게 높은 수준의 의료서비스를 제공하기 위한 노력을 해야 합니다(36). 의사나 간호사는 많은 노동량과 오랜 근무시간으로 인해 흔히 번아웃 증후군(Burnout)을 겪게 되고, 각 직종 간 소통 부재로 인해 환자의 생명을 위협하는 경우가 발생하기도 합니다(40). 반면 좋은 근무환경, 간호사의 안전확보, 의료진 교육을 통해 환자의 재원기간을 줄일 수 있으며, 오랜 입원으로 인해 발생할 수 있는 폐렴, 위염, 상부위장관 출혈, 욕창, 도뇨관 삽입으로 인한 요로감염, 환자사망률을 줄일 수 있습니다(41-48) Nursing roles in 21st-century health systems 13 27. 간호사는 국민건강 증진과 보건교육과 비전염성 질환(NCDs) 관리에도 중요한 역할을 담당하고 있습니다(66-72). 정확한 지식을 갖추고, 기술력을 키움과 동시에 균등한 기회와 재정적 지원을 받는다면 간호사는 본연의 임무와 더불어 관리자이자 대변자, 건강 관련 지식 전파자로서 국민의 평생 건강을 책임지게 될 것입니다(73). 간호사는 NCD 관리와 관련된 넓은 범주의 임무, 예를 들면 고혈압, 심혈관질환, 당뇨병, 정신건강, 신경학적 질환, 호흡기질환, 암과 관련된 질환의 스크리닝과 일차보건의료서비스를 제공하여 NCDs 환자의 케어와 예방에 효과적으로 대응해오고 있습니다(66-72). 이러한 노력으로 인해 혈압강하, 우울 지수 감소 등 환자의 건강 증진에 큰 영향을 미치고 있으며, 또한 심혈관질환, 당뇨병 치료에도 중요한 역할을 하고 있습니다(30.70). 간호사들은 환자의 행동 변화를 끌어내 필요한 약을 먹게 하도록 하기도 하고, 진료 약속에 맞춰 내원하도록 하게 할 수도 있습니다(30, 70). 적절한 방향과 실무범위에 의해 간호사의 역할을 확대한다면, NCDs 케어를 일차보건의료에 포함할 수 있을 것입니다. 의사가 부족한 상황에서 확대된 간호사의 역할은 잠재적으로 부합하는 다양한 세팅에서 건강형평성을 향상시킬 수 있는 가능성이 있습니다(73,76). . © WHO/Tania Habjouqa 14 State of the world’s nursing 2020 28. 간호사는 평생 보건에 기여합니다. 간호사는 조산사, 산부인과의, 각 과 전문의와 협력하여 산전 후, 분만까지 산모를 케어합니다(77). 신생아 간호의 경험과 기술을 갖춘 간호사는 다른 신생아 전문의료진과 협력하여 분만과정을 지원하고 입원 산모를 케어합니다. 대부분의 국가에서 간호사는 아동과 청소년을 위한 학교 간호 서비스의 중추적인 역할을 하고 있습니다(78-81). 간호사는 피임약, 자궁내피임기구 삽입과 같은 부인과 관련 의료서비스도 제공할 수 있습니다(82). 또한 임신 가능 연령에 속하는 여성을 대상으로 자궁경부암 검사와 HIV 검사도 시행하고 있습니다(84). HPV 백신 접종률(Human papilloma virus vaccination services)을 올리기 위해 해당 연령에 속하는 청소년과 부모 혹은 보호자에게 관련 정보를 전달하고 백신의 필요성을 알리는 일도 하고 있습니다(83, 85, 86). 간호사는 또한 노인 연령층에 의료서비스를 제공하는 데 있어 중추적인 역할을 합니다. 노인 연령층에 필요한 통합적인 케어를 통하여 이들의 건강증진에 일조하고 있습니다(Box 3.2)(87). 호스피스(완화치료) 주요 관련자로서 간호사는 죽음을 준비하는 과정을 도와 존엄하게 생을 마감할 수 있도록 합니다(73, 76). Box 3. 2 노인 인구를 위한 간호사 주도 케어 모델 “초고령화 사회”에 진입한 일본의 경우 사사카와 메모리얼 보건재단(Sasakawa Memorial Health Foundation)은 2014년에 지역사회 단위로 가정간호센터(Home care nursing centres) 프로그램을 시작했습니다. 센터를 중심으로 간호사를 파견하여 노인 인구가 가정에서 돌봄을 받을 수 있도록 하여 삶의 질을 진작시킬 수 있도록 하였습니다. 사사카와 메모리얼 보건재단은 또한 보건 네트워크를 세워 각 센터 간 협력을 강화하고 관련 데이터를 수집 분석하고, 가정간호센터 확대를 위해 노력했습니다(89). 재단은 노인과 가정간호를 위한 간호사 교육프로그램을 준비했습니다. 이 프로그램은 8개월 과정으로 진행되며, 간호사가 지역주민에게 일차 보건의료를 제공할 수 있도록 건강사정법을 교육하며, 또한 호스피스 교육도 함께 진행합니다. 또한 가정간호센터의 운영과 관리에 중점을 두고 교육하는 프로그램도 마련하였습니다(89). 2019년 3월 67명의 간호사가 프로그램을 수료했으며, 이 중 56명이 일본 전역 23개 구역에서 가정간호센터를 운영하고 있습니다. 센터 직원의 70%는 간호사이며 30%는 그 외 직종 종사자이며, 이들은 직종 간 협력 방식으로 지역사회의 일차 보건의료 수요를 충족시키고 있습니다. 매달 평균 2만5천 명의 지역민이 센터를 찾고 있습니다. 가정에서 호스피스(완화의료)를 제공함으로 말기 환자의 입원비용과 치료비용 관련 비용을 절감할 수 있습니다(90). Nursing roles in 21st-century health systems 15 © National Health Commission of the People's Republic of China 3.2 전염병과 자연재해와 같은 응급 상황에서 간호사의 역할 29. 간호사는 의학적 응급상황(사고나 심장마비 발생과 같은)에 대한 돌봄제공 및 전염병 예방과 확산을 미연에 방지하고, 자연재해가 발생하거나 분쟁지역에서 발생할 수 있는 인도주의 위기상황의 대처에 관여합니다. 병원에서 환자가 처음으로 보는 의료진이 간호사인 경우가 많습니다. 그러므로 발생하는 상황에 맞게 대응해야 합니다. 환자의 상태를 체크하여 생명이 위급한 상황을 미리 감지할 수 있어야 하며, 약물 투여, 응급조치 후 관련 과에 진료 협력을 요청해야 합니다. 30. 간호사는 세계 보건에 큰 위협이 되는 전염병의 확산을 막는 의료팀에서 핵심적인 역할을 합니다. 2003년 급성호흡기증후군(SARS), 2015년 중동 호흡기 코로나바이러스(MERS-CoV)(92), 2016년 지카 바이러스(Zika virus disease) (93, 94), 2014년 에볼라(Ebola virus disease) (95, 96), 그리고 마지막으로 2019년에 발생한 COVID-19의 확산을 막고 환자를 치료하기 위해 수많은 간호사가 중요한 임무를 수행하고 있습니다. WHO는 응급구조팀 프로그램(Emergency Medical Teams Initiative)을 세워 미래에 발생할 수도 있는 재해와 응급상황에 더욱 잘 대처하기 위해 간호사와 그 외 의료직 종사자를 교육하고 훈련하고자 합니다(97). 이러한 계획은 특히 재해를 겪은 지역이나 분쟁지역에서 약화한 의료체계를 재정립하고 대응력을 키우는 데 도움이 될 것입니다(98). 31. 이렇게 약화한 의료체계에서 간호사를 포함한 의료직 종사자들은 개인적으로 납치위협을 받게 될 수도 있고, 동료의 죽음을 목격하거나, 살해위협과 같은 것을 겪게 될 수도 있으며, 직업적으로 복잡하고 과중한 업무(예를 들어 총상 치료)에 시달릴 수도 있으며, 또한 본인이 지녔던 직업적 윤리기준이 붕괴하는 상황을 자주 겪게 됩니다(99). 이렇게 어려운 상황에서도 간호사를 포함한 의료직 종사자들은 본연의 임무를 꾸준히 수행해나가고 있습니다(99). 난민 구호 활동과 더불어 분쟁지역의 간호사는 폐결핵 퇴치(100), 그 외 호흡기 감염, 충치 예방, 외상후 스트레스 증후군을 치료하는데 큰 진전을 보였습니다(101). 16 State of the world’s nursing 2020 3.3 국민 건강과 안녕 증진에 있어 간호의 역할 32. 국민의 건강과 안녕을 위해 간호사를 포함한 보건의료 인력은 건강 관련 사회적 당면과제를 해결하는데 앞장서야 하며 이를 통해 SDGs목표를 성취하는데 한 걸음씩 나아갈 수 있을 것입니다. 손씻기, 영양개선, 위생(102,103)의 증진을 통해 설사병을 예방하는 것은 건강 관련 사회적 당면과제를 해결하는 데 있어 간호사의 역할이 매우 중요하다는 것을 보여주는 지표가 될 것입니다(4). 간호사는 기후변화로 인해 발생하는 여러 가지 건강 관련 문제를 해결하는 데 있어 최전선에서 빈곤층을 보호하고 기후변화 관련 질병, 예를 들어 설사병, 말라리아, 아프리카 수면병, 리슈마니아증(Leishmaniasis), 주혈흡충증, 장선충감염병(Intestinal nematode infections), 뎅기열 감염으로 인한 사망률을 줄이고, 질병 치료와 예방에 앞장설 것입니다. 33. 건강한 인구를 지속시키는 곳은 보편적 건강보장을 통해 젊은이들의 건강을 확보하는데 달려있으며 이들이 건강을 유지하면서 다음 세대까지 지속가능한 발전을 위해 계속 일할 수 있을 것입니다. 간호사는 신뢰성있고, 편견없이, 환자 중심의 자세로 젊은이들의 요구에 부응할 것이며 젊은이들의 언어로 이들에게 접근해야 할 것입니다(107-110). 34. 간호사는 가족계획과 인공유산 관리와 같은, 특히 여성이 직면한 문제에 대처하는데 긍정적인 결과를 보여왔습니다(111,112). 여성을 위한 의료서비스를 최적화하면 보다 많은 여성이 산부인과 관련 의료서비스를 받을 수 있게 될 것입니다. 또한 여성에게 있어 아주 중요한 문제(예를 들면 임신 기간과 출산(113), 유방암의 발생)가 생길 때 모성 관련 케어를 통해 사회적 지지를 제공해야 하며, 동시에 이들 여성이 의료기관에서 존중받으며 케어를 받아야 하는 것이 매우 중요합니다(114,115). © WHO/Yoshi Shimizu Nursing roles in 21st-century health systems 17 간호사는 또한 성폭력과 관련된 문제를 해결하는 데도 중요한 역할을 하고 있습니다. 배우자 폭력 사건 보고서 조사에 따르면 피해자 신원을 파악하는 일을 간호사(45%)와 조산사(24%)가 자주 담당하고 있는 상황입니다(116). 본 장을 마감하면서 Figure 3.1은 WHO “30억” 목표 실행에 간호사가 기여하는 분야를 요약하여 나타냈습니다. Figure 3. 1 Nursing contribution to the triple billion targets UNIVERSAL HEALTH COVERAGE  Front-line providers of primary care  Preventing and treating wide range of communicable and noncommunicable diseases  Offering care across the life course, from birth to death • F r o n t - l i n e p r o v i d e r s o f p r i m a r y c a r e • P r e v e n t i n g a n d t r e a t i n g w i d HEALTH AND WELL-BEING  Addressing the social determinants of health through collaborative action  Addressing and treating the impacts of climate change  Ensuring access for vulnerable groups, including women and youths EMERGENCIES, EPIDEMICS AND DISASTERS  Delivering care for clinical emergencies  Responding to epidemics, disasters and humanitarian crises  Recognizing life- threatening conditions and performing life- saving procedures NURSES AS PART OF MULTIDISCIPLINARY TEAMS 18 State of the world’s nursing 2020 Policy levers to enable the nursing workforce 19 간호인력 관련 정책 35. 3장에서 말한 바와 같이 간호전문직의 역할을 최적화하려면 관련 정책을 수립하고 근무환경을 개선해야 할 필요성이 있습니다. 공공정책 수립 관점에서 WHO가 제공하는 보건의료 고용시장 기틀을 사용하여 간호인력 충당과 배치, 역량강화, 근무환경, 업무수행을 결정하는 요소를 분석할 수 있습니다(117)(Figure 4.1). 36. 이를 바탕으로 간호 관련 공공정책을 특징짓는 4개의 영역을 제안합니다. 본 보고서의 제안을 공고히 하고자 동료 검증(Peer-reviewed) 연구 결과를 바탕으로 4개의 영역으로 구분 지었습니다. (1) 간호교육과정과 임상실습 (2) 간호인력 유입과 유출 (3) 간호인력의 적정배치와 효율성 (4) 규제와 규정(민영 의료분야 포함). 보건의료 고용시장에 영향을 미치는 사회, 경제, 인구 문제 또한 고려하였습니다. 정책 수립을 위해 고려해야 하는 요소들 가운데 특히 성차별과 국가 소득수준에 관련된 부분은 본 보고서에서 세밀하게 다루었으나, 간호 관련 정책을 수립하는 데 있어 인구동향(고령화와 인구 성장유형)과 기후변화와 같은 요소들은 국가적 차원에서 다루어져야 합니다. 4.1 간호 교육과정과 임상 실습 37. 간호교육의 목적은 간호인력을 양성하여 국민 보건의 요구를 질적, 양적으로 균형 있게 충족시키는 데 있습니다. 간호교육기관에서 학생을 선발하고 간호인력을 배출하는 것은 의료분야의 수요와 고용능력에 근거하여 조정되어야 합니다. 의료, 교육, 노동, 재정 분야 관계자가 규칙적으로 만나 협의하고 협력한다면 간호인력 양성의 적정수준을 찾을 수 있을 것입니다. CHAPTER 20 State of the world’s nursing 2020 Figure 4. 1 Public policy levers to shape health labour markets Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892–4. 38. 간호교육프로그램에 등록하고 이수하는 학생의 수는 각 국가 시민의 기초교육수준과 간호프로그램 등록 전 선행학습에 의해 영향을 받습니다. 또한 간호교육프로그램 등록은 학교의 지역(지리적위치), 교육비용, 교육역량, 임상실습기관, 제공되는 간호교육수준에 따라 결정됩니다. 각각의 요소들은 교육과정의 계획과 목적을 완수할 수 있는 역량있는 교수진과 교육시설, 임상 교육능력에 의해 영향을 받습니다(120). Squires가 보고한바에 따르면 ‘거시적’요인들, 예를 들면 보건의료 인력에 대한 보건의료 체계수준(예를들면 인구 1인당 병상 수)과 여성권익(Gender empowerment) 또한 간호사 양성에 영향을 줍니다(121). 39. 젠더 이슈는 학생들이 간호대학 입학 결정에 영향을 미치며 이로 인해 간호사 양성에 장애가 되기도 합니다. 사회경제적 관점에서 간호 직무(nursing work)가 저평가되어 간호사가 의사결정 과정에 참여하거나 의료체계 안에서 리더가 될 수 있는 기회를 제한하기도 합니다(22, 23,122). 이는 조건을 갖춘 지원자를 모집하려는 간호교육프로그램에서 노력이 허사가 되는 것입니다. high school Training in health Training in other fields Employed Health care sector Other sectors Unemployed Out of labour force Education sector Labour market dynamics Pool of qualified health workers Migration Abroad Available, accessible, acceptable health workforce that delivers quality services Universal health coverage Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address inflows and outflows • to address immigration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to retain health workers in underserved areas Policies to regulate private sector • to manage dual practice • to improve quality of training • to enhance service delivery Policy levers to enable the nursing workforce 21 간호는 여성이나 하는 것이라는 편향된 인식은 남학생의 간호학 입문을 어렵게 합니다. 반면 여성에게 간호학 교육이 사회경제적 지위 상승의 기회로 간주될 수 있으나, 남성에게는 그렇지 않을 수도 있습니다123-125). 나아가 다른 직업군에서 여성에게 기회가 문화적 또는 체계적 제약에 의해 제한될 수 있으며, 간호교육은 성별에 관계없이 보건의료 인력으로서 가치있는 선택이기보다는 여성의 의료보건분야의 직업을 위한 유일한 혹은 가장 확실한 통로로 인식될 수 있습니다. 40. 인종이 다르다는 이유로 혹은 장애를 가졌다는 이유로 인해 간호 교육을 받으려는 노력이 좌절되기도 합니다(126). 이는 간호사와 그들이 일하는 지역사회와의 문화적 단절을 야기합니다. 간호 분야에서 여러 문화권의 사람들을 이해하고 의사 소통하며 효과적으로 소통할 수 있는 문화적 역량을 키우려는 노력을 하고 있으나 이들 소외된 그룹에서 학생들을 모집하고 선발하는 데 더 큰 노력을 기울여야 합니다(Box 4.1). 41. 간호대학의 지역적 위치와 교육과정의 질은 또한 우수한 학생들을 모으는 데 크게 영향을 미칩니다. 간호대학은 주로 대학과 병원이 있는 대도시에 있어, 선택의 기회가 적은 지방 학생들이 입학하기가 어렵습니다(129). 지역적으로 균형 있게 보건의료 인력을 배치해야 한다는 인식의 강화와 간호대학의 사회적 책임 의식으로, 지역 학교와 연계하여 간호 교육과정을 운영하거나, 오랫동안 대학교육의 기회가 없었던 지방 학생들을 모집하여 지원하는 학교가 늘어나고 있습니다. 원격 온라인 교육프로그램은 적절한 임상교육이 제공된다면 지방 학생들이 선택하는 방법의 하나가 될 수 있습니다(130). 교육의 질적 수준을 유지하기 위해 지속해서 모니터링한다면, 원격 온라인 교육프로그램은 다양한 학생들을 간호대학으로 모을 수 있는 하나의 기회가 될 수 있습니다(131). 42. 학비와 생활비를 포함하는 교육비용은 학생이 수업에 참석하거나 교육과정을 마치는데 영향을 미칠 수 있습니다. Box 4. 1 호주 정부 계획: 소외계층 학생을 간호인력으로 양성 호주에서는 원주민들이 같은 원주민 의료진에게 진료받기를 계속 요청해왔습니다. 의료뿐 아니라 문화적으로도 존중받기 위해서입니다(127). 그러나 그저 원주민(애보리진, 토레스 해협 원주민) 학생들의 숫자를 늘리는 것으로 해결될 만큼 간단한 문제가 아닙니다. 이와 더불어 이들 원주민 학생들이 공부할 수 있는 환경을 조성하고, 원주민 교수를 양성하고, 교육과정에 원주민 문화를 포함해야 하고, 학생들의 경제적 문제 또한 해결해야 하기 때문입니다(127,128). 22 State of the world’s nursing 2020 간호 교육 비용은 상황에 따라 천차만별입니다(Box 4.2). 국립 학교는 교육비용을 지원받기 때문에 학비와 개인 기부에 온전히 의존하는 사립학교보다 저렴한 편입니다. 간호대 학생은 수입이 없거나 적기 때문에 생활비 또한 교육비에 포함됩니다. 많은 국가에서 다양한 지원제도를 운용하고 있습니다. 소외계층 학생에게 경제적 지원을 하거나 졸업 후 비인기 분야에서 일하고자 하는 학생을 위한 인센티브제도 있습니다. 43. 자격과 역할은 다르지만 전문직간호·간호협회 분류기준(ISCO08)을 충족하는 간호사를 배출하는 다양한 입문 교육과정(Entry level deducational programmes)이 있습니다. 입문교육과정으로는 자격증취득과정, 전문학사, 학사 과정이 있습니다. 입문 교육과정에 입학하기 위한 자격요건은 다양합니다. 자격증 취득과정에 등록하려면 9학년을 마쳐야 하며 17세 미만, 혹은 학위 과정에 등록하려면 중등교육과정(12학년)을 마치고 2년의 대학 수준의 교육과정을 수료해야 합니다(135,136). 이렇게 간호 교육과정도 다양하고 자격요건이 다양해 오히려 수요와 공급의 불일치 현상이 발생하게 됩니다. 즉 일반적인 간호업무를 수행할 수 있는 교육과정을 이수한 간호사의 공급과 차별화된 분야에서 전문적인 의료업무를 수행할 수 있는 간호사에 대한 수요에 대한 차이가 발생하게 됩니다. 44. 몇몇 국가에서 간호인력의 상당 비율이 입문과정, 즉 자격증취득과정이나 전문학교만을 수료한 간호사로 구성되어 있거나, 현장에서 필요한 최소한의 임상기술만을 교육하는 관계부처 인가 교육기관에서 과정을 수료한 간호인력이 활용되는 국가도 있습니다(137). 대학교육(학사) 과정은 리더십 과정, 사례관리, 다양한 의료현장(입원/외래환자)에서 환자의 보건과 치료 결과에 영향을 미치는 사회경제적 요인을 추가로 교육하며, 연구에 관한 부분을 교육과정에 포함하기도 합니다. Box 4. 2 간호 교육 비용 전 세계적으로 매년 272억 달러(한화 약 33조3,744억 원) 가량이 간호 교육과 조산사 교육 부분에 쓰입니다(132). 전 세계 보건의료 인력에서 간호사와 조산사가 차지하는 비율이 절반이 넘는 데도 정작 간호 교육과 조산사 교육 부분에 드는 비용은 전 세계 의료교육비용의 1/4 수준입니다. 2010년 발행된 보고서에 따르면 전 세계적으로 간호 교육에 드는 비용은 평균 5만 달러(한화 약 6,130만원)로 추산되었으며, 비용 범위는 중국, 3천 달러(한화 약 367만 원)부터 북미지역이 10만 달러(한화 약 1억 2,000만 원)까지 다양합니다(132). 이렇게 교육비용이 크게 차이가 나는 이유는 국가의 재정지원 여부, 교육기관의 민영화 여부, 간호 교육의 재정지원 체계가 다양하기 때문입니다(133). 간호 교육비용이 이렇게 차이가 나는 다른 이유로 다양한 수준의 간호 자격이 존재하고 교육프로그램의 기간이 다양하며, 각 간호 교육프로그램 전 선행학습에 대한 요건이 각기 다르기 때문으로 보입니다(134). 2030년까지 부족한 인력 양성을 위해 필요한 투자계획을 수립하기 위해서는 더욱 자세하고 많은 양의 데이터를 수집해야 합니다. Policy levers to enable the nursing workforce 23 간호교육프로그램은 정확한 임상적 판단과 안정성있는 돌봄제공을 위해 “비판적 사고능력”을 강조하여 교육합니다. 대학수준의 높은 교육과정을 마친 간호사의 활동으로 환자 사망률이 감소하고, 입원 기간을 줄이며, 의료비용을 효율적으로 절감한다고 보고되었습니다(46,138,139). 그러나, 이러한 결과는 좋은 시설을 갖춘 대규모 병원에서 확인된 결과로서, 일반 외래 진료 시설과 지역사회 세팅에서는 찾을 수 없어 연구 결과의 일반화에는 문제가 있습니다(140). 또한 대학 수준의 높은 교육과정을 마친 간호사는 학교에서 배운 지식과 기술을 실제 의료현장에서 충분히 적용하지 않는다는 연구 결과가 있습니다(141). 45. 간호사는 전문자격을 취득하기 위해 석사학위를 받거나, 간호 실무 중심의 교육과정을 이수하여 간호실무 박사학위(DNP)를 취득하거나 또는 연구 활동을 하는 박사학위(Ph. D.)를 취득할 수도 있습니다(142). 간호 교육의 단계가 올라갈수록 교육과정의 수준에 따른 명확한 구분이 있어야 합니다(143). 학위를 갖춘 간호사에 대한 수요가 있는 국가에서, 기존의 간호사자격을 ‘브릿지’ 또는 ‘업그레이드’하는 교육프로그램을 통해 중요한 경력개발 매커니즘을 제공하고, 개인적으로 학위를 취득하도록 도움을 줄 수 있습니다. 참고로, 석사 또는 박사수준의 대학원 교육을 위해서는 학사 수준 간호사의 준비가 필요하며 이는 입문수준 간호프로그램 교수진의 양적, 질적 수준에 영향을 줄 수 있습니다. 46. 간호 교육에서 매우 중요한 동시에 실행이 어려운 부분은 임상 실습의 기간과 수준을 보장하는 것입니다. 임상실습기간동안 학생들은 학교에서 배운 비판적 사고능력과 임상술기, 기술을 통합 적용할 수 있게 됩니다. 학생들을 관리하고 임상기술 평가를 위해 실습지도자가 필요합니다. 대부분의 간호대학이 대도시에 있어서 지방에 떨어져 있는 의료기관에서 실습할 기회를 얻기가 어렵습니다. 이러한 실습 경험은 학생들이 졸업 후 근무지를 결정하는 데 매우 중요하게 작용할 수 있습니다(144). 온라인 간호 교육 과정 또는 원격 교육 프로그램을 통해, 기존의 오프라인에서는 학교와 협력관계에 있지 않은 지방 의료기관에서 실습 기회를 제공하는 경우가 늘어나고 있습니다(145,146). 또한 원격기술과 시뮬레이션 실습은 일차보건의료에 대한 적절하고 보완적인 임상경험을 제공할 수 있습니다(147-150). 온라인 간호 교육 과정은 다른 기존의 간호 교육기관과 같은 수준의 인증 기준(표준)에 따라 모니터링 되고 질적 수준을 유지해야 합니다. 47. 많은 국가에서 비영리, 영리를 포함하여 점점 많은 사립 간호 교육기관이 설립되고 있습니다(151,152). 영리 간호 교육기관은 대게 학비가 높은 편이며 다른규제기관의 요구사항과 인증의 적용을 받을 수 있습니다(152). 이들 영리간호교육기관은 보건 및 교육 공공정책 목표와 함께하지 않아 인구-건강 우선순위에 항상 부합하지 않을 수 있으며, 특히 증가하고 있는 국제보건 고용시장에 배출 목적으로 간호사를 교육하려는 의도가 있는 경우에 더욱 그러합니다. 질적 수준이 보장되지 못하는 경우, 국가표준에 이르지 못하는 허술한 교육과정을 통해 안전하고 양질의 돌봄을 위한 지식, 기술, 태도를 갖추지 못한 간호사를 양성하게 됩니다(153). 병원이나 대학병원(academic medical center)과 연계되지 않은 사립학교의 확산은 기존 임상실습 의료기관에 부담이 될 수 있으며, 이에 따라 그 안에 제공된 교육의 질에 의문을 제기할 수 있습니다. 48. 간호 교육에서 해결하기 힘든 난제 중 하나가 자격을 갖춘 교수진을 충분히 채용하고 유지하는 것입니다(19, 20,154). 학교의 직접 채용이냐 에이전시를 통하느냐의 채용 방법 문제 또한 발생하는데 이로 인해 임금 격차와 교육 시간 보장에 차이가 생기게 됩니다. 미국 간호대학협의회는 현직 간호사가 학교에서 교육을 담당하게 하여 간호사의 직위를 향상하고 추가의 경제적 혜택이 주어짐과 동시에 간호 교육과정에 간호전문가를 연계시켜 교육의 질을 향상할 수 있다고 제안합니다(155). 이러한 파트너십의 성공은 임상간호사가 현장에서 학생을 감독하거나 지도할 수 있는 적절한 여유시간을 제공하는 임상현장을 가능케합니다. 예는 Box 4.3에 있습니다. 24 State of the world’s nursing 2020 Box 4. 3 간호 교육 교수진 부족 문제 해소 전 세계적으로 발생하고 있는 간호 교육 교수진 부족 문제를 해소하기 위해 국내, 혹은 가능하다면 국제적으로 각 기관 간 협력하여 교육 인력풀을 구성하는 방법도 있을 수 있습니다(156). 태국은 치앙마이 대학이 중국 의료위원회(China Medical Board)의 후원을 받아 고급교육 인력개발계획(Higher Nursing Education Development)을 세워 간호대학 교수진의 교원 자격 수준을 올리기 위해 노력하고 있습니다(157). 1994년에 시작된 이 계획은 중국 전역에서 증가하고 있는 간호대학의 교수진을 충당하기 위해 석사학위나 박사학위를 취득한 간호대학 교원을 양성하려는 목적에서 시작되었습니다. 이 계획은 곧 동아시아와 동남아시아 10개 국가로 확대되어 간호교육기관 확대 설립과 국가 간 상호 간호 자격을 인정하게 되었습니다(157). 미국은 재향군인회-간호 교육기관 협력관계 계획(Veterans Affairs Nursing Academic Partnership)을 통해 재향군인 전문의료기관에 필요한 간호사 수요를 충당하기 위해 협력교육기관에서 교수진으로 활용할 숙력된 간호사를 훈련하고 급여를 제공하고 있습니다(158). 르완다에서는 간호대학 교원 능력향상을 위해 교육기술(교수법)과 교육과정계발에 중점을 두고 지속해서 교육하고 있습니다(159). 국제학술협력 관계(International academic partnership)가 지원하나 르완다 정부가 주도하며, 협력을 통해 문화적 정체성을 존중하는 전제로 이루어지고 있습니다(159). Policy levers to enable the nursing workforce 25 49. 석사 및 박사 학위를 소지한 교수진의 부족은 더 높은 수준의 간호교육프로그램을 수립하는 데 장애가 됩니다. 박사학위를 소지한 교수진의 부족은 실무에 정보를 제공하고 학계 및 임상분야에서 리더십 역할을 수행하는데 필요한 연구를 수행하는 능력에도 영향을 미칩니다(20,154,169). 50. 모든 보건의료 관련 전공분야 중 간호학은 건강 관련 전문직간 교육(Interprofessional education)을 가장 많이 사용하는 것으로 보고되었습니다(161). 간호학과 학생들은 이를 통해 의료직종간 협업 역량을 키울 수 있기 때문에 전문직간교육을 중요하게 생각하고 있습니다(149,162). 이와 같은 맥락으로 다른 학과의 교원이 간호학과 학생들을 가르침으로 학생들은 다른 전문지식을 간호 교육에 통합하여 팀으로 진행되는 환자 케어에 간호 역량을 증진할수 있습니다(163). 전문직간 교육은 현재로서는 저중소득국가보다는 고소득국가에서 많이 이루어지고 있으나(159) 기술발전으로 인해 저중소득국가에서도 점점 증가하는 추세입니다(162). 4.2 인력의 유입과 유출 51. 활동 간호사(Active nurses)의 수(또는 간호인력 양)은 여러 측면에서 결정될 수 있습니다. “유입”(Inflows)은 국내 간호대학을 졸업한 신규간호사와 외국에서 들어온 간호사, 복직 간호사를 포함합니다. “유출”(Outflows)은 구직에 실패한 간호사와 의료분야 외에서 일하기 위해 직업을 바꾼 간호사, 퇴직간호사, 해외로 나가는 간호사를 포함합니다. 52. 보건의료 인력 시장으로 보건의료 인력을 유입하는 가장 중요한 결정요소는 바로 국가의 경제적 역량입니다. 국영이든 민영이든 의료기관에 채용 수준을 높일 수 있는 기금을 마련하거나 의료서비스를 제공함으로써 수입이 생길 기회를 제공하는 등 국가의 경제적 지원이 가장 중요합니다. 의료 고용 창출은 국가의 사회경제적 수준과 직접적으로 연관이 되어있으며, 공공 정책 입안자가 특히 의료분야와 보건의료 인력 분야에 우선순위를 두고 있느냐에 따라 달라집니다. 수요를 결정하는 또 다른 요소들로 다음과 같은 것들을 들 수 있겠습니다. 즉 인구노령화와 같은 인구통계학적 변화, 만성질환과 여러 질병을 함께 앓는 환자의 증가 현상과 같은 질병 양상의 변화, 간호사를 비롯한 보건의료 인력 부족, 병원건립 같은 의료시설 확장, 병원의 고용 정책 변화, 간호사 1인당 환자 수 규정과 같은 관련 법안 변경 등입니다(140,164). 간호사 수요가 감소하는 원인으로 새로운 기술이 개발되면서 입원환자 관련 업무가 줄게 되고, 기존 간호사들의 이직률이 낮아지거나, 근거 중심 실무를 활용한 효율적인 진료 활동, 간호사의 업무를 다른 의료직 종사자가 맡는 경우 등을 들 수 있습니다(164). 26 State of the world’s nursing 2020 53. 간호인력의 국제이동이 증가하면서 국내 의료 인력풀에 많은 영향을 미치게 되었습니다. 간호사들의 해외 이주를 원하는 이유는 더 나은 직장, 임금, 근무환경, 의료시설, 의료자원, 교육 기회를 들 수 있습니다. 이밖에 가족 비자가 간호사 해외 이주의 또 다른 목적으로 작용하고 있습니다. 반면 해외로 밀어내는 요인으로 자국 내 간호사 일자리 부족과 열악한 근무조건, 불안정한 사회복지 등을 들 수 있습니다. 해외에서 일하는 간호사들의 수입은 국내에 거주하는 가족들에게는 주요 수입원이 되며 자국의 경제발전에 역할을 하고 있습니다. 국가 간 협약(양자협정)과 같은 정책은 반드시 관련 국가 모두에 WHO 국제 보건의료 인력 채용에 관한 실행 규정(165)에 따른 지원과 보호 혜택이 돌아가야 합니다(Box 4.4 참조). 54. OECD 국가에서 일하고 있는 이주간호사의 숫자는 2011부터 2016년까지 5년간 무려 20%가 증가하여, 같은 기간 55만명이 이주한 의사의 증가속도를 능가했습니다 (168). 수집한 데이터에 의하면 이제 전통적으로 인식되던 “이민을 보내는 국가”(Source)와 “이민을 받는 국가”(Destination)의 구분이 모호하게 되었습니다(167). 여전히 고소득국가의 간호사 수요가 매우 높은 데 반해(Box 4.5 참조), 아시아와 아프리카, 카리브해 연안국 출신의 간호사가 대거 걸프만(灣) 아랍국가와 같은 지역으로 이주하는 경향이 두드러지고 있으며(170), 또한 같은 지역 내 국가들 간 이주 현상도 발생하고 있습니다. Box 4. 4 국제 기술 협약(Global skills partnerships) 2018년 12월에 체결된 유엔 이주 협약(Global Compact for Safe, Orderly and Regular Migration)에 따라 152개 회원국은 국제적 이민 문제를 해결하기 위해 행동에 나섰습니다. 이주 협약의 핵심은 회원국 간 기술협약을 맺음으로써, 노동력을 공급하는 국가에 필요한 교육적 지원을 하면서 노동 인력의 수요와 공급을 맞추는 것입니다(166). 협약의 형식은 무분별한 이민으로 야기되는 문제를 전환하여 이민을 보내는 국가와 이민을 받는 국가 모두 이익이 돌아갈 수 있도록 구성되었습니다. 이는 WHO가 제안한 보건의료인 채용에 관한 실행 규정(WHO Global Code of Practice 이하 실행 규정)과도 일치합니다. 협약을 통해 이민을 받는 국가는 기술과 재정지원을 하여 잠재적 이민자에게 필요한 기술교육을 제공함과 동시에 이민을 보내는 국가는 잠재적 이민자뿐 아니라 자국민에게도 교육의 기회를 제공하게 됩니다(166). 협약의 과정으로 기술 교육을 두 개의 다른 과정으로 진행할 수 있습니다. 간호 교육을 예로 들자면, “비 이민 과정”(Home track)과 “이민 과정”(Away track)으로 나누어 비 이민 과정 학생은 자국에 필요한 간호기술을 교육하며, 이민 과정 학생은 그 나라에서 일하는데 필요한 교육을 받게 됩니다. 협약 관계를 맺은 국가는 필요에 따라서 직종의 종류를 늘릴 수도 있습니다. 영국 국립보건 서비스(NHS) 산하 보건교육원(Health Education England)은 자메이카 정부와 협력관계를 맺고 자메이카의 간호 전문인력을 양성하고 있습니다. 자메이카 간호사는 영국 의료시설에서 2년간의 교육을 마친 후 본국으로 돌아가 전문간호사로 활동하게 됩니다. 동시에 영국은 자국 간호사를 자메이카에 보내 간호 관련 지원 활동(간호 서비스의 질적 수준 향상, 간호사 교육 등)을 통해 자메이카의 의료체계를 강화하는 역할을 하게 됩니다. 이 프로그램은 2019년에 시작되었습니다. 국제이주기구(International Organization for Migration) 또한 이와 유사한 프로그램을 진행하고 있습니다. 효과적으로 보건의료 인력 이주를 관리하고, 의료체계를 공고히 하는 프로그램을 통해 국가들을 연결하여주고 있습니다(167). 이 프로그램은 각국 정부 관계 당국과 단체가 협력하여 진행되고 있습니다. 국제이주기구는 WHO의 중요협력자로 WHO 실행 규정뿐 아니라 관련 정책, 국제보건협의회(World Health Assembly)의 계획도 지지하고 있습니다(167). Policy levers to enable the nursing workforce 27 4.3 간호인력의 적정 배치와 효율성 55. 의료분야에서 간호사들은 일련의 국공립과 사립 의료서비스 제공기관에서 채용되고 있습니다 (175-178). 간호사 배치에 대한 체계적 통계자료는 아직 없는 실정입니다. 그러나 일련의 조사에 따르면 간호사는 일차 보건의료보다는 병원이나 응급치료센터를 선호하는 것으로 보이며, 임금 차이로 인해 국공립 의료기관보다는 사립 의료기관에서 일하는 것을 택하는 것으로 알려져 있습니다(175,177). 56. 케어 모델(Care model)은 일차 보건의료 체계에 최적의 보건의료 인력이 통합되도록 설계되어 간호사가 직업 역량을 최대로 발휘할 수 있도록 해야 합니다. (역주: 케어 모델은 보건의료 체계, 의료서비스 설계, 진료 지원, 임상 정보 시스템 및 자체 관리 지원으로 구성되어있는 통합 의료서비스 형식입니다) 간호사는 통합 의료팀에서 반석과 같은 역할을 맡습니다. 간호사는 의료서비스 제공에 앞장서며 지역사회 보건의료 인력과 협력하거나 관리·감독하는 확대된 역할을 맡고 있습니다(182-193). 간호사가 최대 역량으로 일할 수 있게 된다면 간호사의 직업적 만족도가 높아질 뿐 아니라 환자의 만족도도 높아질 수 있습니다(194). 이를 가능하게 하려면, 간호사의 일차보건의료 교육, 간호지침의 표준화 즉 동일 절차로 진행되는 표준화된 간호지침 수립, 환자의 치료 결과를 추적 관리하는 데이터 체계를 수립해야 합니다(195, 196). Box 4. 5 고소득국가에서 간호사 수요의 예 인구통계학적 그리고 역학적 관점에서 고소득국가의 보건정책은 간호사의 수요가 증가하는 방향으로 기울고 있습니다. 예를 들면, 영국의 보건재단(The Health Foundation)은 매년 해외에서 적어도 5천 명 이상의 간호사를 2024년까지 채용해야 한다고 추산했습니다(171). 일본에서는 새로운 노동비자 프로그램을 마련하여 6만 명의 간호사를 포함하여 24만5천 명의 해외 노동 인력을 유치하기로 했습니다(172). 독일 정부는 고령환자들에 대한 의료서비스 분야에 대략 3만 6천명의 간호인력이 부족하다고 보고했으며, 해외로부터 채용이 필요하다고 언급했습니다. 28 State of the world’s nursing 2020 57. 많은 국가에서 간호사 직무 범위 안에 처방을 포함하고 있습니다 (197,198). 간호사 처방(Nurse prescribing)은 법적으로나 직업적 규제하에 일부 간호사에 제한되어있고 처방 약의 목록도 제한적입니다(199). 특정 상황에서 국민 보건 우선순위, 예를 들면 HIV 환자의 비율이 높은 사하라 남부지역 국가에서 HIV 치료제로 처음 사용되는 항레트로바이러스 치료에 처방, 혹은 항생제 저항균 치료나 만성질환 치료제를 처방할 수 있습니다(200- 202)(Box 4.6 폴란드의 간호사 처방제도 참조). 간호사는 또한 환자의 복약순응도를 높이고, 의사의 진료 처방을 모니터링하여 처방 실수를 줄일 수 있습니다(203,204). 58. 지역의 의료서비스 확대와 부족한 일차보건의료 인력을 충당하기 위해 간호사의 역할이 점점 확대되고 있습니다 (192, 207). 대표적인 예로 전문간호사(nurse practitioner)를 들 수 있습니다. 전문간호사는 독자적으로 진단검사와 의약품을 처방할 수 있으며, 진단을 내릴 수 있습니다(207). 전문간호사가 되기 위해서는 석사학위 이상의 교육 수준과 전문 자격증을 갖춰야 합니다(208). 소수의 고소득국가에서 운영하는 전문간호사제도는 비용대비 효율성 면에서 제한적임에도 의료서비스의 질을 높이고, 의료 접근성을 향상하고 환자의 치료에 대한 만족도를 높일 수 있습니다(208,209). 많은 국가에서 간호학 석사 교육과정이 생기고 전문간호사의 수가 증가하고 있으나(159,211-214) 교육과 자격 관련 규정은 매우 상이한 상황입니다(192). 전문간호사의 역할에 관한 규정이나 자격 조건도 국가마다 매우 다릅니다(192,215). 그러나 전문간호사제도가 생김으로서 간호사 직업에 대한 호감도가 높아진 것으로 보입니다(211,214). 대학 수준의 교육과정을 마치고 특정 그룹의 환자에 대한 전문성을 갖춘 간호사는 전문간호사와는 다른 전문가(specialist) 자격을 취득할 수도 있습니다(Box 4.7 참조). Box 4. 6 폴란드의 간호사 처방제도 폴란드의 국가보건 관련 우선 과제 중 하나는 만성질환의 지역사회 관리 수준을 개선하고 일차보건의료현장에서 치료 및 의약품에 대한 접근성을 높이는 데 있었습니다. 폴란드 정부는 간호 교육과 간호사의 역할에 관련한 정책을 수립하여 의료체계에서 간호사의 역할을 확대하여 의료 접근성을 높였습니다(205). 2016년 관련 자격증을 취득한 간호사가 일정 조건에서 의약품을 처방할 수 있는 권한을 갖게 되었습니다. 이를 위해 처방에 대한 내용이 간호사와 조산사 교육과정에 포함되었으며, 대학 수준의 교육을 마친 간호사가 일정 의약품을 처방할 수 있게 되었습니다(206). 이와 더불어 간호사와 조산사 업무에 관련한 정책을 새로이 수립하여 간호사의 역할과 갖춰야 할 직업적 역량과 근무 여건개선에 대한 규정을 마련하였습니다. 2016년 이래 1만287명의 간호사와 4천799명의 조산사가 관련 교육과정을 마치고 자격을 취득하여 처방업무를 수행하고 있습니다. 2018년 12월까지 간호사와 조산사가 독자적으로 2천538개의 처방전을 발급했으며 기존에 의약품을 복용하던 환자에게 36만3천288개의 처방전을 계속하여 발급했습니다. Policy levers to enable the nursing workforce 29 59. 도시와 지방의 의료 인력 불균형 문제는 어디서나 발생합니다. 도시와 지방의 의료 인력 불균형 해소를 위해 각국 정부는 교육, 규범, 재정, 직업 등 여러 방면에서 정책을 세우고 노력하고 있습니다(217)(Box 4.8 참조). 지역 간 인력 불균형 문제는 다각적 시각에서 원인을 규명하고 이에 대해 지속적인 정책을 세워야 합니다. 따라서 다양한 정책이 미칠 효과에 대해 이해하고, 서로 다른 지역의 다양한 의료현장에서 정책을 공유하고 범위를 확대하는 것이 중요합니다(144). 일개 국가의 연구에 따르면, 지역 간 불균형을 해소하려면 이와 더불어 보건복지부의 공평하고, 투명하고 일관성 있는 보건의료 인력 관리 정책과 보건의료 인력의 고용조건(정규직/계약직)이 중요한 요소로 나타났습니다(218). 중-고소득 국가에서 진행된 연구에 따르면 지역 근무 간호사 인력 수준을 유지하려면 간호 관리 책임자의 전폭적인 지원뿐 아니라 조직적인 관리가 매우 중요한 것으로 드러났습니다(219,220). 인력 수급이 어려운 지방 출신의 간호대학생을 모집하여 졸업 후 고향으로 돌아가서 활동하도록 하는 방법도 효과적일 수 있습니다(146, 221). Box 4. 7 아프리카 간호전문가(전담간호사) 제도의 예 동남 아프리카 지역의 점점 많은 국가가 아동 사망률을 낮추기 위한 정책의 일환으로 아동 전문 간호전문가(Specialist nurse) 또는 아동전담 간호사를 양성하는 데 투자하고 있습니다. 아동 전문 간호전문가는 소아청소년과 보건 교육을 받아 전문자격을 취득한 간호전문가를 가리킵니다. 일반적으로 정규 교육과정 수료 후(대학 수준의 교육기관에서 간호학 전공) 12개월 과정의 아동 간호 교육과정을 마치고 전문자격을 취득하게 됩니다. 전문자격은 국가마다 다르며 일반적으로 아동전담간호사(Registered nurse paediatric specialist, or professional nurse with paediatric specialization)로 업무를 수행합니다. 아프리카지역에 대략 3천650명의 아동전담 간호사가 활동하는데, 국가별로 케나(Kenya) 말라위(Malawi), 우간다(Uganda), 잠비아(Zambia)에 750명의 간호사가 활동하고 있으며, 남아프리카 공화국에 2천900명의 아동전담 간호사가 있습니다(216). 12개의 교육기관(주로 남아프리카 공화국에 있습니다)에서 해마다 205명 정도의 졸업생을 배출합니다. 보츠와나(Botswana), 탄자니아 공화국(United Republic of Tanzania), 짐바브웨(Zimbabwe)에 새로운 프로그램이 개발되고 있습니다(216). 아프리카 지역에는 현재 그 외의 영역별로 세분된 전문분야 간호사제도는 없습니다. 아프리카 아동 간호인력 관측소(The Children’s Nursing Workforce Observatory)는 아동전담 간호사를 양성하는 각국 정부의 정책을 지원하고 있습니다. 2015년부터 연구자, 간호 교원, 그 외 관계자는 아프리카 동남부지역에서 아동전담 간호인력 관련 데이터를 수집하고 보고하는데 협력하고 있습니다. 30 State of the world’s nursing 2020 60. 현장에서 간호사 수준을 유지하는 것은 매우 어려운 일입니다. 간호사 회전(回轉)(기존 인력이 이직하고 새로운 인력이 자리를 채우는 현상)은 시장경제 원리로 피할 수 없는 결과입니다. 이는 의료체계와 환자 그리고 간호사에게도 긍정적 혹은 부정적 영향을 끼칩니다(220,222). 적당한 회전율은 직업 경쟁력 개발이나 조직 재편 관점에서 긍정적 효과를 줄 수 있습니다. 예를 들어 현직 간호사가 경력개발을 위해 같은 의료분야 내에서 이직하는 경우를 들 수 있습니다(223). 반면 기존 간호사 사직과 신규 인력의 유입은 거의 언제나 조직 비용이 소요되므로 환자에 쓰여야 할 의료서비스 비용 면에서 부정적인 영향을 미칩니다. 61. 간호사의 이직에는 공적 요인과 사적 요인이 함께 작용합니다. 사적 요인으로 개인 혹은 가정사, 교육목적, 직무 관련 스트레스, 직업 불만족이나 이와 반대로 권위 의식 (224-225). 공적 요인으로는 근무환경, 근무 관계, 근무조건, 임금, 경영방식과 효율적 관리·감독 등이 있습니다 (226). 호주, 이집트, 이란, 요르단, 필리핀 등에서 이루어진 연구 결과에 따르면 임상 관리자(책임자)의 경영방식과 조직문화가 직접적으로 간호사의 직업 만족도, 이직률뿐 아니라 의료서비스의 질적 변화에도 영향을 미치는 것으로 드러났습니다. 이는 도시뿐 아니라 지방의 작은 의료기관에도 해당합니다(219,220). 좋은 일자리 62. 국제노동기구(ILO)에 따르면, 좋은 일자리는 “생산적인 일자리이며, 공정한 임금과 직장 내 안전보장, 가족에 대한 사회적 보호, 개인의 발전과 사회통합을 위한 보다 나은 비전, 의사 표현의 자유, 노동자의 생활과 기회 보장, 성 평등에 영향을 미치는 모든 결정에 참여할 수 있는 자유와 이를 위한 조직 구성의 자유를 보장”하는 것을 말합니다(230). 간호직과 관련해 좋은 일자리 창조에 장애 요인은 젠더 이슈, 의료사고 위험, 지나친 근무시간, 외국 간호사에 대한 불평등한 처우 등을 들 수 있습니다. 63. 여성 간호사는 다른 의료직에 종사하는 여성과 함께, 같은 일을 하는 남성에 비해 넘어야 할 장애물이 너무나 많습니다 (21,231). 간호는 여성이나 해야 한다는 편견, 성에 관련된 사회규범, 성적 편견 등이 간호사가 나은 근무 조건, 공평한 임금과 공정한 대우, 정책 결정에 참여할 기회, 의료체계 안에서 리더 위치에 오를 기회를 빼앗아 좋은 일자리를 만드는 데 장애가 됩니다(21, 22,122). 2019년 WHO 보고서 “일하는 여성, 관리하는 남성”(Delivered by women, led by men)에서 여성이 대부분을 차지하는 일자리에서 오히려 여성이 차별받고 있다는 것을 밝혔습니다. 예를 들어 36%의 간호사가 상급자에게 존중받고 있지 않다고(무시를 당한다고) 응답했으며, 32%는 자기 의사를 표현하는 데 어려움을 겪고 있다고 대답했습니다(21). 이러한 장애는 여성 간호사의 복리를 저해하며, 성 평등을 이룩하는 데 방해요소로 작용합니다(21). 성차별은 의료서비스의 질적 수준에도 영향을 미칩니다. 간호사에 대한 제도적 지원과 존중이 양질의 의료서비스를 제공하는데 필요한 요소입니다(232). 직장 내 성희롱은 간호사(25%)와 조산사(37%)를 포함한 모든 여성 의료인이 겪는 문제입니다(21). 64. 어떤 경우에는 간호사와 그 밖의 보건의료 인력이 폭행 위험에 노출되어 있습니다. WHO의 보건의료 인력 폭행에 대한 조사(Surveillance System for Attacks on Health Care)에 따르면 2019년 1월1일부터 2020년 1월 1일까지 복잡한 위기상황에 있는 11개국에서 1,005건의 폭행사고가 발생했으며, 의료진과 환자가 198명 사망하고 626명이 중상을 당했습니다(234). 65. 의료 서비스는 지속적으로 환자의 필요에 대처해야 하므로 근무시간이 길어지고 불규칙적으로 될 수밖에 없습니다. 이로 인해 간호사 자신에게도 부정적인 영향(예를 들면 번아웃 증후군 같은 증상)을 겪을 수 있으며 환자에게도 안 좋은 영향을 미칩니다(예를들면 의료사고의 증가)(235). Policy levers to enable the nursing workforce 31 1977년 ILO 간호사협약(Nursing Personnel Convention)에 따라(No. 149) 간호사는 다른 의료인과 동등한 시간에 근무하며, 교대근무와 초과근무 시간에 대한 규정이 있어야 하며, 이에 대한 보상을 받아야 합니다. 66. 이주 간호사는 특히 좋은 일자리에서 일할 수 있는 가능성이 낮습니다. 이주 간호사와 소수 인종 출신 간호사는 본국 간호사나 다수 인종 출신의 간호사보다 직무 관련 부상 위험에 노출될 위험이 높으며 차별대우를 받을 가능성 또한 높습니다(236). 이주 간호사와 소수 인종 출신 간호사의 건강 악화의 원인으로 가장 큰 부분이 차별대우로 인한 것으로 드러났습니다(236). 한편 고국에서의 좋은 일자리 부족 또한 간호사들의 해외 이주를 부추기는 원인으로 작용합니다(237-240). 4 Note that these guidelines are currently being updated. Box 4. 8 지방 간호인력 유지 지침 지방 간호인력 수준을 유지하거나 늘리는 문제가 점점 어려워지고 있습니다. 2010년 WHO는 정책권고안을 마련하여 간호인력 수급에 어려움을 겪고 있는 지방에서 간호인력 수급률을 높이고자 했습니다(217). 4 권고안은 4개의 주요 영역으로 나누어집니다: 즉 교육, 규정, 재정적 인센티브, 개인적 직업적 지원입니다. 권고안은 지방 간호인력 수급률을 높이는 데 중점을 두고 있으나 여전히 매우 제한적입니다. 고소득국가(특히 호주, 캐나다, 미국)에서 효과가 한정적이나 재정적 인센티브와 개인적 직업적 지원, 경력개발이 지방 간호인력수급에 도움이 되는 것으로 보입니다. 32 State of the world’s nursing 2020 4.4 규정과 규제 67. 간호 관련 규정은 간호업무 시행, 간호 교육, 업무기준을 세우고 시행함으로써 국민 보건에 이바지하고 있습니다. 또한 간호사에게 혜택이 돌아가도록 하며 간호 교육 수준을 높이는 데도 중점을 두고 있습니다(241,242). 규제기관은 보건의료 인력 관련 데이터와 사례들을 점점 더 많이 수집하여 시스템을 구축하고 있습니다(243). 지난 15년간 집적한 보건의료 인력 관련 데이터와 사례의 양이 엄청나게 늘었으며 그 중에서도 간호 분야 관련 자료가 방대합니다(244,245). 68. 교육 관련 규정은 간호 교육 표준에 대한 규정, 규제 기간의 간호대학 설립 허가기준, 교육기관의 외부 인증을 포함합니다. 인증(accreditation) 과정에서 교육기관은 교육과정을 평가받으며 양질의 의료서비스를 제공하여 국민 보건증진에 이바지하는 간호사를 배출하도록 장려합니다(246). 기준 설립과 인증과정은 반드시 보건의료와 의료서비스 형식 변화에 발맞추어 바뀌어야 하고, 인증비용은 저렴하거나 중간정도로 해야 합니다. 기준과 인증은 교육과정 기준에 못 미치는 부족한 부분을 보완하는데 필요하며, 극단적이지만 기준에 부합하지 않는 교육기관의 폐쇄도 때로는 필요 할 수 있습니다. 2013년 사하라 이남지역 17개 국가에서 이루어진 연구조사에 따르면, 간호 교육 인증에 관련하여 강력한 법적 규정이 마련되어있으나, 대다수의 간호사를 양성하는 교육기관의 인증 수준이 낮은 것으로 드러났습니다. 또한 이 지역의 국립학교가 사립학교보다 인증 수준이 높은 것으로 조사되었습니다(247). 인증수준 결과를 낮게 받은 일부 사립학교의 경우 이해관계에 얽힌 관계 당국의 일부 인사가 영향력을 끼쳐 불이익을 받은 것으로 드러났으며, 그 결과 정부가 인증 결정 과정에 이해관계가 없는 인사를 구성하여 이를 방지하기로 했습니다(248). 69. 국가마다 교육기관별 인증과정이 매우 다양합니다(249). 일부 국가에서는 국립대학의 경우는 정부 기관이 관리감독하기 때문에 사립대학만 인증을 받아야하는 경우가 있으며, 다른 국가에서는 관련 규제가 없어 사립학교가 인증과정을 거치지 않아도 되는 경우도 있습니다. 인증과정은 법적으로 명시되어있어 직접 규제하거나, 혹은 간호협회에 등록을 해야 하거나, 협회 혹은 관계기관이 인정한 학교를 졸업한 자만이 자격시험을 볼 수 있도록 하여 간접적으로 규제하고 있습니다. 70. 대부분의 간호 교육과정 기준에는 최소 임상 실습 시간과 최소 역량이 명시되어 있어 이론과 실습을 통합하여 교육과정의 범위를 넓히게 되어있습니다. 간호 교육과정의 기준은 관할권 별로 다른 경우가 많은데(예를 들어 국가, 주, 혹은 자치법이 있는 지역 등), 이는 간호인력의 이동에 영향을 미칠 수 있습니다. 지역과 정부 간 상호인증협약과 교육요건을 조정한다면 간호 교육과정의 표준화와 간호인력이 안전하고 효율적으로 이동할 수 있도록 합니다. 예로 미국 간호 면허 협약(Nurse Licensure Compact) (250,251), 카리브해 연안 지역 간호 인증협약(Caribbean Regional Examination for Nurse Registration)(252), 유럽연합 전문직업에 관한 지침(European Union Professional Directive)(253,254), 동남아시아 국가 협약(Association of Southeast Asian Nations agreement)(255), 호주와 뉴질랜드가 상호 합의한 트랜스-타스만협약(Trans-Tasman agreement)(256) 등이 있습니다. Box 4.9 는 교육과정 표준화와 자격시험에 관한 협약의 예가 제시되어있습니다. Policy levers to enable the nursing workforce 33 71. 간호사에 관련한 직업 규정은 다음과 같습니다. (1) “간호사” 자격 인증의 처음 요건(예를 들면 간호사 등록 혹은 자격취득과 등록)으로 면허시험이 전제되어있을 수 있습니다. (2) 면허나 등록 갱신: 보수교육 과정(continued professional development)이 포함됩니다. (3) 간호사 역할, 실행규범과 직업윤리(4) 조사와 징계 조치(259). 규제 당국은 활동 간호사 등록을 계속 관리할 의무와 책임이 있습니다. 72. 60%가 넘는 국가에서 면허시험제도를 운용하고 있어 의료행위에 필요한 최소 수준의 지식과 간호실무에 대한 직업적합도를 평가하고 있습니다(29). 또 다른 평가 방법으로 임상술기시험(clinical examination)이 있는데, 실제 의료현장과 비슷하게 이루어진 시험장에서 직업역량을 직접 평가하는 것입니다. 그러나 비용과 인력이 많이 요구됩니다(260-262). 간호실무에 대한 적합도 시험이 면허갱신이나 복직, 혹은 외국에서 교육받은 간호사에게 적용해야하는지에 대한 논의는 여전히 진행 중입니다. Box 4. 9 교육과정 표준화와 자격시험에 관한 협약의 예 1972년에 카리브해 연안 지역 국가들은 지역 간호협회(Regional Nursing Body)를 창설하여 면허시험 정체 현상을 해소하기 위해 간호 교육 인력풀을 공유하기 시작했습니다(252). 이후 연구조사를 통해 지역 간 간호 교육과정의 목적과 내용, 교수 방법이 어느 정도 일치하기 시작하자 1990년에 단일 간호 면허시험제도에 합의하게 되었습니다. 캐러비안 지역 간호협회는 정부 간 협의가 끝난 간호 자격요건에 근거하여 면허시험을 주관하며, 각 간호대학 교수진과 협회장과 관련 부처, 간호대학 교수진, 각국 간호협회가 협의하여 조정합니다(257). 면허시험이 통일됨으로써 간호 교육과정이 표준화되고 호환성을 확보하면서 지역 간 간호사의 이동성도 높아지게 되었습니다. 유럽연합은 복잡하고 다양한 간호학 학위 체제와 교육과정을 합치(合致)하고자 1970년대 후반에 전문직업에 대한 지침을 도입했습니다. 2005년에 이를 개정하고(Directive 36) 뒤이어 직업역량에 대한 표준화된 기준을 마련했습니다(Directive 36). (253,254). 유럽연합국가 간 고등교육기준과 내용을 조정하여 호환성을 확보하는 볼로냐 협약 (Bologna Agreement)과 함께 유럽연합은 고등교육과정을 3단계로 통일하여(학사-석사-박사과정) 표준화된 교육 수준을 확보할 수 있게 되었습니다(258). 34 State of the world’s nursing 2020 © WHO/Sergey Volkov Current status of evidence and data on the nursing workforce 35 간호인력 현황 73. 5장에서는 WHO 역사상 처음으로 190개국 간호인력 현황에 대해 소개하려 합니다. 관련 데이터는 WHO가 제안한 국가별 보건의료 인력 계정(the National Health Workforce Accounts, 이하 NHWA)에 근거하여 일련의 표준화된 지표와 단일 데이터 수집 과정을 거쳐 체계화했습니다. 74. 주로 간호인력의 확보 가능성(Availiablity), 간호인력 구성, 배치, 간호 교육과정과 실습, 기술교육, 관리, 규정, 재정, 간호인력 리더십과 관련된 데이터를 수집하였으며, 총 30개가 넘는 지표를 활용 분석하였습니다. 데이터 수집 과정에 다양한 관계자들, 정부 보건부처, 노동과 교육 부처, 보건 관련 연구소의 인적 자원, 국립보건기관, 간호협회, 간호정책수석 및 조산정책수석, 그 외 국가별, 지역별, 국제단체가 참여하였습니다. 데이터 정의를 통일하고 단일보고 창구로서 NHWA를 통해 데이터를 수집하였습니다. NHWA는 온라인 데이터보관소로, 회원국이 데이터의 보고와 모니터링, 자국의 인적 자원을 활용하여 보건의료 관련 용도로 사용됩니다. 부록 2에 자세한 사항이 수록되어있습니다. 75. 본 장에서는 주로 간호 현황에 대한 분석에 중점을 두었으나, WHO 의료 인적 자원 활용 전략 2030 (WHO Global Strategy on Human Resources for Health: Workforce 2030)에 제시된 목표와 지속가능한 발전목표(SDGs), 보편적 건강보장에 어느정도 근접하는가에 대해 평가하기 위해 다양한 가정 하에 미래에 대한 예측에도 일정 부분을 할애했습니다(16). CHAPTER 36 State of the world’s nursing 2020 76. 자국의 간호사 수(Nursing stock)에 대한 데이터를 공유하는 국가의 숫자가 유례없이 많아져서, 이를 토대로 간호인력에 대한 보고서 중 가장 포괄적이고 최신내용을 포함할 수 있었습니다(Figure 5.1). 간호 관련 정보는 2020년 세계 간호사와 조산사의 해를 맞아 특히 2013-2018년 사이에 다른 보건의료직종에 비해 증가했습니다. 보건의료 인력 현황에 대한 데이터는 최근 몇 년간 양적으로나 질적으로도 증가했으며, 지난 5년간 대다수의 국가에서 SDG 지표 3. c.1(의사, 간호사, 조산사, 치과의사, 약사)에 대한 자료를 보고했습니다. 현재는 물론 과거 자료까지 축적함으로써 지난 자료 부족분을 보완하고 앞서 진행되었던 연구의 한계를 해결할 수 있게 되었습니다. 77. 본 보고서 작성에 사용된 간호인력에 관한 36개의 지표 중 (부록2 Table A2.1) 대부분의 회원국이 자국 간호인력에 관한 자료를 보고했으며, 연령 분포, 성별 구성, 교육기간과 같은 중요 지표에 대한 자료도 보유하고 있었습니다. 80% 이상 국가에서 적어도 15개 이상의 지표에 대한 자료를 공유했으며, 23% 국가는 적어도 25개의 지표를 분석했습니다. 본 5장에서는 많은 회원국이 응답한 지표에 관한 자료를 중심으로 살펴보도록 하겠습니다(자체 지표목록은 부록2에 있습니다). Figure 5. 1 Number of countries with workforce data available in the WHO NHWA (1990–2018) Notes: (a) Considering the last five years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data. Source: NHWA 2019. Countries with dentistry personnel data Countries with nursing and midwifery personnel data Countries with pharmaceutical personnel data Countries with physicians data 191 countries with recent data 83% for years 2017 and 2018 N u m b e r o f c o u n tr ie s Current status of evidence and data on the nursing workforce 37 5.1 간호인력(Nursing workforce)의 확보가능성, 구성 및 분배 5.1.1 주요 발견 ⚫ 191개국에서 제출한 자료를 보면 2018년 전 세계 간호사 수는 대략 2,800만 명이며 그중 69%가 전문직 간호사로 일하고 있습니다. ⚫ 신뢰성 있는 최신자료를 이용할 수 있게 된 것을 고려하여 2013~2018년간 간호인력은 470만 명이 실제로 증가한 것으로 보입니다. ⚫ 172개국에서 전문직 간호사와 준 전문직 간호사의 숫자는 전체 보건 의료인력(의사, 간호 관련 직종 종사자, 조산사, 치과의사, 약사 등)의 대략 59%를 차지하고 있는 것으로 드러났습니다. ⚫ 전 세계적으로 10명 중 9명은 여성이나, 지역별 차이가 있어 예를 들면 아프리카 지역의 여성과 남성 간호사 비율은 3:1입니다. 13개국에서 남성 간호사가 여성 간호사보다 많습니다. ⚫ 지역간 분포 차이가 심한 것으로 나타났습니다. 미주 지역에서 10명 중 8명의 간호사가 3개국(브라질, 캐나다, 미국)에서 일하고 있으며 전체 인구의 57%를 담당하고 있는 것으로 추정됩니다. 아프리카와 지중해 동부 지역에서는 인구당 간호사 비율이 크게 차이가 나 국가별로 100배의 차이를 보이는 경우도 있습니다. ⚫ 6명 중 1명은 10년 내 퇴직을 할 것이며, 미주 지역에서 이러한 경향이 두드러집니다(24%). 그러므로 앞으로 이 지역의 간호사 수급에 어려움이 있을 것으로 예상됩니다. 5.1.2 세계 및 지역별 간호사 수 78. 191개국에서 받은 자료에 의하면 공공 및 민간분야를 합하여 전세계 간호인력은 2천8백만 명으로 추산됩니다. 이 숫자로 보면 인구 1만 명 당 간호사 수는 36.9명인 셈입니다. 그러나 이 수치는 지역 별, 국가별 간호사 비율에 큰 차이가 있음을 보여주지 못합니다.6 79. 미주 지역과 아프리카 지역 인구수는 거의 비슷하나, 인구 10,000명 당 북남미 간호사 수는 미주가 83.4명, 아프리카는 8.7명으로 미주 지역이 아프리 카지역보다 거의 10배 많습니다. 지중해 동부 지역과 동남아시아 지역은 각각 두 번째, 세 번째로 낮은 간호인력 비율을 보이나(10,000명 당 간호사 수는 지중해 동부 지역은 15.6명, 동남아시아 지역은 16.5명), 아프리카 지역에 비하면 간호사 비율이 거의 두 배 가까이 높습니다. 80. 전 세계 81%의 간호사가 세 지역에 분포되어있습니다(미주, 유럽, 태평양 서부지역). 이 세 지역의 인구를 합치면 대략 전체인구의 51%를 차지하고 있다고 볼 수 있습니다. 6 See section 5.2 on equity. 38 State of the world’s nursing 2020 81. 본 보고서에서 추산한 전 세계 간호사 2천790만 명은 2018년 기준이며, 보건의료 인력 활용전략에서 추산한 간호사와 조산사를 합한 2천70만 명은 (이중 간호사 1천880만 명) 2013년 자료를 활용한 것입니다. 따라서 글로벌 보건의료 인력 추정치를 비교하는데 신중한 해석이 필요합니다. 2013 – 2018년간 간호사 증가분의 일부는 자료 이용성이 높아졌기 때문으로 보이며(440만 명 추산), 실제 증가는 대략 470만 명인 것으로 보입니다(Table 5.2). 간호사와 준 간호사 비율이 일정하다고 가정하면, 이중 360만 명은 간호사 숫자로 추정됩니다. Table 5. 1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 WHO REGION Number of countries reporting headcount/total Number of nursing personnela in millions (%) Density per 10,000 population Africa 44/47 0.9 (3%) 8.7 Americas 35/35 8.4 (30%) 83.4 South-East Asia 11/11 3.3 (12%) 16.5 Europe 53/53 7.3 (26%) 79.3 Eastern Mediterranean 21/21 1.1 (4%) 15.6 Western Pacific 27/27 6.9 (25%) 36.0 Global 191/194 27.9 (100%) 36.9 a Includes nursing professionals and nursing associate professionals. Note: stock data were not available for Cameroon, Comoros and South Sudan. Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations. The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the United Nations, Department of Economic and Social Affairs (263). Table 5. 2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 SOURCE Nursing stock in 2013 Nursing stock in 2018 Change due to actual increase in stock (millions) Number of countries with data for 2009–2013 Stock (millions) Number of countries with data for 2013–2018 Stock (millios) Estimate of Global Strategy on Human Resources for Health, 2016 102 18.8a Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7 Change due to improved data (millions) 4.4 a The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses. Source: NHWA 2019. Current status of evidence and data on the nursing workforce 39 82. 2018년에 전세계 간호사가 2천790만 명이라는 것은 2가지의 긍정적인 추세를 의미합니다. • 이전 데이터를 더 잘 해석하고 분석할 수 있는 간호인력 데이터의 가용성의 개선을 의미합니다. • 그리고 간호인력이 실제로 증가하는 현상은 보건의료 인력시장의 간호인력 수요가 증가하고 있으며 이에 따라 각국 정부가 간호인력 분야에 지속해서 투자하고 있다는 것을 보여줍니다. 83. 172개국에서 조사한 간호인력과 간호를 제외한 그 외 보건 의료인력(의사, 조산사, 치과의사, 약사)과 비교하면 간호사는 전체 보건 의료인력 평균 59%를 차지하고 있으며, 지역별로는 지중해 동부지역에서 보건 의료인력 평균 49%, 태평양 서부지역에서 68%를 차지하는 것으로 나타났습니다(Table 5.3). 84. 66개국에서 제출한 최소 10개 보건 의료직업군의 최근 자료를 보아 간호사는 전체 보건 의료인력의 40~50%가량을 차지하고 있다고 추정할 수 있습니다. 5.1.3 구성 85. 2천790만 명의 간호사 인력 중 1천930만 명(69%)은 전문직 간호사(ISCO 코드 2221)이며, 600만 명(22%)은 준간호사(ISCO 코드 3221)로 일하고 있습니다. 260만 명(9%)은 어느 그룹에도 속하지 않은데, 아마도 국가별 직업 분류체계와 ISCO체계가 다른 경우 발생하는 문제인 것으로 보입니다. 간호사 범주는 전문직 간호사나 준 간호사를 포함하며, 간호조무사나 의료보조원(health care assistants)은 제외되었습니다. 간호인력 범주에 따른 상대 비율은 지역별로 매우 큰 차이를 보입니다 (Figure 5.2). Table 5. 3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives, dentists and pharmacists), by WHO region WHO REGION Nurse stocka compared to the stock of SDG 3.c.1 health professionals Number of countries reporting/ total Average share of nurses Africa 45/47 66% Americas 24/35 56% South-East Asia 11/11 53% Europe 50/53 57% Eastern Mediterranean 20/21 49% Western Pacific 22/27 68% Global 172/194 59% a Includes nursing professionals and nursing associate professionals. Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c. Source: NHWA 2019. 40 State of the world’s nursing 2020 Figure 5. 2 Proportion of nursing headcount within each occupation group, by WHO region Percentage of total nursing personnel headcount 5.1.4 간호의 인구통계학적 분석: 성별, 연령에 따른 분포비교 성별 분포 86. 보건의료 인력에 관한 성평등 정책(Gender mainstreaming)을 수립하기 위해서는 근거 중심의 성 평등 개념을 고려하여 보건의료 인력에 관한 계획을 세우고 관리해야 합니다. (역주. 유럽의회(Council of Europe)에 따르면 성평등 정책(Gender mainstreaming)은 여성과 남성의 관심사와 요구사항을 동등하게 고려하여 정책을 세우려는 시도를 일컫는 용어입니다.) 간호인력의 성별 구성과 고령화에 대한 문제는 여러 가지 이유로 오랫동안 간과되어 왔습니다. 그동안 국가 정책을 세우거나 지역적 상황 비교에 필요한 구체적 자료가 부족했기 때문입니다. 194개 WHO 회원국 중 132개국이 성별로 세분화한 자료를 공개했으며, 106개국에서 연령에 따른 자료를 보내왔습니다. 자료에 의하면 약 10명 중 9명(89%)의 간호사가 여성이며, 지역별로 격차가 크게 나는 것으로 드러났습니다. 여성 간호사 비율이 가장 높은 지역은 태평양 서부지역으로 비율이 95%에 이르며, 가장 낮은 지역은 아프리카로 여성 간호사 비율이 76%로 추산됩니다. 반면 13개 국가에서 남성 간호사의 수가 여성보다 많은 것으로 보고되었습니다(Table 5.4). 연령 분포 87. 전 세계 인구 동향의 변화와 노동인구의 고령화로 인해 앞으로는 노동 인구의 연령별 구성을 고려해야 합니다. 그동안 정책 입안자들이 표준 은퇴 연령만 계산에 포함했지만, 직업별, 성별, 직위별로 실질적 은퇴 연령에 차이가 있기 때문에 이러한 접근법은 한계가 있을 수밖에 없습니다. 106개국 연령별 구조에 관한 자료를 사용하여 간호인력의 인구통계학적 분석을 시행하였습니다. WHO REGION Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific Professional nurses Associate professional nurses Nurses not further defined Global Current status of evidence and data on the nursing workforce 41 7 Herewith called young nurses. Table 5. 4 Percentage of female nursing personnel, by WHO region WHO REGION Number of countries reporting/total % female % male Africa 30/47 76% 24% Americas 26/35 87% 13% South-East Asia 9/11 89% 11% Europe 32/53 89% 11% Eastern Mediterranean 11/21 78% 22% Western Pacific 24/27 95% 5% Global 132/194 89% 11% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. Figure 5. 3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. WHO REGION Africa (n=20) Americas (n=25) South-East Asia (n=8) Europe (n=30) Global (n=106) Eastern Mediterranian (n=5) Western Pacific (n=18) <35 years ≥55 years 42 State of the world’s nursing 2020 자료에 따르면 간호사는 상대적으로 젊은 층이 다수를 차지하는 것으로 보입니다. 38%의 간호사가 35세 이하인 반면, 55세 이상의 간호사 비율은 17%로 확인되었습니다(55세 이상 간호사 그룹은 향후 10년 내에 은퇴하게 됩니다)(Figure 5.3). 그러나 지역별 차이가 있습니다. 지중해 동부지역 국가에서 55세 이상 간호사 1명 당 14명의 35세 이하의 젊은 간호사가 있지만, 미주 지역은 1.2:1, 유럽과 아프리카는 1.9:1의 비율로 간호사 인력풀이 매우 축소된 것으로 나타났습니다. 88. 전 세계적으로 55세 이상의 간호사 비율은 17%입니다. 그러므로 이들은 향후 10년 내에 은퇴하게 될 것입니다. 따라서 현 상태를 유지하기 위해 향후 10년간 470만 명의 새로운 간호사를 교육하고 고용해야 합니다. 인구 성장 속도에 발 맞추어 부족한 간호사를 충당하기 위해서는 앞으로 더 많은 간호사가 필요하게 될 것입니다(section 5.8 참조). 89. 간호인력의 고령화 현상을 살펴보기 위해 Figure 5.4에 젊은 간호인력과 55세 이상 간호인력의 비율을 나타냈습니다. 몇 개 국가에서는 젊은 간호사 비율이 높지만 겨우 현상을 유지하고 있는 국가도 있습니다(35세 이하 그룹과 55세 이상 그룹의 비율이 비슷한 국가들은 Figure 5.4에서 녹색 선으로 표시했습니다). 그리고 18개 국가는(자료를 제공한 국가 6개국 당 1개국) 은퇴에 가까운 연령 그룹의 비율이 35세 이하 그룹보다 높아 간호사 인력 수급에 어려움을 겪고 있습니다. Figure 5. 4 Relative proportions of nurses aged over 55 years and below 35 years ● Each dot represents a country / Green line indicates where the number of nurses near retirement equals the number of young nurses in the workforce. Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. 18 countries at risk of an ageing workforce Percentage of nurses less than 35 years P e rc e n ta g e o f n u rs e s a g e d 5 5 + y e a rs Current status of evidence and data on the nursing workforce 43 5.2 간호인력 수급과 접근에 있어서의 형평성 90. 보편적 건강보장을 성취하기 위해서 보건의료 인력 수급의 인구통계학적, 지리적, 기술적 불균형문제를 해결해야 합니다. 5.2.2 지역별 인구당 간호사 비율 91. Figure 5.5는 인구 1만 명 당 간호사 비율의 지역별 차이를 나타내고 있습니다. 심각한 불균형 현상이 아프리카, 동남아시아, 지중해 남부지역, 라틴 아메리카 일부 지역에 집중되어있습니다. 5.2.3 지역별 인구당 간호사 비율 불균형 92. Figure 5.6은 국가별 간호사의 수급률 차이를 나타냈습니다. 그래프에 찍힌 점은 국가를 가리킵니다. 국가별로 간호사 수급 비율은 다르나 불균형이 가장 심각한 지역은 지중해 동부지역으로 가장 높은 국가대 가장 낮은 국가의 간호인력 밀도의 비율은 121:1 입니다. 아프리카 지역에서는 가장 높은 국가 대 가장 낮은 국가의 간호인력 밀도의 비율은 100:1입니다. 또한, 미주 지역에서 큰 나라의 간호사 수급 비율은 대부분의 작은 나라들보다 높아, 이 지역 간호사의 87%가 브라질, 캐나다, 미국에 집중되어 있습니다. 세 국가 인구는 지역의 57%를 차지하고 있습니다. 간호사 수급 비율이 인구 1만 명 당 10명에서 1명까지 낮은 국가들은 유럽지역에 분포되어 있다는 것을 볼 수 있습니다. 아프리카 대다수 국가가 그래프의 하단에 밀집되어 있으며, 소수의 국가만이 인구 1만 명 당 25명 이상의 간호사 비율을 보이고 있습니다. 아프리카와 비슷한 경향이 동남아시아지역과 지중해 동부지역에도 나타납니다. 간호사 수급 비율이 이렇게 다양하게 나타나는 것은 주로 소득수준에 따른 경제적 이유 때문인 것으로 보이는데, 저소득 국가에서 간호사 수급 비율은 인구 1만 명 당 9.1명인데 반해 고소득 국가에서는 인구 1만명 당 107.7명의 간호사가 배치되어 있습니다(Table 5.5, Figure 5.7). 5.2.1주요 발견 ⚫ 세계 간호인력의 81%는 미주, 유럽, 태평양 서부 지역에 집중되어 있으며, 이 세 지역의 인구 비율은 전 세계 인구의 51%를 차지하고 있습니다. ⚫ 간호사 비율이 낮은 지역은 대부분 아프리카, 동남아시아, 지중해 동부 지역, 라틴아메리카 일부 지역 국가입니다. ⚫ 이렇게 간호사 수급 불균형이 생기는 것은 크게는 경제적 차이 때문인 것으로 보입니다. 저소득 국가는 인구 1만 명 당 9.1명의 간호사 비율이지만 고소득 국가에서는 인구 1만 명 당 간호사 비율이 107.7명에 달하기 때문입니다. ⚫ 지역별 불균형도 심각합니다. 35개 국가에서 인구 49%가 거주하고 있는 지방에는 36%의 간호사가 근무하고 있습니다. 76개국에서 75%의 간호사가 공공부문 의료기관에 고용된 반면 25%는 민간부문에서 일하고 있습니다. 44 State of the world’s nursing 2020 Figure 5. 5 Density of nursing personnel per 10 000 population in 2018 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available data over the period 2013–2018. Figure 5. 6 Regional disparities in density of nursing personnel per 10 000 population (2018) WHO regions Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. not applicable not reported 10 to 19 <10 30 to 39 20 to 29 40 to 49 75 to 99 50 to 74 100+ Ratio maximum: minimum density Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific N u m b e r o f n u rs e s p e r 1 0 0 0 0 p o p u la ti o n Current status of evidence and data on the nursing workforce 45 93. 유엔개발정책위원회(UNCDP)가 저개발국가로 분류한 46개국에서 2018년 12월 기준 인구 1만 명 당 간호사 수는 6.4명으로 국제 간호사 평균 수급률보다 6배 더 낮은 수치이며, 저소득국가 평균 수급률보다도 상당히 낮은 수치입니다. 이들 46개국 대부분이 또한 취약국가지수(the Fragile States Index)에서 높은 순위에(“고위험” 혹은 “주의”단계) 올라있습니다8. Box 5.1 에서 국가 내 자세한 추가 정보를 확인할 수 있습니다. 8 Countries with a Fragile States Index score of 80+. Source: https://fragilestatesindex.org/. Figure 5. 7 Density of nursing personnel per 10 000 population by income group (2018) Level of income Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. Low-income Lower middle income Upper middle income N u m b e r o f n u rs e s p e r 1 0 0 0 0 p o p u la ti o n High-income 46 State of the world’s nursing 2020 Table 5. 5 Density of nursing personnel per income group (2018) INCOME GROUP Number of countries reporting/total Density per 10 000 population Ratio highest to lowest Overall Low High Low-income 30/31 9.1 0.6 42.0 68:1 Lower middle-income 44/46 16.7 1.8 104.6 57:1 Upper middle-income 60/60 35.6 5.0 124.2 25:1 High-income 57/57 107.7 19.4 196.1 10:1 Global 191/194 36.9 0.6 196.1 319:1 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018. For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle- income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018. 9 Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of). Box 5. 1 국가 내 간호인력 수급의 형평성 지방에서 근무하는 간호인력 비율 국가 내 간호인력의 적절한 배치는 의료접근성과 관련하여 매우 중요합니다. 총 35개국(대부분 라틴 아메리카와 아프리카 지역국가)이 지방 간호인력에 대한 자료를 제공했습니다. 평균적으로, 이들 국가들에서 지방 거주 인구의비율은 50%인데, 대략 35%의 간호사가 지방에 배치되어 있습니다. 공공부문과 민간부문에서 간호인력 확보 간호인력 수급 불균형은 일개 국가 내에서도 공공부문과 민영부문에 따라 달라지기도 합니다. 76개국이 제공한 자료에 의하면 평균 75%의 간호사들이 공공부문에서 일하고 있는데, 지역 간 공공, 민간 배치의 지리적 차이가 크지 않습니다. Current status of evidence and data on the nursing workforce 47 5.3 간호사의 국제 이동 5.3.2 간호사 국제 이동 수량화의 어려움 94. 인구통계학적, 역학적, 재정적, 보건 관련 정책의 변화로 최근 수 십 년 동안 보건의료 인력의 국제이동이 가속화되었으며, 앞으로도 이러한 경향은 점점 늘어갈 것으로 보입니다(18). 2010 세계 보건 총회가 채택한 WHO 국제 보건의료 인력 채용에 관한 실행 규정(The WHO Global Code of Practice on the International Recruitment of Health Personnel)은 보건의료 인력의 윤리적인 관점에서 국제이동에 대한 규제를 강화하는 중요한 국제법입니다. 95. 저소득국가에서 고소득국가로 향하는 보건 인력의 이동과 이에 관련된 문제는 오래 전부터 인식되었고 이에 대한 논의가 끊이지 않고 있습니다. 정책 수립에 필요한 자료는 몇몇 고소득 국가들에 한정되어왔습니다. 최근 자료 접근성이 향상되면서, 특히 NHWA를 통해 내린 결론은 이민을 보내는 국가(지구 남반구 지역)와 받아들이는 국가(지구 북반구지역) 사이의 경계가 생각보다 분명하지 않다는 것입니다. 96. 2018년 기준 총 86개국이 NHWA, OECD, 유로스탓(Eurostat), WHO 유럽 지역사무소(Regional Office for Europe reporting systems)를 통해 제공한 외국 출생 혹은 외국에서 교육받은 간호사 비율에 대한 자료는 인력의 국제이동 정도를 가늠하는 간접 지표로 사용할 수 있습니다. 관련 자료에 따르면 8명 중 1명의 간호사(13%)가 외국 출생이거나 외국에서 교육을 받은 것으로 집계되었습니다. 전체 간호사를 보면 대략 370만 명이 외국 출생이거나 외국에서 간호 교육을 받은 간호사로 추정됩니다. 외국 출생이거나 외국에서 교육을 받은 간호사의 15.2%가 고소득국가에서 일하고 있으며, 2%는 그 외 소득 그룹 국가에서 일을 하고 있습니다. 5.3.1 주요 발견 ⚫ 86개국이 제공한 자료에 따르면 간호사 8명 중 1명(13%)은 외국 출생이거나 외국에서 간호 교육을 받은 것으로 드러났습니다. ⚫ 응답 국가 중 고소득 국가에서 외국 출생 간호사 의존율이 많이 증가하고 있는 것으로 나타나 15.2%의 간호사가 외국 출생이거나 외국에서 교육받은 것으로 보고되었습니다. ⚫ 자료 접근성이 확대되었음에도 불구하고 간호사의 이민이나 국제이동에 대한 자료는 이동패턴을 분석하기에는 아직 부족합니다. 48 State of the world’s nursing 2020 Table 5. 6 Percentage of nursing personnel foreign born (or foreign trained) per income group INCOME GROUP Number of countries reporting/total % of nurses foreign born or trained Low-income 3/31 NR Lower middle-income 18/46 0.4% Upper middle-income 27/60 0.7% High-income 38/57 15.2% Total 86/194 13.2% Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that could not provide data on the percentage who were foreign born. Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018. NR = not reported because of the small number of countries. © Ian Miles-Flashpoint Pictures/Alamy Current status of evidence and data on the nursing workforce 49 5.4 간호 교육과정에 대한 제도와 규제 5.4.2 자료 분석 97. WHO 세계 보건의료 인적자원 활용 전략 2030은 2020년에 각국 정부가 간호 교육에 관한 규제와 인증제도를 갖추어야 한다고 권고합니다. 이 섹션은 9개의 간호 교육 관련 지표를 분석하여 정리한 내용을 실었습니다(Figure 5.8). 98. 대다수의 국가가 간호 교육의 교육 기간과 교육내용의 표준화를 시행하고 있으며(91%), 간호 교육기관 인증제도(89%), 인증 교육기관의 종합목록을 갖추고 있습니다(81%). 응답 국가의 77%가 교원 자격 기준을 갖추었고, 73%가 보수교육(continuing professional development systems)을 운영하고 있습니다. 2/3의 국가에서 전문직간 교육(interprofessional education)에 관한 규정(67%), 자격시험에 관한 규정이 있으며(64%), 간호교육협의회(a national association for pre-licensure students)를 운영(62%)하고 있는 것으로 조사되었습니다. 95개의 응답 국가 중 53% 국가에서 전문 간호사제도를 운용하고 있습니다. 이러한 제도를 갖추고 있다고 해서 의료체계 안에서 전문 간호사들이 규정된 대로의 역할을 수행할 수 있다는 의미는 아닙니다. 99. Table 5.7에 WHO 분류지역에서 운영되고 있는 간호 교육 관련 제도와 규정을 요약정리하였습니다. 아프리카, 미주와 유럽지역은 다른 지역보다 간호 교육에 관한 규정을 갖추고 있습니다. 지중해 동부 지역 국가들은 자격시험제도와 전문 간호사제도를 운용하고 있다고 보고했습니다. 동남아시아 지역에서 보수교육체계, 간호대학생협의회, 전문직간 교육에 관한 규정 등을 갖추고 있다고 보고한 국가는 아주 소수에 그쳤습니다. 이렇게 지역 간 격차가 큰 이유로 관련 지표에 대해 해석이 서로 다른 데에도 기인하는 것으로 보입니다. 5.4.1 주요 발견 ⚫ 거의 대부분의 국가에서 간호 교육과정에 대한 제도와 규제에 관한 자료를 제공하였으며, 50% 이상의 국가가 9개의 관련 지표에 대해 긍정적으로 응답했습니다. ⚫ 간호교육 규정과 절차의 존재는 아프리카, 미주와 유럽지역에서 높게 보고되었습니다. ⚫ 각국 정부는 교육 리더십(역주1)이나 거버넌스(역주2) 같은 수평적 규제보다는 교육 기간과 내용의 표준화, 교육 인증제도 등 교육과정에 관한 수직적 규제에 더 중점을 두고 있습니다. (역주: 1. 교육리더십은(Education leadership) 교사, 학생, 학부모가 함께 노력하여 공동의 교육목표를 달성하고자 하는 과정을 말합니다. 2. 거버넌스(governance)란 단어는 정책 수립에 정부뿐 아니라 다양한 이해당사자가 협의하는 수평적 네트워크를 의미합니다. 출처: 교수신문(http://www.kyosu.net)) ⚫ 간호 교육체계, 특히 면허시험과 교원 자격 요건에 대해서 유럽지역이 동남아시아, 지중해 동부지역, 태평양 서부지역 국가보다 더 엄격한 규제를 하고 있습니다. 50 State of the world’s nursing 2020 Figure 5. 8 Percentage of responding countries indicating existence of nursing regulations and standards Standards for duration and content of education (154 yes out of 169) Accreditation mechanisms for education institutions (147 yes out of 165) Master list of accredited education institutions (118 yes out of 146) Standards for faculty qualifications (76 yes out of 99) Continuing professional development (96 yes out of 132) Standards for interprofessional education (66 yes out of 99) Fitness for practice examination (73 yes out of 114) National association for pre-licensure students (55 yes out of 89) Existence of advanced nursing roles (50 yes out of 95) Percentage of countries reporting yes Table 5. 7 Percentage of responding countries reporting existence of nursing regulations on education and training, by WHO region WHO REGION Master list of accredited education institutions Standards for duration and content of education Accreditation mechanisms for education institutions Standards for interpro- fessional education Continuing professional development Existence of advanced nursing roles Fitness for practice examination Standards for faculty qualifications National association for pre- licensure students Africa 91% 100% 90% 81% 68% 74% 68% 78% 66% Americas 77% 91% 94% 49% 71% 55% 57% 75% 91% South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38% Europe 85% 94% 98% 87% 91% 30% 64% 94% 67% Eastern Mediterranean 80% 80% 70% 20% 50% 50% 70% 80% 30% Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35% Global 81% 91% 89% 67% 73% 53% 64% 77% 62% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between 2013 and 2018. Current status of evidence and data on the nursing workforce 51 100. 9개의 관련 지표를 이용하여 국가별 “간호 교육과정”에 관한 점수표를 작성하였습니다(부록2 참조). 각 지표는 점수 0점(없음)에서 1점 (있음)으로 정했으며, 0.5점은 ‘부분적으로 있음’, 답변 누락은 0점으로 처리하였습니다. 점수는 합산되며, 합계점수의 최고점은 9점입니다. 미응답은 0점으로 처리했기 때문에, 지표 값 변수에 따라 나타나는 예상 결과들을 분석하는 민감도 분석(sensitivity analysis)을 사용하였으나 결과에는 크게 변화가 없었습니다. Figure 5.9는 본 보고서에서 간호 교육과정에 관한 점수표를 바탕으로 분석한 것으로, 북미와 서유럽, 사하라 이남 아프리카 지역에서 상대적으로 간호 교육과정에 대한 제도와 규제가 더 엄격하게 시행되고 있음을 보여줍니다. Figure 5. 9 Map of nursing education regulation scores, by country Note: Combining education capacity questions, raw score from 0 to 9. Source: NHWA 2019. not applicable not reported 4 and less 52 State of the world’s nursing 2020 5.5 간호 교육과 간호인력 배출 5.5.2 순차적 교육 체계(Education Pipeline) 101. 현재 의료 체계의 수요를 충족시키고 국가 간 불균형을 해소하기 위해서 그리고 앞으로 예상되는 인력 부족을 해소하기 위해 간호 교육 분야에 지속해서 투자해야 합니다. 102. 기본교육부터 대학까지 연결되는 순차적인 교육체계 평가를 위해 각국에 가장 최근 몇 년간의 간호대학 졸업생 자료를 요청했습니다. 총 88개국(그 중 절반 이상인 44개국이 유럽지역 국가)에서 자료를 제공했습니다. Table 5.8에 보이는 “총합(Total)”은 동남아시아와 유럽지역 국가의 자료가 주로 집적되어 계산된 것이므로 다른 지역의 현황을 파악하기에 부족합니다. 103. 간호사 수급률과 유사하게 소득수준은 인구 10만 명 당 간호대학 졸업생의 배출에 영향을 미칩니다. 104. 자료를 토대로 하여 졸업생 추정치를 산출하여 이를 세계인구에 적용하면, 인구 10만 명 당 간호대학 졸업생을 평균 22.6명으로 산출할 수 있으며, 이를 근거로 하면 매년 172만 명의 졸업생이 배출된다고 볼 수 있습니다. 이 분석 결과는 유럽을 제외한 지역별 소수 국가의 자료를 바탕으로 했기 때문에 순전히 가상의 결과로 봐야 합니다. 이러한 제한성에도 불구하고 이 가상의 분석 결과는 간호 졸업생 비율에 있어 큰 차이를 보이지 않았습니다. 이 가상의 분석 결과를 35세 이하 연령 그룹(약 10년 이내 경력)이 차지하는 비율과 비교하였습니다. 전체 1/10을 차지하는 젊은 연령 그룹의 간호사를 해마다 보건의료 인력시장에 진입하는 졸업생 수라고 보면 106만 명이 추산됩니다. 이를 매년 배출되는 졸업생 추정치 172만 명에 비교하면, 모든 졸업생이 간호사로 채용되지는 않기 때문에, 이렇게 추정된 수치는 타당해 보입니다. 5.5.1 주요 발견 ⚫ 대부분 동남아시아와 유럽 지역의 국가들로 구성된 총 88개국은 매년 배출되는 간호 관련 교육기관의 졸업생 숫자를 보고했습니다. ⚫ 간호사 수급률이 낮은 지역(아프리카, 지중해 동부지역, 동남아시아 지역)은 또한 졸업생의 수도 낮게 나왔습니다(인구 10만 명 당 아프리카는 7.7명, 지중해 동부지역은 7.1명, 동남아시아 지역은 12.2명으로 집계되었습니다). ⚫ 미주지역은 인구대비 아프리카와 지중해 동부지역보다 상대적으로 10배가 넘는 졸업생을 배출했습니다. ⚫ 자료를 제공한 국가들 중 아프리카와 태평양 서부지역 국가의 75% 이상은 간호 교육과정이 평균 2~3년이며, 미주와 동남아시아, 지중해 동부지역 국가의 절반 이상이 4~5년의 교육과정을 운영하고 있었습니다. Current status of evidence and data on the nursing workforce 53 Table 5. 8 Production of graduate nurses, by WHO region and income group BY WHO REGION Number of countries reporting/tota l Mean number of nursing graduates per 100 active nurses Number of graduates per 100 000 population Overall Low High Africa 14/47 8.8 2.8 23.7 7.7 Americas 14/35 9.8 0.8 30.8 81.2 South-East Asia 8/11 7.5 3.9 13.8 12.2 Europe 41/53 4.0 1.0 31.9 31.9 Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1 Western Pacific 6/27 5.7 3.4 12.0 20.6 BY INCOME GROUP Low-income 8/31 13.8 4.1 31.9 10.4 Lower middle-income 15/46 7.7 2.8 13.8 12.8 Upper middle-income 26/60 6.4 0.6 30.8 22.7 High-income 40/57 3.6 1.5 7.6 38.7 Total 88/194 6.2 0.6 31.9 22.6 Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018. 54 State of the world’s nursing 2020 © WHO/Yoshi Shimizu Current status of evidence and data on the nursing workforce 55 5.5.3 간호 교육과정 기간 105. 간호 교육과정 기간에 대한 자료는 157개국에서 수집했습니다. 아프리카와 지중해 동부지역, 태평양 서부지역의 몇몇 국가에 2년의 간호 교육과정이 있으며, 그 외 세계 대다수의 국가는 3~4년 기간의 교육과정을 운영하고 있습니다. 5년 이상의 교육 기간을 가진 국가는 드물었습니다(Figure 5.10). 아프리카와 서태평양 지역에서는 3/4의 국가들이 3년 교육과정을 운영하고 있고 동남아시아 지역에서는 거의 3/4의 국가들이 4년 교육과정을 운영하고 있습니다. 106. 간호사 역할의 범위가 점차 확대되어가는 이 시점에, 고등 간호 교육과정에 대한 논의가 필요한 것으로 보입니다. 더불어 고등 간호 교육과정 입학 경로의 다양화도 생각해 볼 필요가 있습니다. (입학 자격요건에 대한 논의도 함께) 자료를 활용하는 데 있어, 간호 교육과정 기간의 상이성으로 인해 세계적으로 다양하게 시행되는 간호 교육과정, 특히 전문 간호사(advanced practice roles)에 대해 분석하는 것은 어려움이 있습니다. Figure 5. 10 Average duration (years) of education for nursing professionals, by WHO region Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018. WHO REGION Africa Americas South-East Asia Europe Eastern Mediterranian Western Pacific 2 years Global 3 years 4 years 5 years 56 State of the world’s nursing 2020 5.6 고용 및 근무 환경에 관한 규제 5.6.2 결과 분석 107. 고용 특성과 근무환경은 고용과 업무, 생산성을 촉진하는 원동력이자, 이직을 줄여 기존 보건의료 인력 수준을 유지하는 요인이 되기도 합니다. WHO 세계 보건의료 인적자원 활용 전략 2030은 ”모든 의료직 종사자들이 안전하고 좋은 근무환경에서 어떠한 종류의 차별이나 강제, 폭력으로부터 자유롭게 본연의 직무를 다할 수 있도록 개인의 권리와 직업적 권리”를 지지해 달라고 요청하고 있습니다. 이 부분의 평가를 위해 고용 특성과 근무환경을 규정하는 6개의 지표를 분석했습니다(Figure 5.11). 지표 3개는 (근무시간과 근무환경, 간호협의회, 전문 간호사제) 간호 분야에 특정한 것이며, 나머지 3개 지표는(사회보장, 최소임금, 의료진 폭행 방지에 관한 규정) 간호사를 포함한 모든 의료직 종사자에 적용됩니다 108. 응답 국가의 80% 이상에서 근무시간과 근무환경, 사회보장, 최소임금, 간호협의회 혹은 그에 상응하는 조직에 관한 규정이 마련되어있다고 답했으나, 전문 간호사제를 운영하는 국가 비율은 53%에 그쳤습니다. 총 55개국에서 의료진 폭행 방지에 관한 규정이 마련되어 있다고 답했으나, 이 중 1/3 국가(37%)만이 규정대로 운영이 되고 있다고 밝혔습니다. 109. Table 5.9에 보면, 지중해 동부지역 국가들이 높은 수준의 간호사 고용 규정을 적용하고 있으며, 70%가 넘는 국가들이 6개 지표 모두에 긍정적으로 답했습니다. 동남아시아 지역과 지중해 동부 지역은 유일하게 이 지역 대다수 국가가 의료진 폭행 방지에 관한 규정을 마련하고 있다고 답했는데, 이는 아마도 의료진에 대한 공격 발생 빈도수가 높은 것과 연관이 있어 보입니다. 아프리카, 미주, 유럽지역 국가들 또한 거의 모든 지표에 긍정적으로 대답했으나 전문간호사제도를 운용하는 국가의 비율은 30%, 의료진 폭행 방지에 관한 규정이 마련되어 있다고 답한 국가 비율은 26%에 그쳤습니다. 5.6.1 주요 발견 ⚫ 아프리카, 미주, 유럽, 지중해 동부지역 국가들은 간호사의 근무환경에 대한 지표에 대해 자국 내 관련 규제가 높은 수준으로 이루어지고 있다고 답했습니다. ⚫ 반면 대부분의 동남아시아와 태평양 서부지역, 그리고 몇몇 아프리카지역, 남미 지역 국가에서 관련 규정이 미비한 것으로 드러났습니다. ⚫ 동남아시아와 지중해 동부지역에서는 1/3 수준의 국가(37%)만이 의료진 폭행 방지에 관한 규정이 마련되어 있다고 답했습니다. ⚫ 전문간호사제도를 운영하는 국가(95개 국가의 53%)의 경우 의료 인력(의사) 수급률이 낮은 경우가 많았으며, 이로 보아 간호사에게 독자적인 진료 권한을 부여하는 것은 보건의료 인력 부족 현상 해소를 위한 대책으로 마련된 것으로 보입니다. Current status of evidence and data on the nursing workforce 57 Figure 5. 11 Percentage of countries with regulatory provisions on working conditions Regulation on working hours and conditions (133 yes out of 42) Regulation on social protection (125 yes out of 37) Regulation on minimum wage (119 yes out of 134) Nursing council (141 yes out of 164) Existence of advanced nursing roles (50 yes out of 95) Measures to prevent attacks on health workers (20 yes out of 55) Percentage of countries reporting yes Note: The number of countries responding yes out of responding countries for each indicator is shown in parentheses next to each indicator. Source: NHWA 2019. Table 5. 9 Percentage of countries responding on existence of nursing regulations on working conditions, by WHO region WHO REGION Regulation on working hours and conditions Regulation on minimum wage Regulation on social protection Measures to prevent attacks on health workers Existence of advanced nursing roles Nursing council Africa 90% 90% 85% 41% 74% 78% Americas 97% 85% 94% 37% 55% 91% South-East Asia 75% 50% 50% 67% 50% 80% Europe 98% 92% 100% 26% 30% 96% Eastern Mediterranean 85% 100% 92% 73% 75% 85% Western Pacific 100% 86% 57% 30% 52% 78% Global 94% 89% 91% 37% 53% 86% Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013 and 2018. 58 State of the world’s nursing 2020 110. 태평양 서부지역의 많은 국가들이 근무시간과 근무환경, 최소임금에 관한 규정이 있으며, 간호협의회 혹은 그에 상응하는 조직에 대한 규정을 마련했다고 밝혔습니다. 그러나 다른 3개 지표(사회보장, 의료진 폭행 방지에 대한 규정, 전문간호사제도)에 대한 구비 수준은 낮았습니다. 동남아시아 지역은 규제 관련 지표에 대한 긍정적 응답이 가장 낮았으나, 이 지역 절반 가량의 국가들이 6개 지표에 모두 긍정적으로 대답했습니다. 5.4항에서 말했듯 이러한 지역별 응답의 차이는 어느 정도 지표를 개념짓는 생각의 차이에서 기인하며, 지역별 응답률의 차이가 원인인 것으로도 보입니다. 수집된 자료로는 관련 규정의 적합성이나 실행 수준에 대한 내용은 확인할 수 없습니다. 111. 6개 지표 자료는 “근무환경에 관한 규정” 점수표를 만드는 데 사용되었으며, 5.4. 항에서 사용된 것과 유사한 방법으로 작성되었습니다(자세한 사항은 부록2에 기록되어 있습니다). Figure 5.12에서 5.4항 교육체계 분석 결과처럼, 규제 관련 지표도 북미, 사하라 이남 아프리카지역, 유럽지역에서 상대적인 강세를 보입니다. 10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. Figure 5. 12 Percentage of countries with regulatory provisions on working conditions Note: Combining working condition capacity questions, raw score from 0 to 6. Source: NHWA 2019. not applicable not reported 1 or no Current status of evidence and data on the nursing workforce 59 112. Figure 5.13에서 볼 수 있듯이 전문 간호사제도는 의료진(의사) 수급률이 낮은 국가에서 운영하는 경우를 많이 찾을 수 있습니다 Figure 5. 13 Percentage of countries with advanced nursing role by level of density of medical doctors per 10 000 population Medical doctors density per 10 000 population Source: NHWA 2019. P e rc e n ta g e o f c o u n tr ie s w it h a d v a n c e d n u rs in g r o le 60 State of the world’s nursing 2020 © AKDN/Christopher Wilton-Steer Current status of evidence and data on the nursing workforce 61 5.7 거버넌스와 리더십 5.7.1 주요 발견 ⚫ 115개국(71%)이 간호 관련 정책 수립에 관여하는 정부 간호정책수석(GCNO)이나 조산정책수석이 있다 고 응답했으며, 53%의 국가가 간호 리더십 교육과정을 운영하고 있다고 밝혔습니다. ⚫ 간호정책수석 직위와 간호 리더십 교육과정이 있는 국가는 더욱 적극적인 간호 정책을 수립할 수 있는 조건을 갖추고 있는 것으로 볼 수 있습니다. ⚫ 그러나 정부 간호정책수석(GCNO)이나 간호 리더십 교육과정 모두 간호사 배출률 증가와 관련이 있는 것은 아닙니다. 62 State of the world’s nursing 2020 5.7.2 자료 분석 113. 간호 관련 분야 개발을 위해서는 강력한 간호 리더십과 거버넌스가 필요합니다(264,265). 본 보고서의 지표들은 리더십과 거버넌스 평가, 즉 정부 내 간호정책수석(GCNO) 존재 여부(115개국 자료 제공), 리더십 교육과정과 정책연구, 정책 활용 능력을 개발하는 교육과정 시행에 관한 정부 지원(76개국 자료제공)이 이루어지고 있는가를 살펴보고자 했습니다. 114. 간호정책수석 직위에 관해 대답한 115개국 중 71%가 자국 내 간호정책수석 직위가 있다고 응답했으며, 지중해 동부지역 국가의 54%, 유럽지역의 86% 국가는 이러한 직위를 마련하고 있습니다(Table 5.10). 리더십 교육과정을 운영하고 있다고 답한 국가 비율은 보다 적었으며(응답한 76개국 중 53%), 동남아시아 지역 국가의 40%, 아프리카 지역 국가의 64% 국가가 이러한 제도를 마련하고 있다고 답했습니다. 115. 강력한 규제 환경과 리더십, 거버넌스 사이에 의미 있는 관련이 있습니다. Figure 5.14에서 볼 수 있듯이, 간호정책 수석과 리더십 교육과정을 운영하는 국가들은 간호사의 근무 조건과 간호 교육과정에 관한 규정 지표에서 더 높은 점수를 얻었습니다. 116. 간호정책수석과 리더십 교육과정의 존재가 모두 강력한 규제 환경과 연관이 있으나, 간호정책수석 직위보다는 리더십 교육과정 운영이 조금 더 큰 연관성을 보입니다. 즉, 정부 조직 내 고위급 간호 관련 직위체제가 있다고 하여 언제나 리더십 교육과정 도입과 같은 결과를 이루는 것은 아니라는 뜻입니다. 실제 간호정책수석 제도가 있다고 답한 국가의 37%가 리더십 교육과정을 운영하고 있지 않았습니다. 117. 간호 분야에 리더십과 거버넌스 향상이 또한 투자로 이어지느냐에 대한 가설을 확인하기 위해, 간호대학 졸업생을 늘리고 신규간호사 채용이 촉진되었는가를 입증하는 방법을 사용했습니다. 즉 리더십과 거버넌스 제도에 대해 긍정적으로 응답한 국가의 졸업생 비율을 부정적으로 응답한 국가의 졸업생 비율과 비교한 것입니다. 통계적으로 유의미한 연관관계는 밝혀지지 않아, 강력한 리더십과 거버넌스 제도가 반드시 간호인력 증가로 이어지는 것은 아닌 것으로 보입니다. . Table 5. 10 Leadership and governance indicators: percentage of countries with chief nursing officer position and nursing leadership development programme, by WHO region WHO REGION Chief nursing officer position Nursing leadership development programme Number of countries responding/total % yes Number of countries responding/total % yes Africa 26/47 60% 28/47 64% Americas 26/35 79% 16/35 46% South-East Asia 6/11 60% 4/11 40% Europe 30/53 86% 10/53 56% Eastern Mediterranean 7/21 54% 8/21 62% Western Pacific 20/27 74% 10/27 43% Global 115/194 71% 76/194 53% Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018. Current status of evidence and data on the nursing workforce 63 Figure 5. 14 Association between GCNO and nursing leadership programme and the regulatory environment Working conditions Education regulations Source: State of the world’s nursing 2020 specific indicators, 2019. N u rs in g w o rk in g c o n d it io n s c o re N u rs in g w o rk in g c o n d it io n s c o re N u rs in g e d u c a ti o n re g u la ti o n s c o re N u rs in g e d u c a ti o n re g u la ti o n s c o re GCNO GCNO No GCNO No GCNO GCNO GCNO Leadership programme No leadership programme leadership programme No leadership programme leadership programme P=0.008 (Kruskal-Wallis test) P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test) 64 State of the world’s nursing 2020 5.8 2030 SDG 목표 성취를 위한 간호 현황 평가 5.8.1 주요 발견 ⚫ 우리는 2018년 자료와 세계 보건의료 인적자원 활용 전략에서 산출한 총 필요량과 비교하여 590만 명의 간호사가 부족할 것으로 추정했습니다. 이러한 부족 현상은 대부분(89%) 저소득국가와 저중소득 국가에 집중될 것으로 보입니다. ⚫ 만약 모든 국가가 현재 간호대학 졸업생 수준을 유지한다면, 신규간호사 숫자는 2018년 기준 2천800만 명에서 2030년에는 대략 3천600만 명으로 증가하게 될 것입니다. 그러나 예상되는 증가분 70%는 격차가 가장 큰 심각한 지역이 아닌, 중간소득 국가와 고소득국가에서 배출될 것입니다. ⚫ 예상되는 인구증가와 간호인력 고령화를 고려하면, 2030년에는 아프리카, 동남아시아, 지중해 동부지역은 인구 1만 명 당 간호사 수가 25명 이하로 떨어지게 될 것이라고 예상됩니다. 아프리카 지역의 간호사 수급률의 증가는 아주 미미할 것으로 보입니다. ⚫ 간호인력 부족을 겪게 되는 국가에서는 2018년부터 2030년까지 매년 간호대학 졸업생 비율을 8.8%로 증가시켜야 하며(범위: 0.2-13.4%) 인력 채용 능력을 적어도 70%까지 끌어 올려야 합니다. ⚫ 저소득국가에서 인력 부족을 해소하기 위해 간호교육 규모를 확대하려면 2018~2030년까지 1인당 대략 10달러(1만2천 원)의 비용이 소요될 것으로 보입니다. . 118. 보건 관련 SDGs 목표를 이루기 위해서, WHO 회원국은 (1) 직업에 대한 손실 (예를 들어 사망, 이민, 은퇴와 같은 이유로 인한)을 보상할 수 있는 충분한 간호사를 교육해야 하며, (2) 인구증가와 고령화로 인한 보건의료환경 변화로 인해 증가한 간호사 수요를 충족시키고, (3) 기존 전 세계의 인력 부족을 해소해야 합니다. 5.8.2 2030년 간호인력 예상량과 수급률 119. 현재 간호인력량, 은퇴 추산치(간호인력 연령층에 근거하여 추산), 인구 증가, 보건의료 인력 시장 진입을 고려하여 기본적인 “인력 보유량과 흐름(공급량)” 모델(stock and flow)이 개발되었습니다(부록2 참조). 현재 추세로 보아 간호사는 2018년 기준 2천790만 명에서 2030년 3천590만 명으로 증가할 것으로 예상됩니다. 120. 2030년까지 간호인력 증가분은 고소득국가에 집중될 것이며, 저소득국가의 증가율은 매우 한정적일 것으로 보입니다(Figure 5.15). 2018년에 조사된 간호인력 불균형 현상(section 5.2 참조)은 2030년까지 개선되지 않고 계속될 것으로 보입니다. Current status of evidence and data on the nursing workforce 65 Figure 5. 15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. 121. 간호인력의 예상 증가량은 필요량을 완전히 채우지 못합니다. 특히 인구증가율이 34%에 이르는 아프리카지역에서 이 문제는 더욱 심화할 것입니다. 또한 지중해 동부지역의 간호인력 증가율은 아주 미미할 것으로 보입니다(Table 5.11). 122. 본 보고서에서 분석에 사용된 지표 자료에 근거하여 다양한 가정과 시나리오를 통해 미래에 대해 예측을 했습니다. 본 보고서의 미래 예측에 대한 한계점은 부록2에 수록되어 있습니다. 123. 반면 미주, 동남아시아, 태평양 서부지역의 간호사 보유량은 많이 증가할 것으로 예상됩니다. 소득별로 국가를 분류하여 본다면, 중간 소득 국가에서 88% 증가할 것으로 예상됩니다. 5.8.3 간호인력 부족 124. 2016년 WHO 세계 보건의료 인적자원 활용 전략에 따르면 2030년까지 인구 1천명 당 의사와 간호사, 조산사 4.45명 미만인 국가들에서 760만 명의 간호사와 조산사가 부족할 것이라고 추산했습니다. 이 임계치 추정에서 대부분 고소득국가는 제외했습니다. 같은 방법과 임계치를 이용하여 더욱 최신 자료를 분석한 결과 2018년 간호사 부족분은 590만 명으로 추산되었으며, 2030년까지 570만 명의 간호사가 부족하게 될 것으로 예측되었습니다. 2018년 간호인력 부족 현상을(추정된 수치 측면에서) 가장 크게 겪는 나라는 방글라데시, 인도, 인도네시아, 나이지리아, 파키스탄 등입니다. 국가의 소득 수준이 간호사 부족 현상과 강한 연관이 있으며(부록 2, Table A2.2), 2018년에 부족분의 89%가 저소득국가 및 저중소득국가에 집중되어있습니다. not applicable not reported 10 to 19 <10 30 to 39 20 to 29 40 to 49 75 to 99 50 to 74 100+ 66 State of the world’s nursing 2020 Table 5. 11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three scenarios, by WHO region WHO REGION Stock observed in 2018 (million) Stock projected to 2030 (million) SCENARIO 1: ageing and stable young age group SCENARIO 2: ageing and graduation as of recent years SCENARIO 3: ageing and graduation increasing by 50% by 2030 Africa 0.9 1.2 1.5 2.0 Americas 8.4 9.2 12.4 17.7 South-East Asia 3.3 4.7 5.0 6.1 Europe 7.3 8.6 8.0 10.4 Eastern Mediterranean 1.1 1.9 1.5 1.7 Western Pacific 6.9 10.3 9.0 11.2 Global 27.9 35.9 37.4 49.3 Figure 5. 16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group Note: Income grouping is from the World Bank classification as of 2018. Americas Eastern Mediterranean Africa Europe South-East Asia Western Pacific High income Low income Lower middle income Upper middle income BY REGION BY INCOME Current status of evidence and data on the nursing workforce 67 125. 본 보고서의 관련 추정 수치는 최신자료를 이용하여 산출하였으며, 2016년 WHO 세계 보건의료 인적자원 활용 전략의 산출 결과와 비교하여 간호사 부족분만을 추정하여(조산사 부분은 제외), 이의 진행양상에 대해 살펴보고자 하였습니다(Figure 5.17). 126. WHO 세계 보건의료 인적자원 활용 전략에서 사용했던 기준치를 근거로 부족한 인력을 산출했습니다. 기준치를 상회하는 모든 국가는 제외했습니다. 그러나 기준치를 상회하는 국가가 간호사 부족 현상을 피했다는 의미는 아닙니다. 사실 대부분의 국가들은 국가 기준 의료서비스 수준에 도달하기 위해 그리고 의료체계를 구성하기 위해 요구되는 수준에 상당 수준 미치지 못하는 상황입니다. 이러한 국가를 위해 인력 부족에 대한 특정한 분석 방법이 사용되어야 할 것입니다. 분석방법은 인구와 간호인력 고령화, 역학적 양상 변화, 인력 수준 유지 전략, 그 외 노동시장 변화 등을 포함하여야 할 것입니다. 예를 들어 국가 기준 의료서비스 수준 그리고 의료체계를 구성하기 위해 요구되는 인력 수준에 근거하여 분석한 결과 2030년까지 OECD 31개 고소득 국가에서 320만 명에 달하는 간호사 부족 현상을 겪게 될 것이라는 조사 결과가 있습니다(266). 비슷한 연구 결과가 일본(2025년까지 간호사 27만 명 부족)(267), 독일(2030년까지 보건의료 인력 50만 명 부족, 특히 노인요양인력 및 간호사)(268), 영국(2030년까지 간호사 10만8천 명 부족) 등 지역에서도 발표되었습니다. Figure 5. 17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 Correction factors applied: 1 Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of nurses + midwives). 2 Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of improved data as compared to the Global Strategy. Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density. Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level. The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus 5.6 million) the Global Strategy estimate. Global Strategy on Human Resources for Health 2016 The State of world’s nursing 2020 9.0 million nurses and midwives 8.2 million nurses 6.6 million nurses 7.6 million nurses and midwives 6.9 million nurses 5.6 million nurses 5.9 million nurses 5.7 million nurses 1 Correcting for nurses only 2 Correcting for improved data Consistent estimation of shortage by 2030 68 State of the world’s nursing 2020 5.8.4 2030년까지 간호 부족을 해소하는데 필요한 인력과 비용 127. 2030년까지 인력 부족을 완전히 해소하기 위해 필요한 간호대학 졸업생 수와 간호직은 다른 가정 하에 산출했습니다. • 현재 추세로 간호대학 졸업생 수는 매년 평균 10% 증가하여야 하는 것으로 보입니다(범위 1.5-14.9%). • 만약 간호대학 졸업생 70%가 일자리를 찾을 만큼 보건의료 인력 시장의 고용력이 증가한다면, 간호대학 졸업생 수는 매년 평균 8.8% (범위 0.2% - 13.4%) 증가해야 합니다. • 보건의료 인력시장의 고용력이 더 증가한다면 (졸업생의 80%), 2030년까지 간호 부족 현상을 해소하기 위해 간호대학 졸업생 수는 매년 평균 8.1%가 증가해야 합니다(범위0.03%~12.2%). 128. 2030년까지 인력 부족을 해소하기 위해 필요한 투자치를 추정하기 위해, 2018년부터 2030년까지 간호사 증가분(졸업생 80% 고용 가정하에)에, 각 나라당 간호사 1명을 양성하는 데 필요한 교육비용을 평균치로 산출한 비용을 곱하여 산출했습니다(270). 저소득국가에서 발행된 관련 문헌(출판문헌과 비출판문헌(회색문헌)포함)을 토대로 간호사당 평균 교육비용을 세 가지 가정으로 산출했습니다: 5천 달러(한화 약 600만 원), 1만 달러(한화 약 1,200만 원), 2만 달러(한화 약 2,400만 원) (역주: 회색 문헌(Grey literature): 발행은 되었지만, 정식으로 출판되어 시판되는 것이 아닌 문헌을 말하며, 예를 들어 기관에서 만들어진 보고서 또는 학술적인 기술보고서 등이 대표적인 회색 문헌입니다.) 간호사를 추가 교육하여 간호사 부족 문제를 해소하기 위해 투자해야 할 비용은 세 가지 가정에 따라 간호사 1인당 각각 평균 5.2달러(한화 6천원), 10.5달러(한화 1만 원), 21달러(한화 2만 원)입니다.11 이처럼 다른 가정과 자료 부족에 대한 민감도 분석을 근거로, 가정안을 더 진행하기 위해 중앙값인 1인당 10달러를 투자 비용으로 산출하는 것이 타당해 보입니다. 11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates. Current status of evidence and data on the nursing workforce 69 © WHO/Yoshi Shimizu State of the world’s nursing 2020 70 간호인력 정책이 나아가야 할 방향 129. 본 보고서는 기존 연구방식과 그 동안 발행되었던 연구자료(2, 3, 4장)를 바탕으로 간호인력 현황을 분석(5장)하면서, 간호인력 교육과 배치, 관리, 지원 방식에 있어 근본적인 변화를 위해 도움이 되는 적절한 사례들을 보건의료 인력 증강과 의료체계 확장 정책의 일환으로 제시합니다. 130. 이에 필요한 투자량은 상당할 것입니다. 그러나 수억 명 인구의 보건향상, 수백만 명의 의료 인재 고용 기회, 특히 여성과 젊은이들, 그리고 세계 보건 수준의 향상이라는 측면에서 돌아오는 사회∙경제적 수익은 그보다 훨씬 클 것입니다. 131. 이러한 잠재력을 활용하기 위해서는 지역적, 국가적, 세계적 수준에서 여러 분야에 걸쳐 다각도로 노력을 기울여야 합니다. 본 6장에서 우리는 본 보고서에서 다룬 포괄적인 주제와 구체적인 자료 분석으로 도출된 주요 결과들에 대해 차례로 논의할 것입니다. 이를 바탕으로 지속 가능한 투자 계획을 수립하고, 제도적 역량을 구축하고, 필요한 역량을 갖춘 간호인력을 양성하고 지원하기 위해 필요한 과정을 전반적으로 그려내고자 합니다. 132. 본 보고서에서 제안하는 정책안은 회원국뿐 아니라 그 외 관계자에게도 해당하는 내용입니다. 본 보고서에서 제안하는 정책안의 적용도와 관련성은 해당국의 의료체계 목표, 전제 조건 및 실행 역량을 근거로 하여, 사례별로 고려해야 합니다. CHAPTER 71 State of the world’s nursing 2020 6.1 근거기반 계획, 모니터링, 책임성 강화 결과 133. 본 보고서는 간호 관련 가장 포괄적이고 구체적인 자료를 분석하여 결과를 도출해냈습니다. 최소15개 이상 지표에 대해 응답한 국가 비율이 80%인 반면, 국가 간 지표 격차는 국가별 보건의료 인력 정보체계 수준의 격차를 반영하고 있으며, 앞으로 나아가야 할 방향을 찾을 좋은 기회를 제공합니다. 134. 간호인력 현황과 연령별 구분에 관한 자료 접근성은 가장 높으나(간호인력 현황 지표 응답 국가 191개국, 연령별 구분 지표 응답 국가 132개국), 간호 교육, 재정, 보건의료 인력 시장 흐름과 관련된 지표에 대한 응답률은 현저히 낮아서 포괄적인 보건의료 인력 시장 분석에 어려움을 겪었습니다. 예를 들면 간호인력 현황에 대한 수치는 있으나, 양적인 면에서 간호인력 양성 능력, 구인율, 실업률과 인력 감소율에 대한 구체적인 근거자료가 없어 간호인력 양성에 관한 정책 수립에 있어 양성 수준을 늘려야 하는가 아니면 이미 적정수준을 유지하고 있는가에 대한 불확실성이 증가합니다. 따라서 정부 당국은 교육 부문의 간호인력 양성 능력과 보건의료 인력 시장의 고용 능력이 균형을 이루는가 아니면 어느 형태든 불균형을 보이는 가에 대해 인지하고 있어야 합니다(간호인력 부족과 실업 문제) (Box 6.1 스코틀랜드의 보건의료 인력 시장 분석 참조) Box 6. 1 스코틀랜드의 보건의료 인력 시장 분석 2019년 12월 스코틀랜드 정부는 의료와 사회복지 인력에 관련한 통합 계획을 발표했습니다(272). 이 계획의 목적은 국민의 입원율을 높이기보다 가정에서 치료받도록 하는 것입니다. 그러나 계획을 실행하려면 지역사회 간호사 인력 증원이 필요합니다. 스코틀랜드 정부는 국립보건원(NHS National Services Scotland), 정보부서(Information Services Division)에서 제공한 자료를 바탕으로 계획 실행이 가능하게 하기 위해 필요한 간호 학생의 수를 여러 경우로 가정하여 산출했습니다. 또한 다른 보건직의 공급과 부족에 대해 고려하여, 인력 부족이 보건의료 서비스가 필요한 곳에 어떤 영향을 미치는지, 이를 어떻게 해결해야 할 지에 대해 주장했습니다. 정부가 수집한 자료와 산출한 결과는 그 외 관계자(the Nursing and Midwifery Student Intake Reference Group 등)와 공유했습니다. 그 결과, 정부는 지역사회 간호사를 양성하고, 이에 대한 투자를 강화하고, 기존 간호사를 재교육하는 등 일련의 정책을 적극적으로 실행하기로 하였습니다. 스코틀랜드 정부의 계획은 국가 차원에서 의료와 사회 보건의료 인력 문제를 해결하기 위해 단일 직종에 대한 계획에서 다학제간 팀 기반 케어를 위한 계획으로 전환하려는 적극적인 시도를 의미합니다. Current status of evidence and data on the nursing workforce 72 135. 자료 접근성에 영향을 미치는 요소와 각 지표에 관한 자료를 제공하는 각국의 능력은 보건, 노동, 교육, 재정 부처 간 협력 수준과 그 외 관계자, 예를 들면 직업협의회, 관련 위원회, 교육기관의 관여도 수준을 반영합니다. 정책 제안 136. 각국 정부는 보건 인력에 대한 구체적인 세부사항을 포함하여 NHWA를 이용한 정보공유를 강화해야 합니다. 보건의료 인력 시장 분석을 위해서 필수 자료 제공에 대한 국가별 차이를 줄이는 것이 급선무입니다. 이를 위해 보건의료 인력 활용 정보 체계(human resources for health information system)를 수립하고 강화하려는 포괄적인 노력을 해야 합니다. 본 보고서에 사용된 간호 관련 자료는 각국이 NHWA를 이용하여 자료를 공유하고 자료 원천을 다각화하려는 노력을 기울였기 때문에 신뢰성을 확보할 수 있게 되었습니다. 보건의료 인력 활용 정보 체계를 수립하는 정부의 역량은, 정보의 수집과 교환, 정보 접근성, 수준 향상, 문제점을 해결하고 호환하는 정보 체계를 구축할 수 있도록 간호 관련 분야 책임자와 같은 관계자와 협의 체계를 구성하는 데 중요합니다. 이러한 협의 체계는 또한 자료 이용과 공유에 관한 규정을 법제화하고, 각 분야 관계자들이 협의하여 수집한 자료를 분석하여 이를 바탕으로 정책적으로 의미 있는 변화를 이끄는 계기를 마련합니다. 각국 정부는 이렇게 강화된 간호와 보건의료 인력 관련 자료를 보건노동시장 분석에 활용해야 합니다. 이를 바탕으로 정부 수준에서 정책 방향과 투자를 결정해야 합니다(Box 6.2 NHWA지표자료를 이용한 간호 노동시장 분석의 예). 6.2 이동과 이주 결과 137. 대략 370만 명(8명 중 1명)이 본인이 태어나거나 교육받은 국가가 아닌 타 국가에서 간호사로 활동하고 있습니다. 본 보고서의 결과에 따르면 자국 내 간호사 수급률이 낮은 국가에서 외국 출생 간호사에 의존하는 경향이 심화되어 간호사의 국제 이동 경향이 증가하는 것으로 드러났습니다. 고소득 국가(간호사의 15% 이상이 외국 출생 또는 외국 교육을 받은 간호사인 국가)의 간호사 수요가 높아짐으로 인해 저소득국가의 가장 역량 있는 간호사가 해외로 빠져나감으로써 의료수준의 질적 저하와 수급 불균형 문제가 심화하여 국민 보건에 악영향을 미치게 되었습니다(Box 6.3 독일의 이민 정책). 138. 간호인력의 해외 유출이 심각한 국가(간호인력의 수출 정책으로 인한 경우 제외하고)의 경우 근무 조건이 열악하다는 해석이 가능하다고 볼 수 있습니다. 그러므로 정책을 수립할 때 이민 현상 자체를 분리하여 해결책을 찾는 것이 아니라 근본 원인(근무환경 개선, 의료체계 지원, 임금수준 향상 등)을 개선하는 데 중점을 두어야 합니다. 이와 비슷하게 간호사 양성에 있어 간호 기술과 역량 그리고 학생들의 요구와 관심 사이에 적절한 균형을 맞춰야 합니다. 즉 지역사회와 일차 보건의료 활동에 대한 필요에 맞게 간호사를 교육해야 하는 정책적 필요성과 개인의 금전적 수입이 최대화할 가능성이 있는, 보다 전문적 분야에서 일할 기회를 얻기 위해, 혹은 해외 보건의료 체계에서 일하기 위해 교육의 기회를 찾는 각 개인의 동기와 균형을 맞춰야 합니다. 73 State of the world’s nursing 2020 Box 6. 2 아프리카 동부, 중부, 남부지역 보건공동체(ECSA-HC): NHWA지표를 사용한 간호정책 수립의 예 아프리카 동부, 중부, 남부지역 의료공동체(ECSA-HC)는 이 지역 정부 간 협력 보건기구로서 보건의료 분야에 지역 간 협력을 증진하는 역할을 하는 조직입니다. 이 지역은 만성적으로 간호사 부족 현상을 겪고 있습니다. 열악한 근무 조건과 높은 업무량은 이 지역 간호사들의 이직과 해외 이민을 부추기는 원인이 되고 있습니다. 적절한 교수진 수급이 어려운 상황과 관련 당국의 규제가 미비하여 이 지역의 교육체계는 통합적으로 운영이 어려운 상태입니다. 이로 인해 학생들을 역량 있는 간호사로 양성할 수 있는 교육 체계가 갖추어져 있지 않습니다. 세계 은행 기구(The World Bank Group)는 Jhpiego (역주:Jhpiego는 국제적인 보건 비영리단체로 미국 존스홉킨스 대학과 제휴단체입니다), 국제 간호협의회(International Council of Nurses), ECSA 간호대학협의회(ECSA College of Nursing)와 협력하여 간호 노동과 교육 시장에 관한 연구를 진행했습니다. 연구의 목적은 이 지역 의료와 교육체계에 관련된 문제를 분석하고, 공공 및 민간 투자 대상을 적절하게 지정함으로써 간호 교육체계를 확립하고 확대하는 정책안을 제안하는 것입니다. 규제 관련 문제와 더불어, 연구진은 간호 노동시장이 교육체계와 의료체계 간 상호작용에 미치는 영향을 살펴보았습니다. 연구자료로 NHWA(273) 지표와 지역협의회가 수집한 자료를 추가하여 활용하였습니다. 연구를 위해 공중 보건 간호단체 연합인 ‘쿼드(quads)’가 자료를 수집하고 정리하였으며 WHO가 연구 결과의 리뷰를 지원했습니다(6.3.3 section 참조). 연구 결과에 따르면 이 지역 간호 노동시장은 수요와 공급 균형이 심각하게 무너져 있다고 드러났습니다. 지난 10년간 간호사의 증가율은 인구증가율을 앞섰으나, 동시에 공공의료 부문에 간호사 고용력이 매우 낮았으며(빈번한 채용과정 비효율성과 부실한 근무환경으로 인해), 반면 필요한 간호사 수요는 증가하였습니다. 2019~2039년까지 수요는 33%까지 증가하리라고 분석했으나, 여전히 이 지역의 공공 의료부문과 민영 의료부문이 고용할 수 있는 한계를 넘은 22만 명의 초과공급인력 문제가 여전히 남아있게 됩니다. 반면 국민 보건 수준을 유지하기 위해 필요한 간호사 수요 부족은 2030년까지 84만1000명으로 증가할 것으로 분석되어, 현재 간호 노동시장의 불균형이 더욱 심화할 것으로 보았습니다. 연구진은 ECSA 지역에서 SDGs목표를 성취하기 위해 필요한 간호사의 공급을 늘리기 위해서는 간호 교육체계를 확대하고, 간호 교육기관의 질적 성장이 필요하며(교육 인증체계의 확립을 포함하여), 지역과 국가의 의료시장의 고용흡수력을 높이기 위한 재원을 확대해야 한다고 제안합니다. 따라서 물적∙ 인적 자원에 대한 투자를 확대하고, 간호 관련 규제와 규범을 완비해야 하며, 동시에 정부의 자료수집력과 분석력을 높여 투자과정과 효과에 대한 규제와 관리능력을 향상해야 한다고 결론을 내립니다. . Current status of evidence and data on the nursing workforce 74 139. 해외에서 유입되는 간호사의 규모가 급격하게 성장하고 있는 상황에서 특정 지역에 한정된 접근방식은 공공 보호 차원에서 적절하지 않으며, 이에 따라 지역적, 세계적 해결방식으로 발전시키기 위해 해외 간호사 유입 과정을 개선해야 합니다. 더 나아가 이제는 많은 국가가 공급자이자 수요자인 상황이라 보건 인력의 이동을 관리하고 앞으로 수요를 맞추기 위해 이동패턴을 이해하는 것이 아주 중요합니다. 그러나 86개국만이 자국 내 의료체계에서 외국 출생이거나 외국에서 간호 교육을 받은 간호사의 비율을 공유하였습니다. 이 지표는 WHO 국제 보건의료 인력 채용에 관한 실행 규정(the WHO Global Code of Practice on the International Recruitment of Health Personnel)에서 기본적인 보고 요구 지표 중 하나입니다. 정책 제안 140. 각국 정부는 간호인력을 포함한 국제적인 보건의료 인력 이동에 대한 관련 규정을 강력하게 시행해야 합니다. 수요국(간호사가 해외에서 유입되는 국가)의 정책입안자는 국민의 안전을 위하여 외국 출생 간호사의 자격과 교육 배경에 대해 자국에서 요구하는 자격요건, 교육기준, 윤리적 규범에 부합한 규정을 마련하고 실행해야 합니다. 한편 간호사 자격을 취득하기 위한 간호 교육과정 입학과 자격을 유지하기 위한 교육내용에 관련된 규정을 개정하여 간호사의 이동성을 향상할 수도 있습니다. 지역 내 국가 간 간호 자격의 상호 인증에 관한 협정을 맺고 시행하여 좋은 결과를 맺는다면, 미래에는 협정 범위의 확대로 이어질 기회가 될 것입니다. Box 6. 3 독일의 이민정책 2018년 11월 9일 독일 의회는 돌봄 강화법(Care Strengthening Act)을 통과시켰습니다. 이 법은 독일 병원과 요양 시설에서 일하는 보건의료 인력의 유입을 증진시키고자 마련된 법입니다(275). 시설에서 일하는 의료진의 수를 확대하는 것이 이 법의 핵심입니다. 몇 년 동안 독일의 의료시설과 요양 시설은 고질적인 간호 사 부족으로 고충을 겪고 있습니다. 인력 부족으로 운영에 난항을 겪고 있는 병원과 요양 시설이 전국에 걸쳐 있습니다. 은퇴나 직업 불만족을 이유로 이직한 간호사의 수가 신규간호사의 증가 속도를 추월했습니다. 의료진 부족으로 인해 근무환경이 열악하게 되고 의료서비스의 수준을 떨어뜨립니다. 2012년 연구에 따르면 독일은 2030년까지 26만3000-50만 명의 간호사가 부족할 것으로 진단되었습니다. 인력 부족을 해소하기 위해 독일 정부는 간호 교육과정 확대, 신규간호사 일자리 창출, 중부와 서남부 유럽지역의 간호사 채용계획을 확대하는 등 다방면으로 정책적 노력을 기울이고 있습니다(277). 채용확대를 위해 독일 정부는 보건의료인력을 공급하는 국가와 상호이익을 얻을 수 있는 여러 기회를 활용하고 있습니다. 예를 들어 공급국가와 기술협력을 하고, 양자협정을 맺어 공급국가에 교육과정을 확대하기 위한 투자를 하는 방식 등을 사용하고 있습니다(168). 75 State of the world’s nursing 2020 141. 각국 정부와 관련 단체는 WHO 국제 행동 강령(WHO Global Code of Practice)을 준수하도록 해야 합니다. 간호인력의 국제적 이동을 효과적으로 모니터하고 규제하기 위해서 각국의 협력관계를 증진해야 합니다. 각국 규제 당국 간 협력, 보건의료 인력 정보 체계 확립, 고용주와 관계부처, 간호협의회와 같은 그 외 관계자 간의 협의와 협력이 필요합니다. 간호인력의 해외 이주로 급격한 인력손실을 겪고 있는 국가들은 임금수준을 올리거나 (공평한 임금체계 확립) 근무조건 개선, 좋은 일자리 보장과 같은 간호인력 수준을 유지할 방안을 마련해야 합니다. 6.3 간호인력 양성과 지원 방안 6.3.1 교육 결과 142. 본 보고서를 통해 현재 간호 교육과정을 통해 양성되는 간호인력과 관련한 복잡한 상황을 알 수 있습니다. 기존 간호인력 대비 간호대학 졸업생 비율이 가장 낮은 지역은 유럽과 지중해 동부지역 국가, 그리고 일부 고소득 국가들입니다. 중∙고소득 국가에서 양성 수준을 올리지 않는다면 국외 채용에 지나치게 의존하게 되어 결국에는 인력 부족 현상을 더욱 심화시켜 접근성과 공정성 이슈를 낳게 될 것입니다. 143. 간호 교육과정의 기간은 지역별 격차가 심하게 있습니다. 그러나 대다수의 국가(169개 응답국 중 154개국)가 교육 기간과 교육내용에 대한 표준화 규정이 마련되어 있다고 답변했습니다. 간호 교육 관련 규정을 수립할 때, 공공의료에서 필요한 부분, 예를 들어 일차 보건의료와 예방의료, 재해와 응급상황 대처, 관련 분야의 기술적 상충, 리더십 함양, 기술의 적절한 사용 등을 중요하게 고려해야 합니다(Box 6.4 간호 교육 분야에서 기술의 활용). 144. 응답 국가의 대다수(89%)가 간호 교육기관에 대한 인증체계를 마련했으며 인증 교육기관의 통합목록을 보유하고 있다고 답했습니다. 이는 효과적이고 경제적인 과정체계를 수립하는 등 인증과정을 강화하기 위한 좋은 기회가 될 수 있으며, 인증 교육기관에 대한 사회적 책무를 키울 수 있고, 보건 취약계층과 관련된 교육과정을 확대할 수 있습니다. 강력한 인증 메커니즘은 내용, 커리큘럼, 학생 실습 경험, 교원 자격요건과 전문직간 교육을 포괄할 수 있다. 본 보고서의 조사에 따르면 응답 국가의 67%가 전문직간 교육에 관한 관련 규정이 있다고 대답했으나 어떤 지역에서는 이에 대한 응답률이 20%에도 못 미치고 있습니다. 145. 인구 고령화와 같은 변화에 따라 달라지는 의료서비스 분야에서 일할 수 있는 보건의료 인력을 양성하기 위해서는 간호 교육과정을 거쳐 양성되는 인력 구성의 다양화가 요구됩니다. 본 보고서의 분석 결과에 의하면, 아직도 많은 지역, 특히 미주와 태평양 서부지역 국가에서 간호인력의 대부분은 여성입니다. 간호인력 구성의 다양화를 확보하기 위해서는 다양한 배경의 학생을 모집하는 것이 전부는 아닙니다. 더불어 학생을 배제하는 간호교육과정(예를 들어 입학 자격 요건으로 중등교육 완료)이나 교육과정을 마치는 데 있어 어려움(예를 들어 비싼 학비)을 초래하는 구조적 조직적 문제를 해결해야 합니다(126). 또한 몇몇 국가에서 간호직의 지나친 성별 분리 현상이나 간호사의 낮은 사회적 지위 또한 간호 교육의 수요에 영향을 미치는 요인입니다. 계속 이러한 문제를 해결해야 간호직을 선택하고 싶은 직업으로 만들 수 있으며, 이는 특별히 미주지역과 같이 인구 대비 간호대학 졸업생의 비율이 매우 낮은 국가들에서 특히 중요합니다. Current status of evidence and data on the nursing workforce 76 정책 제안 146. 간호 교육과정은 양질의, 통합적이고 환자 중심의 의료서비스를 제공하는 간호사를 양성해야 합니다. 우선하여 해결해야 할 과제는 간호 관련 직종 간 전문기술이 뒤섞이는 상황(skill mix)에 대해 특별히 관리해야 하며, 간호사의 업무 수준과 전문분야가 의료체계의 목적에 부합하는지를 판단해야 하며, 필요한 분야와 고용 흡수력에 근거하여 적절한 수의 임상 실습 장소를 확보해야 합니다. 고등 간호 교육과정을 수립하거나 확대하는 문제는- 예를 들면, 학사과정, 석사과정 혹은 박사과정- 구조적 영향을 미칩니다. 즉 새로운 교육과정을 개발해야 하며, 교원 구성뿐만 아니라, 학위 취득 후에 간호사가 전공 관련 분야에서 규정된 역할과 직위를 얻을 수 있도록 해야 하기 때문입니다. (역주: WHO에 따르면, ‘skill mix’는 의료직무 또는 직종의 혼합, 다양한 범주의 보건의료 인력의 역할 및 활동의 구분, 사용 가능한 기술의 조합 또는 각 직종에 필요한 기술의 조합을 의미할 수 있습니다.) Box 6. 4 간호 교육 분야에서 기술의 활용 기술의 발전은 간호 교육과 간호 업무에 점점 많은 영향을 미치고 있습니다. 기술 발전으로 진단 지원, 원격진료, 원격교육(280)이 가능해졌으며, 이로 인해 의료 접근성이 높아지고, 소외 지역의 의료서비스 지원, 일차 보건의료 활동 촉진과 환자의 권한이 강화되었습니다. 간호사는 이에 맞게 디지털 독해 능력, 의료기계 사용 능력, 인터넷과 같은 디지털 지식을 갖추어야 하고 의료 관련 디지털 기능에 능통해야 합니다(281). 디지털 의료 기술, 예를 들어 인공지능, 증강 현실, 로봇의 이용 등은 이미 간호 분야와 의료서비스 분야의 상황을 바꾸어 놓았습니다(282). 맞춤형 의약품과 유전학의 등장으로 환자 개인에 맞는 의료 서비스를 제공하게 되었습니다(283). 디지털 의료 기술이 가진 가장 강력한 힘은 평생학습의 기회를 제공한다는 데 있습니다. 인공지능과 같은 첨단 기술로 개인의 필요에 맞는, 최신의 관련 분야를 배울 수 있습니다. 코크란(Cochrane)의 체계적 문헌고찰에 따르면, 모바일 기기(휴대전화 같은)로 건강을 관리하는 모바일 헬스케어(mHealt)에 대해 보건의료 종사자(간호사 포함)들은 의료서비스를 제공하는 데 있어 매우 유용하다는 반응과 동시에 어려움도 있다고 대답했습니다(284). 모바일 헬스케어는 소통력과 업무조정능력 강화, 양질의 보건의료서비스 제공, 환자와의 소통개선, 원거리에 있는 환자의 건강관리까지 다양하게 적용되어 유용합니다(284). 동시에 보건의료 종사자들이 느끼는 어려움은 여러 방면에서 복잡한 경향을 가집니다. 즉 개인적 문제일 수도 있고(예를 들어, 낮은 디지털 독해능력), 관계면 일수도 있으며(환자나 동료와 면대면 관계를 선호하는 경우), 직업적일 수도 있으며(임상 지원 도구와 같은 디지털 기술에 대해 직업적 위협감을 느끼는 경우), 환경적(환자가 휴대전화를 사용하고 있지 않은 경우), 혹은 인프라에 대한 문제(전기공급 부족)일 수도 있습니다 (284). 기술발전으로 인해 얻는 유익한 효과가 많이 있으나, 코크란(Cochrane)의 체계적 문헌고찰에 포함된 연구 참여자인 보건의료 종사자들은 그들이 겪는 문제를 최소화하기 위해 관련 당국은 이 기술을 의료체계에 어떻게 적용할 것인가를 진지하게 고민할 필요가 있다고 답했습니다. 77 State of the world’s nursing 2020 147. 각 국가는 간호대학 내의 인구통계학적, 지리적 배경을 바탕으로 한 학생 구성 다양화를 추구해야 합니다. 이렇게 학생 구성을 다양하게 하면, 간호직에 대한 성적 편견을 타파하고, 젊은이들이나 특정 인종이 간호직을 선택하는 데 있어 부정적으로 작용하는 요인들을 바로잡을 수 있으며, 간호사를 제2의 직업이나 후속 직업으로 선택하길 원하는 이들을 수용하는 효과를 거둘 수 있게 됩니다. 또한 환경적인 관점에서 간호 학생 구성의 성비균형을 맞추기 위해, 지방과 의료서비스 소외지역에 “지방의 순차적 교육과정”(rural pipeline)을 개발하는 것이 필요할 수 있습니다. 재정 지원 대상을 특정하고 인센티브제를 운영하는 방법 또한 소수 그룹이나 취약층에 간호 교육의 기회를 제공하는 데 도움이 될 것이며, 또한 학생과 지역사회 구성 비율을 반영하여 교원을 채용할 수 있도록 할 것입니다. 사회적 책무을 강화하는 쪽으로 유도하도록 교육기관의 인증제도를 개선하는 것도 그러한 방법의 하나가 될 것입니다. 148. 간호 교육기관과 관련 당국은 간호기술 역량을 키우는데 기반을 둔 교과과정을 구성해야 하며, 적절한 기술을 활용해야 합니다. 간호 서비스의 질적 수준은 교과과정을 통해 결정되어야 합니다. 간호사는 관련 기술 지식과 임상 처치 과정에 대한 지식뿐 아니라 다 직종으로 구성된 의료팀에서 일할 수 있는 기량을 갖추고 있어야 합니다. 환자에 대한 공감과 관심이 있어야 하며, 압박을 받는 상황에서 결정을 내릴 수 있어야 합니다. 또한 간호직을 수행하는 동안 끊임없이 보수교육을 받아야 합니다. 교과과정은 간호업무의 범위와 보건의료 체계의 요구에 맞도록 설계되어야 합니다. 온라인으로 교과 강의나 임상 실습 관련 강의를 제공하는 것은 기존 교육 방법을 보완하는 데 유용하게 사용될 것입니다. 이러한 “분산학습”(distributed learning)을 성공적으로 확립하기 위해서는, 학생들이 교육과정의 일환으로 최소수준의 디지털 건강문해력을 배워야 하며, 임상 실습 지원과 관리와 더불어 교과과정에도 원격진료와 건강관리 교육이 포함되어야 합니다(285). 또한 국가자원과 인프라를 사용하여 지역별 계층별 정보통신의 격차를 줄이도록 해야 합니다(286). 149. 정부와 관계기관은 부문 간 협력관계를 세워 간호 교육 관련 계획을 실행해야 합니다. 관계 당국은 관련 정책을 세워 간호대학 입학요건과 간호사의 최소 교육요건을 검증할 수 있으며(의료체계에서 간호사의 현 역할과 앞으로 수행하게 될 역할 범위를 고려하여), 지역 간 간호 교육과정의 표준화를 촉진할 수 있습니다. 인증기관의 관련 부문 간 협의로 인증과정을 통한 교육기관의 사회적 책임을 유도할 수 있습니다. 예를 들어 간호 교육기관이 학생들로부터 받은 학비와 정부 보조금과 이익에 중점을 두기보다 양질의 의료서비스를 제공할 수 있는 인력을 양성하는 것을 최우선 목표로 두게 하는 것입니다. 교육과 의료 관련 부처의 협력으로 간호직의 중요 요소로 과학과 기술을 강조하여, STEM(과학, 기술, 엔지니어링, 수학) 분야 로서의 간호를 마케팅하도록 도울 수 있으며, 이로써 다양한 중등교육과정을 마친 학생들을 간호 분야로 끌어올 수 있게 할 것입니다. 민영기관의 협력관계로 임상 실습으로 위한 일차 보건의료 현장을 더 많이 확보할 수 있습니다. 더불어 다른 의료 직종 관련 교육과정과 연계함으로써 간호 학생의 직종 간 업무능력을 높일 수 있습니다. Current status of evidence and data on the nursing workforce 78 150. 간호 교육기관은 인력 부족 해소를 위해 능력을 갖춘 간호사를 양성해야 하며, 관련 시설을 개선해야 하며, 적절한 임상 실습 현장을 확보해야 합니다 (Box 6.5 간호 교육 역량 강화를 위한 파키스탄의 노력 참조). 적절한 임상 실습 현장을 확보하기 위해 교원 개발프로그램을 위한 투자가 필요할 수 있습니다. 고소득국가 혹은 해외 인력 유치에 의존하고 있는 국가는 국내 간호사의 양성과 고용력을 키워야 합니다. 151. 보건의료 인력 시장 불균형을 해소하기 위해 각국 정부는 재정자원을 활용하여 간호 교육의 질적 수준을 높이는 데 노력해야 합니다. 재정 지원으로 간호 학생 구성의 다양화, 교원확보, 간호 교육과정 학생 인원수 증가, 적절한 임상 실습 현장 확보 등 많은 문제를 해결할 수 있습니다. 또한, 고등 간호 교육과정을 확대할 수도 있습니다. 그러나 재정지원을 하는 데 있어 비용 대비 효율성을 따져야 하고, 투자조건, 방법, 공정성과 효율성이라는 목표에 있어 직접적으로 효과를 거둘 수 있는 우선 투자대상을 고르는 데 있어 조사에 기초한 결정을 내려야 합니다. 예를 들어, 보건의료 인력시장 분석을 통해 의료체계 필요보다 간호인력이 부족한 분야와 과잉공급 분야를 파악해야 합니다. 간호인력 공급 부족 현상의 원인이 구조적인 문제로 파악된다면 정부가 개입하여 학생들이 간호 교육을 선택하는 데 있어 발생할 수 있는 불필요한 장애를 낮출 수 있습니다. 필요하다면 재정적 지원을 해야 합니다. 특히 가정형편이 어려운 학생들을 대상으로 하여 재정적 지원에 대한 복무의 방식으로 공공 의료부문에서 정해진 최소기간을 일하게 함으로써, 일차 보건의료진으로 활동하게 유도할 수 있습니다(140). Box 6. 5 간호 교육 역량 강화를 위한 파키스탄의 노력 파키스탄은 보건의료 인력이 1백만 명이 부족할 정도로 심각한 의료 인력 부족 문제를 겪고 있습니다. 파키스탄 정부는 이를 해소하기 위해 다양한 노력을 하고 있습니다. 2018년 의료 인적 자원 양성계획(Human Resources for Health Vision for 2030)을 세워 의료현장에서 의료진의 전문기술이 뒤섞이는 상황(skill mix)에 대한 체계 확립과 간호인력 양성에 주력하기로 했습니다. 간호는 의료분야의 중추적 역할을 담당하고 있다는 인식하에 간호인력 양성이 이 계획의 핵심이며(287), 또한 2019년 파키스탄에서 지정한 간호사의 해를 맞아 국민 보건의료 서비스에 있어 간호사의 역할을 강조하고 있습니다. 간호사의 해를 지정하면서 알비(Alvi) 파키스탄 대통령은 수도 이슬라마바드에 간호대학을 세워 매년 2만5000명의 간호인력을 양성하겠다고 공표했습니다(287). 파키스탄 정부는 2년 이내 기존 간호인력을 2배로 증강하여 부족 현상을 해소하고자 하고 있습니다. 파키스탄 보건 국무장관 나신 하미드(Dr Nausheen Hamid)는 간호인력 부족을 보편적 의료보장을 이루는 데 장애로 보고 있으며, 보건의료 체계가 효율적으로 작동하기 위해 능력 있는 간호인력이 충분히 보장되어야 한다고 말했습니다(288). 79 State of the world’s nursing 2020 6.3.2 간호 실무(Nursing Practice) 결과 152. 본 보고서의 분석 결과에 따르면, 간호인력은 이전의 조사한 결과보다 더 큰 규모인 것으로 보입니다. 2018년 기준으로 약 2천800만 명인 것으로 추산되며, 이 중 69%가 전문직 간호사(professional nurse), 22%가 준 전문직 간호사(associate professional nurses)인 것으로 보고되었습니다. 본 보고서의 추산 결과가 2016년 WHO 세계 보건의료 인적자원 활용 전략(the Global Strategy on Human Resources for Health)에서 추산한 것보다 더 많은 이유로, 실제 간호인력 증가와 더불어 높아진 자료접근성과 질적 수준이 향상되었기 때문으로 보입니다. 153. 보건의료 인력이 양적으로 성장하고 있지만, 간호사를 비롯한 보건의료 인력의 지리적 불균형은 여전히 큰 문제입니다. 본 보고서의 분석 결과에 따르면, 간호 사의 배치는 국내외, 지역별로 매우 상이한 것으로 드러났습니다. 응답 국가 중 53%가 전문간호사제도를 운용하고 있다고 답했습니다. 전문간호사제도는 주로 의사(medical doctors) 수급률이 낮은 지역에서 운영되고 있습니다. 전문간호사제도는 보건의료 인력 범주가 더 넓은 상황에서 간호인력의 유연성과 대처능력을 강조합니다. 의료 현장에서 의료진의 전문기술이 뒤섞이는 상황(skill mix)에서 의료서비스의 효율성을 높이기 위해 의료서비스에서 소외된 지방에서 전문간호사가 활동하는 것은 적절한 해결책이 될 수 있을 것으로 보입니다. 154. 국가 내에서도 도시와 지방간 간호사 배치에 심각한 불균형을 해소해야 공정한 의료접근성을 확보할 수 있습니다. 보건의료 인력의 유지는 근무조건, 직업적 만족도, 임금수준, 비금전적 인센티브 등 복잡하고 상호 관련된 요소에 의해 결정됩니다. 간호 사의 양적 수준을 유지하기 위해서는 각 국가와 지역에 맞는 다양하고 체계적인 정책적 노력이 따라야 합니다. 간호사의 근무환경과 생활 조건을 개선하는 등 근본적 원인을 해결하지 않으면 이 문제는 해결하기 어려울 것으로 보입니다. 정책 제안 155. 간호사가 교육과 훈련을 통해 기른 기량을 마음껏 펼칠 수 있도록 해야 합니다(180). 이 목표는 통합 일차 보건의료팀의 업무 분담을 최적화하는 돌봄 모델을 적용하기 위한 광범위한 국가적 노력의 일부가 되어야 합니다(179). 이를 통해 먼저 필요한 곳에서 일차 보건의료 서비스를 향상하는데 간호사가 최대로 이바지하게 될 것입니다(Box 6.6 ‘오만에서의 지역사회 의료접근성 향상 사례’ 참조) 간호사의 역할을 극대화하기 위해 전문간호사제도, 간호사 주도 클리닉의 확대, 간호사의 처방권 확대가 필요하며 자질에 맞는 훈련과 교육이 동반되어야 합니다. 전문간호사는 지식과 기술적 역량을 발휘할 수 있는 조건에서 전문적인 의료활동 혹은 의료진 관리책임을 맡아야 합니다. 전문간호사 직무를 수행하거나 클리닉을 운영하는 전문간호사는 멘토링 지원을 받아야 하며, 필요하다면 협의체의 지원도 받을 수 있어야 합니다. 또한 업무를 위해 적절한 의료장비와 의약품을 받아야 하고, 정확한 임상실무가이드라인과 관련 온라인 자료 등을 포함한 기술적 지원도 받아야 합니다. 관련 교육, 의료, 노동정책을 여기에 맞게 개선하려면 효과적인 협력을 위한 제도적 노력이 필요합니다. 예를 들면 지원제도와 이와 관련된 자원, 리더십과 정책 개선의 의지, 효과적인 경영관리•감독, 효율적 조직문화 등을 들 수 있습니다. 간호사의 기량에 따른 역할 확대는 다른 보건의료직은 물론이고 공적으로도 정확히 소통되고 공지되어야 합니다. Current status of evidence and data on the nursing workforce 80 156. 각국은 간호인력 양성과 관리를 위한 정책을 수립하고 계속 개선해나가야 합니다. 좋은 일자리 구현을 위해 간호사 채용과 배치과정을 효율적이고, 공정하고 투명하게 운영하는 것이 가장 중요합니다(16). Box 6. 6 오만(Oman)에서의 지역사회 의료접근성 향상 사례 오만의 사례를 보면, 간호사와 조산사 교육과정을 개선하여 일차 보건의료 활동을 강조하게 되었습니다. 일차 보건의료 활동의 확대는 66회 지중해 동부지역 위원회(Regional Committee for the Eastern Mediterranean) 협의 내용 중 일부로 간호인력 증강 계획의 하나입니다(290). 오만은 그동안 급격한 인구증가를 겪었으며, 국민의 평균 기대수명이 크게 늘었습니다. 사회경제적 지위가 향상되었으나 동시에 만성질환자의 수도 증가하고 있습니다. 이 문제를 해결하고자 오만 정부는 지역사회 간호인력 증강에 투자하기로 했습니다(291). 보건부의 간호, 조산부는16주 간호 교육과정을 수도인 무스카트(Muscat)에서 시범운영 후 다른 지역으로 확대하기로 했습니다. 따라서 지역사회 간호 서비스는 일차 보건의료 서비스를 제공하는 기관에 통합되어 일차 보건의료와 관련된 일을 하게 되었습니다(292). 결국 16주 교육과정은 간호대학의 지역사회 간호 서비스에 중점을 둔 학위 과정으로 통합되었다가, 지역사회 간호에 관한 전문과정으로 발전했습니다. 이 전문과정의 설립으로 자격을 갖춘 지역사회 간호사를 계속 양성하여 오만의 증가하는 일차 보건의료 서비스 수요를 충족시키는 데 큰 역할을 맡게 되었습니다. 81 State of the world’s nursing 2020 156. 국가는 간호인력의 효과적인 배치와 관리를 위해 신뢰할만한 자료체계를 수립해야 합니다. 고용과 배치의 효율성, 형평성, 투명성은 양질의 일자리의 핵심 요소입니다. 예를 들면 정책 입안자 및 관리자는 자격 취득 후 3개월, 6개월, 1년 안에 채용되는 간호대학 졸업생 비율, 졸업 후 자격증 취득까지의 평균 기간, 자격 취득 후 채용까지 걸리는 평균기간 등 구체적인 측정 항목을 통해 채용과정의 효율성과 신속성을 평가할 수 있어야 합니다. 간호대학 졸업생의 취업 비율이 낮게 나오는 것은 보건노동시장의 포화 현상 때문일 수도 있지만, 대신 졸업, 자격증취득, 취업간의 지연시간이 너무 길게 나온다면, 이는 관료주의로 인한 경직된 행정체계 문제일 수도 있기 때문입니다. 채용 방법 또한 문제가 될 수 있습니다. 공공 의료부문에서 자격요건을 충족하는 모든 지원자를 수용할 수 없다면, 선택할 수 있는 채용과정은 채용인원을 공지한 후 시험을 통해서 지원자를 추려내는 경쟁 채용 방법을 쓸 수밖에 없습니다. 경력개발과 진급 또한 근무연한에 근거한 순차적 방법이 아닌, 기량과 성과에 따른 방법을 사용해야 합니다. 다른 의료직 종사자처럼, 간호사도 강제적인 근무지배치와 업무배당은 다시 한번 고려해야 합니다. 가능하면 간호사의 근무지와 업무배치는 간호사의 업무 선호도를 고려하여 자발적인 선택에 근거하여 이루어져야 합니다. 그러나 간호사의 개인적 선택과 의료체계의 공적인 필요성을 조화시키는 일은, 특히 지역적 배치의 형평성에 있어, 매우 어려운 일입니다. 근무지와 업무 배치에 있어 갈등이 조성될 때, 지방 근무와 간호사 유지를 동시에 강화할 수 있는 전략이 필요합니다(289). © Kieran Dodds 157. 국가는 간호사의 이직률이 높아가는 문제를 명확히 인식하고 이에 관련 대책을 세워야 합니다. 간호사 이직 방지 대책으로 리더십 개발, 멘토링(293,294), 유연한 근무시간, 인센티브, 평생교육의 기회를 제공하는 등의 방법이 있습니다. 신규간호사 대상 공식화된 프리셉터 과정을 수립하여 업무능력과 임상적 기량을 높이고, 직업에 대한 만족도를 높일 수 있도록 도움을 주고, 전문적인 사회화 관계를 수립하도록 교육할 수 있습니다. 이 모든 과정을 통해 신규간호사의 이직률을 낮추는 데 도움이 될 것으로 보입니다(295). 프리셉터 교육과정의 결과 직업적 역량을 성장시키고 이직률을 낮추는 효과는 지방과 도시의 지역적 구분 없이 비슷할 것으로 보입니다(296). 여성리더십 향상과 성 평등, 직장 내 성적 괴롭힘을 방지하는 특별한 정책을 수립해야 합니다. 이 문제들은 노동자의 존엄과 권리를 침해하는 동시에 갈등과 문제를 야기하는 원인이 되기 때문입니다 Current status of evidence and data on the nursing workforce 82 6.3.3 간호 관련 규정 결과 158. 간호 관련 규제와 규범은 공공 보호와 더불어 의료체계를 공고히 하여 변화하는 의료서비스 요구에 대처하도록 합니다. 또한 간호직 개발을 위한 토대를 마련하기도 합니다(243,299). 164개국(응답 국가의 86%)이 간호 교육과정과 임상 실습에 관련한 규정을 마련했으며 이를 관장하는 관계기관이 있다고 보고했습니다. 관련 규정의 강도와 효과는 반드시 국가별로 평가가 이루어져야 합니다. 예를 들어 73%의 국가가 보수교육 관련 규정을 마련했다고 답했으나, 이보다 적은 64%의 국가에서 간호 자격(면허) 관련 규정이 있다고 보고했습니다. 159. 점점 증가하고 있는 보건의료 인력의 해외 이동 현상으로 인해 의료서비스 수준의 질적 하락을 막기 위한 규정 또한 매우 중요합니다. 이를 통해 해외에서 유입되는 간호인력이 자국의 의료적 필요성에 적합한지, 그리고 공중보건을 위협하는 일 없이 업무를 수행할 수 있는 능력을 갖추고 있는지 검증이 가능하게 됩니다. 간호사의 면허 소지 여부, 현재 자격 상태와 경력에 관한 정보를 검색할 수 있는 유용한 방법으로 실시간 웹정보시스템이 개발되어 운영되고 있습니다. 이 실시간 웹정보시스템은 현재 지역 단위로 운영되고 있으나, 앞으로는 국제적 수준으로도 확대될 수 있습니다(168,300-302). 정책 제안 160. 국가는 확실하고, 지속 가능하고, 양질의 간호교육과 임상 실습 과정을 수립하기 위해 관련 규정을 개발하고 개선해야 합니다. 관계 당국은 관련 법의 개정을 추진하여 규제기관의 역할과 간호 교육과정과 임상 실습 과정에 관한 규정을 제정할 수 있습니다. 중요한 점은 적절한 균형을 유지하여 최소한의 규제로 공공의 이익과 안전을 보호하는 결과를 이루는 것입니다(303-306). 또한, 간호 관련 평생교육에 관한 규정을 마련하여, 다양한 직위의 간호사들에게 그들의 역할에 맞는 교육 기회를 제공해야 합니다. 간호업무 수행을 위한 최소 수준의 지식을 평가하는 자격(면허)시험은 점점 더 보편화되고 있습니다(255,307). 다른 방식의 평가 방법도 고려해야 하나, 자격시험이 다양한 의료현장에서 업무를 수행하는데 요구되는 지식과 기술에 근거하여, 객관적이고 공정한 방식으로 평가할 수 있다는 데에는 공통으로 동의하는 방향으로 가고 있습니다. 161. 간호 교육의 강화와 질적 향상을 위해 규제체계의 역량을 높이는 데 투자해야 합니다. 관계 당국은 자체 간호 등록체계를 구성하여 의료체계와 그 외 관련 당국의 데이터베이스와 상호운용이 가능하도록 하는 것이 중요합니다. 등록체계를 확립하는 한 가지 방법으로 면허 갱신제 혹은 자격 갱신제를 통해 관리하는 방법이 있습니다. 이를 통해 간호사의 보수교육을 활성화할 수도 있고, 규제기관의 수입이 창출되기도 할 수 있습니다. 규제기관의 개별 담당관의 역할 또한 중요합니다. 개별 담당관은, 다른 의료 관련 직업종사자와 마찬가지로, 규제직무에 관한 교육을 받을 기회가 없을 것입니다. 개별 담당관은 외국이나 다른 지역의 규제사례나 규제강화의 예를 통해 관련 지식을 습득해나갈 수 있을 것입니다(Box 6.7 아프리카 의료직 규제 협력 참조) 83 State of the world’s nursing 2020 Box 6. 7 아프리카 의료직 규제 협력 아프리카 의료직 규제 협력(ARC)는 아프리카 지역 국가들이 HIV 환자를 위한 간호사 주도 의료활동(nurse-led models of care and treatment for patients with HIV)을 확립하고 발전시키기 위해 간호사와 조산사 관련 규정을 개정하는 것을 돕고 있습니다. ARC 창설에 아프리카 지역 17개국이 참여하였으며, 또한 아프리카 동부, 중부, 남부지역 간호대학 협의회(ECSACON) 대부분의 국가로 구성되어 있습니다(308). ARC는 각국 간호정책수석, 간호협의회장, 대학 등 교육기관장, 간호사와 조산사등록위원회 등을 소집하여, 국가별로 발생하는 의료직 자격등록 관련 문제에 대해 논의하여 우선 과제를 해결하도록 지원하였습니다. 공중 보건 간호단체 연합 (이들은 자신을 스스로 quads라고 명칭 합니다) 구성원들은 매년 만나 규제 관련 우선 과제를 논의하고 협력하고 있습니다(예를 들면 HIV 환자 치료를 포함한 간호사의 업무 범위 규정, HIV 치료 관련 교육 개발 등). Quads는 국내뿐아니라 HIV관련 지역관계자와도 협력관계를 가지고 있습니다. 더불어 진행 상황과 결과를 정기적으로, 다양한 방법을 통해 평가하고 있습니다(309). 5년에 걸친 간호사와 조산사 관련 규정 강화기간(2011, 2016) 동안, quads는 리더십 성장, 조직 역량, 국가 간 간호사와 조산사 조직 간의 협력관계가 성공적으로 이루어졌다고 보고했습니다(310). ARC가 재정후원단체였던 반면, quad는 ECSACON 회원국 안에서 제도화되어 의료 관련 우선 과제를 논의하고 협의하는 간호사∙조산사 리더 단체로 활동하고 있습니다. 6.3.4 좋은 일자리 결과 162. 좋은 일자리 근무환경을 만드는 일은 모든 보건의료직과 연관이 있으며 필요한 일이지만, 간호직은 많은 문제를 겪고 있습니다. 간호사의 대부분은 여성이고, 간호직은 전통적으로 보조하는 역할이라는 편견이 지배하고 있어 간호직 분야는 내재적으로 성 편견과 차별에 노출되어 있습니다. 간호직은 또한 오랜 근무시간, 특정 세팅의 경우 폭력에 노출될 위험, 성희롱과 외국 출생 간호사가 부당한 대우를 받는 등의 많은 문제가 있습니다. 참여국 94%가 간호사 근무시간과 근무 조건에 관한 규정이 마련되어 있다고 답했으며, 그 밖에 사회보장은 91%, 최소임금에 관한 규정 89% 라고 보고했으나, 이러한 규정의 실행 강도와 적절성은 판단하기 어렵습니다. 의료진에 대한 폭행 방지에 관한 규정이 마련되어 있다고 답한 국가는 총 55개국(참여국의 36%)이며, 대부분 동남아시아와 지중해 동부지역에 위치한 국가들입니다. 정책 제안 163. 국가는 좋은 일자리 실행규칙(the Decent Work Agenda)을 준수해야 하며, 간호사의 근무 조건을 개선하는데 투자해야 합니다. 가장 중요한 부분은 적정 임금수준, 사회보장, 공정한 근무조건, 합리적인 근무시간, 직업적 안전보장, 비금전적 인센티브, 능력에 따른 승진 기회 제공 등입니다. 이러한 근무 조건은 간호사의 이직률과 밀접한 관련이 있습니다. 성별, 사회적 배경, 태생 지역과 국가, 인종, 언어에 상관없이 모두에 적용되어야 하며, 이의 실행을 위한 강력한 규제가 있어야 합니다. 적정 수준의 임금과 근무 조건은 의료직 종사자의 권리이며, 또한 의료직 종사자들의 파업 원인이 되기도 합니다. (Box 6.8 의료 파업 참조) Current status of evidence and data on the nursing workforce 84 164. 국가는 인도주의적 위기에 직접 영향을 받는 간호사들을 보호하고 지원해야 합니다. 보건부처, 간호단체, 비영리 단체 등은 관련 당국 및 관계자들과 협력하여 난민캠프나 쉼터와 같이 의료자원이 부족하고 힘든 환경에서 일하고 있는 간호사, 혹은 그들 자신이 난민인 간호사를 보호하고 지원해야 하며, 간호사로 일할 수 있는 공식적인 자격이 없는 곳에서 일하고 있는 간호사를 지원해야 합니다. 궁극적으로 이러한 노력은 세계 모든 의료직 종사자와 의료기관의 안전을 확보하는 일이 될 것이며, 특히 인도주의적 위기 상황에 있는 여성을 보호하는 일이 될 것입니다. Box 6. 8 의료 파업 많은 나라에서 노동자의 파업은 법적으로 보장받으며, 이를 국민의 권리로 인정합니다(311). 그러나 의료종사자의 경우, 이러한 권리를 행사하기가 어렵습니다. 환자의 치료를 받을 권리와 보편적 의료보장의 권리와도 충돌하기 때문입니다. 의료종사자의 파업은 또한 사망률을 높이는 원인이 될 수도 있습니다(311- 314). 그런데도 간호사를 비롯한 의료종사자의 파업은 저소득국가에서부터 고소득국가까지 전 세계에서 발생하고 있습니다(313,314). 2009년에서 2018년 사이 23개 저소득 국가에서 일어난 의료 파업을 분석한 결과 의료직 종사자들의 파업 일이 875일에 달하는 것으로 드러났습니다(311). 연구진은 이들 저소득 국가에서 발생하는 의료 파업 기간이 적게는 며칠에서 몇 달, 그러나 몇 달에서 몇 년을 거쳐 반복적으로 발생했다고 보고했습니다(311). 파업의 주요 원인으로는 임금수준과 임금 연체에 대한 불만, 계약조건에 대한 불만족, 의료 관련 정책과 규정, 근무 조건과 안전 문제 등이 있었습니다. 의료 파업을 줄이기 위해서 관련 당국과 다양한 이해 관계자들이 모여 해결 방법을 다각도로 논의해야 할 것입니다(311,314,315). 개별 파업의 원인을 규명하고, 지역별 파업 양상을 분석하여 해결방안을 모색하는 심층적인 연구가 진행되어야 할 것입니다(311,314,315). 분명한 것은 의료 파업의 주요원인을 해결하려면 정치권의 지원으로 의료를 비롯한 다른 부문 간 협력이 필요하다는 점입니다. 보편적 의료보장의 권리를 성취하고 보호하기 위해, 의료직 종사자들이 안전하고 효율적인 근무환경에서 일하도록 투자해야 합니다(314) 85 State of the world’s nursing 2020 6.3.5 성 평등과 여성의 권리 결과 165. 전세계적으로 간호인력의 90%가 여성입니다. 간호영역에서 극심한 성차별은 복잡한 보수 패턴의 결과로 이어집니다. 이는 고소득국가들 대상으로 하는 조사 결과이긴 하지만 많은 국가에 “성별 임금 격차”가 존재하기 때문입니다(21). 성별 임금 격차를 줄이는 정책적 노력으로 보건의료 인력 내 성 평등을 이루어야 하며, 성 편견을 비롯한 간호직을 평가 절하하는 편견을 극복하도록 해야 합니다(121,232). WHO가 조사한 바에 의하면, 보건의료분야의 관리직은 대부분 남성이 차지하고 있으며, 25%만이 여성에게 할애되고 있다고 보고했습니다(21). Nursing Now 캠페인이 주관한 간호 분야에서 여성의 고위직 진입장벽에 관한 연구에 의하면, 이러한 장벽이 단지 여성에게 “유리천장”(glass ceiling)일 뿐만 아니라 남성에게는 “투명승강기”(glass elevator)로 작용해, 이 분야에서도 남성의 고위직 진출을 촉진한다고 보고했습니다(122). 이는 단지 겉으로 드러난 문제의 하나일 뿐이지, 사실 성별 불평등 현상은 의료체계 모든 분야에 스며 들어 있으며, 간호인력 관리의 모든 방면에 영향을 미치고 있다고 볼 수 있습니다. 정책 제안 166. 국가는 간호사의 성별 임금 격차 문제를 해결해야 합니다. 몇몇 국가에서 성별에 따른 임금 격차는 간호 분야에 여성 인력이 다른 직종에 비해 지나치게 편중되어 있기 때문으로 보입니다. 따라서 문제 해결을 위해서는 임금체계를 분석하여 이에 따라 성적으로 평등하고 공정한 임금이 보건의료 인력에게 돌아갈 수 있도록 해야 합니다. 임금체계 확립을 위한 올바른 정책 수립이 필요하며, 보건의료 인력 임금체계를 고려하여 재정계획을 재고해야 합니다. 시장에 작용하는 힘이 임금수준에 영향을 미친다는 것을 인지하면서, 성별 임금 격차 해소에 관한 정책을 적용할 때 민영 의료부문 또한 고려해야 합니다. 임금체계의 공평성을 평가하고, 관련 정책을 수립할 때 간호계의 리더가 포함되어야 합니다. 167. 각국 정부는 간호 분야를 포함한 모든 보건의료 인력 분야에서 성적 괴롭힘과 차별을 방지하는 정책을 우선으로 수립하여 실행해야 합니다. 모든 형태의 폭력과 언어적, 물리적 성적 괴롭힘에 대해 불관용 정책을 수립해야 하고, 여성을 위한 근무환경을 조성해야 하며(예를 들어 여성 간호사에 유연한 근무시간 제공 등), 간호인력 분야에서 여성에게 리더십 개발의 기회가 동등하게 돌아가도록 노력해야 합니다. 6.4 효과적인 정책 실행을 위한 제도적 역량과 행정력 강화 정책 제안 168. 80개국 이상의 국가가 간호정책수석이 있어 의료와 간호 분야 정책 제안과 수립에 관한 책임을 맡고 있다고 답했습니다. 간호정책수석은 다른 의료 관련 정책담당 고위직과 협력하여 의료서비스 계획, 방법, 의료직 종사자의 근무환경에 관한 정책 수립에 관여해야 합니다. 간호 교육 역량을 강화하고, 간호 관련 직업을 창출하고, 간호사의 이직률을 낮추기 위해서는 근거 중심의 해결방안을 모색해야 하고, 우선 과제를 파악해야 합니다. 이를 위해 각국 정부는 보건의료 인력시장과 재정 유연성 분석능력을 키우고 인력 관련 정책 수립과 실행 역량을 강화해야 할 필요가 있습니다. 본 보고서의 조사 결과에 의하면, 76개국 중 53% 국가가 간호사 리더십 개발 교육과정을 운영하고 있다고 보고했습니다. 그러나 대부분 아프리카와 지중해 동부지역 국가들에 집중되어 있어 고른 분포를 보이지 않습니다. Current status of evidence and data on the nursing workforce 86 169. 간호와 보건 관련 정책의 설계와 실행을 위해서는 우선 과제를 파악하여 정책을 수립하고 이를 의료분야 뿐 아니라 더 넓은 분야에서 실행할 수 있는 기관과 체계와 과정이 필요합니다. 본 보고서에서 간호정책수석 직위와 간호사 리더십 개발 교육과정 운영하는 국가에서 간호 관련 규제가 더 엄격하게 시행되고 있다는 것을 밝혔습니다. 그러나 간호정책수석 직위 존재 여부와 간호사 리더십 개발 교육과정의 운영 여부는 강한 연관성이 없는 것으로 드러났습니다. 이는 아마도 간호협의회와 같은 단체가 회원들에 대한 배려차원 혹은 수익 차원에서 간호사 리더십 개발 교육과정을 운영해오고 있기 때문인 듯 보입니다. 정책 제안 170. 간호 분야 리더십은 반드시 국가, 지역, 그리고 나아가 세계적 차원으로 발전해야 합니다. 간호사는 반드시 리더십 역량을 기를 기회를 받아야 하고 정책 결정 포럼에 참여해야 합니다. 정부 차원이든 지역 혹은 다른 조직이나 단체 고위직을 지명하는데 있어 간호사를 다른 의료직과 동등하게 고려해야 합니다. 이를 위해 간호사 리더십 양성을 위해 특별히 예산을 할당해야 합니다. 국가 차원의 수상(award) 제도를 마련하는 것도 보편적 의료보장 성취에 간호사의 기여도를 알리고 젊은 간호사가 따를 만한 롤모델을 세울 수 있는 좋은 방법이 될 것으로 여겨집니다(Box 6.9 태평양 서부지역의 리더십 펠로우십 참조). © Janice Mullings-George 87 State of the world’s nursing 2020 171. 국가 정책 포럼에서 의료 관련 정책을 논의할 때 간호사의 관점도 고려해야 합니다. 모든 수준의 의료 관련 정책 결정에 간호사도 역할을 해야 하고 의료체계와 공공보건에 관련된 정책 결정에 간호사도 목소리를 낼 수 있도록 정책적으로 보장되어야 합니다. 간호사는 대규모의 임상 의사결정 과정에 참여해야 합니다. 예를 들면 임상 실무 가이드라인 개발에 참여한다던가, 임상 실무 가이드라인 검증 패널에 참여하여 간호 관련 연구조사와 결과에 근거하여 임상권고의 타당성과 수용성을 검증해야 합니다 6.5 간호 관련 직업 창출을 위한 투자 확대 결과 172. 본 보고서는 또한 보편적 의료보장을 위해 보건의료 인력 확충을 위해 간호분야 투자 확대가 필요하다는 것을 밝히고 있습니다. 지난 몇 년간의 긍정적으로 변화에도 불구하고 간호사 공급과 고용흡수력이 성장하지 않으면 간호 수급률은 향후 10년 내로 대부분의 지역에서 미미한 수준의 증가율을 보일 것입니다. 이에 따라 저소득국가 및 저중소득국가, 특히 아프리카, 동남아시아, 지중해 동부지역 국가들은 심각한 인력 부족 현상을 지속적으로 겪게 될 것입니다. Box 6. 9 태평양 서부지역의 리더십 펠로우십 태평양 서부지역 국가들은 현재 비전염성 질환과 전염성 질환의 이중고를 겪고 있으며, 더불어 증가하고 있는 경제적, 사회적, 환경적 문제들로 골치를 앓고 있습니다. 태평양 서부지역 78%의 보건의료서비스를 간호사들이 맡고 있습니다(317). 따라서 간호 분야의 성장과 더불어 간호 교육 수준을 올려 지역사회 의료서비스 수준을 높이기 위해 노력해야 합니다. 그러나 이 지역은 일반적으로 리더십 교육과정이 드물게 운영되고 있으며, 의료직을 위한 리더십 과정은 거의 찾아볼 수 없는 지경입니다(320-322), 간혹 있다 하더라도 이 지역 문화적 관점에서 검증된 경우는 없다고 볼 수 있습니다(317, 323, 324). 2009년부터 2017년까지 호주 시드니 기술대학 (University of Technology Sydney)은 태평양 남부지역 간호와 조산 관련 정책 수석 협의회(South Pacific Chief Nursing and Midwifery Officers Alliance)의 후원으로 간호사 리더십교육과정(Australia Awards)을 운영하였습니다. 교육과정은 의료 인적 자원, 조직문화, 멘토링, 정책실행과 보편적 의료보장에 중점을 두고 진행되었습니다. 교육과정에 대한 평가에는 14개국 300명 이상의 관계자와 교육과정 참여자들이 참여하였습니다(318). 최초 조사 결과 리더십 교육과정에 참여한 85%의 간호사와 조산사가 진급하여 책임직을 맡은 것으로 알려졌으며, 자국에서 후속 프로그램 개발, 직업 능력 개발, 보수교육 등의 관련 과정을 설립하였습니다(319). 다른 조사 결과에 의하면 리더십 과정에 참여했던 이들이 이제는 국제회의에서 자국을 대표하여 국제적, 지역적, 국가적 차원의 정책 수립에 영향을 미치고 있습니다(325). 리더십 과정에 참여했던 9명의 간호와 조산 관련 관리자는 제72회 세계보건회의에 참석했으며, 그 중 6명은 자국에서 간호정책 수석으로 임명되었고 2명은 보건부 장관직을 수행하고 있습니다. Current status of evidence and data on the nursing workforce 88 173. 간호 교육, 기술, 간호관련 일자리 창출, 채용과 배치, 간호 자격과 인증과정을 담당하는 간호 관련 기관의 행정력 함양 등과 관련한 투자계획을 수립하고 적절한 투자대상을 정하는 데 있어 부문간 정책협의가 필요할 것입니다. 보건의료 인력 시장을 확대하는 것은 간호 관련 일자리 창출 기회가 될 수 있습니다. 특별히 여성의 경우에 더욱더 그렇습니다. 간호관련직 고용을 확대하면 현재 전 세계적으로 75%로 압도적인 남성에 비해 48%만을 차지하는 여성의 노동시장 참여율을 높일 수 있으며 여성 고용률도 향상될 것으로 보입니다(326, 327). 간호관련 일자리 창출을 위해 투자를 하면 건강증진과 성 평등, 개발의 ‘1석 3조’로 효과가 나타나게 될 것입니다(21). 정책 제안 174. 국가는 간호 관련 일자리 창출을 위해 필요한 경제적 지원을 확대하기 위해 관련 분야와의 상호협력을 조정하고 재정자원을 마련해야 합니다. 임금상승률을 효과적으로 조정하는 것으로도 기존의 재정자원을 이용하여 대부분 국가에서 590만 개의 간호 관련 일자리가 창출될 수 있을 것입니다(현재 간호인력 부족분만을 고려한다면). 정책 입안자는 다른 직업군과 비교하여 간호 분야에 효율적 투자책을 모색해야 하며, 적절한 인센티브와 관리체계를 통해 현재와 미래 간호인력 양성을 최대화할 방법을 찾아야 합니다. 대부분의 고소득 국가와 중간 소득 국가에서는 공공자금으로 보건의료 인력 유지 비용을 충당할 수 있습니다(정상적인 재정의 성장률과 보건정책을 우선으로 한다고 가정하면)(328). 몇몇 고소득국가와 중간 소득 국가는 보건 인력 공급에 대한 제한을 완화함으로써 해외 간호인력 채용에 지나친 의존을 줄이면서 동시에 간호인력 부족을 해소할 수 있습니다. 89 State of the world’s nursing 2020 175. 개발 협력관계자는 간호교육과 보건 인력 고용을 위한 공식개발지원을 계획하는 데 있어 국가적 차원의 보건의료 인력을 고려하면서 의료 관련 정책을 토대로 조정해야 합니다. 저소득국가 및 저중소득국가들은 부족한 재정 유연성으로 인해 새로운 간호 관련 일자리를 창출하는 데 어려움을 겪게 될 것입니다. 대신 기부자와 개발협력자의 지원을 조절하여 보편적 의료보장 실현을 위해 필요한 자금을 확대함과 동시에 의료와 사회복지 인력을 강화하기 위한 재정을 확보할 수 있습니다. (Box 6.10 인적 자원 투자 참조) 국내자원이 중장기적으로 부족하다고 판단되면, 예를 들어 저소득국가나 분쟁 취약 지역은 행정적 지원이 가능한 한 기금모금제도 같은 방법을 모색해볼 수도 있습니다. 176. 국가는 지역적, 국가적, 국제적 보건의료 인력 시장 상황을 고려하여 간호사 수급 문제를 해결해야 합니다. 관계 당국은 전형적인 함정에 빠지는 것을 경계해야 합니다. 예를 들어 임금수준을 너무 낮게 유지하거나(이로 인해 노동자의 동기 상실, 이직률 상승, 불법 행위등을 유발할 수 있습니다), 너무 높게 잡는 경우(임금 인플레이션을 일으킬 수 있으며, 임금 지급과 관련된 재정 문제를 겪게 될 수 있습니다) 혹은 성별 임금 격차 현상을 지속시키는 등을 들 수 있습니다. 임금 지급방식 또한 중요합니다. 간호사들은 일반적으로 고정임금을 받습니다. 그리고 다른 직종과 비교하여 이중직업을 갖기 어렵습니다. 특정 질환 치료나 일정 프로그램에 대해 최고 인센티브를 부여하는 것은 국가적 우선 과제를 왜곡시키고 지속할 수 있지도 않기 때문에 피해야 합니다. 정부 당국은 전 의료직종에 대해 일관성 있는 임금체계를 적용해야 합니다. 임금체계의 차별은, 예를 들어 간호직 선택을 망설이게 하는 중요한 동기가 될 수 있습니다. 마지막으로 새로운 간호사를 유인하고, 이직률을 낮춰야 하며 필요에 부응할 만큼 충분한 수준의 임금을 간호사에게 지급해야 합니다. Box 6. 10 인적 자원 투자 보편적 의료보장을 실현하기 위한 기초로 일차 보건의료 접근성을 높이기 위해 의료 인프라(병원이나 의료센터)와 이에 관련한 인적 자원(보건의료 인력, 의료지식과 의료기술)에 충분한 투자를 해야 합니다(14, 328). 많은 인적 자원 양성 계획이 정부의 재정 투자의 방향을 인적 자원으로 유도하여 보건의료, 영양, 교육, 기술방면에서 괄목할 만한 결과를 나타내고 있습니다. •세계 은행(The World Bank)은 저소득 국가 특히 아프리카에 중점을 두고 인적 자원개혁을 지원하기 위해 150억 달러(한화 약 18조 5000억 원)를 지원하기로 했습니다. 63개국이 참여하기로 합의했습니다. •국제통화기금(IMF)은 사회복지계획을 핵심목표로 삼아 모든 프로그램에 이에 대한 내용을 강조하고 있습니다. 따라서 사회지출, 사회보장, 교육과 의료분야의 추가로 기술지원을 하게 될 것입니다. •보편적 의료보장의 맥락에서 유럽투자은행(European Investment Bank)과 WHO는 유럽투자은행의 투자금이 선정된 의료교육 분야, 의료기술, 의료부문에 연결하게 하는 재정 기구 설립을 통하여 인적 자원 개발에 협력하기로 했습니다. • OECD와 WHO, ILO는 변형 교육(transformative education), 기술 및 일자리 창출과 관련된 유엔 고위급회담(United Nations High-Level Commission on Health Employment and Economic Growth)에서 권고된 사항의 실행을 위한 자원을 모으기 위해 유엔 다중 파트너 신탁 기금을 설립했습니다. Future directions for nursing workforce policy 90 6.6 간호 연구와 근거 안건(agenda) 177. 본 보고서는 회원국과 그 외 관계자의 간호 관련 정책 개발을 도우려고 간호인력에 관해 전례가 없을 정도의 풍부한 자료량과 관련 연구 결과를 검토하였습니다. 그러나 동시에 본 보고서의 분석 결과는 수집 자료, 연구와 관련된 한계점 또한 있습니다. 우리가 발견한 문제들은 밑에 수록하였으며 앞으로의 연구에 도움이 될 것으로 기대합니다. 178. 간호에 국한되는 양적 그리고 반정량적 연구자료 본 보고서에서 발견한 가장 중요한 점은 수집한 자료에서 발견한 내용이 아니라 바로 자료 자체에 관한 것입니다. 간호인력을 포괄적으로 파악하고 보건의료 인력 시장을 분석하기 위해 필요한 정보 간에 중요한 간극이 있습니다. 특히 간호인력 수급력, 간호인력 감소, 임금 격차, 보건의료 인력시장의 고용흡수력에 관한 자료에서 상이점을 발견했습니다. 자료를 조사하고 분석하기 위해서 지원체계를 강화할 필요가 있었습니다. NHWA는 각 부문 간 참여를 연결하여 정책 협의와 간호 분야의 중요영역 성장을 촉진하는 계획적이고 지속적인 투자에 대한 결정 과정을 지원했습니다. 179. 일차 보건의료와 보편적 의료보장에 있어 간호인력의 효과에 대한 근거 본 보고서는 다양한 의료활동과 공공 의료영역에서 간호사들의 기여에 대한 자료들을 요약 정리했습니다. 18개의 무작위 대조군 실험설계에 대한 체계적 문헌 고찰(systematic review)에서 일차 보건의료 기능 확장에 있어 간호사 주도의 의료활동이 효과적임을 입증했습니다(30). 그러나 18개의 임상시험 중 17개는 고소득 국가에서 진행되었으며, 오직 1건의 임상시험만이 중간 소득 국가에서 진행되었고, 저소득국가의 경우는 진행되지 않았습니다. 이후 진행된 코크란 리뷰와 캠벨 리뷰에서도 항레트로바이러스 치료나 금연, 정신건강, 성폭력 등 특정 분야 혹은 프로그램에 제한되었습니다. 이들 리뷰에서 무작위 대조군 실험설계는 오직 하나였으며, 실험연구와 유사 실험연구, 대조시험(무작위 혹은 비 무작위), 시행 전후 대조시험, 코호트 연구(전향적 혹은 후향적), 비연속 시계열(ITS) 연구 방법을 통해 실험군과 대조군을 비교•분석하였습니다(31, 33, 34). 캠벨 리뷰는 미국과 영국의 의료에 중점을 두었기 때문에 그 외 나라에 대한 자료 접근성이 낮았습니다. 항레트로바이러스 치료에 대한 리뷰만이 아프리카 지역에서 진행된 연구를 다루었습니다. 금연에 관련된 연구는 고소득 국가, 주로 미국에서 진행되었습니다. 정신 건강에 관한 리뷰는 저소득국가와 중간소득 국가에서 진행된 연구를 사용했는데, 7개의 임상시험은 저소득국가에서, 15개는 저소득국가와 중간 소득 국가에서 진행된 것들입니다(31, 33, 34). 본 보고서의 개요에서도 또한 자료 간 차이점을 주목했습니다. 예를 들어 기후변화와 같은 사회적 결정요소와 관련한 간호 중재(nursing interventions), 복잡한 응급상황에서 간호 중재에 대한 자료 같은 것을 들 수 있습니다. 91 State of the world’s nursing 2020 © WHO/Yoshi Shimizu 180. 다양한 연구설정과 방법 활용. 앞서 언급했던 리뷰의 결과들은 간호 중재(nursing interventions)의 효과를 입증하는 데 매우 중요한 반면, 연구설정의 한계로 인해 일반화와 국제적 적용에는 무리가 있습니다. 더욱이 실험 연구와 유사 실험 연구는 대부분 간호사를 다른 의료직과 비교했습니다. 이 방법은 유용한 통찰력을 줄 수 있으나, 여전히 효과적인 의료서비스를 제공하기 위해 서로 다른 직종의 의료진이 팀을 이루어 상호연관된 의료활동을 수행하는 과정을 완전히 파악하고 분석하기에는 적절한 방법이 아닙니다. 더욱 다양한 범위의 연구들, 양적 1차 연구(실험 연구, 비 실험 연구 포함), 질적 1차 연구, 혼합연구, 데이터베이스의 각 항목 분석 방법 등을 통해 국제적으로 논의되는 의료정책 문제에 대해 포괄적으로 접근할 수 있습니다. 그러나 연구 우선순위 지정을 포함하여(330) 대부분의 연구가 고소득 국가에서 진행되었다는 한계가 있습니다(30, 329). 181. 저소득 국가와 중간 소득 국가에서 진행되고 있는 간호 중재에 대한 연구가 이루어져야 하고, 이들 국가에서 간호학을 지원하여 간호사들이 현장경험을 바탕으로 연구를 이끌어나갈 수 있도록 해야 합니다. 간호사는 혁신적인 연구방법을 개발하고, 세계 보건을 향상시키는데 주요한 주제를 연구하는 데 연구방법들을 적용하며 이미 보건의료 및 건강과학 발전에 지대한 공헌을 하고 있다(331). 저∙중간 소득 국가에서 인력의 실무역량을 발전시키는 효과적인 전략에 대한 근거 연구는 부족합니다(332). 그러므로 간호 연구 분야에 대한 투자는 양적 성장뿐 아니라 연구의 질적 수준을 높이는 방향으로 나아가야 합니다. 이는 결국 보건의료 인력에 관한 지식 수준을 높이는 데 기여할 것이기 때문입니다. Future directions for nursing workforce policy 92 182. 간호사의 역할을 최적화하기 위한 효과적인 정책과 지원 체계에 관한 근거 본 보고서는 간호교육, 간호관련 규정, 간호인력 배치, 업무와 이직률 등 다양한 영역에서 간호인력 활용 정책의 중요성을 강조했습니다. 그러나 아직 부족한 부분이 있습니다. 예를 들면 간호 분야에 대한 투자 수익에 관한 부분, 그리고 다양한 배경과 정책적 관점에서, 더욱 더 넓은 영역에서 간호사의 역할에 대한 연구가 필요합니다. 특히 저∙중소득국가의 일차 보건의료 현장에서 간호의 비용 대비 효율성에 관한 연구를 통하여 이를 파악할 수 있습니다. 또한 간호사의 이직률을 낮추기 위한 정책, 일차 보건의료 현장에서 간호사의 역량 발휘, 민영 교육 부문 규제에 대한 연구가 진행되어야 합니다. 이민 문제 해결 정책에 대해 더욱 더 강력히 검증하여 정책 개선과 더욱 현실적인 정책목표를 세울 수 있도록 해야 합니다. 이 모든 영역에서 성 평등의 관점으로 접근하고 분석할 필요가 있습니다. 대다수의 연구가 단기간 횡단연구로 이루어졌기 때문에, 장기간에 진행되는 종단연구를 수행하여 연구 결과를 실제 정책으로 이어질 수 있을 정도로 신뢰도를 높일 수 있을 것입니다. 93 State of the world’s nursing 2020 © AKDN/Christopher Wilton-Steer Conclusion 94 결론 183. 본 보고서는 보편적 의료보장과 그 외 국가적, 세계적 의료과제를 수행하는 의료통합팀의 일원으로서 간호사의 핵심적 역할을 강조하였습니다. 간호사는 전 세계적으로 대략 2천800만 명으로 추산되는 가장 큰 규모의 보건의료직 그룹이며 다양한 사회경제적 개발단계를 거치고 있는 모든 국가의 일차 보건의료를 포함한 보건의료 체계의 가장 중요한 구성요소입니다. 184. 본 보고서 작성을 위해 수집한 데이터와 관련 연구의 양은 그 어느 때보다도 방대합니다. 총 191개국이 제공한 관련 자료를 기본으로 한 본 보고서는 2018년 보건의료 인력 관련 자료보다 53%가 더 증가하였으며 가장 높은 양을 축적하였습니다. 최초로 80%가 넘는 참여국이 WHO에 15개 간호 관련 지표에 관한 자료를 제공했으며, 이 자료들은 각국의 인력 관련 정책을 총망라하는 내용을 담고 있습니다. 분석 결과에 따르면 2018년 간호사 부족분은 590만 명에 달했으며, 주로 아프리카, 동남아시아, 지중해 동부지역 국가들의 부족 현상이 심각한 것으로 드러났습니다. 이 수치는 세계 보건의료 인적자원 활용 전략이 밝혔던 기준 수치와 비교해 많이 증가한 것입니다. 185. 간호인력 증가 현상에도 불구하고 본 보고서는 몇 가지 우려되는 부분을 강조했습니다. 2016년 세계 보건의료 인적자원 활용 전략에 의하면, 이러한 발전 속도를 가속하려면 저소득 국가와 저중소득 국가들, 특히 아프리카, 지중해 동부지역 국가의 간호인력 격차를 해소해야 한다고 보고했습니다. 특히 동남아시아 지역의 간호인력은 절대적으로 부족한 상황입니다. 미주와 유럽지역의 국가들은 간호인력 고령화에 따른 또 다른 문제에 직면해 있습니다. 미국과 유럽, 지중해 동부 몇몇 고소득 국가들이 해외 간호인력에 과도하게 의존하고 있는 것으로 나타났습니다. CHAPTER 92 State of the world’s nursing 2020 186. 각국 정부는 국내외 관련 기관이나 단체와 협력하여 다음과 같은 노력을 해야 합니다: • 간호교육, 건강, 일자리, 성 평등 문제를 해결하기 위해서 간호사의 리더십, 간호사 권익 보호, 관리 능력 향상을 위해 노력해야 합니다. • 교육, 좋은 일자리, 공정한 배치, 업무능력 향상, 관련 규제, 이직률에 관한 정책을 수립하여 이를 수행함으로써 간호 분야 투자에 대한 수익을 극대화해야 합니다. • 간호 분야를 비롯한 보건의료 인력에 막대한 투자를 통해 일자리 창출, 성 평등, 젊은이들의 성장력을 강화하는 등 다양한 결과를 도출해야 합니다. 187. 본 보고서의 연구 결과, 권고하는 정책 제안들, 각 정책 세부사항과 투자 결정의 방향 설정을 위해 각 정부 부문 간 협력과 조정, 그리고 중요한 관련 기구와의 협의와 협력이 필요합니다. 본 보고서의 자료와 연구 결과들을 활용하여 관련 기구의 참여를 보장하면서, 국가 간 정책 수립의 논의를 활발히 진행해야 합니다. 정책 수립 논의 과정은 구체적인 정책 수립과 적재적소의 투자계획 수립을 위해 필요한 결정을 이끌어 내도록 조절하여야 합니다. © WHO/Yoshi Shimizu INVESTING IN NURSING education, jobs and References 96 References 1. Benton DC, Catizone CA, Chaudhry HJ, DeMers ST, Grace P, Hatherill WA et al. Bibliometrics: a means of visualizing occupational licensure scholarship. Journal of Nursing Regulation. 2018;9:31–7. doi:10.1016/s2155-8256(18)30052-8. 2. International Council of Nurses: who we are. 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Lancet Global Health. 2018;6:e1163–75. doi:10.1016/s2214- 109x(18)30398-x. 111 State of the world’s nursing 2020 Annex 1. 간호사는 어떤 직업입니까? 간호사는 전문병원부터 지역사회까지 망라하는 모든 의료현장에서 다양한 형태의 의료서비스를 제공합니다. 간호직을 직분에 따라 구분하는 여러 명칭이 있으며 이에 따른 교육과정도 다릅니다. 간호직을 보통 직무에 따라 6분류로 나눕니다: 공인 간호사(RN), 간호사(nurse), 실무간호사(LPN), 전문간호사(APRN), 전문간호사(nurse practitioner), 간호조무사(nursing assistant). 그러나 한 국가의 간호사 역할은, 같은 직업명을 가졌더라도 다른 국가의 간호사 역할과 다를 수 있습니다. 따라서 국제적 수준에서 분류/분석 방법으로 간호사직 명칭을 사용하는 것은 부적절합니다. 본 보고서는 2008년 국제노동기구(ILO)가 제안한 국제표준 직업군 분류(ISCO-08)에 따라 정의된 간호인력에 관한 자료를 제시하여 국가별 비교가 가능할 수 있도록 하였습니다. WHO 회원국은 이에 따른 관련 자료를 제공하였습니다. 따라서 NHWA는 ISCO-08분류에 따라 보건의료 인력을 범주화했습니다. 각국 정부에게 간호인력을 2개의 주요 ISCO- 08 코드에 따라 분류하도록 요청했습니다: 전문직 간호사(professional nurse: ISCO 코드 2221)와 준 전문직 간호사(nursing associate professional: ISCO 코드 3221). 주의할 점은, 본 보고서는 간호인력을 ISCO-08 코드에 따라 분류하였으나, “간호”(nursing care)에 대한 개념은 다 직종으로 구성된 의료 체계 안에 간호인력을 투입하면서 이루어지는 과정을 뜻하는 용어이므로 위에 언급되지 않은 다른 간호인력의 활동을 포함하고 있음을 인지해야 합니다. 예를 들어 ISCO분류를 도입한 국가는 “간호조무사”(nurse aids)를 보다 넓은 범위의 지원직으로 보아 의료 관련 보조인으로 분류합니다.12 ISCO 지침은 간호인력의 범주와 역할에 대해 구체적으로 구분하여 기준을 제시하고 있습니다(Box A 1.1). 요약하면, 전문직 간호사는 환자 간호에 대한 계획과 관리를 책임지며, 독립적으로 의료활동을 하거나 의사를 비롯한 의료진과 팀을 이루어 일합니다. 준 전문직 간호사는 기본 간호업무와 개별 환자의 케어를 맡으며, 주로 의사와 간호사 등 의료진의 지시하에 일하며, 의료진을 지원하는 일을 맡고 있습니다. 그러나 몇몇 국가에서는 전문직 간호사와 준 전문직 간호사 간 업무의 구분이 불분명합니다. 이와 유사하게 준 전문직 간호사와 간호조무사의 역할 구분 또한 불분명할 때가 많습니다. 이런 경우에는 관련 국가가 판단을 내려 구분해야 합니다. 국가는 직업군을 전문직 간호사로 분류할지 또는 준 전문직 간호사로 분류할지 아니면 간호사가 아니라고 결정할 때 역할과 책임과 간호교육 기간을 모두 고려해야 합니다. 예를 들어, 일반적으로 전문직 간호사는 최소 3년 이상 지속되는 간호교육을 이수하도록 되어 있습니다. 국가가 사용할 범주를 결정하기 어려운 경우, NHWA는 “간호사: 더 이상 정의되지 않음” 옵션을 포함하였고, 몇몇 국가는 그들의 간호인력 일부 혹은 모두를 이 범주에 포함시켰습니다. 이 범주는 전문직 간호사 또는 준 전문직 간호사 중 하나에 포함되지만, 보조인력 직업군에 포함되는 간호조무사는 제외하였고 본 보고서에서 분석되지 않았습니다. 12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/. Annex 1 112 Box A1. 1 ISCO 분류에 따른 간호사 정의 전문직 간호사의 역할은 다음을 포함합니다: 준 전문직 간호사의 역할은 다음을 포함합니다: · 환자를 위한 간호를 계획, 수행, 평가합니다. · 타 보건의료 전문직과 협의하여 환자 케어를 조정합니다. · 타 보건의료 전문직과 협의하여 환자의 치료에 대한 간호 계획을 세우고 수행합니다. · 약물 중재와 치료나 간호의 반응을 모니터링하는 등 환자의 간호와 치료를 계획하고 수행합니다. · 상처 소독과 드레싱을 합니다. · 환자의 통증과 불편함을 사정하여 진통제 투약을 포함한 통증 경감 중재를 수행합니다. · 건강교육 프로그램, 건강증진 및 간호교육 활동을 계획하고 참여합니다. · 환자와 환자 가족의 질문에 응답하며 질병예방, 치료와 간호에 관한 정보를 제공합니다. · 타 보건의료 인력의 업무를 관리감독하고 이를 조정합니다. · 간호 실무와 절차에 관한 연구를 수행합니다. · 보건의료 전문직이 수립한 간호계획에 따라 간호, 개인위생 간호, 치료, 건강관련 조언을 제공합니다. · 약물 중재와 기타 중재, 환자 상태와 치료에 대한 반응을 모니터링하고 전문적인 간호가 필요한 경우 환자와 가족을 보건의료 전문직에게 의뢰합니다. · 상처 소독과 드레싱을 합니다. · 환자 진료기록 시스템에서 환자 상태와 환자가 받은 치료에 관한 정보를 업데이트합니다. · 개별 환자의 치료계획 수립과 관리를 보조합니다. · 응급상황에서 필요한 응급처치 활동을 보조합니다. Note: 전문직 간호사와 준 전문직 간호사의 구분은 위에 명시된 특정 역할과 연관된 간호사의 업무 특성에 따라야 합니다. 간호사의 자격과 특정 국가에서 자격이 더 우세한가의 여부는 구분을 내리는 데 있어 주요 요소가 아닙니다. 간호교육 방식은 국가마다 상이하며, 기간에도 차이가 있기 때문입니다. 출처: ISCO-08 113 State of the world’s nursing 2020 Annex 2. 조사 방법 2020년 세계 간호 현황 보고서에 사용된 지표 WHO 회원국에 2019년 7월부터 2019년 11월까지 간호인력 관련 36개의 지표(NHWA의 30개 지표와 6개의 특정 지표 자료)에 대한 가장 최신 자료를 제공해달라고 요청했습니다(Table A2.1 참조). 30개의 지표는 NHWA 안내서에 소개되어 있으며13, 구체적인 정의와 메타데이터가 각 지표마다 제공되어 있습니다. 자료수집과정 NHWA는 보건의료 인력 자원에 대한 자료의 접근성을 높이고 질적 수준을 향상하도록 개발된 정보시스템입니다. 이러한 과정의 일환으로 각국에 다양한 관련 기관 관계자로 구성된 팀을 구성하여, 자료 제공전에 이에 대한 내부 검증과정을 거치도록 요청하였습니다. 많은 국가가 내부 검증과정을 거친 후 자료를 제공하였습니다. 본 보고서의 준비과정은 표준화된 자료의 모니터링과 보고체계를 위한 각국의 노력을 촉진시켰습니다. 각국에 NHWA에 제시된 내용 중 중요한 사항을 선정하도록 요청하였고, 이는 NHWA 온라인 플랫폼을 통해 입력하거나 검증할 수 있었습니다. 추가로 유럽지역의 자료수집을 위한 질문지(Europe data collection questionnaire)에 관한 주제로 모인 OECD, 유로스탓(Eurostat), WHO의 지역관계자 협의회에서 나온 OECD 국가와 관련된 자료항목은 미리 채워서 국제기관에 이중으로 보고하는 것을 방지하도록 했습니다. 또한 협의회에 자료의 검증을 위한 주요사항에 대해 안내했습니다. 각 국가의 인구 규모와 연도는 UN 경제사회부에서 발간하는 세계 인구 전망 2019년 개정판(World population prospects of the United Nations Department of Economic and Social Affairs)을 근거로 하였습니다14. 몇몇 국가의 자료를 완성하기 위해서 행정 및 정책환경에 대해 평가하는 지표에 관한 자료는 시그마학회와 미국 간호사 면허시험국 데이터베이스(NCBSN databases)15에서 추가로 수집되었습니다. 이 자료는 간호교육과 임상실습관련 제도와 과정, 기간에 대한 존재 여부를 알기 위해 이분형(예 혹은 아니오) 형식으로 구성되었습니다. 자료수집을 원활히 하고자 WHO는 6개 지역별로 NHWA 워크샵을 개최하여 여러 언어로 구성된 양식과 정보를 제공하였습니다. 80개국에서 250여명의 대표자가 이 워크샵에 참석하여 NHWA 활용능력을 높였습니다. 2019년 7월부터 11월까지 자료를 제공받았으며, 2019년 10월부터 12월 사이에 데이터 정제과정(data cleaning)과 분석이 이루어졌습니다. 본 보고서는 2019년 12월 17일 기준으로 NHWA 온라인 플랫폼에 수록된 자료에 근거하여 작성되었습니다. NHWA 중요사항으로 간호관련 책임자와 그 외 다른 관련기관이 참여하도록 권고하였습니다. WHO 국가별 지역 사무소는 자료수집, 자료의 관련성 검증과 보고과정을 포함하여, NHWA 실행과 자료입력과정을 지원했습니다. 데이터 보고 WHO회원국 194개 참여국 중 193개국은 NHWA를 통하여 자료를 제공하거나 WHO 지역 사무소를 통해 보고하거나, 지역사무소와 다른 국제기관 (예를 들어 OECD, 유로스탓(Eurostat), WHO 유럽지역 사무소)을 통해 비금전적 보건의료 통계에 대해 공동으로 데이터 수집을 하였습니다. Figure A2.1은 80%의 국가가 적어도 36개 지표중 15개이상에 응답하였으며, 23%의 참여국이 적어도 25개 지표 자료를 제공하였음을 나타냅니다. 임금수준, 간호교육 비용, 그 외 교육과 관련된 문제에 관련된 지표에서는 각 국가에서 제공한 자료간 차이가 있습니다. 교육기관, 임상실습, 임금, 그 외 역량 지표 차이에 관해 NHWA 자료를 보완하기 위해 특정 지표에 한해 대체 자료를 요청하였습니다. 예를 들어 국제 간호협의회, 시그마학회는 국제 간호교육 상태에 대한 데이터베이스를 운영하고 있어, 50여 개국의 관련 자료 예를 들어 신규 간호사의 임금수준, 교육과정 기간과 같은 자료를 보유하고 있습니다. 간호 실무와 간호교육에 관련한 정책과 규제 관련 지표에 관해, 미국 간호사 면허시험국 협의회(NCSBN)에서 발행한 세계간호면허관련 규정지도 (Regulatory Atlas)를 사용하여 면허시험제도를 운영하고 있는 국가와 관련 규제의 존재 여부를 확인하였습니다. 13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018. 14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York, United States of America: United Nations; 2019. 15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https:// www.ncsbn.org/national-nursing-database.htm. Annex 2 114 Table A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report. Indicator name (NHWA abbreviated) NHWA number Response rate as of 17 December 2019 NURSE WORKFORCE STOCK AND DISTRIBUTION Nurse density by type/level of nurse 1-01 98% Nurse density at subnational level 1-02 31% Nurse distribution by age group 1-03 55% Female nurse workforce 1-04 68% Nurse distribution by facility ownership 1-05 47% Nurse distribution by facility type 1-06 34% Share of foreign-born nurses 1-07 35% Share of foreign-trained nurses 1-08 46% EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88% Duration of education and training 2-02 56% Number of applications for education and training 2-03 12% Ratio of nursing students to qualified educators 2-05 10% EDUCATION AND TRAINING REGULATION AND ACCREDITATION Standards for duration and content of education 3-01 87% Accreditation mechanisms for education institutions 3-02 84% Standards for interprofessional education 3-06 80% Continuing professional development 3-08 82% EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7% HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14% Replenishment rate from domestic efforts 5-02 45% Entry rate of foreign nurses 5-03 11% Voluntary exit rate from health labour market 5-04 9% Unemployment rate 5-06 8% EMPLOYMENT CHARACTERISTICS, WORKING CONDITIONS Health workers with a part-time contract 6-02 6% Regulation on working hours and conditions 6-03 86% Regulation on minimum wage 6-04 86% Regulation on social protection 6-05 86% Measures to prevent attacks on health workers 6-09 80% NURSING WORKFORCE SPENDING AND REMUNERATION Entry-level wages and salaries 7-05 42% Gender wage gap 7-07 3% SKILL MIX COMPOSITION FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79% ADDITIONAL STATE OF THE WORLD’S NURSING 2020 SPECIFIC INDICATORS National chief nurse (or equivalent) role – 84% National leadership development opportunities – 76% National association for pre-licensure students – 76% Authority that regulates nursing – 98% Standards for faculty qualifications – 68% Fitness for practice or licensure examination – 92% Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook: https://www.who.int/hrh/documents/brief_nhwa_handbook/en/. Metadata for the additional six non-NHWA indicators are available on request to SOWN2020@who.int. 115 State of the world’s nursing 2020 191개국 중 83%가 2017년부터 2018년까지 간호인력 수에 관한 자료를 제공했습니다. 그 외 국가가 제공한 간호인력 수에 대한 자료는 더 오래된 것입니다(2013년부터 2016년까지). 그런 경우, 2018년 수치는 가장 최근의 수급률에 2018년 인구 수를 적용하여 추정했습니다. 간호인력 수치를 제공하지 않은 4개국의 간호인력 추정치는 그 지역 간호사 수급률에 2018년 인구 수를 적용하여 계산했습니다. 많은 국가, 주로 서부 및 중앙 아프리카와 중앙 아시아 지역 국가들은 몇몇 지표자료를 제공할 여력이 되지 않는다는 사실은 이들 지역의 보건의료정보체계를 운영하는 인적자원을 지속적으로 강화해야 한다는 중요한 필요성을 보여줍니다. 수집한 모든 자료가 본 보고서에 수록되지는 않았습니다. 관련 통계자료가 있는 지표만 분석하고 제시되었습니다. 추가 자료는 NHWA를 통해 점차적으로 공개할 예정입니다. 간호교육관련 규정과 간호사 근무조건에 대한 점수표(5.4항과 5.6항) 대부분의 분석은 서술적이며 주로 비율에 초점을 맞추고 있지만, 구성점수는 간호교육 관련 규정과 간호사 근무조건에 관한 지표를 요약하는데 사용되었습니다. 비율 산출과 점수표 계산을 위해 각각의 지표에 ‘예’라고 응답한 국가는 1점을, ‘부분적’이라고 응답한 국가는 0.5점, ‘아니오’는 0점으로 처리하여 합산하였습니다. 가능한 최대점수는 9점, 최소점수는 0점이 됩니다. 누락한 지표에 대해서는 ‘아니오’로 간주하여 0점 처리하였습니다. Figure A2. 1 Number of indicators reported globally for the State of the world’s nursing 2020 report Note: includes 30 NHWA indicators and six capacity questions. Source: NHWA 2019. Annex 2 116 5.4항과 5.6항의 교육관련 규정과 근무조건에 관한 다중대응분석(Multiple correspondence analysis) 간호교육관련 규정에 관한 지표와 간호실무에 관한 규정에 관한 지표는 매우 높은 연관성을 보이고 있습니다. 즉 한가지 지표에 ‘예’라고 대답했다면, 다른 지표에 대해서도 ‘예’라고 할 가능성이 높습니다. 이러한 양상을 보다 더 확실하게 파악하기 위해서 다중대응분석을 사용하여 단일 2차원 그래프에 있는 많은 변수들간의 관련성을 단순화시켰습니다(Figure A2.2). 분석을 통하여 2차원을 구성했습니다(X축과 Y축). ‘1차원’ 즉 X축의 오른쪽에 가까운 인자(factors)는 간호교육 관련 규정의 부재쪽이며, 왼편으로 갈수록 규정의 존재쪽에 가까워집니다. 1차원은 변수 간(지표 간) 79.7%의 변동률이 있다는 것을 보여줍니다. 인수들이 2차원 즉 Y축의 위로 향할수록 인증제도의 부재를 나타내고 반대로 Y축의 아래쪽으로 향할수록 간호교육 관련 규정의 부재를 나타냅니다. 2차원은 변수 간 2.1%의 변동률을 나타내고 있습니다. 그래프에서 지표들이 서로 매우 밀접해있는 지역을 볼 수 있습니다. 동남아시아지역, 지중해 동부지역, 태평양 서부지역이 그래프 오른쪽에 위치하고 있으며, 이 지역은 간호교육 관련 규정 마련이 미비한 상태인 것과 연관되어 있습니다. 다중대응분석 결과에서 보듯이 근무조건과 관련된 지표들은 매우 강하게 연관되어 있습니다(Figure A2.3). 의료진 폭행 방지 규정과 전문간호사제도는 매우 강한 연관성을 가지고 있는 것으로 드러났는데, 이는 아마도 위험한 환경에서 일하는 간호사에게 높은 수준의 직업적 자율권을 부여함으로 어려운 상황이 닥쳐도 환자를 케어할 수 있도록 하기 위한 것으로 보입니다. 유럽지역은 다른 지역과 매우 다른 양상을 보이는데, 의료진 폭행 방지 규정과 전문간호사제도 모두 미비한 것으로 드러났습니다. 117 State of the world’s nursing 2020 2030년 인력 예상치 2030년까지 간호사의 예상치를 산출하기 위해, 다음의 세가지 시나리오를 개발했습니다. • 시나리오 1: 고령화(간호인력의 고령화 단일 조건에 대한 영향력). 국가별 연령분포와 35세이하 연령그룹을 이용하여 추정치를 계산하는 경우입니다. 이 35세이하 연령층을 간호인력 1/10을 보충할 수 있는 수준으로 고려했습니다. 즉 35세 이하 연령층은 55세이상 간호사 그룹에서 은퇴하는 인력의 1/10 수준으로 간주했습니다. 이 시나리오는 간호대학 졸업생 통계와 35세미만의 더 젊은 연령그룹의 비율을 미래의 상수(constant)로 고려하지 않았습니다. Figure A2. 2 Correlation of education indicators with a multiple correspondence analysis Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables. Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education; M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development; NN2: fitness for practice examination; NN3: standards for faculty qualifications. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacific Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. D im e n s io n 2 ( 2 .1 % ) Dimension 1 (79.7%) Annex 2 118 • 시나리오2: 인력의 보충. 시나리오 1과 유사한 고령화율을 이용하였으나, 5.5항에서 언급한 지역별 최근 간호대학 졸업생 비율을 사용하여, 보정계수 0.6을 적용하였으며, 신규졸업생의 60%가 의료 부문에 고용된다는 전제하에 추정치를 산출했습니다. 이는 OECD국가에서 졸업생의 비율과 보건노동 시장에 진입하는 실제 비율을 참고한 수치입니다. • 시나리오3: 인력보충의 가속화. 시나리오2와 유사하나 간호대학 졸업생 비율의 증가와 보건의료 인력시장의 고용 흡수력 증가를 고려하였습니다. 2030년까지 매년 졸업생이 더욱 늘어나 2018년부터 2030년까지 각 국가의 졸업생 배출 능력이 50% 성장할 것으로 추정했습니다(매년 졸업생 증가율 3.44%과 동일한 수치). 이 시나리오는 또한 보건의료 인력시장의 고용흡수력을 60%로 잡고 있습니다. 위의 세가지 시나리오를 바탕으로 2030년 유엔 인구전망 (United Nations population prospect estimates for 2030)에서 산출한 인구규모을 사용하여 2030년까지 간호사 수급률을 산출했습니다. 시나리오 3을 평가하기 위해 졸업생 증가 변동률을 가설에 사용하였습니다: 25%, 50%, 100% 증가(생산량 배가) (Figure A2.4). 졸업생 증가율을 다르게 선택해도 2030년까지 추정되는 변화량에는 크게 차이가 드러나지 않았습니다. 즉 25%의 경우 3천800만 명, 50%의 경우 3천970만 명, 100%의 경우 4천280만 명의 인력이 증가하는 것으로 산출되었습니다. 119 State of the world’s nursing 2020 결과 해석에 있어 주의해야 할 점 위에서 산출한 수치를 분석할 때 계산방식에 몇 가지 한계가 있음을 고려해야 합니다. 1. 자료접근성과 관련하여, 모든 국가가 시나리오1에서 사용되었던 간호사의 연령분포와 시나리오2에서 사용되었던 졸업생 비율을 보고한 것은 아닙니다. 분석 결과 시나리오 1과 2의 추정치가 일관됨을 보여주므로 신규 졸업생이 보건의료 인력시장에 진입하는 비율에 있어서도 일관된 경향이 있다는 것을 다시 한번 보여줍니다. 2. 55세 이상 연령의 인력 감소율에 대해서 여러가지 가정을 해볼 수 있습니다. 이는 잠재적으로 지역마다 다를 수 있으며 은퇴 연령이 최대 65세에 이르는 것을 고려하면 긍정적일 수도 있습니다. 간호대학 졸업생 증가율에 0.6의 비율을 적용하는 것은 OECD 국가의 실제 고용된 간호인력에 대한 졸업생의 비율에 근거하여 이루어졌습니다. 그러나 증가율 변동은 지역에 따라 다르게 나타날 수 있습니다. 위에서 설정한 3가지의 시나리오의 유효성을 평가하기 위해서 민감성분석을 진행하였습니다. 결과 변화는 미미한 수준이었으며, 결과 수치는 크게 바뀌지 않았습니다. 3. 우리가 추정한 수치 결과는 최근 경향을 반영하고 미래의 간호인력 증가 양상을 예상하는데 단초를 제공합니다. 그러나 미래에 수집할 수 있는 더 많은 자료를 바탕으로 추정 방법을 개선할 필요가 있습니다. 또한 이러한 본 보고서의 예상안이 정부차원에서, 보다 넓은 범위의 보건의료 인력을 고려하고 보건의료 인력시장 전반에 관한 또 다른 지표를 근거로, 재정 유연성을 포함한 구체적인 경제적 통계수치를 고려하여 수립하는 계획안을 대신하지는 않습니다. Figure A2. 3 Correlation of working condition indicators with a multiple correspondence analysis Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables. Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage; M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council. AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region; WPR = Western Pacific Region. Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018. D im e n s io n 2 ( 2 .1 % ) Dimension 1 (79.7%) Annex 2 120 간호인력 부족 예상량 본 보고서의 간호인력 부족 예상량은 세계 보건의료 인적자원 활용 전략에 제시된 방법과 유사한 것을 사용하여 추정하였습니다. 그러나 자료접근성의 향상으로 인해 과거 자료를 사용했던 세계 보건의료 인적자원 활용 전략에서 추정한 수치와 직접 비교할 수는 없습니다. 세계 보건의료 인적자원 활용 전략은 102개국의 이용가능한 자료(2009년부터 2013년까지)를 근거로 추정하였으며, 자료를 제공하지 못한 국가에 관해서는 더 오래된 자료를 사용하였던 것입니다. 본 보고서 작성을 위해 수집한 최신 자료에 의하면, 174개국이 2013년 혹은 그 5년 이전 자료를 (2013년 자료를 보유하고 있는 130개국을 포함하여) 보유하고 있는 것으로 드러났으며, 2013년 간호사 수를 2천320만 명으로 산출하였습니다. 2018년 간호인력 예상수치는 191개국의 데이터를 기반으로 하고 2013년부터 2018년까지의 최신 자료(자료의 89%가 2017년부터 2018년 사이 자료)에 근거하여 산출된 결과입니다. 그러므로 본 보고서의 산출 결과가 더 신뢰성이 있다고 볼 수 있습니다. 간호인력 부족분을 추정하기 위해 2018년부터 2030년까지 간호인력 수급률을 세계 보건의료 인적자원 활용 전략에서 사용했던 기준치와 비교했습니다. 활용 전략에서 사용되었던 기준치인 인구 1천 명 당 4.45명의 의사, 간호사, 조산사를 간호인력을 위한 기준치로 변환시켰습니다. Figure A2. 4 Evolution of global nursing stock (millions) under a “business as usual” scenario and three “increased production of graduate nurses” scenarios, 2018 to 2030 Note: “Nursing stock” includes nursing professionals and nursing associate professionals. Correction factors used, region specific: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice. Nursing stock graduation constant Nursing stock - 25% increase in graduation Nursing stock - 50% increase in graduation Nursing stock - 100% increase in graduation N u rs in g p e rs o n n e l s to c k i n m ill io n s 121 State of the world’s nursing 2020 • 먼저 세계 보건의료 인적자원 활용 전략에서 사용했던 간호사와 조산사 인력을 이 기준치에 적용했습니다. 즉 2013년 기준으로 인구 1만 명 당 20.7명의 간호사와 조산사, 인구 1만 명 당 9.8명의 의사를 기준치에 적용한 것입니다. 그리고 이 기준치는 인구 1천 명 당 간호사와 조산사 3.02명으로 교정했습니다(4.45 x (20.7/(9.8+20.7))). • 그리고 간호사만을 고려한 기준치를 계산하기 위해, 간호사와 조산사를 합친 수치(가장 최근 해 90.7%)에 이 기준치를 적용하여 새로운 기준치 인구 1천 명 당 간호사 2.74명을 산출했습니다. • 보건의료 인력 수급률을 인구 1만 명으로 계산하기 때문에 인구 1만 명 당 간호사 27.4명으로 환산하여 새로운 기준치로 변환시켰습니다. • 다음에 이 새로운 기준치는 2018년 간호사 수급률과 비교하였으며, 위의 세 가지 시나리오에 근거하여 2030년 간호사 수급 비율을 추정하게 된 것입니다. 2030년까지 추정된 간호인력 부족 예상량은 위에서 설명한 세 가지 예측 시나리오에 의해 추정되었으며, 각 시나리오는 저소득 국가 및 저중소득 국가에서 여전히 부족량이 높을 것으로 나타났습니다(Table A2.2). 간호교육 학비 간호사 부족 현상이 심각한 저소득 국가 및 저중소득 국가의 간호교육 학비를 파악하였습니다. 간호교육 학비는 마다가스카르 5,180달러(한화 약 650만원)부터, 세계은행 ECSA가 분석한 5,589달러(한화 약 690만원), 모잠비크 5,656달러(한화 약 700만원), 가나 19,794달러(한화 약 2,400만원)에 이릅니다. 그러므로 학비가 낮은 경우를 가정하여 비용 계산을 하면 1인당 5,000달러(한화 약 600만원), 중간인 경우 1인당 1만 달러(한화 약1,200만원), 가장 높은 경우 1인당 2만 달러(한화 약 2,400만원)에 이릅니다. 간호교육 학비는 아프리카 지역 자료로 산출되었으며 고소득국가는 포함되지 않았습니다. 그러나 고소득국가의 경우 출판된 연구조사에 의하면 아프리카 지역보다 훨씬 높을 것으로 예상됩니다. Table A2. 2 Estimates of shortage of nursing personnel (millions) in countries below the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) INCOME GROUP 2018 2030 Ageing and stable young age group Ageing and graduation as of recent years Ageing and graduation increasing by 50% by 2030 Low-income 1.34 1.80 1.54 1.26 Lower middle-income 3.91 3.44 2.81 1.54 Upper middle-income 0.67 0.45 0.25 0.12 High-income (used as reference, all with density above threshold) – – – – Global 5.91 5.69 4.60 2.92 Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018. 16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings, unpublished). Washington (DC): World Bank; 2020. 17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World Bank; 2009.

教育、労働、 リーダーシップへの投資 STATE OF THE WORLD'S NURSING 2020 2020 In vestin g in edu cation , job s an d leadersh ip S T A T E O F T H E W O R L D ’S N U R S IN G 2020 看護 世界の 日本語版作成　国立研究開発法人 国立国際医療研究センター 国際医療協力局

教育、労働、 リーダーシップへの投資 STATE OF WORLD’S NURSING 2020 2020 世界の 看護 日本語版作成　国立研究開発法人 国立国際医療研究センター 国際医療協力局 世界の看護2020：教育、労働、リーダーシップへの投資 © 国立研究開発法人 国立国際医療研究センター 国際医療協力局 2020 本著作物は、クリエイティブ・コモンズ CC BY-NC-SA（表示 - 非営利 - 継承）4.0 国際ライセンスの条件下で使用可 能である。 この翻訳は国立研究開発法人国立国際医療研究センター国際医療協力局が作成したものである。WHO によって作成 されたものではなく、WHO はこの翻訳の内容または正確性について責任を負わない。オリジナルの英語版 (https:// www.who.int/publications/i/item/9789240003279　よりダウンロード可能 ) を、拘束力のある原本とする。 本ライセンスのもとで生じる紛争に関するいかなる調停も、世界知的所有権機関の調停規則に従って行われるものとする。 第三者マテリアル：本著作物内の第三者に帰属するマテリアル（表、図、画像など）の再利用を希望する場合、再利用 許可の要否の判断、および著作権所有者からの再利用許可の取得は、使用者の責任となる。本著作物内の、第三者が 所有するいかなる内容への著作権侵害の申し立てを受けるリスクも、使用者のみが負うものとする。 一般的免責条項：本出版物で用いられた表記や記述は、いかなる国・地域・都市または地方もしくはその当局の法的ステー タス、または国・地域の境界についても、国立研究開発法人国立国際医療研究センター国際医療協力局の見解を示す ものではない。地図上の点線または破線は、まだ完全な合意のない可能性がある地域のおおよその境界線を示している。 内容の解釈および使用上の責任は読者に帰属する。本出版物の使用によって生じるいかなる損害についても、国立研究 開発法人国立国際医療研究センター国際医療協力局は責任を負わないものとする。 表紙： 上段（左から右）：©Vladimir Gerdo/TASS via Getty, ©Irene R. Lengui/ L’IV com, ©Tanya Habjouqa 下段（左から右）：©Jaime S. Singlador /Photoshare, ©AKDN /Christpher Witton-Steer ISBN 978-4-909675-72-9 1CHAPTER第１章 序文 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 共同議長からのメッセージ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii 協力者と謝辞 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix 用語集 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x エグゼクティブサマリー . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi はじめに . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 より広範な労働力と保健の優先事項における看護 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 SDGsの達成における保健人材の役割 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 看護職とは誰を指すのか . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 目次 3 21世紀の保健システムにおける看護職の役割 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5 6 看護労働力に関するエビデンスとデータの現状 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5.1 看護労働力の供給、構成、配置 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 5.2 看護労働力の供給とアクセスの公平性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 5.3 看護職の国際的な移動 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 5.4 看護教育と実践の法規 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 5.5 看護人材の教育と輩出 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.6 採用と労働条件の法規 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 5.7 ガバナンスとリーダーシップ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 5.8 SDGsの成果に向けた現状の評価 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 看護人材政策の今後の方向性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 6.1 計画、モニタリング、説明責任のためのエビデンスの強化 . . . . . . . . . . . . . . . . . . . . . . . . . . .64 6.2 看護職の移動と移住 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 6.3 看護人材の開発と支援 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 6.4 効果的なガバナンスのためのキャパシティー ・ビルディングとリーダーシップスキルの構築 . . . .74 6.5 看護職養成のための投資の促進 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 6.6 研究とエビデンスの展望 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 7 結論 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 参考資料 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 付属文書 1.　看護職とは誰を指すのか . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 付属文書 2.　方法 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Web Annex. Nursing roles in 21st-century health systems https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf 4 看護人材を支援する政策 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.1 卒前教育と実習 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 4.2 保健人材の流入と流出 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 4.3 公平な配置と効率性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 4.4 法規 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 3.1 ユニバーサル・ヘルス・カバレッジの実現における看護職の役割 . . . . . . . . . . . . . . . . . . . . . .11 3.2 緊急事態、感染症流行、災害対応における看護職の役割 . . . . . . . . . . . . . . . . . . . . . . . . . .14 3.3 集団の健康と福祉の実現における看護職の役割 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 CHAPTER 第2章 CHAPTER 第3章 CHAPTER 第4章 CHAPTER 第5章 CHAPTER 第6章 CHAPTER 第7章 iii目次 表 5.1 2018年の世界の看護職数と人口1万人あたりの密度（WHO地域別）. . . . . . . . . . . . . . . . . . . . . . . . . . 36 5.2 2013年から2018年のデータ改善と実際の増加による看護ストックの変動 . . . . . . . . . . . . . . . . . . . . . . 36 5.3 保健医療専門職（医師、看護師・助産師、歯科医、薬剤師）における看護職の割合 . . . . . . . . . . . . . . . . 37 5.4 女性看護職の割合（WHO地域別）. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 5.5 所得グル プーごとの看護職密度（2018年） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5.6 外国出身の（または外国で教育を受けた）看護職の割合（所得グル プー別） . . . . . . . . . . . . . . . . . . . . . 44 5.7 教育と訓練に関する看護職規制が「ある」と報告している回答国の割合（WHO地域別） . . . . . . . . . . . 47 5.8 新卒看護職の養成数（WHO地域別・所得グル プー別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 5.9 看護職の労働条件に関する規制があると回答した国の割合（WHO地域別） . . . . . . . . . . . . . . . . . . . . 53 5.10 リーダーシップとガバナンスの指標：主任看護官の役職と看護職リーダーシップ育成プログラムの 　　　ある国の割合（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.11 3つのシナリオのもとでの2018年から2030年に予測される看護職ストックのシミュレーション 　　　（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 A2.1 本報告書に使用された36の指標のリスト. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 A2.2 ｢世界戦略」のしきい値を下回る国の看護職不足の推計値（百万人）（所得レベル別）： 　　　2018年と2030年（3つのシナリオによる） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Box 3.1 患者の安全に対する看護の貢献. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 看護職による高齢者のためのコミュニティケアモデル . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.1 オーストラリア：看護人材が少ない集団への取り組み . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 4.2 看護教育のコスト . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 4.3 看護教育者不足への対策. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4.4 世界規模のスキル・パートナーシップ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 4.5 高所得国の看護職に対する経済的需要の例. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.6 ポーランドでの看護職の処方によるアクセス拡大 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.7 アフリカ地域における看護職の例 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 4.8 へき地での定着のガイドライン . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 4.9 教育基準と資格試験の統一の事例. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 5.1 国内での公平性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 6.1 スコットランドの保健労働市場分析 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 6.2 東部、中央部、南部アフリカ保健共同体：国家保健人材統計を用いた看護職データ集積の 　　　国家レベルの協力体制 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 6.3 ドイツの移住管理アプローチ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.4 看護教育と実践におけるテクノロジー. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.5 看護職養成能力を高めるためのパキスタンの取り組み . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6.6 オマ ンーにおける地域保健サービスへのアクセス拡大. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.7 アフリカ保健人材法規共同体 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 6.8 保健医療従事者のストライキ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 6.9 西太平洋地域におけるリーダーシップ・フェローシップ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 6.10 人的資源への投資. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 A1.1 ISCOによる看護職の定義 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 iv 図 1. 2018年の人口1万人当たりの看護職密度 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 2. 55歳以上および35歳未満の看護職の相対比率（一部の国） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv 3. WHO地域別および国の所得グル プー別の看護職ストックの増加予測（2030年） . . . . . . . . . . . . . . . . xv 4. 看護職の平均教育年数（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvi 5. 労働条件に関する規制条項がある国の割合 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii 6. 看護職の男女の割合（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx 2.1 保健人材に関する世界戦略：戦略的目標と看護への関連性 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 各WHO地域内で識別される看護職の職名数. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 ｢3つの10億」の目標への看護職の貢献 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1 保健労働市場形成のための公共政策レバー . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 5.1 WHO 国家保健人材統計で労働力データが得られる国の数（1990–2018年） . . . . . . . . . . . . . . . . . . 34 5.2 各職業グル プーの看護職数の割合（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.3 35歳未満および55歳以上の看護職の割合（WHO地域別）. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 5.4 55歳以上および35歳未満の看護職の相対比率 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5.5 2018年の人口1万人あたりの看護職密度 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.6 人口1万人あたりの看護職密度の地域ごとの格差（2018年） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.7 人口1万人あたりの看護職密度（所得グル プー別）（2018年）. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5.8 看護の規制や基準が「ある」と答えた回答国の割合 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 5.9 看護教育規制スコアのマップ（国別）. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5.10 看護職教育の平均年数（WHO地域別） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.11 労働条件に関する規制条項がある国の割合 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 5.12 労働条件規制スコアの地図 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5.13 高度実践看護職を有する国の割合（人口1万人あたりの医師密度のレベル別） . . . . . . . . . . . . . . . . . . . 55 5.14 看護行政責任者と看護職リーダーシップ・プログラムの規制環境との関連性 . . . . . . . . . . . . . . . . . . . . . 57 5.15 2030年の人口1万人あたりの看護職密度の予測（世界分布） . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 5.16 看護ストックの増加予測（2030年）（WHO地域別・所得グル プー別）. . . . . . . . . . . . . . . . . . . . . . . . . 60 5.17 2013年、2018年、2030年の看護人材不足数の推計 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 A2.1 本報告書のために世界で報告された指標の数 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 A2.2 複数対応分析が示す教育指標の関連. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 A2.3 多重対応分析が示す労働条件指標の関連性. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 A2.4 ｢現状のまま」のシナリオと3通りの「新卒看護職の養成数増加」シナリオのもとでの 　　　世界の看護職ストック数の進化（2018-2030年）（単位：百万人）. . . . . . . . . . . . . . . . . . . . . . . . . . . 107 v目次 Elisabeth Iro WHOチーフ・ナーシング・オフィサー Annette Kennedy 国際看護師協会会長 Sheila Tlou Nursing Now共同議長 Nigel Crisp Nursing Now共同議長 Tedros Ghebreyesus WHO事務局長 看護職への投資は、 持続可能な開発目標 (Sustainable Development Goals: SDGs)の 保健医療関連（SDG3） のみならず、 教育（SDG 4）、 ジェンダー（SDG 5）、 働きがいのある 人間らしい仕事、 経済成長（SDG 8） にも貢献する。 vi State of the world’s nursing 2020　世界の看護 2020 SDG 3 SDG 4 SDG 5 SDG 8 序文 『世界の看護：教育、雇用、リーダーシップへの投資』は、世界がユニバーサル・ヘルス・カバ レッジ（Universal Health Coverage: UHC）に対する前例のない政治的取り組みを目の当 たりにしているタイミングで発行される。また同時に、私たちの緊急事態への備えと対応能力 は、現在の新型コロナウイルス（COVID-19）のアウトブレイクと、紛争によって引き起こされた 大量人口移動によって試されている。看護職は、この各々の状況に不可欠なケアを提供する。 現在世界はこれまで以上に、受けた教育や経験を最大限に生かして働くことを看護職に求め ている。 この初の報告書『世界の看護』は、看護人材に関する多くの明るい事実を明らかにしている。 政策レベルなどにおける、高度看護教育および専門的役割強化の機会によって、集団の健康 の向上を促すことが可能である。また同時に世界における看護職の配分には依然として大き な不均衡があり、対処が求められている。 2020 年は「国際看護師・助産師年」であり、報告書『世界の看護 2020』のエビデンスを活 用して、2030 年に向けた課題に取り組む好機である。この実現を目指し、各国政府とすべて のステークホルダーに次のことを要請する。 ●　国内と世界のニ ズーにこたえ、技術の変化やヘルスケアとソーシャルケアの統合モデルの 　　進歩に対応するため、看護教育の大幅な促進に投資する。 ●　主に低所得国および中所得国において、2030 年までに少なくとも600万人の新たな雇 　　用を創出し、予測される看護職不足を補填し、世界における看護職の配置の不均衡を是 　　正する。 ●　看護職のリーダーシップを強化し、看護職が保健医療政策の策定と意思決定に影響力 　　のある役割を果たし、ヘルスケアとソーシャルケアのシステムの有効性の向上に貢献でき 　　るようにする。 この課題に対する行動を起こすことは、すべての国において可能である。ほとんどの国は、自国 のリソ スーでこれらの行動を実現できる。国際社会の援助を必要とする国に関しては、ヘルス ケアおよびソーシャルケア経済における人的資源投資の割合を増やしていかなければならな い。このような投資は、持続可能な開発目標全体の進展をも促進し、ジェンダー平等、女性の 経済的エンパワーメント、若者の雇用を前進させるであろう。 いまこそ看護職の教育、労働、リーダーシップに投資し、2030 年のSDGｓ達成に貢献しよう。 vii序文 　共同議長からのメッセージ 第 72 回世界保健総会は、2020 年を国際看護師・助産師年と定めた。これは、フローレンス・ナイチンゲー ルの生誕 200 周年を記念するためだけでなく、世界中の人々の健康とウェルビーイングへの看護師と助産師 の日々の貢献を認識するためでもある。 COVID-19 のパンデミックにより全世界で看護職に注目が集まる中、世界保健デーに報告書『世界の看護』 を発表できることを光栄に思う。この報告書は、世界の看護人材に関する最新のエビデンスと最先端の政策 オプションを提示している。また、看護職の教育、雇用、リーダーシップへの、多額ではあるが実行可能な 投資を促す、説得力のある事例を紹介している。こうした投資は、持続可能な開発目標を実現するために看 護人材を強化し、すべての人々の健康を改善し、ユニバーサル・ヘルス・カバレッジへの道のりにおいてプラ イマリ・ヘルスケアの労働力を強化するために必要なものである。 報告書『世界の看護 2020』は、各国の多大な協力によって生み出された。多くの国において、活動を率いた のは政府の看護・助産行政責任者であり、それを支援したのは教育、労働、財務等の各省によるデータの提 供だった。看護の教育者と規制当局は、データを提供し、トライアンギュレーションを実施した。各国の看 護職能団体と Nursing Now 団体は、本報告書で取り上げられる問題の報告と問題への関与において、重要 な提唱者としての役割を果たした。これらの関係は、看護業務に関する確実かつ日常的な報告に不可欠なも のであり、今後さらに強力な報告を可能にするであろう。 私たちは共にすばらしい成果を実現した。しかし、まだ実現できていないもののほうがはるかに重要である。国、 地域、世界のデータと国際看護師・助産師年を活用し、一次医療提供の向上とユニバーサル・ヘルス・カバレッ ジへの前進を目的とする労働力強化について、すべての部門間でより緊密な対話と協力体制を促進する必要が ある。私たちは看護職の教育、雇用、リーダーシップへの投資を促進し、それを維持しなければならない。 世界の健康のためには、看護人材への支援と投資にすべての国が取り組む必要がある。読者がこの呼びかけ に加わることを望む。 James Campbell WHO保健人材担当部長 Howard Catton 国際看護師協会 事務局長 Mary Watkins Nursing Now 議長代理 viii State of the world’s nursing 2020　世界の看護 2020 運営委員会 共同議長： Howard Catton, Mary Watkins メンバ ：ー Sultana N . Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) WHO 主執筆者： Carey McCarthy, Mathieu Boniol, Karen Daniels, Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell 管理支援： Beatrice Wamutitu, Elizabeth Tecson 協力者： Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor, Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez エビデンスレビューへの協力者 Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen, António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron, Aurelija Blaževicˇiene˙, Julia Bluestone, Jo Booth, Debora Bossemeyer, Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse, Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong, Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit, Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström, Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf, Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley, Doris Grinspun, Valerie A . Gruss, Mark Hathaway, Karen Heaton, Aisha Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston, Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu, Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi- Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint, Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson, Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega, Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova, Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon, Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell, Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka, Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill, Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten, Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White, Barbara Wienkamp-Weber, Tegbar Yigzaw データ報告への協力者 WHOは、すべての「国家保健人材統計」担当者、各国政府の看護・助産行政責任者、本報 告書作成のためのデータ報告プロセスに協力したその他の人々に感謝する。 アフリカ地域 Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh, Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau, Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Nkosinathi R . Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto, Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya, Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande アメリカ地域 Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads, Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro, Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto, Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra, Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin, Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez, Jeaneth Vega Chavez 南東アジア地域 Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung, Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K . S . Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed, Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena, Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim, Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage, Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota, Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam Yangchen ヨーロッパ地域 Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ays˛e Boysan, Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref, Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artu¯ras Šimkus 東地中海地域 Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi, Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud, Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh, Nasir Yama, Lubna Yaqoob 西太平洋地域 Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam, Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle, Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch, Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi, Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou 編集調整、デザイン、制作 シャラド・アガーウォール、プログラフィックス社、ジョン・ドーソン、WHOの翻訳、出版、印 刷部門、ヨルダンのムナー王妃、個々の看護職およびパートナー機関に対し、写真への協力 を感謝する。WHOは、リベリアの看護職サロメ・カルワーに特別な敬意を表したい。彼女は エボラ熱感染から生還したものの、治療を拒否されて出産の合併症で亡くなった。 JHPIEGOとジョンズ・ホプキンズ大学看護学部 には、この報告書作成のための エビデンスレビューおよびデータ報告プロセスへの協力を感謝する。 協力者と謝辞 Mary Watkins Nursing Now 議長代理 ix協力者と謝辞 労働市場（labour market）とは、労働サービスを 求めること（需要）と提供すること（供給）を可能にす る構造を指す。賃金と雇用条件（適切なインフラ、支 援的管理、専門能力開発とキャリアアップの機会など） が、保健医療従事者と雇用者による選択を決定する役 割を果たす（1）。 需要（Demand）とは、市場でオファーされている職 を指す。需要とは、役職への資金提供またはサービス の経済的需要の面で保健システムが支えることのでき る保健医療従事者の数である。政府の保健医療関連 支出、民間保険、自己負担額と関連にある（2）。 供給（Supply）とは、保健医療従事者の供給とは、 ヘルスケア部門で働く意欲のある有資格の保健医療従 事者ストックを指す。養成能力と保健医療従事者の純 移動、死亡数、退職数と関連にある（2）。 ニーズ（Need）とは、保健システムのサービス提供目 標の達成に必要な保健医療従事者の数を指す。保健 労働市場は主に需要と供給によって形成され、ニーズ は間接的に影響を及ぼすのみである（1）。 保健労働市場による保健医療従事者の雇用能力 （absorption capacity for health care workers by the health labour market）とは、保健システム （公的部門と民間部門の両方を含む）が、主に教育と 移住によって生み出された雇用可能な有資格の保健医 療従事者ストックを、完全かつ生産的に雇用する能力 を指す。雇用能力は、経済的需要を雇用の創出と補充 に置き換える効率性と適時性の影響を受ける。 卒前教育（Pre-service education）とは、実践環 境での就業前に、その前提条件として行われる正式な 学習プログラムを指す（3）。 資格付与（Licensing）とは、個人が所定の実務範囲 内の役割と職務を、求められる基準に達するよう実践 できることを証明し、特定の法域内で特定の職業に従 事することを法的に許可するための資格を付与するプ ロセスを指す。 認証（Accreditation）とは、あらかじめ定められた、 教育の提供に必要な基準に対する教育機関の評価プ ロセスを指す。このプロセスの結果、教育プログラム の適合性と、教育機関の教育提供能力の認定が行わ れる。 資格認定（Credentialing）とは、保健医療機関内で、 または保健医療機関のために、ケアまたはサービスを 提供するための実践者資格の取得、検証、および評価 のプロセスを指す。資格認定書は、資格、教育、研修、 経験、またはその他の資格を文書化したエビデンスで ある（4）。 職業認定（Professional certification）とは、個 人が事前に定められた標準的基準を満たしていること を確認した後、組織がその個人に対し、5 限定期間内 の認定と資格の使用を許可する任意のプロセスを指す （5）。 用語集の参考文献 1. McPake B、Maeda A、Araujo EC、Lemiere C、El Maghraby A、Cometto G。Why do health labour market forces matter? Bulletin of the World Health Organization2013; 91：841–6. doi：10.2471/BLT.13.118794 2. Scheffler RM、Campbell J、Cometto G、Maeda A、Liu J、Bruckner TAet al. Forecasting imbalances in the global health labor market and devising policy responses、Human Resources for Health、2018; 16：5. doi：10.1186/ s12960-017-0264-6 3. Integrated Management of Childhood Illness: planning, implementing and evaluating pre-service training, Geneva: World Health Organization; 2001. 4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging.、Joint Commission (https://www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed, 5 March 2020). 5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education- events/facultyresources/research-grants/styles-credentialing-research-grants/credentialing-definitions/. accessed 5 March 2020). 用語集 x State of the world’s nursing 2020　世界の看護 2020 エグゼクティブサマリー 2020 上記画像： © AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh xi ユニバーサル・ヘルス・カバレッジと 持続可能な開発目標の実現において 看護職が果たす中心的役割 エグゼクティブサマリー 看護職は、 保健セクターで最大の 職業グループであり、 保健医療専門職の約 を占める。 59% © Shapecharge/Getty Images 看護職は、「だれひとり取り残さない」という公約と、持続可能な開発目標（SDGs）の達成に向けた世界的な取り組みを実 現する上で、不可欠な存在である。看護職は、ユニバーサル・ヘルス・カバレッジ、メンタルヘルスと非感染性疾患、緊急事態 への備えと対応、患者の安全、人間中心の包括ケアの提供など、保健医療のさまざまな優先事項に関連する国および世界 の目標実現に向けて、中心的な貢献を果たしている。 看護人材の貢献と多職種からなる医療チーム内での看護人材の役割を最大化するための協調的かつ継続的な努力なし には、世界的な保健医療の課題は実現できない。そのためには、看護職の業務範囲とリーダーシップを適正化するとともに 、看護職の教育、スキル、雇用への投資を加速することで、看護職の影響と効果の最大化を可能にする政策介入が求めら れる。そのような投資は、教育、ジェンダー、働きがいのある人間らしい仕事、包括的な経済成長に関連するSDG目標にも 貢献するであろう。 WHOが、国際看護師協会、グローバルなNursing Nowキャンペ ンーと協力し、各国政府および幅広いパートナーの支援 を得て作成したこの報告書『世界の看護 2020』は、世界の看護人材の価値についての説得力ある事例を提示する。 xii State of the world’s nursing 2020　世界の看護 2020 2020年のエビデンスの現状 3エグゼクティブサマリー 看護人材の規模と業務範囲は拡大しつつある。しかし、その拡大は公平なものではなく、増大する需要に応じるには不十 分であり、一部の人々は取り残されている。 191 カ国が本報告書のためにデータを提供した。これは過去最大の数であり、2018 年のデータ提供国数から53% 増加している。約 80%の国が15以上の指標について報告している。しかし、教育能力、資金調達、給与と賃金、保健労働 市場の変化に関するデータに関しては欠損が大きい。このため、看護人材の政策と投資を決定する保健労働市場分析実 施に制限が生じている。 世界の看護人材は2,790万人で、そのうち1,930万人が看護師である。これは、2013 年から2018 年で看護職の総 数が470万人増えたことを示している。また、看護職は保健セクターで最大の職業グル プーであり、保健医療専門職の約 59%を占める。2,790 万人の看護職のうち、1,930 万人（69%）が看護師、600万人（22%）が准（準）看護師、どちらに も分類されない人が260万人（9%）となっている。 世界全体では、ユニバーサル・ヘルス・カバレッジとSDGsに見合う看護人材が不足している。世界の看護職の80％ 以上は、世界の人口の半分を占める国々にいる。世界全体の看護職の不足数は2016 年には660万人と推計されたが、 2018 年にはわずかに減少して590万人となった。この不足のうち530万人（89%）は低所得国および低中所得国に集 中すると推定される。こうした国々では、看護職の数の伸びが人口の増加にかろうじて追いつく状況であり、人口当たりの 看護職数にはわずかな改善がみられるのみである。図 1は、人口当たりの看護職数の密度のばらつきの大きさを示してお り、不足が大きいのは、アフリカ地域、南東アジア地域、東地中海地域の国 と々、中南米の一部の国である。 図 1 2018年の人口1万人あたりの看護職密度 。む含を師護看）準（准と師護看はに」職護看「* 出典：国家保健人材統計 、WHO、2019年。　2013～2018年の最新の入手可能なデータ。 回答なし該当なし 0 1,000 2,000 3,000 4,000500 km 10未満 10～19 20～29 30～39 40～49 50～74 75～99 100以上 xiiiエグゼクティブサマリー 4 世界の看護2020 一部地域での保健人材の高齢化は、看護職ストックの安定性に影響を及ぼす。世界的に見ると看護人材は比較的 若いものの、地域によって差があり、アメリカ地域とヨーロッパ地域では年齢構成がかなり高くなっている。退職が近 い看護職（55歳以上）と比べて初期キャリアの看護職（35歳未満）の数が少ない国は、保健医療サービスへのアク セスを維持するため、看護基礎教育課程卒業生数を増やし、定着策を強化する必要がある。看護人材の年齢が若い 国は、国全体での均等な配置を強化すべきである。図 2に示す通り、退職の近い看護職の割合が若手看護職に比 べて高い国（緑色の線より上の国）は、今後看護人材確保の課題に直面するであろう。 70% 60% 50% 40% 30% 20% 10% 0% 60%0% 10% 20% 30% 40% 50% 70% 18カ国が 看護人材高齢化のリスクあり 各点は１つの国を表す/緑色の線は、労働力内で退職の近い看護職の数と若手看護職の数が等しい位置を示す。 55 合 割 の 職 護 看 の 上 以 歳 35歳未満の看護職の割合 図 2 55歳以上および35歳未満の看護職の相対比率（一部の国） ＊看護師と准（準）看護師を含む。 出典：「国家保健人材統計」、WHO、2019 年。2013～2018年に報告された最新の入手可能なデータ。 xiv State of the world’s nursing 2020　世界の看護 2020 4 世界の看護2020 一部地域での保健人材の高齢化は、看護職ストックの安定性に影響を及ぼす。世界的に見ると看護人材は比較的 若いものの、地域によって差があり、アメリカ地域とヨーロッパ地域では年齢構成がかなり高くなっている。退職が近 い看護職（55歳以上）と比べて初期キャリアの看護職（35歳未満）の数が少ない国は、保健医療サービスへのアク セスを維持するため、看護基礎教育課程卒業生数を増やし、定着策を強化する必要がある。看護人材の年齢が若い 国は、国全体での均等な配置を強化すべきである。図 2に示す通り、退職の近い看護職の割合が若手看護職に比 べて高い国（緑色の線より上の国）は、今後看護人材確保の課題に直面するであろう。 70% 60% 50% 40% 30% 20% 10% 0% 60%0% 10% 20% 30% 40% 50% 70% 18カ国が 看護人材高齢化のリスクあり 各点は１つの国を表す/緑色の線は、労働力内で退職の近い看護職の数と若手看護職の数が等しい位置を示す。 55 合 割 の 職 護 看 の 上 以 歳 35歳未満の看護職の割合 図 2 55歳以上および35歳未満の看護職の相対比率（一部の国） ＊看護師と准（準）看護師を含む。 出典：「国家保健人材統計」、WHO、2019 年。2013～2018年に報告された最新の入手可能なデータ。 看護職の均等な配置と定着は、 ほぼすべての国が 抱える課題である。 © ICAP/Sven Torfi nn 5エグゼクティブサマリー 2030 年までにすべての国の看護職不足に対処するには、看護基礎教育課程卒業生の総数を年平均 8% 増や しつつ、その卒業生を雇用し、定着させる能力を高める必要がある。現在の傾向が続く場合、2030 年には看護職 数は3,600 万人となり、主にアフリカ地域、南東アジアおよび東地中海地域において、ニ ズーに基づく不足人数が 570万になることが予測される。それと並行して、アメリカ地域、ヨーロッパ地域、西太平洋地域の多くの国も、国ご とに異なる不足に直面する。図 3 は、看護職数の増加予測をWHO 地域別および国の所得グル プー別に示したも のである。 ENGLISH 低中所得 27% 高中所得 61% 高所得 6% 低所得 6% アメリカ 43% ヨーロッパ 7% アフリカ 6% 東地中海 4% 西太平洋 22% 南・東アジア 18% 地域別 所得別 *看護師と准（準）看護師を含む。 図 3 WHO地域別および国の所得グループ別の看護職ストックの増加予測（2030年） xvエグゼクティブサマリー © Nazeer Al-Khatib/AFP via Getty 6 世界の看護2020 看護基礎教育の平均年数（WHO地域別） 図 4 2年 3年 4年 5年 0% 20% 40% 60% 80% 100% アフリカ アメリカ 南・東アジア ヨーロッパ 東地中海 西太平洋 WHO地域 世界全体 出典：「国家保健人材統計」（2019）より99カ国のデータ、Sigmaデータベースより58カ国のデータ。 各国によって報告された2013～2018年の最新の入手可能なデータ。 過半数の国（回答のあった157カ国中152カ国、97%）は、最短の看護基礎教育は3年間であると報告してい る。ほとんどの国々は、教育の内容と期間（91%）、認証の仕組み（89%）、教員の資格認定（77%）と多職種連携教育 （67%）に関する国の基準を報告している。ただし、これらの政策と仕組みの有効性についてはあまり明らかになって いない。さらに、看護職の教育・実習の最低ラインには依然としてかなりの開きがある上、教員不足、インフラや臨地 実習の場の不足など、環境の制約にも開きが見られる。図 4に示す通り、世界の看護基礎教育の期間は、3～4年が ほとんどである。 合計78カ国（回答のあった国の53%）は、看護職が高度実践の 役割を担っていると報告している。高度実践看護職が、地方での プライマリ・ヘルスケアへのアクセスを高め、また都市部の脆弱な 集団のアクセス格差に対処し得ることを示す強いエビデンスがあ る。すべての看護職は、受けた教育を最大限に生かして働けるよう 支援があれば、効果的なプライマリ・ヘルスケアや予防的ケア、ユ ニバーサル・ヘルス・ケアの実現に役立つその他の多くの保健医 療サービスを提供することが可能である。 8人中1人の看護職は、出身国または教育を受けた国以外で働 いている。看護人材の国際的な移動が増加している。パターンは 異なるが、看護職の均等な配置と定着は、ほぼすべての国に見ら れる課題である。移住の管理が行き届かないと看護職不足が進み、 保健医療サービスへの不公平なアクセスの一因となるおそれがあ る。高所得国の多くは、看護職の求人数と保健システムの新卒看 護職雇用能力に対して、看護基礎教育課程卒業生が少ない、また は現在既に看護職が不足しているため、看護職の国際的移動に過 度に依存しているように思われる。 7エグゼクティブサマリー 大半の国（86%）には、看護職の規制を担当する機関がある。約 3分の2の国（64%）が看護の実務に就く前の能力認 定（資格試験等）を要件としており、約 4分の3の国（73%）が現職看護職に対し専門能力開発・向上を求めている。た だし、看護教育と実践の規制の統一は、一部における相互認証協定にとどまっている。規制当局は、デジタル化が進み移 動性が高い近年において、教育と実践の規制を常に更新し、看護人材の登録を最新の状態に保つよう求められている。 図 5は、労働条件に関する規制を設けていると回答した国の割合を示す。 看護職は依然として女性が多数を占める職業であり、それに伴う偏りや格差が見られる。看護人材の約 90% は女性 だが、保健医療分野におけるリーダー的地位を看護職または女性が占める例は少ない。ジェンダーに基づく賃金格差や、 職場でのジェンダーに基づくその他差別のエビデンスも複数みられる。労働時間や労働条件、最低賃金、社会的保護な どの法的保護は、大半の国での整備が報告されているが、地域によっては未整備である。3分の1をわずかに超える国 （37%）が、保健医療従事者への攻撃防止策を講じていると報告している。 115カ国のうち82カ国（71%）が、看護政策や保健医療政策に意見を述べる責任を負う、看護分野のリーダー的役 職があると報告している。全国規模の看護職指導力育成プログラムが整備されている国は78カ国（回答国の53%）に のぼる。看護行政責任者と看護職指導力育成プログラムの存在は共に、看護職のための規制の整備状況と関係している。 労働時間と労働条件に関する規制 （142カ国中133カ国が「ある」と回答） 社会保護に関する規制 （137カ国中125カ国が「ある」と回答） 最低賃金に関する規制 （134カ国中119カ国が「ある」と回答） 看護職能団体 （164カ国中141カ国が「ある」と回答） 高度実践看護職の存在 （95カ国中50カ国が「ある」と回答） 保健医療従事者への攻撃防止策 （55カ国中20カ国が「ある」と回答） 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 「ある」と答えた国の割合 出典：国家保健人材統計、WHO、2019年 図 5 労働条件に関する規制条項がある国の割合 xvi State of the world’s nursing 2020　世界の看護 2020 7エグゼクティブサマリー 大半の国（86%）には、看護職の規制を担当する機関がある。約 3分の2の国（64%）が看護の実務に就く前の能力認 定（資格試験等）を要件としており、約 4分の3の国（73%）が現職看護職に対し専門能力開発・向上を求めている。た だし、看護教育と実践の規制の統一は、一部における相互認証協定にとどまっている。規制当局は、デジタル化が進み移 動性が高い近年において、教育と実践の規制を常に更新し、看護人材の登録を最新の状態に保つよう求められている。 図 5は、労働条件に関する規制を設けていると回答した国の割合を示す。 看護職は依然として女性が多数を占める職業であり、それに伴う偏りや格差が見られる。看護人材の約 90% は女性 だが、保健医療分野におけるリーダー的地位を看護職または女性が占める例は少ない。ジェンダーに基づく賃金格差や、 職場でのジェンダーに基づくその他差別のエビデンスも複数みられる。労働時間や労働条件、最低賃金、社会的保護な どの法的保護は、大半の国での整備が報告されているが、地域によっては未整備である。3分の1をわずかに超える国 （37%）が、保健医療従事者への攻撃防止策を講じていると報告している。 115カ国のうち82カ国（71%）が、看護政策や保健医療政策に意見を述べる責任を負う、看護分野のリーダー的役 職があると報告している。全国規模の看護職指導力育成プログラムが整備されている国は78カ国（回答国の53%）に のぼる。看護行政責任者と看護職指導力育成プログラムの存在は共に、看護職のための規制の整備状況と関係している。 労働時間と労働条件に関する規制 （142カ国中133カ国が「ある」と回答） 社会保護に関する規制 （137カ国中125カ国が「ある」と回答） 最低賃金に関する規制 （134カ国中119カ国が「ある」と回答） 看護職能団体 （164カ国中141カ国が「ある」と回答） 高度実践看護職の存在 （95カ国中50カ国が「ある」と回答） 保健医療従事者への攻撃防止策 （55カ国中20カ国が「ある」と回答） 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 「ある」と答えた国の割合 出典：国家保健人材統計、WHO、2019年 図 5 労働条件に関する規制条項がある国の割合 xviiエグゼクティブサマリー 看護人材 政策の 今後の方向性 10の重要な対策 1 © John W. Poole/NPR 8 世界の看護2020 看護職が不足する国々は、少なくとも590万人の看護職を追加で養成し、雇用するために 予算を増やす必要がある。看護教育への追加投資額は、低所得国、中所得国では国民 1人あたり10米ドル 以内と推計される。新卒の看護職を雇用するためには、さらなる投資が必要となる。大半の国は、国内資金で実現可 能である。対策には、国の賃金支払総額の見直しと管理が、また一部の国では、看護職養成数の制限解除などがあ る。国内での養成が中・長期的に制約される、たとえば低所得国や紛争の影響下にあるような場合や、脆弱な状況 にある場合は、資金プールの取り決めなどの仕組みを検討する必要がある。開発パートナーや国際金融機関は、教 育、雇用、ジェンダー、保健医療、スキル開発のための人的資源への投資を、プライマリ・ヘルスケア推進とユニバー サル・ヘルス・カバレッジ達成のための国の保健人材戦略に移管することで、支援が可能となる。看護人材への投 資は、雇用創出、ジェンダー平等、若者の雇用促進にも有益である。 xviii State of the world’s nursing 2020　世界の看護 2020 看護人材 政策の 今後の方向性 10の重要な対策 1 © John W. Poole/NPR 8 世界の看護2020 看護職が不足する国々は、少なくとも590万人の看護職を追加で養成し、雇用するために 予算を増やす必要がある。看護教育への追加投資額は、低所得国、中所得国では国民 1人あたり10米ドル 以内と推計される。新卒の看護職を雇用するためには、さらなる投資が必要となる。大半の国は、国内資金で実現可 能である。対策には、国の賃金支払総額の見直しと管理が、また一部の国では、看護職養成数の制限解除などがあ る。国内での養成が中・長期的に制約される、たとえば低所得国や紛争の影響下にあるような場合や、脆弱な状況 にある場合は、資金プールの取り決めなどの仕組みを検討する必要がある。開発パートナーや国際金融機関は、教 育、雇用、ジェンダー、保健医療、スキル開発のための人的資源への投資を、プライマリ・ヘルスケア推進とユニバー サル・ヘルス・カバレッジ達成のための国の保健人材戦略に移管することで、支援が可能となる。看護人材への投 資は、雇用創出、ジェンダー平等、若者の雇用促進にも有益である。 2 3 5 9エグゼクティブサマリー 4 各国は、保健人材データの収集、分析、および使用の能力を強化すべきである。 必要な対策には、「国家保健人材 統計」の導入の推進と、保健労働市場分析へのデータの活用などがある。このような看護職データの活用には、政府 のすべての機関の参加、また規制当局、看護基礎教育課程、保健医療サービス提供者、職能団体などのステークホ ルダーが関わることが必要である。 看護職の国際的な移動は、適切なモニタリングと、倫理的な管理が必要である。必要な対策には、国、雇用者、国際 的なステークホルダーによる「保健人材の国際採用に関するWHO世界実施規範」の実施強化などがある。規制当 局、保健人材情報システム、雇用者、政府省庁、その他のステークホルダーとのパートナーシップと協力により、国際 的な看護職の移動のモニタリングや管理が可能となる。一方、移民の看護職に過度に依存している国は、国内の看 護職養成への投資を増やすことによって、自国内での養成数増加を目指すべきである。大量の国外移住により看護 人材を失っている国は、給与（給与の公平性を含む）と労働条件の改善、専門能力開発の機会の創出、看護職が受 けた教育を最大限に生かして働ける環境づくりなどの対策と、定着のための対策を検討する必要がある。 看護基礎教育課程においては、プライマリ・ヘルスケアとユニバーサル・ヘルス・カバレッジを推進する看護職 を養成する必要がある。対策には、看護教員への投資、臨地実習の場の増加、教育課程への多様な学生のアクセス 向上などがある。看護職は、科学技術や、チームワークと健康の公平を求めるキャリアとしての選択肢となるべきであ る。政府の看護行政責任者や各国のステークホルダーは、看護基礎教育と専門性の高い教育について国内での議 論を主導し、保健システムの需要を満たすことのできる看護基礎教育課程の卒業生数を確保することが可能である。 多職種からなるチームで効果的に勤務できるよう看護職を養成し、卒業時の保健医療技術の能力を最大化するた めには、優先すべき国内の保健問題と新たな世界的問題に沿ったカリキュラム内容にする必要がある。 看護職のリーダーシップとガバナンスは、看護人材の強化にとって不可欠である。対策には、国の看護人材強化と 保健政策の決定に貢献する責任を負う、政府内における看護行政責任者のポストの確立と支援などがある。政府の 看護行政責任者は、看護人材のデータを強化し、看護人材への投資についてエビデンスに基づいた政策対話への 取り組みを推進すべきである。また、若手看護職のリーダーシップ育成に向け、リーダーシップ・プログラムを整備・ 開発すべきである。紛争の影響下などの脆弱な状況では特別な取り組みが必要であり、効果的な看護人材管理の ための制度と個人の能力の構築または再構築が必要である。 xixエグゼクティブサマリー 0% 20% 40% 60% 80% 100% 76% 89% 89% 95% 78% 87% 24% 11% 11% 5% 22% 13% 6 7 8 10 世界の看護2020 計画立案者と規制当局は、看護実践の効果を最大化する必要がある。対策には、プライマリ・ヘルスケア・チー ムの業務において、看護職がすべての範囲をカバーできるようにすることなどがある。非感染性疾患やヘルスケアと ソーシャルケアの統合の需要の高まりなど、集団の健康のニ ズーを満たし、プライマリ・ヘルスケアへのアクセスを 改善するため、状況に応じて看護職主導の効果的なケアモデルを拡大する必要がある。看護職主導のケアと高度実 践に必要な支援、デジタル技術の活用、看護人材の高齢化への考慮などを含む労働環境対策は、実践の場での看 護職の定着に影響を与える。 政策立案者、雇用者、規制当局は、働きがいのある人間らしい仕事の支援のために連携して対応する必要がある。 各国は、看護人材の養成、配置、定着、モチベーションの向上のため、看護業務を行いやすい環境を提供する必要が ある。紛争の影響下の脆弱な状況で活動する看護職に対しては特別な措置を講じつつ、適切な人員配置と、職場・ 労働の安全衛生を優先的に実施する必要がある。看護職を引き付け、定着させ、意欲を持たせるためには、報酬は公 正かつ適切でなければならない。さらに、各国は看護職へのセクシャルハラスメント、暴力、差別に対応する政策を優 先的に実施すべきである。 各国はジェンダーに配慮した看護人材政策を慎重に計画すべきである。対策には、保健医療従事者の間での公平 でジェンダー格差のない報酬システムの実施、ジェンダー間の賃金格差への政策と法律を民間部門にも確実に適用 することなどがある。看護人材が依然として圧倒的に女性である事実を考慮し（図 6）、教育、実践、規制、リーダー シップ機能の全域にわたる看護政策に、ジェンダー上の配慮を取り入れるべきである。政策としては、例えば看護職 の女性として変化するニ ズーに対応する柔軟で変更可能な労働時間など、女性にとって働きやすい環境づくりや、看 護人材における女性のためのリーダーシップ育成の機会などがある。 図 6 看護職の男女の割合（WHO地域別） WHO地域 アフリカ アメリカ 南・東アジア ヨーロッパ 東地中海 西太平洋 女性　　　　　 男性 出典：「国家保健人材統計」、WHO、2019年。2013～2018年に報告された最新の入手可能なデータ。 xx State of the world’s nursing 2020　世界の看護 2020 © Yoshinobu Oka via Sasakawa Health Foundation 9 10 看護職主導のケアと高度実践に必要な支援、 デジタル技術の活用、看護人材の高齢化への 考慮などを含む労働環境対策は、 実践の場での看護職の定着に影響を与える。 看護職の関連法規の近代化を進めなければならない。対策には、看護教育と資格認定基準の統一、看護教育と専 門資格認定の相互承認の制度化、規制当局が看護職の資格や経歴（犯罪歴などを含む）を簡単かつ迅速に検証で きる相互連携システムの開発などがある。業務範囲、基礎能力評価、継続的な専門能力開発の必須化などの規制の 枠組みにより、看護職は、ダイナミックな多職種連携の中で、自らが受けた教育を最大限に生かして働くことができる ようになる。 コラボレーションが鍵である。対策には、保健省と政府の看護行政責任者が主導する部門横断的な対話、他の関 係省庁（教育、移民、財務、労働担当省庁など）と公共部門・民間部門の関係者の関与などがある。重要な要素は、 効果的な公共政策管理の能力を強化し、民間部門の投資、教育能力、保健サービス提供における看護職の役割を 適正化して公共政策の目標に沿ったものとすることである。看護職能団体、教育機関と教育者、看護職の規制当局 と労働組合、看護学生と青少年グル プー、草の根グル プー、Nursing Nowなどのグローバルキャンペ ンーは、集団の 健康の優先事項実現のために活動するケアチームにおける看護職の役割強化に向けた貴重な貢献者である。 結論 教育、労働、 リーダーシップへの投資 本報告書は、看護人材に関する強力なデータとエビデンスを提供している。これらの情報は、プライマリ・ヘ ルスケアの強化、ユニバーサル・ヘルス・カバレッジの実現、SDGs 達成への前進を目的とする、看護職へ の投資についての政策対話の支援と意思決定の促進に不可欠である。 進展は見られるものの、本報告書は大きな課題をも明らかにしている。それらの課題に対処するためには、 アフリカ、南東アジア、東地中海地域の多くの低・中所得国での対応の促進が求められるであろう。ただし、 高所得国も予断を許さない状況である。養成人数の制限、看護人材の高齢化、国外からの看護職採用への 過度の依存などにより、国の看護人材ニ ズーの充足達成が脅かされている状況である。 © St Thomas’ Hospital, London 各国政府は、必要に応じて国内または国際的開発パートナーから支援を得て、次のような取り組みを促進 し、加速する必要がある。 看護人材のリーダーシップ、財務管理、マネジメント能力を構築し、関連する教育、保健、雇用、 ジェンダーの課題を前進させる。 看護人材の教育、働きがいのある人間らしい仕事、公正な報酬、配置、実践、養成、法規、定着な どに必要な政策の適用により、現在の看護職への投資利益率を最大化する。 看護職の教育、スキル、雇用への追加投資を加速し、維持する。 求められる投資には追加の財源が必要となる。これらの投資が行われた場合、社会と経済が受ける利益は、 何十億人もの健康の改善、特に女性と若者の数百万の適正な雇用の創出、さらに世界的な健康の安全保 障強化という点で、明らかになるだろう。看護教育、労働、リーダーシップへの投資の重要性は明確であり、 関連するステークホルダーは、今こそともに対策に取り組まなくてはならない。 © St Thomas’ Hospital, London 各国政府は、必要に応じて国内または国際的開発パートナーから支援を得て、次のような取り組みを促進 し、加速する必要がある。 看護人材のリーダーシップ、財務管理、マネジメント能力を構築し、関連する教育、保健、雇用、 ジェンダーの課題を前進させる。 看護人材の教育、働きがいのある人間らしい仕事、公正な報酬、配置、実践、養成、法規、定着な どに必要な政策の適用により、現在の看護職への投資利益率を最大化する。 看護職の教育、スキル、雇用への追加投資を加速し、維持する。 求められる投資には追加の財源が必要となる。これらの投資が行われた場合、社会と経済が受ける利益は、 何十億人もの健康の改善、特に女性と若者の数百万の適正な雇用の創出、さらに世界的な健康の安全保 障強化という点で、明らかになるだろう。看護教育、労働、リーダーシップへの投資の重要性は明確であり、 関連するステークホルダーは、今こそともに対策に取り組まなくてはならない。 © Carrie Tudor/The Union xxiv State of the world’s nursing 2020　世界の看護 2020 1. 看護師および准（準）看護師 1 からなる看護職は、 保健医療分野における世界最大の職能集団であ り、「すべての人に健康を」という目標を実現する、 多職種からなる保健医療チームの基盤である。 2. 高度実践者、臨床家、リーダー、政策立案者、 研究者、科学者、教育者としての看護職の責任と 役割は、保健医療専門職の教育と実践の効果的 な機能の中心をなす。集団の健康とウェルビーイ ングの改善は、看護職の研鑽、革新、創造性を 通じて、これまでもこれからも、実現されていく だろう。 3. 看護職には長い歴史があるが、近代看護の創始 者とされる 200 年前のフローレンス・ナイチン ゲールの登場によって、大きく進化した。体系的 な教育、標準的な看護、看護職能団体は1800 年代に生まれ、看護職の質、コンピテンシー、労 働条件を徐々に向上させてきた。1900 年代には、 専門性と自律性の発展と共に、説明責任と安全 性を確実なものとするためのより強力な職業規制 が導入された(1)。保健医療専門職の初の国際的 組織が、1899 年に設立された国際看護師協会 である。現在創立 121年目となる国際看護師協 会は、130 を超える各国の看護職能団体の連合 体であり、全世界の 2,000 万人を超える看護職 を代表している(2)。 4. WHO は、創設間もない時期から、看護師と助 産師の大きな価値と貢献を認めてきた(3)。看護 師と助産師は長年にわたり、天然痘の根絶、感 染症との闘い、全世界における妊産婦および新生 児・小児の死亡率と罹患率の劇的な減少など、グ ローバルヘルスにおける主要な課題解決に貢献し てきた(4、5)。看護師と助産師が果たした大き な役割は世界保健総会でも注目を集め、保健医 療人材開発の優先事項の一環として、看護師と助 産師の教育、雇用、定着に関する国際基準の採 用促進をめざして、70 年以上の間に10 の決議 を採択した(3、6)。 1CHAPTER はじめに 1.　国際労働機関の国際標準職業分類の定義による。(https://www.ilo.org/public/english/bureau/stat/isco/isco08/) 1はじめに 5. WHO が国際看護師協会と世界規模の Nursing Now キャンペーンと共同で作成したこの報告書 「世界の看護 2020」では、看護政策の展望と将 来的な課題を提供することを目的として、現代の エビデンスを示している。世界保健総会で定めら れた通り(7)、世界が 2020 年を国際看護師・助 産師年として祝う中、この画期的な報告書は、持 続可能な開発目標（SDGs）達成までの残り10 年間の国、地域、世界規模の看護人材関連対策 への情報提供を目指している。 6. 本報告書は、現在の世界の看護人材に関する包 括的な最新のエビデンスを提示している。保健 目標達成に向けた看護職の役割に関するおもな 課題とエビデンスを評価し、保健人材、プライマ リ・ヘルスケア、保健システムを強化する統合的 なアプローチの一環として看護職を前進させるた めの、具体的な政策オプションを提供している。 7. 本報告書のオンライン版はWHOのウェブサイト2 で読むことができる。そこには個々の国のプロファ イルが含まれており、本報告書のために各国が提 供したデータが示されている。 © WHO/NOOR/Sebastian Liste 2.　http://apps.who.int/nhwaportal 各章のテーマ CHAPTER 2 第２章 より広範な労働力と保健の優先事項における看護 この章では、持続可能な開発のための 2030 アジェンダ（SDGs）、特に健康とウェルビー イングに関する SDG 3（8）への保健人材の貢献を示す。 CHAPTER 3 第3章 21 世紀の保健システムにおける看護職の役割 この章では、ユニバーサル・ヘルス・カバレッジの実現、公衆衛生の緊急事態への対処、 すべての人の健康とウェルビーイングの向上というWHO の「トリプル・ビリオン（3 つの『10 億』）」の目標（9）について、優先的に保健介入を行うための看護職の役割と貢献について 概説する。 CHAPTER 4 第４章 看護人材を支援する政策 この章では、国内と世界の両方において、保健医療施設と地域社会で最大限の能力を発 揮すべく勤務する看護職の課題に取り組む上での、保健労働市場、労働力政策とガバナン スの決定要因について説明する。 CHAPTER 5 第５章 看護労働力に関するエビデンスとデータの現状 この章では、現在の看護人材の概況を提示する。ここには、国と地域および世界の政策開 発に最も関連性の高い分野、すなわち看護職のストック、その構成と配置、養成能力、教 育・規制・実践・政策・ガバナンス、リーダーシップ、労働市場の要因が含まれる。2030 年までに予測される1,800 万人の保健医療従事者不足問題に対処する上での、看護の貢 献に関する進展と課題も強調されている。 CHAPTER 6 第６章 看護人材政策の今後の方向性 この章では、今後の課題を、政策オプションと加盟国、教育機関、規制当局、看護職能団体、 開発パートナー、国際機関、その他のステイクホルダーに向けた行動の呼びかけと共に概 説する。 3はじめに © Cecilie Arcurs/ Getty Image 4 State of the world’s nursing 2020　世界の看護 2020 2.1 SDGsの達成における保健人材の役割 8. 2015 年、世界は、人類と地球にとってきわめて 重要な分野における 2030 年に向けた国連の持 続可能な開発アジェンダ（SDGs）を、相互に関 連した17の目標と共に導入した（8）。この SDGs には、貧困の撲滅（SDG 1）、すべての人の健康 とウェルビーイングの実現（SDG 3）、包括的で 公平な教育の確保（SDG 4）、ジェンダー平等の 達成（SDG 5）、適正な働き方と包括的で持続可 能な経済成長の促進（SDG 8）が含まれる。 9. WHO は、SDG 3 の進展を加速させるための世 界での取り組みを主導しており、この SDG 3 は、 ユニバーサル・ヘルス・カバレッジの概念に基づ いている。ユニバーサル・ヘルス・カバレッジの漸 進的な実現は、国連総会の「ユニバーサル・ヘル ス・カバレッジに関するハイレベル会合の政治宣言」 （10）および議会同盟での決議（11）などを通して、 すべての国連加盟国が全会一致で取り決めた目標 である。 10. プライマリ・ヘルスケアは、ユニバーサル・ヘル ス・カバレッジの礎である。世界の指導者たちは、 1978 年に出されたプライマリ・ヘルスケアに関す るアルマ・アタ宣言の40周年にアスタナ宣言3 （12） を発表し、プライマリ・ヘルスケアがユニバーサ ル・ヘルス・カバレッジ実現のための主要なアプ ローチであることを確証した。WHO は、「トリプ ル・ビリオン（3 つの『10 億』）」の目標という形で、 SDGs とプライマリ・ヘルスケアの論理を、自ら の第 13 次総合事業計画の策定と実施に組み込ん でいる。これは、10 億人が新たにユニバーサル・ ヘルス・カバレッジの恩恵を受け、さらに10 億人 が公衆衛生の緊急事態から守られ、さらに10 億 人が健康とウェルビーイングの向上を享受すると いう目標である（9）。 11. WHO の 2019 年の報告書「ユニバーサル・ヘル ス・カバレッジへの道のりにおけるプライマリ・ヘ ルスケア」では、サービス提供範囲の改善に向け た目覚ましい進歩のエビデンスを明らかにしてお り、各国は国内の法的枠組みにおいて保健医療 より広範な 労働力と保健の 優先事項における看護 2CHAPTER 3.　プライマリ・ヘルスケアに関するアスタナ宣言：アルマ・アタから、ユニバーサル・ヘルス・カバレッジと持続可能な開発目標に向けて 5より広範な労働力と保健の優先事項における看護 サービス・医薬品などへの普遍的なアクセスに関 する法的義務を確立しつつある（13）。しかし、そ の進捗状況は国によっても各国内でも一様ではな く、最も脆弱な人々への財政的保護が依然として 課題となっている。脆弱な保健システムと社会経 済的要因が前進を妨げており、投資の優先順位 を特定し、進捗状況を追跡するためには、より良 いデータとエビデンスが求められる。柔軟性に欠 ける医療サービス提供モデルと役割から、より機 動的でアクセスしやすい連携したシステムへ移行 する好機である。 12. WHO の推計によると、2030 年までに SDG 3 の健康目標を達成するために必要な全投資額は 合計 3.9 兆米ドルである（10）。今後 12 年間で、 この投資額の 40% を超える額が、2030 年まで に予測される1,800 万人の保健医療従事者不足 への対応に必要な保健人材の報酬、給与、手当 に使われる（14–16）。保健人材の教育と生涯に渡 る学習ニ ズーに必要な追加投資を含む予測額によ ると、保健関連の投資の平均 50% 以上を保健人 材の養成、報酬、維持にあてる必要がある。 13. 2016 年、「保健医療の雇用と経済成長に関する 国連ハイレベル委員会」は、保健人材のコストは 抑制すべきである（17、18）という長年の誤った 考えに反して、保健医療の職と雇用は経済成長 を促進し、他の部門の生産性を向上させることを 示すエビデンスを発表した（17、18）。保健システ ムとその労働力への投資は、特に女性（SDG 5） と若者の雇用とエンパワーメントを通じて、包括 的な経済成長（SDG 8）に大きく貢献する（19、 20）。女性は、世界のヘルスケア、ソーシャルケア 労働力の70% を占め（21）、看護師・助産師のほ ぼ 90% を占めている（22、23）。 14. 「保健医療の雇用と経済成長に関する国連ハイレ ベル委員会」は、ヘルスケア、ソーシャルケア部 門への投資の理論的根拠を示した。またその投 資によって養成能力を拡大して、保健医療従事者 の持続可能な供給を確保し、ニーズを満たすよう コンピテンシーを変革し、よりよい保健医療サー ビス提供のために適切な場所で適切な仕事に就く ことができる適切なスキルを備えた医療従事者を、 予測される1,800 万人の保健人材不足回避に十 分な人数を生み出すための枠組みを提示した。 15. 2017 年に WHO 加盟国は、「保健医療の雇用と 経済成長に関する国連ハイレベル委員会」の提 言を実現するための 5 カ年計画を採択した。この 提言は、「保健医療のために働く」プログラムと、 WHO、国際労働機関（ILO）、経済協力開発機構 （OECD）のマルチパートナー基金に取り入れられ ている（15、17）。WHO は、「保健人材に関する 世界戦略：労働力 2030」（図 2.1）（16）で概説さ れている保健人材強化のアプローチに沿って、こ れらの提言を実践している。 16. ユニバーサル・ヘルス・カバレッジと SDG 3 達成 に向けた前進は、保健人材への投資ニーズに再び 重点を置くことで加速が可能となる。このために は供給、需要、およびニーズの包括的な理解と定 数化が必要であり、これらは総合的な保健人材の 戦略と計画に情報をもたらす労働市場の分析に使 用される。 6 State of the world’s nursing 2020　世界の看護 2020 保健人材に関する世界戦略：戦略的目標と看護への関連性 図 2.1 看護の重要分野： 予防や一次医療 提供における 看護職の業務範囲 と役割の適正化を 通じた、看護職の 貢献の最大化など。 看護の重要分野： 看護職の移住の 管理、看護教育の 質の確保、地方や 医療過疎地での 看護職定着に対する 投資など。 看護の重要な分野： 看護人材の正確な人数の 把握、保健労働市場 分析の実施に必要な情報 の理解などである。 モニタリングと説明責任 のためのデータには、 政府省庁だけでなく 看護および保健医療 以外の関係者の関与も 求められる。 看護の重要分野： 保健政策立案への 看護界のリーダー の関与、看護職の リーダーシップ 育成など。 パフォーマンス、質、生 産 性、 有 効 性、スキル ミックス、定着を適正化 し、公平性とユニバーサ ル・ヘルス・カバレッジ に向けて効率化と配置の 不均衡に対処する。 戦 略 目標 1 戦 略 目 標 3 戦略目 標 2 戦略 目標 4 人々の健康のニーズに対 処できるよう保健人材へ の投資を促し、保健労 働市場の動きや教育政 策を考慮しながら、人材 不足と配置の不均衡に対 処する。 保健人材に関する効果的 な公共政策の管理、リー ダーシップ、ガバナンスの ための公共機関の能力を 構築する。 保健医療のモニタリング と説明責任のために人材 データを強化する。 7より広範な労働力と保健の優先事項における看護 17. 看護職は、適正な人数、公平な配置と定着、質 の高い教育、効果的な規制、働きやすい労働条 件、ユニバーサル・ヘルス・カバレッジの質と効 率など、すべての保健医療従事者に共通する課題 に直面している（24–26）。しかし、ジェンダーバ イアス、政策リーダーシップ、法規、教育と実践 上の役割の多様性など、看護職固有の課題もある （25）。これらの問題と優先事項を明確に理解する ことで、適切な政策と投資決定の判断を促すこと ができる。 2.2 看護職とは誰を指すのか 18. 本報告書は、看護人材に関して入手できる限り最 良の、国際的に比較可能なエビデンスとデータを 提示することを目的としている。そのためには「看 護職とは誰を指すのか」を具体的に示す必要があ る。第 3 章と第 4 章にまとめられたエビデンスで は、既に出版された文献に見られる看護職の広い 解釈を使用している。本報告書のために収集され たデータと、本報告のために実施された分析を示 す第 5 章では、「看護師」という語は、具体的に 2008 年の国際標準職業分類（ISCO-08）によっ て定義された 2 つの職業グル プー、すなわち看護 師（ISCO コード 2221）、および准（準）看護師（ISCO コード 3221）のみを指す。 19. 各国は、この 2 つの職業の定義を満たすと判断す る対象についてデータを報告しており、他の職業 グル プー（伝統的助産師、看護助手、その他の補 助的な保健医療従事者など）についての報告は求 められてはいない。一部の国では一部の保健医療 従事者を「看護助産師」として分類しており、そ の養成経路や役割は混在している。「看護助産師」 は国際的に分類された職業グル プーではないため、 本報告書には各国が看護師または准（準）看護師 として分類した保健医療従事者に関するデータの みが含まれている。これらの定義の詳細と、各国 が自国の看護職について報告する上でどのような 支援を受けたかについては、第 5 章の方法の説明 と、本報告書の付属文書 1を参照されたい。 20. 看護は、病気であれ健康であれ、あらゆる状況 におけるすべての年齢、家族、グル プー、コミュ ニティにおける個人の自律的かつ協調的なケアを 含み、そこには健康の増進、病気の予防、病気 のケア、障がい者や死に瀕した人のケアも含む（7、 © AKDN/Christopher Wilton-Steer 27）。このほかの重要な看護の役割として、啓発 活動、医療安全の推進、患者および保健サービ スの管理、保健政策の形成、教育、研究などが ある（27、28）。看護職は、第三次医療機関から 遠隔地のヘルスポスト（医師のいない保健医療施 設等）に至るあらゆるヘルスケアの場で、人々に 多種多様な保健サービスを提供している。看護職 にはさまざまな形があるものの、「看護師」の職 名は、看護を実践するための法的、教育的、およ び行政的要件を満たす者を指すべきである。 21. 「看護師」として看護を実践できるようになるため には、さまざまな養成経路がある。看護基礎教 育課程修了後、さらに高等・専門教育を受けられ る機会も多く、それによって異なる役職や役割を 得る場合もある。その結果、同じ国内でも看護の さまざまな職名、役割、コンピテンシーが混在す ることとなる。どの国にも見られる多様性は、地 域レベルで見るとさらに広がり、世界レベルで評 価するとまたさらに広がる（図 2.2）。世界法規ア トラス（29）のデータは、専門家や高度実践者の 職名を含め、資格試験を必要とする看護職の職名 が世界には少なくとも144 あることを示している。 南・東アジア地域における10 の職名から、アメリ カ、ヨーロッパ地域における 30 を超える職名ま で、看護職の種類数の幅が反映されている。 22. 看護職の役割は、同じ職名であっても国によって 異なる場合がある。このことは、「看護職が誰を 指すか」という議論の前提であり、看護の機能を 理解し、人々の健康の目標達成に向けた看護職の 貢献が最大化されるような保健医療サービスを計 画する上で、国際的な看護職の定義の標準化の 重要性をはっきりと示している。 各WHO地域での看護職の職名数図 2.2 ヨーロッパ 西太平洋 東地中海アメリカ 南・東 アジア アフリカ WHO地域 0 5 10 15 20 25 30 35 31 19 32 11 20 10 ????????????? 注：数字は、各国で試験を必要とする看護職の職名数を地域ごとにまとめて 示したもの。 出典：NCSBN世界規制アトラス（29） 9より広範な労働力と保健の優先事項における看護 © WHO/Atul Loke 10 State of the world’s nursing 2020　世界の看護 2020 23. この章では、SDG 3 に貢献する看護職の役割と 責任について、具体的には「健康を促進し、世界 を安全に保ち、脆弱な人々に奉仕する」WHO の 使命とその総合事業計画の「トリプル・ビリオン（3 つの『10 億』）」目標に関連した、現在のエビデ ンス（詳細は web の付属文書を参照）を提示する。 3.1 ユニバーサル・ヘルス・カバレッジの実 現における看護職の役割 24. あるコクラン系統的レビューでは、看護職は一部 の症状に対する意思決定、健康や予防教育など、 感染性・非感染性疾患に関する幅広い分野におい て、プライマリ・ヘルスケアの提供に効果的であ ることが示されている（30）。このレビューは、一 定の条件・状況では、看護主導の一次医療・サー ビスがその他のケア提供モデルと比べ、同等ある いはより良い患者の健康アウトカムおよびより高い 患者満足度につながり得ることを示している。ま た看護職は、より長時間患者の相談に対応してい る（30）。ほかのコクラン系統的レビューでは、看 護職が HIV 治療の開始とフォロ アーップに効果的 であり（31）、また看護職の介入は禁煙成功の確率 を高めることが示されている（32）。ほかにも、看 護職を含む保健医療従事者が、一般的および周 産期のうつ病、心的外傷後ストレス障害およびア ルコール性障害、ならびに認知症の患者と介護者 の状態を改善する可能性があることが示されてい る（33）。キャンベルの系統的レビューでは、性暴 力被害者支援看護師や法医学関連分野で働く看 護師は、性暴力の法医学検査や文書化に効果的 であり、またこの看護師によるケアは性感染症と 妊娠の予防を提供でき、費用対効果も高いことが 示されている（34）。 21世紀の 保健システムにおける 看護職の役割 3CHAPTER 1121世紀の保健システムにおける看護職の役割 25. 看護職は、ケアの質と患者の安全確保、感染症 予防・制御、また薬剤耐性（AMR）への対処に おいて重要である（35）。これらは、患者の症状悪 化のモニタリング、エラーやニアミスの検出（36）、 感染予防の介入や感染制御のモニタリングの実施 （37）、水、衛生、手指衛生に関わる適切な実践 （38）など、様々な実践により達成される。手指 衛生、身体的距離、消毒が封じ込め策の中心とな る COVID-19 のようなアウトブレイクにおいては、 看護職の感染予防と感染制御の役割が極めて重 要である（Box3.1）。 26. 感染症の予防、治療、制御に対する看護職のこ れまでの貢献もまた、多数報告されている（4、 49）。たとえば、看護職主導の介入は、ワクチン 接種率の増加につながり得る（50）。世界全体で 看護職は結核の管理と予防のために積極的に活動 しており、「診療の補助」と「療養上の世話」（健 康増進や心理社会的支援など）の両方に効果的 に従事している（51-54）また男性の医学的割礼 や（55-61）、HIV 暴露前予防投与プログラムを計 画・実施している（62）。また看護職は、コミュニ ティ教育、集団への予防剤投与、症例の把握と 診断、有病率の判定、コミュニティ・ヘルス・ワー カーによって特定された疑い症例のスクリーニング と確認、調剤、特定の手術の実施（トラコーマな ど）、リンパ浮腫のセルフケアなどの患者教育を通 じて、顧みられない熱帯病との戦いにも貢献して いる（63）。アフリカ中の複数の場所で、看護職は コミュニティ・ヘルス・ワーカーの研修や指導監督 を通じて、感染症看護の質の向上にも貢献してい る（63–65）。 27. 看護職は、ヘルスプロモーションや健康リテラ シー向上、非感染性疾患（Non Communicable Diseases: NCDs）の管理においてきわめて重要 な役割を果たしている（66–72）。適切な知識、ス キル、機会、財政支援によって、看護職は、患者 と家族にとって一生涯の効果的な実践者であり、 健康のコーチであり、代弁者でもあり、知識の仲 介者としてのユニークな存在である（73）。高血 圧、心血管疾患、糖尿病、メンタルヘルス、神 経疾患、呼吸器疾患およびがん（70）など、複数 の NCDs のスクリーニングとそれに対するプライ Box 3.1 患者の安全に対する看護の貢献 低・中所得国では、質の低いケアに起因する死者が毎年800万人を超えている（39）。看護職は、有害事象の防 止を通じてケアの質の向上と患者の安全に貢献できるが、そのためには強力なチームを組み、良好な労働環境 で最適な量の業務を行う必要がある。看護職は、患者の症状の悪化をモニターし、エラーやニアミスを検出し、 ケアプロセスの理解に加え、システムに内在する弱点を理解し、患者が質の高いケアを受けられるようその他多 くの対策を講じることにより、患者の安全確保に欠かせない役割を果たしている（36）。仕事の過負荷、長距離 の移動、むずかしい人間関係による看護職や医師の心身疲労は、患者の安全性の低下に関わる（40）一方、良 好な職場環境、看護職の適切な配置、多職種チームでの教育は、入院期間を短縮し、肺炎、胃炎、上部消化管 出血、褥瘡、カテーテル関連尿路感染症などの有害事象の発生率の低下、全体的な死亡率の低下と関連がある （41–48）。 12 State of the world’s nursing 2020　世界の看護 2020 マリ・ヘルスケア・サービスの提供を含めたさまざ まな NCDs 関連業務で、看護職の貢献がいくつ も実証されている（66–72）。看護職は、これらの 業務を通して、血圧低下やうつ病スケールのスコ ア低下など健康アウトカムを改善し、心不全や糖 尿病の患者にも同様にケアを提供してきた（30、 70）。また看護職は、薬剤服用率の向上など行動 変容にも貢献しており、看護職のケアを受けた患 者は経過観察の予約をとり続ける確率が高い（30、 70）。看護教育と業務範囲の適切な方向づけによ り、保健医療ケアチーム内で看護職の役割が拡 大することで、NCDs の一次医療への統合ができ る（74、75）。看護職の役割が拡大すれば、さま ざまな状況でその重要性も大きくなるが、特に医 師不足の状況では、健康の公平性を向上させる可 能性を持っている（73、76）。 28. 看護職は人々の生涯にわたり、質の高いケアの 提供に貢献している。看護師は、助産師、産科 医、その他の専門医と共に働くことで、妊産婦に 産前、分娩時、産後のケアを提供する（77）。新 生児ケアに特化したスキルを持つ看護職は、他の 新生児専門家のサポートを得て、特別な支援やタ イムリーで質の高いケアを効果的に提供している。 大半の国において看護職は、小児と青少年にケア を提供する学校の保健医療サービスの中核を成 す（78–81）。また看護職は、性と生殖に関する健 康全般においてもサービスを提供している。例え ば、安全かつ効果的に経口・注射避妊薬、避妊 用皮下インプラント、子宮内避妊用具の提供であ る（82）。子宮頸がん検診および生殖年齢以上の 女性に対する HIV サービスの提供における看護職 のはたらきの有効性も、エビデンスが示されてい る（83、84）。看護職は、子宮頸がん (HPV) ワ クチン対象年齢の青少年とその親や保護者への情 報提供と啓発活動などを通したワクチン接種サー ビス拡大において、中心的な役割を果たす（83、 85、86）。また看護職が高齢者ケアの提供におい ても中心的役割を果たすことで、包括的なケアが 有効に提供され、その結果高齢者の健康が改善 される（Box3.2）（87）。さらに看護職は、尊厳と 思いやりのある人生の最終段階を可能にする、終 末期ケアの主要な提供者でもある。 © WHO/Tania Habjouqa 1321世紀の保健システムにおける看護職の役割 3.2 緊急事態、感染症流行、災害対応に 　 おける看護職の役割 29. 看護職は、救命救急の場面（事故や心臓発作な ど）でのケア提供、感染症のアウトブレイクの予 防と対応、災害と人道的危機への対応に関わって いる。多くの場合、看護職は患者が医療施設で 最初に会う保健医療従事者である。その役割は 状況によって異なるが、おもにトリアージ、生命の 危機的状態の早期発見、与薬、救命処置、搬送 などがある。 30. 看護職は、2003 年の重症急性呼吸器症候群 （SARS）（91）、2015 年の中東呼吸器症候群コロ ナウイルス（MERS-CoV）のアウトブレイク（92）、 2016 年のジカウイルス感染症（93、94）、2014 年のエボラウイルス病（95、96）、そして 2019 年に始まった COVID-19 のアウトブレイクなど、 世界の人々の健康を脅かす感染症流行に対応す るチームの一員として重要な役割を果たしてきた。 看護職やその他の保健医療従事者は、WHO 緊 急医療チームイニシアチブを通じて、自国で起こ り得る災害や緊急事態への対応能力向上の訓練 を受けている（97）。これは、災害や紛争によって 脆弱化している保健システムの強靭性を高める上 で、特に重要である（98）。 Box 3.2 看護職による高齢者のためのコミュニティケアモデル 笹川保健財団は、日本社会の「超高齢化」をきっかけとして、看護職による地域密着の在宅看護センターの 起業、運営、経営を支援するプログラムを 2014 年に開始した（88）。在宅看護センターは地域の保健医 療のハブとして機能し、看護職はここを拠点として、高齢者が自宅で尊厳ある生活を送るためのサービスを提 供し、地域社会の人々の生活の質を向上させる。また笹川保健財団では、センター間の協力体制を強化し、デー タを収集し、地域密着型の在宅看護センターの起業を提唱するためのネットワークも支援している（89）。 看護職は、高齢者介護と在宅看護に関する 8 カ月のプログラムによって、フィジカルアセスメントを行い、地 域住民のプライマリ・ヘルスケア・ニ ズーを満たし、家族による自宅での終末期ケアを支援できるようになる。 在宅看護センターを開設・運営するための起業、経営、事業計画に重点を置いた講義も行われる（89）。 2019 年 3 月までに 67 名の看護職がプログラムを修了し、そのうち 56 名を超える看護職が全国 23 都道 府県で在宅看護センターを運営している。センターのスタッフは平均して看護職が 70%、その他の専門職が 30%となっており、地域社会のプライマリ・ヘルスケアのニ ズーを満たすためにセンターや患者の家庭で行わ れる多職種協働アプローチの有効性が証明されている。これらの在宅看護センターは、ネットワーク全体で 1 カ月あたり平均 25,000 回の訪問を行っている。終末期ケアの提供における家族のサポートは、入院治療に 関連する医療費の削減に貢献している（90）。 14 State of the world’s nursing 2020　世界の看護 2020 31. 看護職を含む保健医療従事者は、治安の悪化や 紛争などの状況においては、誘拐の危険、同僚 の死への対処、自分の死への恐怖、仕事の増加 や複雑化（銃創への対応など）、倫理的・専門的 規範の崩壊など、数多くの個人的・職業的課題 に直面する（99）。看護職を含む保健医療従事者 は、これらの課題に直面しながらも、必要不可欠 なサービスを提供し続けてきた（99）。紛争地域 にいる看護職、難民に対応する看護職は、支援 を受けながら肺結核（100）やその他の呼吸器系 感染症、歯科疾患、心的外傷後ストレス障害（101） など、さまざまな症状のケアに対応している。 3.3 集団の健康とウェルビーイングの実現に 　　おける看護職の役割 32. 集団の健康とウェルビーイングの向上のためには、 看護職その他の保健医療従事者が健康の社会的 要因に取り組む必要があり、その実践は SDGs の達成に貢献する。看護の有効性が明らかになっ た代表的な例としては、手洗い、栄養、トイレ利 用の促進による下痢性疾患の予防（102、103） がある（4）。また看護職は、気候変動の影響を受 けやすい貧困層や脆弱な集団にも、最初に対応 する可能性がある（104-106）。そこには、脆弱な 集団の強靭性強化や、下痢性疾患、マラリア、ア フリカトリパノソーマ症、リーシュマニア症、住血 吸虫症、腸内線虫感染症、デング熱など、気候 変動の影響を受けやすい疾患による死亡率の削 減などが含まれる。 33. より健康な集団の実現と維持は、ユニバーサ ル・ヘルス・カバレッジへの公平なアクセスによ り、若者が健康で、持続可能な社会を次世代に 引き継げるかどうかにかかっている。看護職は、 信頼できて中立的であり、若者に寄り添い、相 談しやすいなど、若者の期待に応えるために必 要なアプローチを理解し、実践できる存在である （107–110）。 © National Health Commission of the People's Republic of China 1521世紀の保健システムにおける看護職の役割 34. 看護職は、家族計画や中絶ケアなど、女性が特 に課題に直面する分野でプラスの結果を出してい る（111、112）。これらのサービスの提供における 看護職の役割を最大化することで、多くの女性が 性と生殖に関する健康（リプロダクティブ・ヘルス） のケアにアクセスしやすくなる。看護職は、女性 が重要なライフイベント（例えば産前産後（113） や乳がんなど）におけるヘルスケアを受けられる よう社会的支援をしており、女性が保健医療サー ビスの場で敬意のあるケアを受けられるようにす るための鍵となる（114、115）。また看護職は、ジェ ンダーに基づく暴力との闘いにおいても不可欠で ある。親密なパートナーからの暴力に関する研究 では、被害者の同定を最も多く行っている医療従 事者は看護師と助産師（それぞれ 45% と 24%） であると報告されている（116）。この章の最後の 図 3.1は、「トリプル・ビリオン（3 つの『10 億』）」 の目標に対する看護の貢献をまとめたものである。 16 State of the world’s nursing 2020　世界の看護 2020 © WHO/Yoshi Shimizu トリプル・ビリオン（3つの『10億』）」の目標への看護職の貢献図 3.1 多職種チームの 一員としての 看護職 ユニバーサル・ヘルス・カバレッジ ・ 第一線での一次医療の提供者 ・ 幅広い感染性・非感染性疾患の予防と治療 ・ 誕生から死まで生涯にわたるケアの提供 健康と ウェルビーイング ・ 多分野協働に 　よる健康の 　社会的要因への 　対処 • 気候変動の影響 　への対処とケア • 女性や若者など、 　脆弱な集団の 　ためのアクセスの 　確保 緊急事態、 感染症流行、災害 • 救命救急での 　ケアの提供 • 感染症流行、災害、 　人道上の危機への対応 • 生命にかかわる状況の 　早期発見、救急処置の実施 1721世紀の保健システムにおける看護職の役割 © WHO/ Yoshi Shimizu 18 State of the world’s nursing 2020　世界の看護 2020 35. 前章で述べたように、看護職の貢献を最大化す るには、政策による支援と実践環境が必要である。 看護人材の安定供給、配置、能力、働きやすい 労働環境、パフォーマンスに影響を及ぼす要因の 多くは、WHO の保健労働市場の枠組みを活用し、 公共政策の視点から分析することができる（117） （図 4.1）。 36. この枠組みに基づき、本報告書では、看護に関 する保健人材の政策対話の特徴である 4 つの側 面を検討し、（a）卒前教育と実習、（b）労働力の 流入と流出、（c）公平な配置と効率性、（d）法規（民 間部門を含む）に関する査読付き論文から得たエ ビデンスをまとめた。この枠組みでは、保健労働 市場に影響を及ぼす社会的、経済的、集団的要 因にも言及している。これらの要因の一部（ジェ ンダーバイアス、国の所得レベル）は本報告書で 詳細に議論されているが、人口統計学的傾向（高 齢化、成長パターン）や気候変動その他の要因 は、関連する看護人材政策を策定し実施する際 に、各国の状況に合わせてその場で検討する必 要がある。 4.1 卒前教育と実習 37. 看護教育の目的は、量、質、配置の観点から、 集団のヘルスニーズを満たす看護人材を養成す ることである。したがって、看護基礎教育課程の 入学者数と卒業者数は、保健セクターのニーズと 雇用能力に合わせて調整する必要がある。保健、 教育、労働、財政セクター間で定期的な対話と調 整を行うことで、ミスマッチが起こらないように することが可能である。 38. 看護基礎教育課程の入学・卒業生の人数は、ま ず集団の基礎教育レベルと、看護基礎教育課 程への入学要件の影響を受ける（118、119）。看 護基礎教育課程への入学は、教育を受ける場所、 4CHAPTER 看護人材を 支援する政策 19看護人材を支援する政策 費用、定員、臨地実習先、提供される看護教育 のレベルの影響を受ける。また、看護教育の使命 と目的を達成するための資格を持つ教員数や、臨 地実習のためのインフラと受け入れ能力の影響も 受ける（120）。スクワイア等の報告によると、保 健システムが受け入れられる保健人材数（人口あ たりの病院のベッド数）やジェンダ ・ーエンパワー メントなどの「マクロ」要因もまた、国によっては 看護職の養成数に影響を及ぼす（121）。 39. ジェンダー問題は看護学生の入学に影響を与え、 看護職の供給に影響を与える可能性がある。看 護業務が社会的・経済的に過小評価されること により、看護職が保健システム内での意思決定に 参加したり、リーダーになったりする機会が制限 され（22、23、122）、優秀な志願者の看護基礎 教育課程への入学が阻害される可能性がある。ケ アの提供は女性の役割であるという偏った認識と 社会のジェンダー規範によって、男性の入学は依 然として課題となっている。看護教育は、女性の 場合は社会的地位が上がると見なされるかもし れないが、男性の場合はそうならない場合がある （123–125）。また他の職種においては、女性のキャ リア形成の機会が文化的または組織的な制約に よって制限される場合がある。そのため看護師に なることは、保健分野を目指す人にとって男女問 わず魅力的というより、女性にとってより確実な キャリアパスとなっている。 40. 一部では、特定の人種、民族、またはその他の 脆弱なグル プーの人々が看護教育を受ける割合が 少ない状況がある（126）。このことは、看護職と 看護職が働く地域社会との文化的適合に悪影響 を及ぼす。看護職全体において、教育と研修への 労働市場形成のための公共政策図 4.1 Education sector Labour market dynamics Economy, population and broader societal drivers Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to refrain health workers in undeserved Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery * Supply of qualified health and social workforce willing to work ** Demand for health and social workfoce in the health and health-realted social care sectors Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA). U ni ve rs al h ea lth c ov er ag e w ith s af e, e ffe ct iv e pe rs on - ce rt ifi ed h ea lth s rv ic es Abroad H ig h Sc ho ol Education in health Education in other field Poor of qualified health workers* Employed Unemployed Out of Labour Force Health care sector** Other Sectors Health workforce equipped to deliver quality health service 教育セクター 労働市場の変動要因 高等学校 保健分野の 基礎教育 その他分野の 基礎教育 資格を持つ 保健人材プール 移住 国外へ 就業 未就業 労働力外 ヘルスケア セクター 質の高い サービスを提供する、 利用可能で アクセス可能で 期待に沿う保健人材 ユニバーサル・ ヘルス・ カバレッジ 養成についての政策 • インフラと教育資材について ・ 入学について ・ 学生の選抜について ・ 教員について その他のセクター 流入と流出に取り組む政策 • 移住への取り組み ・ 未就業の保健人材を引きよせ ・ 保健医療従事者のヘルスケアセクターへの復職 不均衡な配置と非効率に取り組む政策 • 生産性とパフォーマンスの改善 ・ スキルミックスの構成の改善 ・ 保健人材の地方への定着 民間セクターを規制する政策 • 兼業／副業の管理 ・ 研修の質の改善 ・ サービス提供の強化 出典：Sousa A、Scheffler RM、Nyoni J、Boerma T. A comprehensiv health labour market framework for universal health coverage. Bulletin of the World Health Organization. 2013; 91：892–4 20 State of the world’s nursing 2020　世界の看護 2020 異文化適応力の導入が重視されるようになっては いるものの、看護教育への参加機会が少ない集 団出身の学生の選抜と募集を増やすための、さら なる取り組みが求められる（Box4.1） 41. 看護基礎教育課程と臨地実習の場所もまた、優 秀な受験者の確保に影響を及ぼす。看護基礎教 育課程は主に大学や病院のある都市部に位置して おり、へき地からの入学希望者にとって、教育の 選択肢ははるかに少なくなる（129）。保健人材の 地理的分布と養成機関の社会的説明責任が重視 されるようになるにつれ、一部ではへき地研修を 取り入れたり、これまで中等以降の教育を受ける 機会の少なかったコミュニティ出身の学生を積極 的に募集したり支援したりしている。オンライン の遠隔教育プログラムと適切な臨地実習の教育 機会を組み合わせることで、へき地の入学希望者 に効果的な選択肢を提供できる可能性が出てくる （130）。教育の質のモニタリングとその維持には常 に注意を払うべきだが、状況によっては、このア プローチによって、看護基礎教育課程の学生の多 様性が高まる可能性がある（131）。 42. 費用（学費と生活費）は、学生が看護基礎教育 課程に入学・卒業に影響を及ぼす。看護教育の 費用には大きな幅があるが（Box4.2）、公立の教 育機関は、民間の教育機関と比べて公的助成金 の額が大きく、多くの場合民間よりも安価である。 フルタイムの学生の場合は収入が少ないか皆無の 場合もあり、学費に生活費負担が加わる。資金 調達スキームは国によって異なり、これまで修学 機会の少なかったコミュニティ出身の学生や、卒 業後に看護職が不足している地域で働く意欲のあ る学生のために、そのほかの対策や奨励金が設 けられている場合もある。 43. 看護職と看護職能団体の分類基準（ISCO-08） を満たすなかにも、いろいろな資格や職業上の役 割があり、その養成のために多様な看護基礎教 育課程がある。看護基礎教育課程には、修了証 明書（certificate）レベル、卒業証明書（diploma） レベル、学位取得（bachelor）レベルがある。 それらの課程の入学要件は、修了証明書レベルで は 9 年生以下の課程を修了して 17 歳に達してい ること、学位取得レベルでは、中等教育課程（12 年生）に加え 2 年間の大学レベルの教育を修了 していること、など幅がある（135、136）。教育 課程と入学要件がさまざまであるため、幅広い 人々が看護職に就くことができるものの、雇用者 は教育のレベルに基づいて実務上の役割を区別で きないことが多く、ジェネラリストを養成する教 育課程と、専門性の高い看護職を求める雇用者と の間でミスマッチが起こる。 44. 世界の一部の国では、看護人材のかなりの割合 が certificate・diploma レベルの教育を受けて おり、多くの場合、タスク指向の臨床スキルに重 点を置いた看護基礎教育課程で教育を受けてい Box 4.1 オ スートラリア：看護人材が少ない集団への取り組み オ スートラリアでは、オ スートラリア先住民が、先住民の看護師を増やすよう要請し続けている。これは、単な るケアだけでなく、文化的に安全なケアへのアクセスを増やすためである（127）。しかしその解決策は、先 住民族、アボリジニ、トレス海峡諸島出身の学生の数を増やすといった単純なものではない。これらの学生が 直面する課題への確実な対応も必要なのである。たとえば、彼らが学習しやすい環境の整備、先住民の看護 教育者の配置、カリキュラムに先住民向け内容を取り入れること、また学生の経済的ニ ズーに対処することな どである（127、128）。 21看護人材を支援する政策 る（137）。通常、大学の bachelorプログラムで は、リーダーシップ、症例管理、入院・外来患者 のさまざまな環境において健康に影響を与える社 会経済的要因に関する講義も行われる。研究の 要素が含まれることもある。また bachelorプロ グラムでは、より高度な臨床判断に寄与し、ケア 提供の安全性を高めることのできる「クリティカル・ シンキング・スキル」にも力を入れる。bachelor 取得者の割合が高い看護職グル プーからケアを受 ける患者は、死亡率が低く、入院期間が短く、医 療費が安くなることが研究で明らかになっている （46、138、139）。ただし、bachelor 取得看護 職によって患者の状態が良くなるとの結果が示さ れている研究の大半は病院内で行われたもので あり、外来および地域社会の場ではそうした結果 は出ておらず、調査結果の一般化には限界がある （140）。一方、bachelorプログラムで学習した看 護職は、持っている知識とスキルのすべてを職場 で活用できていない可能性も示されている（141）。 45. また看護職は、学士号取得の専門職となるための 教育を受けることも、専門的または高度実践のた めの修士号レベルの教育を受けることも、実践指 向（Doctor of Nursing Practice）または研究 指向（Doctor of Philosophy）のいずれかの看 護学の博士号を取得することも可能である（142）。 看護職の学歴を高めるためには、教育課程の様々 なレベルの違いを明確にし、それまでの学習を基 盤として履修単位を認める必要がある（143）。学 位を取得した看護職の需要がある国では、既存 の看護職資格を「ブリッジ」または「アップグレー ド」する教育プログラムが重要なキャリア開発の 仕組みとなる。看護職が修士または博士レベルの 大学院教育を受けるためには、まず学士レベルの 教育を受けている必要があり、看護基礎教育課 程の教員の量と質にも影響が及ぶ可能性がある。 46. 看護教育において、学生の臨地実習での適切な 時間と体験の確保は、非常に重要でありながら実 現への困難も伴う。臨地実習で、学生は授業で 学んだクリティカルシンキング、臨床評価、看護 能力を実践し、統合する。臨地実習の指導教員 は、適切に監督を行い臨床スキルを評価する必要 がある。多くの看護基礎教育課程は都市部に位 置しているため、へき地での適切な臨地実習の提 供は困難な場合がある。臨地実習体験は、どこ で看護業務に就くかという学生の最終決定にも寄 与し得る（144）。オンラインプログラムや遠隔プ ログラムによって、それまで「実際の」教育機関 と接点のなかったへき地の臨床施設へのアクセス が向上することが示されている（145、146）。ま た、遠隔医療技術とシミュレーション実習によっ Box 4.2 看護教育のコスト 世界全体の推計では、年間 272 億米ドルが看護師と助産師の教育に費やされている（132）。看護師と助 産師は世界の保健人材の半数を超えているが、看護師・助産師教育への支出額は、世界の保健人材教育支 出の約 4 分の 1 である。2010 年に発表された推計によると、看護基礎教育課程の卒業生 1 人あたりの世 界全体の平均コストは 5 万米ドルであり、中国の 1 人あたり平均約 3,000 米ドルから北米の 10 万米ドル超 まで幅がある（132）。看護教育の資金調達モデルは、一つの国のなかでも国によっても多様であるため、こ の支出額の幅は、教育機関の資金調達、所有、管理運営における官民の割合による可能性がある（133）。 看護教育のコストの幅を生むもう 1 つの要因は、さまざまなレベルの資格が存在し、教育課程の期間と入学 要件が多様なことである（134）。2030 年までに予想される人材不足を補うための投資を導くためには、看 護師と助産師の教育機関の卒業生および教育と研修の費用に関する、より多くのより質の良いデータが求め られる。 22 State of the world’s nursing 2020　世界の看護 2020 て、一次医療における適切かつ補完的な臨床経験 を提供することができる（147–150）。オンライン 遠隔教育プログラムは、これに対するモニタリン グを行い、他の教育機関と同じ認証および質の基 準に準拠させる必要がある。 47. 多くの国で、非営利・営利共に、私立の教育機関 の大幅な増加がみられる（151、152）。営利の教 育機関は学費が高額であることが多く、規制当 局による異なる要件と認証を課される場合がある （152）。こうした教育機関は保健と教育における公 共政策の目的から外れている場合があり、そのた め、特に拡大する国際的な保健労働市場に向け た看護教育を意図している場合は、必ずしも常に 集団の健康の優先事項に沿っているとは限らない。 教育の質の保証の仕組みが整っていない場合、カ リキュラムの内容と提供方法は、必要な臨地実習 経験などの点で国の基準を満たしていない可能性 があり、安全で質の高いケアを提供するための知 識、スキル、行動を備えていない卒業生が生み出 されることになる（153）。医療機関や教育病院と 提携していない私立の学校の急増によって、既存 の臨地実習の場に負担がかかり、そこで提供され る臨地実習の質が疑問視される可能性がある。 48. 看護教育における最大の課題の1つが、資質を 備えた看護教員の十分な人数の採用と定着である （19、20、154）。教員の雇用の場（教育機関対 臨床機関）も課題となっており、ここには給与の 違いや指導のための拘束時間が関連する場合もあ る。アメリカ看護大学協会の報告書では、ベテラ ン臨床看護職の看護教育における地位、報酬およ び教育への関与を高めるために、教育と実践の役 割の統合を提案している（155）。その他の戦略と しては、臨床看護職が臨床現場で学生を教育でき るよう教育学的な訓練を受ける教育機関と臨床の パートナーシップ、ならびに学費の減免やさらなる 研修機会へのアクセスなど、看護教育を深めるた めの奨励制度などがある。こうしたパートナーシッ プの成否は、多くの場合、ベテラン看護職が学生 に教育や指導する時間を臨床現場が捻出できる か否かにかかっている。国内および国際間の例を、 Box4.3 に示す。 49. 修士、博士レベルの教育を受けた教員の不足は、 特に認証基準などで教員要件が指定されている場 合、高学歴の看護教育プログラム確立の妨げとな る。また博士レベルの教育を受けた教員の不足は、 実践に役立つエビデンスの開発に必要な研究を実 施したり、学術分野やヘルスケア分野で指導的役 割を果たしたりする看護職の能力にも、影響を及 ぼす（20、154、160）。 50. すべてのヘルスケア分野の中で、看護では多職種 連携教育を最大限に活用していることが示されて いる（161）。この教育手法は看護学生にとっても重 要なものであり、多職種間での共同作業の能力を 促進するものと認識されている（149、162）。さら に、異なる分野の教員を看護教育に取りこむこと により、他分野の専門知識が看護職教育にもたら される見込みがあり、チームでの患者ケアに必要 な看護職の能力が強化される可能性がある（163）。 現在この教育手法は低・中所得国よりも高所得国 で活用されている（159）ものの、リソースの乏し い環境でもテクノロジーの活用が増えれば、学際 的な学習を強化するための真の機会が生み出され る（162）。 4.2 保健人材の流入と流出 51. 現役看護職（または看護人材の「ストック」）の人 数は、多くの要素によって決定する。「流入」は、 看護実務を始める国内の看護基礎教育課程の卒 業生、他国から移住してきた看護職、看護実務に 復帰する看護職からなる。「流出」には、国内の 保健分野で採用・雇用継続されなかった看護職、 保健分野以外で働くことを選択した看護職、退職 者、国外への移住者が含まれる。 52. 保健医療従事者の保健労働市場への流入の基本 的な決定要因は、財源の確保された雇用ポジショ ン（公共部門、民間部門を問わず）を創出する、 つまり保健サービスの提供を通じて収入の機会を 創出する、国の経済能力である。したがって、雇 用の創出は国の社会経済レベルと直接関連してお り、国の中では、公共部門の政策立案者による 保健分野への投資、とりわけ保健人材への投資の 優先レベルと関連している。需要に影響を与える その他の要因には、高齢化などの人口動態の変化、 慢性疾患や複数疾患の増加などの疾病構造の変 化、看護職の高い離職率やその他保健医療専門 23看護人材を支援する政策 職の不足、病院の建設や病院の雇用方針の変更 などによる医療施設の増加、看護職と患者の比 率についての人員配置基準などの法律の変更など がある（140、164）。看護職の需要を減らし得る 要因には、入院ケアまたはケア提供者の必要性 に影響を及ぼす新技術、高い定着率、生産性の 向上（たとえば、エビデンスに基づく看護実践や テクノロジーの利用拡大による）、看護職から別 の職種への業務の移譲などがある（164）。 53. 看護人材の国際的な移動は増加しており、各国 の保健人材労働力に大きな影響を与えている。看 護職が移住する理由には、より良い仕事、給与、 労働条件、保健インフラ、診療所または病院のリ ソース、教育の機会などがある。これらのプル（引 き寄せる）要因に加え、移住先国における家族の ビザ取得も移住の動機になる場合がある。プッ シュ（押し出す）要因には、移住元国における雇 用機会の欠如、劣悪な労働条件や勤務条件、不 安定な情勢などがある。国外で働く看護職からの 送金は、家族の主な収入源であったり、移住元 国によっては国家経済への多大な貢献になったり もする。国際間の協定（二国間協定）などの政策 的解決策は、支援と保障措置の点で「保健人材の 国際採用に関する WHO 世界実施規範」（165）の 政策規定と一貫し、移住元国と移住先国にとって 互いに有益なものでなければならない（世界規模 のスキル・パートナーシップについては、Box4.4 を参照のこと）。 Box 4.3 看護教育者不足への対策 世界中で見られる看護教育者不足の課題は、教育機関の間での、場合によっては国の間での人材のプールな ど、より協調的なアプローチによって緩和される場合がある（156）。 タイには、高等看護教育開発プログラムという、教育者の学歴を向上させるための共同アプローチがある。これ は中国医学委員会が資金を提供し、チェンマイ大学で実施されている（157）。1994年に開始されたこのプログ ラムは、中国全土で増加する看護学士プログラムで教えるために、修士号や博士号を持つ看護教育者を訓練す ることに重点を置いている。その後このプログラムは、東アジアや東南アジアの10カ国に影響をおよぼし、地域 全体での看護教育プログラムの拡大と看護職の相互認証を可能にした（157）。 米国では、復員軍人看護学術パートナーシッププログラムが、急性期ケア、一次医療の場で復員軍人特有のヘル スケアニ ズーを満たせる卒業生の数を増やすことを目的に、ベテラン看護職をパートナー教育研究機関の教員 にするための給与と研修資金を提供している（158）。 ルワンダでは、さまざまなアプローチの中でも特に、高度な教育法およびカリキュラム開発に重点を置く継続的 な教育を通じて、看護教員の能力が強化された（159）。このプログラムはルワンダによって運営されるべき、ま た協力体制を通じて多文化を尊重する姿勢の実践が必要であるという認識のもとに、国際的な学術パートナー シップに支えられている。（159）。 24 State of the world’s nursing 2020　世界の看護 2020 54. OECD 諸国で働く、国外で教育を受けた看護職 の人数は、2011年から 2016 年までの 5 年間で 20% 増加し、医師の数を上回って約 55 万人に 達した（168）。大幅に改善されたデータでは、「移 住元」国と「移住先」国に対する従来の認識が 曖昧になっていることが示されている（169）。高 所得国では依然として看護職に対する高い経済 的需要があるものの（Box4.5 の例を参照のこと）、 アジア、アフリカ、カリブ海諸国からその他の地 域や国（湾岸諸国など）への移住パタ ンー（170）や、 同じ地域内の国での南南移住が出現している。 4.3 公平な配置と効率性 55. 看護職は、公立・私立を問わず、一連の保健サー ビス提供のなかの、さまざまな場で雇用される （175–178）。看護職が、異なるタイプ、異なる 所有形態の施設にどのように配置されているのか、 体系的な記録はない。ただし、看護職は地域で の一次医療よりも病院や急性期ケアの場で働くこ とを好む場合があり、また公立と比較して報酬が 良いために私立の施設での勤務を選択することも ある（175、177）。 56. ケアモデルは、包括的なプライマリ・ヘルスケ ア・チームにおける最適なスキルミックスを追求し （179）、看護職が看護教育で得たものを、全面的 に活用できるようにする必要がある（180、181）。 看護職は包括ケアチームの礎であり、ケアの提供 を主導し、場合によってはコミュニティ・ヘルス・ワー カーとの共同作業や指導など、より広い実務上の 役割を担うことが多い（182–193）。看護職が教育 と経験を十分に生かして看護を実践できるように することで、仕事への満足度が高まり、患者もケ アに対する満足度が高まる（194）。これらを可能 にする要因には、プライマリ・ヘルスケアの研修、 標準化された看護実践ガイドラインまたは服務規 程の策定、および患者ケアのアウトカムを追跡す るためのデータシステムがある（195、196）。 57. 多くの国で、薬の処方を看護職の業務範囲に含 めている（197、198）。看護職による薬の処方は、 法律または職業規制に定められた特定のものに 限定されることがある（199）。また、サハラ以南 アフリカの HIV 感染者の多い国々においては、第 一選択の抗レトロウイルス治療、薬剤耐性、慢性 疾患への対処など、集団の健康の優先事項であ る薬の処方をする場合もある（200–202）（ポー ランドでの処方については Box4.6 を参照のこ と）。看護職はまた、適切な服薬を支援し、処方 の判断をモニタリングし、処方ミスを減らす上で も、重要な役割を果たしている（203、204）。 58. 医療過疎地やへき地の人々の医療へのアクセスを 向上し、一次医療の場における人員不足に対処 するために、高度実践看護職の役割が開発され た（192、207）。高度実践看護職の役割の最も 一般的なタイプはナース・プラクティショナーであ り、その臨床上の業務範囲には、自身の判断で 検査をオーダーし、診断を行い、治療と薬を処方 する権限が含まれる（207）。通常は、看護職能 団体による認定と修士レベルの教育が必要である （208）。少数の高所得国では、ナース・プラクティ ショナーと高度実践看護職が適切に訓練された 場合、質の高いケアを提供し、ケアへのアクセス を向上し、ケアに対する患者の満足度を高めるの に有効である、という強力なエビデンスが見られ る（208、209）が、費用対効果に関するデータ は限定的である（208–210）。他の国でも看護の 修士課程の数とナース・プラクティショナーの人 数は増加しているが（159、211-214）、その教育 課程や認定・資格付与に影響する規制は、大きく 異なる（192）。高度実践看護職の役割と関連能力 の定義の認識も国によって大きく異なるが（192、 215）、各国の経験から、高度実践看護職の役割 は看護職のキャリアとしての魅力を高めることが 示されている（211、214）。学士レベルの教育を 受け、特定の患者集団のケアについての専門知識 を備える看護職もまた、専門職として認定される ケースがあるが、高度実践看護職としての資格は 付与されていない（専門看護職の例は Box4.7 を 参照のこと）。 59. 保健人材配置の、都市部と地方での地理的不均 衡は、世界共通の課題である。各国は、へき地 に医療従事者を公平に配置し、定着させるために、 複数の分野（教育、規制、財政、専門性）でさ まざまな政策措置を採用している（217）（へき地 での定着については Box4.8 参照）。この多面的 な問題に対処するには多面的アプローチが必要で あることから、さまざまな介入の影響を理解する 25看護人材を支援する政策 ことが、実践の場や地域で戦略を拡大・共有す るための鍵となる（144）。ある国の調査では、へ き地の保健サービス提供者にとってさらなる方策、 特に、保健省による保健人材管理の公平性、透 明性、予測可能性、雇用形態（正雇用か契約雇 用か）が、重要であることが明らかになった（218）。 中・高所得国での研究では、へき地などで働く看 護職の定着には、組織的な取り組みと看護管理 職からの集中的な支援が関連していることが明ら かになった（219、220）。保健サービスが行き届 かないコミュニティの学生を看護基礎教育課程に 入学させることは、自分の出身コミュニティに戻っ て職に就く場合、より高い定着につながる可能性 がある（146、221）。 60. 看護実践の場において、看護職の定着は常に課 題である。看護職の離職は、市場の力の必然的 な結果であり、保健医療機関、患者、および看 護職自身にプラスとマイナスの両方の影響を与 え得る（220、222）。例えば、適度な離職率は、 Box 4.4 世界規模のスキル・パ トーナーシップ 2018 年 12 月、国連加盟の 152 カ国による「安全で秩序ある正規移住のためのグローバル・コンパクト」 の採択により、国際移住に取り組むための包括的アプローチが推し進められた。「グローバル・コンパクト」 の中心的信条は、世界規模のスキル・パートナーシップ、すなわち、移住元国での的を絞った教育的支援を 伴う労働者の需要と供給のマッチングを通じて、移住による機会を活用するための、二国間協定の構築であ る（166）。このパートナーシップの形式は、移住圧力を、移住元国と移住先国双方にとっての具体的で相互 に公平に共有される利益へと導くよう設計されており、WHO 世界実施規範の原則と一致している。 このような協定を通じて、移住先国は、移住希望者が移住前に移住元国において的を絞ったスキルを身につ ける訓練を行うための、技術と資金の提供に同意する一方、移住元国はその訓練を提供することに同意し、 さらに移住者以外の訓練への支援も受ける（166）。このパートナーシップの一環として、看護職は、たとえば 「ホーム」と「アウェイ」で訓練を受けることができ、この場合、ホームで訓練を受けた看護職は移民元国の ニ ズーに適したスキル研修を受け、アウェイで訓練を受けた看護職は移住先国での勤務に備える。各パートナー のニ ズー次第で、このパートナーシップは単一の職業に限定する必要はない。（イギリス国民保健サービスの） イングランド保健医療教育とジャマイカ政府とのパートナーシップは、ジャマイカの看護人材の向上を意図し たものである。ジャマイカの看護職は、英国の病院で 2 年間救急医療の研修を受けた後、ジャマイカに戻っ て専門的役割へ移行する。それと並行して、英国の看護職はジャマイカで、保健サービスの提供、質の向上、 研修など、保健システムの強化活動を支援する。この交換プログラムは 2019 年にスタートした。 国際移住機関は世界中で同様のプロジェクトを実施しており、保健医療従事者の移住の効果的な管理、移 住元国での保健システムの能力構築、および移住者からのスキルと知識の移転を促進するプログラムを通じて、 移住元国と移住先国を結びつけている（167）。こうした活動は、各国政府やその他ステークホルダーとの協 力によって進められている。国際移住機関は WHO の取り組みの主要パートナーであり、WHO 世界実施規範、 関連する政策、および世界保健総会決議を支持している（167）。 26 State of the world’s nursing 2020　世界の看護 2020 専門能力開発と組織内での調整にとって有益な場 合がある。看護職が、退職によって組織内または 保健システム内でのキャリアアップを目指す場合 などである（223）。一方、退職と離職はほとんど の場合組織のコストを伴い、患者のケアに悪影響 を及ぼす可能性がある。 61. ある仕事を辞める、またはとどまるという看護職 の意思には、組織的要因と個人的要因の両方が 影響する。個人的要因には、本人や家族の生活 や健康状態の変化、自身の進学など教育上の目 標、仕事のストレスや不満、あるいは逆に意思決 定における自信などがある（224、225）。定着に 影響を与える組織的要因には、労働環境、職場 の人間関係、労働条件、給与、管理スタイルや 適切な卒後教育・指導などがある（226）。オース トラリア、エジプト、イラン・イスラム共和国、ヨ ルダン、フィリピンを対象とする研究では、臨床 管理者のリーダーシップスタイルと組織文化が看 護職の仕事の満足度と離職率に直接影響し、病院 （227–229）と地域（219、220）の両方で看護の 質に影響を与えることが明らかになっている。 働きがいのある人間らしい仕事 62. ILO によると、働きがいのある人間らしい仕事に は「生産的で、公平な収入を生み、職場の安全 と家族の社会的保護、個人の発達と社会的統合 のより良い見通し、自らの懸念を表明し、団結し、 自らの人生に影響を与える決定に参加する自由、 すべての男女の機会と待遇の平等性が伴う」（230）。 看護職に関連する働きがいのある人間らしい仕事 に向けた典型的な課題には、ジェンダー問題、攻 撃を受けるリスク、過度の労働時間、移民看護職 の不当な扱いなどがある。 63. 女性看護職は、保健人材の他の女性とともに、 男性の同僚よりも多く職場での障壁に直面してい る（21、231）。ここには、ケアにおける女性の役 割の偏った認識、社会的ジェンダー規範、ジェン ダーバイアス、ステレオタイプなどが含まれ、こ れらはすべて、看護職が良好な労働条件を獲得 し、公正な賃金と平等な待遇を受け、意思決定 に参加し、ヘルスケアのリーダーになるための手 腕を損なう（21、22、122）。2019 年 WHO の 報告書「女性が提供し、男性が主導する」によ り、女性が過半数を占める仕事では格差が大きく なるケースが多いことが明らかになった。ある状 況では、看護職の 36% が上司から敬意を払われ Box 4.5 高所得国の看護職に対する経済的需要の例 人口・疫学・保健政策の変化は、高所得国における看護職への需要の高まりを示している。例は次のと おりである。 • 英国の保健財団の推計によると、2024 年まで毎年少なくとも 5,000 人の看護職を国外から集める必要 がある（171）。 • 日本では、最大 245,000 人の外国人労働者を誘致するための新しいビザプログラムが制定され、そこ には 6 万人の看護・福祉関係者が含まれている（172）。 • ドイツ政府は、高齢者や病気のケアで約 36,000 人の不足を報告しており（173）、国外から採用する 必要があると述べている（174）。 27看護人材を支援する政策 ていないと答え、看護職の 32% が自分の意見に 耳を傾けてほしいと答えている（21）。これらの障 壁は、女性の保健医療従事者の幸福と生計を脅 かし、ジェンダー平等の進展を制限する（21）。制 度的支援と看護職への敬意がケアの質を向上さ せることから、ジェンダー差別もまたケアに直接 影響を与える（232）。職場でのセクシャルハラス メントは、看護師（25%）（233）および助産師（37%） （21）を含む保健人材全体において、女性が直面 する問題である。 64. 一部の状況では、看護職と保健医療従事者が攻 撃の危険にさらされている。2019 年 1月1日か ら 2020 年 1月 1日までの間に、WHO は保健 医療従事者への攻撃監視システムを通じて、保健 医療従事者に対する攻撃を1,005 件記録してお り、この結果、複雑な緊急事態に直面する11カ 国で、保健医療従事者と患者に198 人の死者と 626 人の負傷者が出ている（234）。 65. 保健サービスの提供には、患者への昼夜を問わ ない対応が求められる。その結果、長く不規則な 勤務時間に関連する課題がもたらされ、看護職 自身（心身疲労など）と患者（医療ミスの増加など） に悪影響が及ぶ可能性がある（235）。1977 年の ILO 看護職員条約（第 149 号）は、批准国に対し、 看護職が他の労働者と同等の労働時間を享受し、 残業、不都合な勤務時間、シフト勤務を規制し、 補償するよう求めている。 66. 移民看護職もまた、働きがいのある人間らしい仕 事としての労働条件を得られないという、特有の リスクにさらされている。移民や少数民族の看護 職は、移民先国のまたは多数民族の看護職と比 べ、労働関連の負傷や差別のリスクが高い（236）。 報告によると、差別は、移民看護職と少数民族 看護職の健康障害の主原因である（236）。しかし、 自国での働きがいのある人間らしい仕事の欠如も また、看護職の移住を促すプッシュ要因になって いる（237–240）。 Box 4.6 ポーランドでの看護職の処方によるアクセス拡大 ポーランドの保健における国家的優先事項の 1 つは、コミュニティレベルの慢性疾患の管理を改善し、 プライマリ・ヘルスケアの場での治療と薬へのアクセスを向上することであった。看護教育と規制メカ ニズムに関する政策決定により、保健システムにおける看護職の機能が効果的に拡大され、患者の保健 サービスへのアクセスが向上した（205）。 2016 年、特定の資格を持つ看護職は、特定の条件下で薬を処方する権限を与えられた。 看護学校の 卒業生がこの役割を果たせるようにするために、すべての看護師・助産師基礎教育課程に薬の処方が組 み込まれ、法令によって、看護学士号を取得して卒業したすべての看護職が、所定の薬物リストを処方 することが許可された（206）。これと並行して、看護師と助産師の養成に関する新たな国家戦略によっ て、看護職のさまざまな役割と専門的能力および改善された労働条件に関する組織基準が導入された。 2016 年以降、10,287 名の看護師と 4,799 名の助産師が研修を修了し、処方ができるようになった。 2018 年 12 月までに、看護師と助産師は独自に 2,538 件の処方箋を発行し、363, 288 件の過去の処 方の継続を承認した。 28 State of the world’s nursing 2020　世界の看護 2020 4.4 法規 67. 法規は、行動基準、教育基準、実践基準を設定 し施行することで、国民を保護する役割を果たす。 また、保健医療提供者に利益をもたらし、公共 部門と民間部門全域にわたって、看護教育（241、 242）と看護実践の質を向上させることができ る。規制当局もまた、保健人材のデータとエビデ ンスを数多く生み出している（243）。過去 15 年 間で、複数の分野で法規に関する研究エビデンス が著しく増加しており、中でも看護分野が最も多 い（244、245）。 68. 教育法規には、看護教育に関する国家基準の設 定、看護規制当局による看護教育および研修プ ログラムの承認、外部機関による教育機関の認 証が含まれる。教育機関を基準に照らして評価 する認証は、教育機関にとって、集団に提供する 保健サービスの質、公平性、適切性、および有 効性を高められる卒業生を生み出すためのインセ ンティブとなる（246）。ただし、基準と認証のサ イクルは、保健科学とケア提供モデルの変化に遅 れず、かつ施設にとって妥当で中立的でなくては ならない。規制が執行されるのは、プログラムの 欠陥を修正する際、または極端だがやむを得ない 措置として、水準を満たせないプログラムを中止 させる際である。2013 年に実施されたサハラ以 南アフリカ17 カ国の調査では、看護教育の認証 には強力な法的権限があるものの、同地域の看 護職の大半を生み出したプログラムは認証のレベ ルが低く、公的プログラムのほうが民間のプログ ラムより認証レベルの高いことが明らかになった （247）。一部のケースでは、認定者に利益相反 があるとして、民間部門が認証の結果に異議を唱 え、その結果政府は、規制当局の構成員を変更し、 一般人の参加を増やしている（248）。 Box 4.7 アフリカ地域における看護職の例 アフリカの東部と南部では、小児の死亡率を下げる戦略の一環として、小児専門の看護職の役割に投資 する政府が増えている。小児専門看護職とは、専門的な教育を受け、小児科専門・小児保健担当看護職 として、さらなる認定資格を得た看護職のことである。 最も一般的なルートは、看護基礎教育卒業後、12 カ月の大学院相当の小児看護学専門コースを修了する、 というものである。この結果得られる職名と資格は国によって異なる。一般的には、登録小児看護スペ シャリスト、小児看護専門職などがある。 この地域には、小児専門として登録された看護職が約 3,650 人おり、ケニア、マラウイ、ウガンダ、 ザンビアで約 750 人、南アフリカで 2,900 人となっている（216）。12 の教育プログラム（大半は南 アフリカ）から、毎年約 205 人の小児専門看護職が卒業している。さらに 3 つのプログラム（ボツワナ、 タンザニア連合共和国、ジンバブエ）が設置準備中である（216）。 現在この地域の国々の情報システムにおいて、看護職の専門知識による分類が整備されているものはわ ずかである。「小児看護人材概況」では、この地域の小児の特別な保健医療ニーズを満たすスキルミッ クスの最適化に向けた国家計画を支援している。2015 年以降、研究者、看護教育者、その他のステー クホルダーが協力して、東部・南部アフリカにおける小児専門看護人材の役割を把握し、報告している。 29看護人材を支援する政策 69. 認証は、教育プログラムの種類によって国ごとに 異なる場合がある（249）。一部の国では政府機 関が公立大学を設立・監督しており、認証を受け る必要があるのは民間機関のみである。また別の 国では、政府の指示がなければ、民間機関は一 切認証を受ける必要がない。認証は、法律によっ て直接義務づけられるか、あるいは、看護職能 団体からの承認を得た、または適切な組織の認 証を受けたプログラムを卒業した者が、協会に登 録を申請したり資格試験を受験したりすることで、 間接的に義務づけられる。 70. ほとんどの看護教育基準で、プログラムの整合性 と範囲を確保するために、最低限の臨地実習時間 とコンピテンシーを規定している。多くの場合、看 護教育の基準は個々の法域（特定の一連の法律ま たは規則を遵守する必要がある国、州、またはそ の他の地域）に固有のものであり、看護基礎教育 課程卒業生の可動性に影響を及ぼす可能性があ る。相互承認協定と教育要件の統一により、看護 実践者の標準化と、安全かつ効率的な移動性が 向上している。例としては、米国の看護職資格協 定（250、251）、カリブ諸国の看護職登録の地域 共通試験（252）、欧州連合の職業資格指令（253、 254）、東南アジア諸国連合の協定（255）、トラン ス・タスマン協定（256）などがある。Box4.9 は、 教育基準と資格試験の統一の例を示す。 71. 個々の看護職に関する職業規制には次のものが含 まれる。（a）「看護職」の職名の取得（登録また は登録と資格付与）の要件設定。資格試験を含 む場合もあり。（b）復職、再登録または資格再 取得の要件。継続的な専門性開発の要件を含む 場合もあり。（c）看護職の業務範囲、行動規範 および倫理規定の設定。（d）看護職の取り調べ および懲戒処分の容易化（259）。また規制当局は、 現役の看護人材の最新の登録状況を更新し続ける 義務と責任を負うようになってきている。 72. 60% を超える国が、看護基礎教育機関の卒業 生が実践に入るための資格を与える前に、最低 限の初期知識または「実践適性」を評価し強化 するため、資格試験を活用している（29）。初期 の実施適性のひとつの評価法は客観的臨床能力 試験（OSCE）で、これは臨床環境を再現した場 で能力を直接観察しようとするものである。ただ し、その実施には費用と手間がかかる場合があ る（260-262）。実践適性の試験を、免許再申請、 看護職への復職、国外で教育を受けた看護職に 実施すべきかどうかについては議論がある。 Box 4.8 へき地での定着のガイドライン 世界中の多くの国々で、へき地での看護スタッフの募集、採用、定着への懸念が高まっている。2010 年、 WHO は、定着の改善を通じた「へき地における保健医療従事者へのアクセス向上に関する世界的な政策 提言」を作成した（217）4 。 提言では、教育、規制、奨励金、個人的・職業的サポートの 4 つの主な介入分野がカバーされている。へ き地での看護にフォーカスした研究は、増えてはいるもののまだ非常に限定的である。このエビデンスは主 に高所得国（特にオーストラリア、カナダ、米国）から得られたものではあるが、奨励金、個人的・職業的サポー ト、保健キャリアパスの加速が、へき地の看護職の定着に影響することが示されている。 4.　このガイドラインは現在更新作業中。 30 State of the world’s nursing 2020　世界の看護 2020 Box 4.9 教育基準と資格試験の統一の事例 1972 年、カリブ共同体の国と地域は「地域看護機関」を設立し、その最初の業務として、教員資格者の共 有プールを作り、看護基礎教育機関卒業生のコンピテンシーを評価する際の障壁を軽減した（252）。分析の 結果、看護教育のカリキュラムの目的、内容、および教育方法がこの地域全域で類似していることが示され、 各国は看護職のための単一共通試験を行うことに同意し、1990 年から開始した。地域看護機関は試験の調 整を行い、試験は相互に合意されたコンピテンシーに基づくものとし、管理運営は、各国の看護行政の責任者、 臨床指導者、看護職能団体、この地域の大学の教育者が共に担当する（257）。この試験により、看護教育の 標準化と改善、この地域内での看護職の相互認証と容易な移動が可能となる。 欧州連合では、多様で複雑な看護教育の構造と教育課程を統一する取り組みが、1970 年代後半の看護分野 の通達によって開始され、2005 年の改正（通達 36）とそれに続く更新による一連のコンピテンシー基準の 導入で加速した（通達 55）（253、254）。これらの変更にボローニャ宣言（1999 年）が加わることで、学士号、 修士号、博士号の 3 サイクルの教育構造がもたらされ、すべての分野にわたって統一された学位が提供され るようになった（258）。 31看護人材を支援する政策 © WHO/Sergey Volkov 32 State of the world’s nursing 2020　世界の看護 2020 73. この章では、WHO 史上初めて、一連の標準指標 と統一されたデータ報告プロセスに基づく190 カ 国以上の看護労働力に関するデータを、「国家保 健人材統計」アプローチに従って報告する。 74. データは、看護労働力 5 の供給力、構成、配置、 教育と実習、スキル、管理、法規、財政、リーダー シップについて、合計 30 を超える指標のデータ が収集・分析された。データ収集の取り組みには、 保健・労働・教育などの省庁、保健人材管理部 門、国の公衆衛生機関、看護職能団体、政府の 看護・助産行政責任者、ならびにその他の国、地域、 国際的組織など、様々なステークホルダーが参加 した。データ収集は、データの定義と報告のため の統一されたシステムである国家保健人材統計プ ラットフォームを通じて行われ、同プラットフォー ムは加盟国が保健データのために自国の人的資源 を報告、モニタリング、使用するオンラインデータ 管理としての機能を持つ。詳細な方法は、付属文 書 2 に示す。 看護労働力に関する エビデンスとデータの現状 5CHAPTER 75. 分析の重点は現在の看護労働力に置かれている が、この章の最後では、「WHO 保健人材に関す る世界戦略：労働力 2030」で概説されている目 標に向けた進捗状況を評価するため、さまざまな 仮定のもとで想定される看護労働力の将来のシナ リオを、2030 年の持続可能な開発目標（SDGs） とユニバーサル・ヘルス・カッバレッジのアジェン ダとの関連において検討する（16）。 76. 看護職のストックについては、かつてない数の国 が報告しており、これまでまとめられた看護労働 力に関するデータセットの中で最も包括的かつ最 新のものとなった（図 5.1）。2020 年が国際看護・ 助産年に指定されたことのおかげで、特に 2013 ～ 2018 年の期間についての看護師に関する情報 は他の職業と比べ増加した。近年、保健人材のス トックに関するデータは、情報量だけでなく、報 告の適時性においても向上しており、過半数の国 が、SDGs の指標 3.c.1に含まれる 5 つの職業（医 師、看護師、助産師、歯科医、薬剤師）に関す 5.　看護人材については、ILO の定義を用いた。付属文書 1 を参照のこと。 33看護労働力に関するエビデンスとデータの現状 る過去 5 年以内のデータを報告している。実際 のデータと過去に遡ったデータが入手できたため、 以前の推定値を遡及的に更新することができ、以 前の分析と報告のデータ上の制限への対処が可能 となった。 77. 本報告書で使用した看護労働力に関する 36 の指 標（付属文書 2 の表 A2.1を参照）のうち、ほぼ すべての WHO 加盟国は、看護職のストックおよ びその他の主要指標（年齢分布、ジェンダー構成、 研修の期間）の大半について、報告した。回答国 の約 80% が少なくとも15 の指標のデータを提供 し、23% が少なくとも 25 の指標のデータを提供 した。この章では、加盟国による回答率の高かっ た一部の指標について報告する（全指標の一覧は 付属文書 2 に示す）。 歯科医のデータのある国 看護師・助産師のデータのある国 薬剤師のデータがある国 医師のデータがある国 160 140 120 100 80 60 40 20 0 191カ国中2017・2018年の データのある国は83% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 ??? 注：（a）過去5年間に関しては、191カ国の看護職のストックのデータが収集された。最新のデータポイントは異なる年を参照している可能性がある。大半の国（83%） は2017年または2018年の人数データを提供している。（b）データの入手可能性と報告のラグタイムが、近年の明らかな減少傾向の説明となる。2014～2018年に ついてはより多くのデータポイントが入手可能になるものと予想され、看護職のストックデータは増加傾向にある。 出典：国家保健人材統計 2019年 WHO 国家保健人材統計で労働力データが得られる国の数（1990–2018年） 図 5.1 34 State of the world’s nursing 2020　世界の看護 2020 5.1 看護労働力の供給、構成、配置 5.1.2　世界と地域の看護職のストック 78. 191カ国のデータが示すところによると、世界に は、公的部門と民間部門の両方で、約 2,800 万 人の看護職が存在する（表 5.1）。これにより、世 界の看護職密度は人口 1万人あたり36.9 人とな る。ただし、この世界の数字には、地域内・地域 間の大きな差が隠れている 6。 79. アメリカ地域とアフリカ地域は人口が同程度であ るが、アメリカ地域の看護職数はアフリカ地域の 約 10 倍で、人口 1万人あたりの看護職数はそれ ぞれ 83.4 人と 8.7人である。東地中海地域と南・ 東アジア地域は看護職密度が 2 番目と 3 番目に 低い（それぞれ人口1万人あたり15.6人と16.5人） が、それでもアフリカ地域の密度の約 2 倍である。 80. 世界の看護職の約 81% が 3 つの地域（アメリカ、 ヨーロッパ、西太平洋）で働いており、これらの 地域の人口の合計は世界の人口の 51% となる。 81. この 2018 年の 2,790 万人という看護職総数の推 計値と、2013 年のデータを使用して看護職と助 産師 2,070 万人（うち1,880 万人が看護職）と 算出した「保健人材に関する世界戦略」の推計値 の比較には、慎重な解釈が求められる。2013 年 から 2018 年の看護職数増加は、部分的にはデー タ供給の向上（看護職 440 万人分）によるもの であり、実際の増加数は 470 万人と推定され（表 5.2）、看護職および准（準）看護職の割合が一定 であると仮定すると、そのうち 360 万人が看護職 である（図 5.2）。 5.1.1　主な調査結果 191カ国のデータによると、2018年の世界の看護師のストックは約2,800万人で、その大半（69%）が看護 の専門職である。 データの入手可能性と質の向上を考慮しても、2013年から2018年の間に世界の看護師の実数は470万人 増加した。 看護師および准（準）看護師は、データの得られた172カ国の保健医療専門職（医師、看護師、助産師、歯 科医、薬剤師）の約59%を占める。 世界の看護職の10人のうち9人は女性であり、地域によって大きな違いが見られる。アフリカ地域では、女 性と男性の比率は3：1である。13カ国で男性看護職は女性看護職の数を上回っている。 地域内の配置にも大きな差が見られる。アメリカ地域では、看護師10人中8人以上が3カ国（ブラジル、カ ナダ、米国）で働いており、この3カ国は地域の人口の57%を占める。アフリカ地域および東地中海地域で は、各国の人口あたりの看護職密度には100倍の差が見られる。 世界の看護職の6人に1人は、今後10年で退職することが予想される。この割合はアメリカ地域で非常に高 く（24%）、さらなる補充が課題である。 6.　公平性については、5.2 を参照のこと。 35看護労働力に関するエビデンスとデータの現状 WHO地域 人数を回答した 国の数／全体数 看護職a数 （100万人）（%） 人口1万人あたりの 密度 アフリカ 44/47 0.9 (3%) 8.7 アメリカ 35/35 8.4 (30%) 83.4 南・東アジア 11/11 3.3 (12%) 16.5 ヨーロッパ 53/53 7.3 (26%) 79.3 東地中海 21/21 1.1 (4%) 15.6 西太平洋 27/27 6.9 (25%) 36.0 世界全体 191/194 27.9 (100%) 36.9 a 看護師および准（準）看護師を含む。 注：カメル ンー、コモロ、南スーダンの看護職のストックデータは入手できず。 出典：国家保健人材統計 2019年。2013年から2018年の間に各国によって報告された最新の入手可能な密度。2013年から2017年までの間に人数が 報告された国については、すべての国の基準を2018年とするため、最新の入手可能な密度を2018年の人口に適用して人数を報告した。 密度の算出に使用した各国・各年の人口は、国連経済社会局の「世界人口推計」の2019年改訂版（263）から抽出した。 2018年の世界の看護職数と人口1万人あたりの密度（WHO地域別）表 5.1 看護職数（2013年） 看護職数（2018年） 看護職数の 実増による 変動 （百万人）データソース 2009- 2013年の データの ある国の数 ストック数 （百万人） 2013- 2018年の データの ある国の数 ストック数 （百万人） 「保健人材に関する世界戦略」の推計、 2016 年 102 18.8a 「世界の看護 2020」の推計 174 23.2 191 27.9 4.7 データの改善による変動 （百万人） 4.4 a 元の出版物では助産師が含まれており、看護師と助産師が2,070万人としている。割合に合わせて補正すると、看護師は1,880万人となる。 出典：国家保健人材統計2019年 2013年から2018年のデータ改善と実際の増加による看護職数の変動表 5.2 36 State of the world’s nursing 2020　世界の看護 2020 82. したがって、2018 年の看護職ストックの総数とし て報告された 2,790 万人という数は、2 つの肯定 的傾向を明確に示している。 • 看護労働力データの供給の向上。これによっ て、以前の分析をより適切に解釈・再評価 できる。 • 世界の看護職数の実際の増加。この職業グ ル プーに対する労働市場の需要の高まりと、 加盟国による投資を反映するもの。 83. 看護職数を、データが得られる172 カ国の医師、 助産師、歯科医、薬剤師数の合計と比較すると、 保健医療専門職のうち看護職の占める割合は平 均 59% であり、東地中海地域の 49% から西太 平洋地域の 68% まで幅がある（表 5.3）。 WHO地域 SDG 3.c.1が示す保健医療専門職数に対する看護職数a 報告国数／全体数 看護職の割合の平均 アフリカ 45/47 66% アメリカ 24/35 56% 南・東アジア 11/11 53% ヨーロッパ 50/53 57% 東地中海 20/21 49% 西太平洋 22/27 68% 世界全体 172/194 59% a 看護師および准（準）看護師を含む。 注：SDG 3.c.1とは、SDGsターゲット3.cの進捗状況の評価に使用される指標である。 出典：国家保健人材統計 2019年 保健医療専門職（医師、看護師、助産師、歯科医、薬剤師）における看護職の割合（WHO地域別）表 5.3 84. 66 カ国が最低 10 の職業について近年の保健人 材数を報告することができた。データを入手でき たこれらの全保健医療従事者と比較して看護職を 検討すると、看護職が保健人材の 40 ～ 50% を 占めていることが分かる。 5.1.3　構成 85. 世界の 2,790 万人の看護職のうち、1,930 万人 （69%）は看護師（ISCO コード 2221）、600 万人 （22%）は准（準）看護師（ISCO コード 3221）に 分類される。260 万人（9%）はどちらにも分類さ れず、国のデータシステムと ISCO システムの間の 統一性に関する潜在的課題が示される。ここでい う看護職は看護師および准（準）看護師であり、こ の分類には看護助手やヘルスケアアシスタントは含 まれない。図 5.2 に示すとおり、さまざまな分類 の看護職の相対的割合は、地域によって大幅に異 なる。 37看護労働力に関するエビデンスとデータの現状 5.1.4　看護職の人口統計：性別と年齢の分布 性別分布 86. 保健人材戦略におけるジェンダー主流化は、保健 人材の計画と管理において、エビデンスに基づく ジェンダーに配慮したアプローチが確実に取られ るようにするために必要である。看護職の男女構 成と高齢化の側面は、国の計画や地域・世界での 比較のための質の高いデータの欠如など、さまざ まな理由から長い間見過ごされてきた。WHO 加 盟国 194 カ国のうち、132 カ国が性別ごとのデー タを提供し、106 カ国が年齢に関するデータを提 供した。この132 カ国では、看護職 10 人のうち 約 9 人（89%）が女性であり、地域ごとに大きな 差が見られる。看護職における女性の割合が最も 高いのが西太平洋地域（95%）であり、最も低い のがアフリカ地域（76%）である。13 カ国が、女 性看護職よりも男性看護職の方が多いと報告して いる（表 5.4）。 年齢分布 87. 87. 人口と労働力の高齢化は世界的に見られる傾 向であることから、予測においては労働力の年齢 構成を考慮する必要がある。多くの国で、計画立 案者は標準的な退職年齢をもとにしているが、実 際の退職年齢は職業、性別、職位によって異なる ため、このアプローチには限界がある。106 カ国 から得られた年齢プロファイルのデータを利用し、 看護職統計の現在の傾向を示した。全体としては、 入手できた情報は看護労働力が比較的若いことを 示している。看護職の 38% が 35 歳未満 7 であ るのに対し、55 歳以上の看護職は17% である（後 者のグル プーは、今後10 年以内に退職すると考 えられる）（図 5.3）。ただし、地域的な違いが重 要である。東地中海地域では、若手看護職 14 人 に対し退職が近い看護職 1人の割合となっている が、対照的にアメリカ地域ではこの比率は1.2：1、 ヨーロッパ地域とアフリカ地域では1.9：1となっ ており、代替プールがはるかに小さいことを示して いる。 アフリカ アメリカ 南・東アジア ヨーロッパ 東地中海 西太平洋 世界全体 全看護職数に占める割合 看護師　　　　准（準）看護師　　　　定義のない看護職WHO地域 0% 20% 40% 60% 80% 100% 各職業グループにおける看護職の割合（WHO地域別）図 5.2 7.　若手看護職と呼ばれる。 38 State of the world’s nursing 2020　世界の看護 2020 WHO地域 報告国数／全体数 女性の割合 男性の割合 アフリカ 30/47 76% 24% アメリカ 26/35 87% 13% 南・東アジア 9/11 89% 11% ヨーロッパ 32/53 89% 11% 東地中海 11/21 78% 22% 西太平洋 24/27 95% 5% 世界全体 132/194 89% 11% 注：「看護職」には、看護師および准（準）看護師を含む。 出典：国家保健人材統計2019年。2013年から2018年の間に国によって報告された最新の入手可能な人数。 女性看護職の割合（WHO地域別）表 5.4 アフリカ (n=20) アメリカ (n=25) 南・東アジア (n=8) ヨーロッパ (n=30) 東地中海 (n=5) 西太平洋 (n=18) 35歳未満 55歳以上 0% 20% 40%80% 60% 40% 20% WHO地域 世界全体 (n=106) 注：「看護職」には、看護師および准（準）看護師を含む。 35歳未満および55歳以上の看護職の割合（WHO地域別） 図 5.3 39看護労働力に関するエビデンスとデータの現状 88. 世界の看護職の17% が 55 歳以上であり、今後 10 年以内に退職することが予想されるため、現 状維持のみを目的としても、今後10 年間で 470 万人の新しい看護職を養成し、雇用する必要があ る。人口増加のペ スーに合わせて看護人材不足を なくすためには、さらに多くの人数が必要となる（セ クション 5.8 を参照）。 89. 看護人材の高齢化を説明するため、若手看護職 と年長看護職の比率を図 5.4 に示した。若手看 護職の割合が高い国もあれば、何とかバランスの 取れている国もあり（図 5.4 の緑色の線で示すと おり、35 歳未満と 55 歳以上の看護職の割合が ほぼ等しい）、18 か国（データが入手できた国の 6 カ国に1カ国）では退職が近い看護職より若 手の看護職が少ないという看護人材の高齢化が 見られ、特に困難な状況に直面している。 注：「看護人材」には、年齢ごとのデータを提供した106カ国の看護師および准（準）看護師を含む。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能な人数。 70% 60% 50% 40% 30% 20% 10% 0% 60%0% 10% 20% 30% 40% 50% 70% 18カ国が 看護人材高齢化のリスクあり 各点は１つの国を表す/緑色の線は、退職の近い看護職の数と若手看護職の数が等しい位置を示す。 55?????????? 35歳未満の看護職の割合 図 5.4 55歳以上と35歳未満の看護職の相対比率 40 State of the world’s nursing 2020　世界の看護 2020 5.2 看護労働力の供給とアクセスの公平性 5.2.1　主な調査結果 世界の看護職の約 81% がアメリカ、ヨーロッパ、西太平洋地域に見られ、この地域は世界の人口の 51% を占める。 看護職密度が低い国が主に見られるのは、アフリカ、南・東アジア、東地中海地域、および中南米の一部 である。 世界で見られる看護職の供給の不均衡は、主に所得を要因としており、低所得国では人口1万人あたりの 看護職数が 9.1人であるのに対し、高所得国では人口1万あたり107.7人である。 各国内にも大きな差があり、都市と地方の地域ごとのデータが得られた 35 カ国では、看護職の 36% が 地方に配置されているが、地方の人口は全体の 49% を占める。データが得られた 76 カ国では、看護職 の75% が公的セクターで雇用されており、残る 25% が民間セクターで雇用されている。 90. ユニバーサル・ヘルス・カバレッジを実現するに は、保健人材の供給とアクセスにおける人口動態 的、地理的およびスキル格差への対処が求められる。 5.2.2　地域間の公平性 91. 図 5.5 は、人口1万人あたりの看護職密度の世界 的な差を示しており、アフリカ、南・東アジア、東 地中海地域と、中南米の一部に密度の低い国や 地域が集中している。 5.2.3　地域内の公平性 92. 図 5.6 は、各地域内での看護職密度の違いを示 しており、各点は一つの国を表す。すべての地域 で看護職密度に大きな差が見られるが、差が最も 大きいのは、最高密度と最低密度の比率が 12 対 1である東地中海地域と、100 対 1となっている アフリカ地域である。またアメリカ地域では、少 数の大国で看護職密度が高い一方、その他大半 の国では比較的低密度となっている。この地域の 看護職の 87% はブラジル、カナダ、米国におり、 これらの国は人口の約 57% を占める。10 対1と 密度の差が小さいのがヨーロッパ地域である。ア フリカ地域の国々では、人口 1万人あたりの看護 職密度が 25 人を超える国はわずかである。同様 のパタ ンーは南・東アジアと東地中海地域でも見 られる。密度の差は主に所得水準に左右され、低 所得国では人口1万人あたりの看護職数が 9.1人 であるのに対し、高所得国では人口 1万人あたり 107.7人である（表 5.5 および図 5.7）。 93. 2018 年 12 月時点で国連開発政策委員会により 後発開発途上国として分類された 46 カ国につい て見ると、人口 1万人あたりの看護職密度は 6.4 人であり、他のすべての国の平均の 6 分の１で、 低所得国の平均と比べても大幅に低くなっている。 これらの国の大多数はまた、脆弱国家指数8によっ て脆弱（「強い警告」または「警告」カテゴリー） とも見なされている。ボックス 5.1で、国内の公 平性に関するさらなる情報を紹介する。 8.　脆弱国家指標が 80 以上の国々。 41看護労働力に関するエビデンスとデータの現状 図 5.5 2018年の人口1万人あたりの看護職密度 *「看護職」には看護師と准（準）看護師を含む。 出典：国家保健人材統計 2019年。2013～2018年の最新の入手可能なデータ。 回答なし該当なし 0 1,000 2,000 3,000 4,000500 km 10未満 10～19 20～29 30～39 40～49 50～74 75～99 100以上 0 50 100 150 200 最大密度：最小密度 100:1 22:1 18:1 10:1 12:1 33:1 WHO地域 アフリカ 東地中海ヨーロッパアメリカ 南・東アジア 西太平洋 ????????????? 注：「看護職」には、看護師および准（準）看護師を含む。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能な人数。 図 5.6 人口1万人あたりの看護職密度の地域ごとの格差（2018年） 42 State of the world’s nursing 2020　世界の看護 2020 所得のレベル 低所得 低中所得 高中所得 高所得 0 50 100 150 200 ????????????? 注：「看護職」には、看護師および准（準）看護師を含む。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能な人数。所得グル プーは、2018年の世界銀行の分 類による。 図 5.7 人口1万人あたりの看護職密度（所得グループ別）（2018年） 所得グループ 報告国数／ 全体数 人口１万人あたりの密度 最高：最低全体 低 高 低所得 30/31 9.1 0.6 42.0 68:1 低中所得 44/46 16.7 1.8 104.6 57:1 高中所得 60/60 35.6 5.0 124.2 25:1 高所得 57/57 107.7 19.4 196.1 10:1 世界全体 191/194 36.9 0.6 196.1 319:1 注：「看護職」には、看護師および准（準）看護師を含む。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能な人数。 クック諸島とニウエについては、所得グル プーの分類は入手不能。したがって、同地域の他の国と同じ高中所得国に分類した。 所得グル プーは、2018年の 世界銀行の分類による。 所得グループごとの看護職密度（2018年）表 5.5 43看護労働力に関するエビデンスとデータの現状 Box 5.1 国内での公平性 へき地における看護職の供給 国内での看護人材の配置は、アクセスの公平性の関連でも同様に重要である。合計 35 カ国（主に中南米と アフリカ）9 が、へき地の看護人材の割合に関するデータを提供した。これらの国では平均約 36% の看護職 がへき地で働いており、これに対しへき地では人口の 50% が暮らしている。 公的セクターと民間セクターの看護職の供給 国内における不均衡のもう1つの潜在的原因は、公的セクターと民間セクターの配分である。データを提供し た76 カ国で、平均 75% の看護職が公的セクターで働いており、地域間のばらつきは比較的少ない。 所得グループ 報告国数／全体数 外国で生まれた、または 訓練を受けた看護職の割合 低所得 3/31 NR 低中所得 18/46 0.4% 高中所得 27/60 0.7% 高所得 38/57 15.2% 全体 86/194 13.2% 注：「看護職」には、看護師および准（準）看護師を含む。外国出身者の割合に関するデータを提供できなかった30カ国に関しては、「外国で教育を受けた」 人数を代用値として使用した。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能な看護師数。所得グル プーは、2018年の世界銀行 の分類による。 NR＝国数が少ないため報告なし。 外国出身（または外国で教育を受けた）看護職の割合（所得グループ別） 表 5.6 © Ian Miles-Flashpoint Pictures/Alamy 9.　アンティグア・バ ブーーダ、ベリ ズー、ブラジル、ブルネイ、カンボジア、エクアドル、エジプト、エルサルバドル、エスワティニ、ガンビア、ガーナ、ギニアビサウ、ガイアナ、ホンジュ ラス、アイスランド、ケニア、ラオス、マダガスカル、マーシャル諸島、モンゴル、ミャンマー、パキスタン、パラグアイ、ペルー、サモア、セルビア、シエラレオネ、スリランカ、タ ジキスタン、タイ、東ティモール、ウガンダ、タンザニア、ウルグアイ、ベネズエラ、（ボリビア） 44 State of the world’s nursing 2020　世界の看護 2020 5.3.2 看護職の国際移動の定量化における課 題 94. 人口政策、疫学政策、財政政策および保健政策 の動向によって、ここ数十年で保健医療従事者 の国際的移動が促進されており、今後も増加す ることが予想される（18）。2010 年に世界保健 総会で採択された「保健人材の国際採用に関する WHO 世界実施規範」は、保健医療従事者の国 際的移動の倫理的な管理を強化するための、重要 な国際的規範である。 95. 所得の低い国から高い国への保健医療従事者の 移動、およびそれに付随する課題については、長 年認識され、議論されてきた。しかしながら、政 策決定に情報を提供するためのデータは、主に一 部の高所得国に限定されている。近年のデータ供 給の改善、特に国家保健人材統計のシステムによ る改善によって、移住元国と移住先国の違いは従 来考えられていたような明確なものではないこと が示されている。 96. 2018 年の時点で、合計 86 カ国が、国家保健人 材統計および OECD、ユーロスタット、WHO ヨー ロッパ地域事務局の報告システムを通じて、移住 現象の規模の代用指標として、外国出身または外 国で教育を受けた看護職の割合のデータを提供し ている（表 5.6）。報告国においては、看護職の 8 人に1人（13%）が、現在看護を実践している国 以外出身または外国で教育を受けている。この割 合を看護職数に当てはめると、世界全体では、外 国出身または外国で教育を受けた看護職が 370 万人いるものと推計される。 外国出身または外国 で教育を受けた看護職は、主に高所得国で見ら れ、その割合が 15.2% であるのに対し、その他 の所得グル プーの国では 2% 未満となっている。 5.3.1 主な調査結果 86 カ国からのデータに基づくと、看護職 8 人のうち1人（13%）が、現在看護を実践している国以外の出 身、または教育を受けている。 回答国の中で見ると、高所得国では外国出身の看護職に大きく依存しており、看護職の15.2% が外国出 身または外国で教育を受けたと報告している。 移住と可動性に関するデータは、供給が向上したものの、複雑な移住パタ ンーを包括的に評価するには依 然として不十分である。 5.3 看護職の国際的な移動 45看護労働力に関するエビデンスとデータの現状 5.4.2 結果分析 97. 「WHO 保 健 人材に関する世界 戦 略：労 働力 2030」には、2020 年に向けたマイルスト ンーが 含まれ、各国は保健人材の教育のための法規と認 証のメカニズムを整えるべきであると述べられて いる。このセクションでは、看護職の教育・実習 の法規に関して報告された 9 つの指標についてま とめる（図 5.8）。 98. 大多数の国は、看護教育の期間と内容の基準、 教育機関の認証メカニズム、および適格性が認定 された教育機関のマスターリストがあると報告して いる（それぞれ回答国の 91%、89%、81%）。回 答国の 77% が教員資格の基準があると報告し、 73% が継続的な専門能力開発システムがあると 報告している。回答国の約 3 分の 2 は、多職種 連携教育の基準、実践適性の試験、および資格 取得前の学生のための全国組織（それぞれ 67%、 64%、62%）を備えていた。回答した 95 カ国の うち、53% が高度な看護実践の役割があると報 告した。ただし、これらの規制プロセスや規制シ ステムが存在しても、それらが適切に機能してい るとは限らない。 99. 表 5.7 は、WHO の各地域における教育と実習に 関する規制メカニズムとシステムの存在に関する データを示している。教育規制は、アフリカ、ア メリカ、ヨーロッパ地域の国々において、他の地 域の国々よりも多数報告されている。東地中海地 域の国は、実践適性の試験と高度な看護実践の 役割が他の地域に比べ多いと報告している。南・ 東アジア地域では、他の地域の国よりも、継続的 な専門能力開発システム、資格取得前の学生のた めの全国組織、多職種連携教育の基準があると 報告した国が少なかった。こうした地域的な差に は、指標の解釈の違いがある程度反映されている 可能性がある。 100. 9 つの指標のデータを使用して、各国の複合的な 「教育と実践の法規」スコアを導き出した（付属文 書 2 を参照）。各指標につき 0（存在せず）から 1（存在する）までのスコアが与えられ、部分的に 存在する場合は 0.5 の値となり、回答がない場合 は 0 と見なす。その後、これらのスコアを最大値 が 9 となるよう合計する。本分析では指標への回 答がない場合はスコアを 0 と見なすことから、感 度分析を実施し、欠落値について異なる分類を行っ た場合の影響を調べたところ、結果の解釈は変わ らなかった。図 5.9 は、本報告書で調査した規制 メカニズムの有無についての報告によると、教育 規制環境が北米、西ヨーロッパ、サハラ以南アフ リカで比較的強いという調査結果を強く示すもの である。 5.4.1 主な調査結果 ほぼすべての国が看護教育の法規の指標について報告しており、報告国の 50% 以上が、関連する 9 つの 指標すべてに「ある」と答えた。 法規のメカニズムとプロセスが存在するとの報告は、アフリカ、アメリカ、ヨーロッパ地域で高かった。 教育のリーダーシップとガバナンスよりも、教育の内容の法規（教育期間と内容の基準、教育機関の認証 メカニズムなど）に、より注意が向けられている。 看護教育システム、特に実践適性の試験と教員資格基準に関連する看護教育システムは、ヨーロッパ地域 では規制が厳しく、南・東アジア、東地中海、西太平洋地域では規制が緩いようである。 5.4 看護教育と実践の法規 46 State of the world’s nursing 2020　世界の看護 2020 WHO地域 認証教育機関 のマスター リスト 教育の期間と 内容に関する 基準 教育機関の 認証メカニズム 多職種 連携教育の 基準 継続的な 専門能力開発 高度な 看護実践の 役割 実践適性の 試験 教員資格の 基準 資格取得前の 学生のための 全国組織 アフリカ 91% 100% 90% 81% 68% 74% 68% 78% 66% アメリカ 77% 91% 94% 49% 71% 55% 57% 75% 91% 南・東アジア 69% 85% 78% 60% 61% 75% 72% 64% 38% ヨーロッパ 85% 94% 98% 87% 91% 30% 64% 94% 67% 東地中海 80% 80% 70% 20% 50% 50% 70% 80% 30% 西太平洋 70% 77% 78% 52% 63% 52% 56% 71% 35% 世界全体 81% 91% 89% 67% 73% 53% 64% 77% 62% 出典：国家保健人材統計 2019年。最後の3つの要素は「世界の看護の現状 2020」固有の指標。2013年から2018年の間に国によって報告された最新 の入手可能なデータ。 教育と実習に関する法規が「ある」と回答した国の割合（WHO地域別）表 5.7 0% 20% 40% 60% 80% 100% 教育の期間と内容に関する基準 （169カ国のうち154カ国が「ある」と回答） 教育機関の認証メカニズム （165カ国のうち147カ国が「ある」と回答） 認証教育機関のマスターリスト （146カ国のうち118カ国が「ある」と回答） 教員資格の基準 （99カ国のうち76カ国が「ある」と回答） 継続的な専門能力開発 （132カ国のうち96カ国が「ある」と回答） 多職種連携教育の基準 （99カ国のうち66カ国が「ある」と回答） 実践適性の試験 （114カ国のうち73カ国が「ある」と回答） 資格取得前の学生のための全国組織 （89カ国のうち55カ国が「ある」と回答） 高度な看護実践の役割 （95カ国のうち50カ国が「ある」と回答） 91% 53% 62% 64% 67% 73% 77% 81% 89% 「ある」と回答した国の% 図 5.8 看護の規制や基準が「ある」と回答した国の割合 47看護労働力に関するエビデンスとデータの現状 看護教育規制スコアのマップ（国別）図 5.9 4以下 5 6 7 8 9 報告なし該当なし 注：教育能力の質問を組み合わせたもので、素点は0から9。 出典：国家保健人材統計 2019年。 48 State of the world’s nursing 2020　世界の看護 2020 看護教育規制スコアのマップ（国別）図 5.9 4以下 5 6 7 8 9 報告なし該当なし 注：教育能力の質問を組み合わせたもので、素点は0から9。 出典：国家保健人材統計 2019年。 5.5.2 教育パイプライン 101. 保健システムの現在のニーズおよび今後予想され るニーズに適合し、国および地方のニーズを満た すためには、教育と実習への多大な投資が必要で ある。 102. 教育パイプラインの妥当性を評価するため、各国 に可能な限り直近の新卒看護職数を提供するよう 求めた。合計 88 カ国（ほぼ半数の 41カ国がヨー ロッパ地域）がこの指標について報告した。した がって、表 5.8 の「合計」の数値は、南・東アジ アおよびヨーロッパからのデータによる傾斜が見 られ、他の地域の状況を表すものではないため、 細心の注意を払って解釈する必要がある。 103. 看護職密度に関連したのと同様に、所得レベルは、 人口 10 万人あたりの卒業者の増加数に関連する 要因であった。 104. 入手可能なデータに基づいてシミュレーションし、 世界の人口に適用すると、人口 10 万人あたり 22.6 人という卒業者の全体の密度から、年間の 新卒看護職は172 万人と推計される。この分析は、 ヨーロッパ地域を除き、一部の国のデータに基づ くため、純粋な実数として見る必要がある。ただ し、このデータの回答率は限定的であったものの、 卒業者数と看護職数の比率に大きな開きは見られ なかった。さらに、人数について推計したこれら の結果を、35 歳未満の年齢層、つまりおおよそ 10 年以内に雇用を開始した労働力の割合と比較 した。この若手のカテゴリーの10 分の1を、毎 年市場に参入するストック数の代用値として使用す ると、現在の卒業者の推計数が 170 万人であるの に対し、ストック数は106 万人となる。すべての 労働者が雇用されるわけではないので、数値はお およそ妥当であると思われる。 5.5.3 卒前教育の就学年数 105. 様々な情報源から、157 カ国についての看護職 の卒前教育プログラムの就学年数に関するデータ が得られた。アフリカ、東地中海、西太平洋の各 地域を中心とする少数の国では 2 年間のプログラ ムを実施している一方、全地域の大多数の国では、 3 年間または 4 年間のプログラムを実施しており、 5 年間のプログラムは全地域でほとんど認められ ない（図 5.10）。アフリカ、西太平洋の各地域では、 約 4 分の 3 の国で 3 年間のプログラムを実施して おり、南・東アジア地域では、ほぼ 4 分の 3 の 国が 4 年間のプログラムを実施している。 5.5.1 主な調査結果 合計 88 カ国（主に南・東アジアとヨーロッパ）が、年間の新卒看護職の数に関するデータを報告した。 看護職密度が最も低い地域（アフリカ、東地中海、南・東アジア地域）は、同じく卒業率も最も低い（人 口10 万人あたり、それぞれ 7.7人、7.1人、12.2 人）。 人口比の値で見ると、アメリカ地域の卒業者はアフリカ地域、東地中海地域の10 倍である。 データの報告があった国の中では、アフリカ地域、西太平洋地域の看護職教育の平均就学期間は約 75% の国で 2 ～ 3 年であったが、アメリカ、南・東アジア、東地中海の各地域では半数を超える国が 4 ～ 5 年であった。 5.5 看護人材の教育と輩出 49看護労働力に関するエビデンスとデータの現状 報告国の数／ 全体数 人口10万人あたりの卒業者の数 人口10万人あた りの卒業者の数WHO地域別 全体 低 高 アフリカ 14/47 8.8 2.8 23.7 7.7 アメリカ 14/35 9.8 0.8 30.8 81.2 南・東アジア 8/11 7.5 3.9 13.8 12.2 ヨーロッパ 41/53 4.0 1.0 31.9 31.9 東地中海 5/21 4.6 0.6 16.5 7.1 西太平洋 6/27 5.7 3.4 12.0 20.6 所得グループ別 低所得 8/31 13.8 4.1 31.9 10.4 低中所得 15/46 7.7 2.8 13.8 12.8 高中所得 26/60 6.4 0.6 30.8 22.7 高所得 40/57 3.6 1.5 7.6 38.7 全体 88/194 6.2 0.6 31.9 22.6 出典：国家保健人材統計 2019年。所得グル プーは、2018年の世界銀行の分類による。 新卒看護職の養成数（WHO地域別・所得グループ別）表 5.8 © WHO/Yoshi Shimizu 50 State of the world’s nursing 2020　世界の看護 2020 看護基礎教育の平均年数（WHO地域別） 図 5.10 2年 3年 4年 5年 0% 20% 40% 60% 80% 100% アフリカ アメリカ 南・東アジア ヨーロッパ 東地中海 西太平洋 WHO地域 世界全体 出典：99カ国については国家保健人材統計 2019年、58カ国についてはシグマデータベ スー。2013年から2018年の間に国によって報告された 最新の入手可能なデータ。 106. 看護の実務範囲が拡大しつつある時代においては、 卒前教育の範疇を超えた看護教育だけでなく、変 則的入学（事前要件を定義した上で）についても 検討することが重要である。卒前教育の就学年数 に関する報告は、固有の制限の影響を受けるため、 世界の看護教育の多様性（特に高度な看護実践 の役割に向けた教育）を示す上でのデータは限定 的なものとなる。 51看護労働力に関するエビデンスとデータの現状 5.6.2 結果の分析 107. 採用の形態と労働条件は、保健人材にとって雇用 の魅力、パフォーマンスと生産性、定着の主要な 推進力となる。「WHO 保健人材に関する世界戦 略：労働力 2030」は、「安全で適切な労働環境、 あらゆる種類の差別、強要、暴力からの自由を含 む、すべての保健医療従事者の個人的権利、雇 用上の権利および職業上の権利」の支持を求めて いる。この側面を評価するために、採用の形態と 労働条件の規制に関連する 6 つの指標について 調査を行った（図 5.11）。このうち 3 つの指標（労 働時間と労働条件に関する法規、看護職能団体、 高度な看護実践の役割）は看護職固有の指標で あり、残りの指標は看護職を含む保健人材全体に 適用されることに注意されたい。 108. 回答国のうち 80% を超える国が、労働時間と労 働条件、社会的保護、最低賃金に関する規制が あり、看護職能団体または同等の組織があると報 告したが、高度な看護実践の役割があると答えた 回答国は比較的少なかった（53%）。合計 55 カ 国が保健医療従事者への攻撃予防策に関する指 標について回答しており、そのうちの 3 分の1以 上の国（37%）がそのような対策を講じていると 回答している。 109. 表 5.9 は、東地中海地域の国々が、本報告書で 調査した看護職の雇用規制の水準が高いことを示 しており、70% 以上の国が 6 つの指標すべてに「あ る」と答えている。南・東アジアと東地中海の２ つの地域だけが、大多数の国が保健医療従事者 へ業務上のリスクに対する予防策を講じていると 報告しており、これらの地域ではそうしたリスクの 発生率が比較的高いことが反映されているものと 思われる10。アフリカ、アメリカ、ヨーロッパの各 地域も、ほとんどすべての指標に「ある」と回答 している。ただし、高度な看護実践の役割がある と答えたのは、回答のあったヨーロッパ地域の国 のわずか 30% であり、保健医療従事者への業務 上のリスク予防策を講じていると答えた国は 26% であった。 5.6.1 主な調査結果 アフリカ、アメリカ、ヨーロッパ、東地中海の各地域は、看護職の労働条件に関連する規制メカニズムの 水準が高いと報告している。 一部の国（主に南・東アジアと西太平洋の各地域であるが、アフリカ地域と南アメリカでも）では、こうし た規制の水準が低いと報告している。 3 分の1以上の国（37%）が、保健医療従事者への攻撃の予防策を講じていると報告しており、これらは 主に南・東アジア、東地中海の各地域である。 高度な看護実践の役割（回答のあった 95 カ国のうち 53% が「ある」と報告）は、医師の密度が低い国 でより多く認められ、看護職の職業的自立性の確保が、医師不足緩和のための政策のひとつである可能性 を示唆している 。 5.6 採用と労働条件の法規 10.　保健医療従事者への攻撃監視システム：https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx. 52 State of the world’s nursing 2020　世界の看護 2020 WHO地域 労働時間と 労働条件に 関する規制 最低賃金に 関する規制 社会保護に 関する規制 保健医療 従事者への リスク予防策 高度な 看護実践の 役割 看護 職能団体 アフリカ 90% 90% 85% 41% 74% 78% アメリカ 97% 85% 94% 37% 55% 91% 南・東アジア 75% 50% 50% 67% 50% 80% ヨーロッパ 98% 92% 100% 26% 30% 96% 東地中海 85% 100% 92% 73% 75% 85% 西太平洋 100% 86% 57% 30% 52% 78% 世界全体 94% 89% 91% 37% 53% 86% 出典：国家保健人材統計 2019年、最後の要素は 「世界の看護の現状　2020」からの指標。 2013年から2018年の間に国から報告された最新の入手可能なデータ。 看護職の労働条件に関する規制があると回答した国の割合（WHO地域別）表 5.9 労働時間と労働条件に関する規制 （142カ国中133カ国が「ある」と回答） 社会保護に関する規制 （137カ国中125カ国が「ある」と回答） 最低賃金に関する規制 （134カ国中119カ国が「ある」と回答） 看護職能団体 （164カ国中141カ国が「ある」と回答） 高度な看護実践の役割 （95カ国中50カ国が「ある」と回答） 保健医療従事者へのリスク予防策 （55カ国中20カ国が「ある」と回答） 0% 20% 40% 60% 80% 100% 94% 53% 86% 37% 89% 91% 「ある」と回答した国の% 注：各指標の回答国のうち、「はい」と回答した国の数を各指標下の括弧内に表示。 出典：国家保健人材統計 2019年。 図 5.11 労働条件に関する規制条項があると回答した国の割合 53看護労働力に関するエビデンスとデータの現状 110. 西太平洋地域の多くの国は、労働時間と労働条件、 最低賃金に関する法規、および看護職能団体また は同等の組織があると報告している。しかし、そ の他の 3 つに関しては低いレベルにあると報告し ている。南・東アジア地域は、法規を取り巻く環 境を評価する指標について「ある」と答える割合 は最も低いものの、この地域の半数の国は 6 つの 指標のそれぞれについて「ある」と回答している。 セクション 5.4 で述べたように、地域ごとの差は ある程度、指標の意味に関する認識の違いや地域 ごとの報告率の違いを反映している可能性がある。 収集されたデータは、法規の妥当性や関連規定の 実施レベルについての情報を提供するものではな い。 111. セクション 5.4 と同様、付属文書 2 で説明する方 法を用いて、6 つの指標のデータから各国の複合 的な「労働条件法規」スコアを導き出した。図 5.12 は、セクション 5.4 で分析した教育システムにお ける法規を取り巻く環境が北米、サハラ以南アフ リカ、およびヨーロッパ地域で比較的高いと報告 されているという調査結果を補強するものであっ た。 112. 図 5.13 に示すように、高度実践看護職は、医師 密度が低い国でより多く認められていた。 労働条件規制スコアのマップ 図 5.12 1以下 2 3 4 5 6 報告なし該当なし 注：労働条件能力の質問を組み合わせたもので、素点は0から6。 出典：国家保健人材統計 2019年。 54 State of the world’s nursing 2020　世界の看護 2020 労働条件規制スコアのマップ 図 5.12 1以下 2 3 4 5 6 報告なし該当なし 注：労働条件能力の質問を組み合わせたもので、素点は0から6。 出典：国家保健人材統計 2019年。 図 5.13 高度実践看護職を有する国の割合 （人口1万人あたりの医師密度のレベル別） 人口1万人あたりの医師密度 ???????????????? 80% 60% 40% 20% 0% <5 5-19 20+ 65% 59% 43% 出典：国家保健人材統計 2019年。 © AKDN/Christopher Wilton-Steer 55看護労働力に関するエビデンスとデータの現状 5.7.2 結果の分析 113. 看護職の今後の発展のためには、看護職の強力 なリーダーシップとガバナンスが必要である（264、 265）。「世界の看護の現状 2020」の 2 つの指標 を用いて、看護のリーダーシップとガバナンスの現 状、すなわち、各国政府における看護行政責任者 の役職の有無と、看護職のリーダーシップ、研究、 政策リテラシースキルを開発するために国が支援 するプログラムの有無（それぞれ115 カ国、76 カ 国が回答）を評価した。 114. 回答した115 カ国のうち、71% が看護行政責任 者の役職があると報告しており、東地中海地域の 54% からヨーロッパ地域の 86% まで幅がある（表 5.10）。看護職のリーダーシップ育成プログラムを 実施していると報告する国は比較的少なく（回答 した 76 カ国の 53%）、南・東アジア地域の 40% からアフリカ地域の 64% まで幅がある。 115. 法規の整備が強力であることと看護職のリーダー シップおよびガバナンス環境との間には、重要な 関連がある。図 5.14 は、看護行政責任者と看護 職リーダーシップ・プログラムを持つ国が、看護職 の労働条件の法規と看護教育の法規に関して、平 均してより高いスコアを出していることを示す。 116. 看護行政責任者の役職と看護職リーダーシップ育 成プログラムの存在はどちらも強力な法規の整備 に関連性があるが、リーダーシップ・プログラム のほうが看護行政責任者よりもわずかに関連性が 高い。言い換えれば、政府に高レベルの看護職 が存在しても、必ずしもリーダーシップ・プログラ ム導入などの行動につながるわけではない。実際、 看護行政責任者の存在する国の37%が、リーダー シップ育成プログラムを備えていなかった。 117. 看護職不足に取り組むための新卒看護職数とその 後の採用数の増加によって証明されたように、看 護職のリーダーシップとガバナンスと投資の増加の つながりについての仮説を検証するために、リー ダーシップとガバナンス対策のある国の卒業者の 割合を、ない国の割合と比較した。統計的に有意 な関連性は確認されず、看護職の強力なリーダー シップとガバナンスが必ずしも新卒看護職の加速 的養成につながるわけではないことが示された。 5.7.1 主な調査結果 回答国 115 カ国のうち 71% が政府に看護及び助産行政責任者の役職があると報告しており、回答国 76 カ国のうち 53% が看護職のリーダーシップ育成プログラムがあると報告している。 政府の看護行政責任者の役職の存在と看護職リーダーシップ・プログラムの存在は、共に看護職のための 強力な規制環境と関連している。 ただし、看護行政責任者役職の有無もリーダーシップ・プログラムの有無も、看護職養成率の増加とは関 連性がなかった。 5.7 ガバナンスとリーダーシップ 56 State of the world’s nursing 2020　世界の看護 2020 看護行政責任者の役職 看護職リーダーシップ育成プログラム WHO地域 回答国の数／全体数 「ある」と答えた国の 割合 回答国の数／全体数 「ある」と答えた国の 割合 アフリカ 26/47 60% 28/47 64% アメリカ 26/35 79% 16/35 46% 南・東アジア 6/11 60% 4/11 40% ヨーロッパ 30/53 86% 10/53 56% 東地中海 7/21 54% 8/21 62% 西太平洋 20/27 74% 10/27 43% 世界全体 115/194 71% 76/194 53% 出典：「世界の看護の現状2020」固有の指標、2019年。2013年から2018年の間に国によって報告された最新の入手可能なデータ。 リーダーシップとガバナンスの指標：看護行政責任者の役職と看護職リーダーシップ育成プログラムの ある国の割合（WHO地域別） 表 5.10 0 2 4 6 0 2 4 6 8 10 0 2 4 6 8 10 0 2 4 6 8 10 看護行政責任者 リーダーシップ・プログラム 労働条件 教育法規 P = 0.008（クラスカル＝ウォリス検定） P <0.001（クラスカル＝ウォリス検定） ??????????? 看護行政責任者なし 看護行政責任者あり ??????????? リーダーシップ・ プログラムなし リーダーシップ・ プログラムあり 看護行政責任者 リーダーシップ・プログラム??????????? ??????????? P = 0.007（クラスカル＝ウォリス検定） P <0.001（クラスカル＝ウォリス検定） 看護行政責任者なし 看護行政責任者あり リーダーシップ・ プログラムなし リーダーシップ・ プログラムあり 出典：「State of World Nursing Report 2020 世界の看護の現状」より、2019年。 図 5.14 看護行政責任者・看護職リーダーシップ・プログラムと規制環境との関連性 57看護労働力に関するエビデンスとデータの現状 118. 保健医療関連の SDGs を達成するために、WHO 加盟国は（a）看護職の減少（死亡、移住、退職 などによる）を補填、（b）人口増加、高齢化、ヘ ルスケアのニ ズーの変化によって世界の多くの地域 で増大する需要に対応、（c）既存の世界的な不足 を解消するために、十分な看護職を教育する必要 があるであろう。 5.8.2 2030 年の看護職ストックと密度の予測 119. 各国の基本的な「確保数とフロー」のモデルは、 現在の看護職の人数、推定退職率（看護人材の年 齢分布に基づく）、人口増加、および労働市場へ の参入の想定数を考慮して開発された（シナリオ の説明については付属文書 2 を参照）。現在の傾 向のまま行けば、看護職のストックは、2018 年 の 2,790 万人から 2030 年には 3,590 万人に増 加するものと予測される。 120. 2030 年までの看護職のストックの増加は高所得 国に集中し、低所得国の伸びは非常に限定的とな る（図 5.15）。2018 年に報告された格差（セクショ ン 5.2 を参照）は、2030 年までほぼ変化なく継 続することが予測される。 121. 予測されるストックの成長軌道は、特に 34% の 人口増加が予想されるアフリカ地域でのニーズに 完全に対処するのに十分ではない。また、東地中 海地域では、看護職のストックはわずかしか増加 しないことが予測される（表 5.11）。 122. 本分析で使用した要素のためのデータを使用し、 さまざまな仮定とシナリオのもとで予測を行った。 潜在的な限界については、付属文書 2 で説明する。 123. 対照的に、アメリカ、南・東アジア、西太平洋の 各地域では、看護職のストックが大幅に増加する と予測されている。所得レベルによるグル プーを 考慮すると、ストック増加の 88% は中所得国で 発生するものと予測される（図 5.16）。 5.8.1 主な調査結果 2018 年のデータと「保健人材に関する世界戦略」で定義された水準との比較から、590 万人の看護職が 不足すると推計される。不足分の大半（89%）は低・低中所得国に集中している。 すべての国が現在の新卒看護職養成数の水準を維持する場合、看護職の人数は 2018 年の約 2,800 万人 から 2030 年には約 3,600 万人に増加すると予測される。ただし、この予測増加数の70% は高中・高所 得国で発生するものと予想されており、最大の不足が見られる国ではない。 予測される人口増加と看護人材の高齢化を考慮に入れると、アフリカ、南・東アジア、東地中海の各地域 では、2030 年にも依然として、人口1万人あたりの看護職密度が 25 人未満であると予測される。アフ リカ地域の密度の改善はごくわずかなものとなると予測される。 看護職密度の低い国の看護職不足に対処するには、2018年から2030年までの年間卒業者数を平均8.8% 増加させ（0.2 ～13.4%）、雇用能力を最低 70% まで改善する必要がある。 不足に対処するための看護教育の拡大には、影響を受ける低・中所得国において、2018 年から 2030 年 の間、国民1人あたり約 10 米ドルの費用がかかる可能性がある。 5.8 SDGsの成果に向けた現状の評価 2030年の人口1万人あたりの看護職密度の予測（世界分布）図 5.15 0 1,100 2,200 3,300 4,400550 km 10未満 10～19 20～29 30～39 40～49 50～74 75～99 100以上 報告なし該当なし 注：「看護職」には、看護師および准（準）看護師を含む。 58 State of the world’s nursing 2020　世界の看護 2020 2030年の人口1万人あたりの看護職密度の予測（世界分布）図 5.15 0 1,100 2,200 3,300 4,400550 km 10未満 10～19 20～29 30～39 40～49 50～74 75～99 100以上 報告なし該当なし 注：「看護職」には、看護師および准（準）看護師を含む。 5.8.3 看護労働力の不足 124. 「WHO 保健人材に関する世界戦略」の 2016 年 の予測では、2030 年までに人口千人あたりの医 師、看護師、助産師の密度が 4.45 人の水準を 下回る国において、看護師と助産師が 760 万人 不足するとしている。この閾値によって、高所得 国の大半は除外される。同じ方法と水準を採用し つつ、より直近のデータを使用すると、2018 年 には看護職 590 万人の不足、2030 年には 570 万人の不足が予想された。2018 年の不足（数の 上で）が最も大きい国は、バングラデシュ、イン ド、インドネシア、ナイジェリア、パキスタンである。 所得レベルは看護人材の不足と密接に関連してお り（付属文書 2、表 A2.2）、2018 年の不足分の 89% が低・低中所得国に集中している。 125. この推定値は、以前の推定値を補正して看護職 の不足数のみを表示し（すなわち、助産師の分を 除く）、データの改善部分を計算に入れることで、 2016 年の「世界戦略」の調査結果と比較するこ とができる（図 5.17）。 126. 不足数の推計は、「世界戦略」で使用された水準 を考慮して算出された。したがって、水準を超え るすべての国はこの推計から除外される。これは、 水準を超えるすべての国が看護職の不足を経験し ていないことを示すものではない。実際、大半の 国は、各国で設定されたサービス提供目標および 保健システム構造に対し、重大なレベルの不足を 経験している。これらの国に関しては、個々に不 足数の推計を行う必要がある。この場合、人口と 労働力の高齢化、疾病構造の変化、定着戦略の 実施、その他の労働市場の変動要因を考慮した 方法を適用する必要がある。たとえば、各国が定 義した集団のニーズと保健システムの要件に基づ く分析では、2030 年に OECD 加盟の高所得国 31カ国で最大 320 万人の看護職が不足する可能 性があることが明らかになった（266）。同様の将 来的な看護職不足の推定値は、日本（2025 年ま でに 27 万人の看護スタッフが不足）（267）、ド 59看護労働力に関するエビデンスとデータの現状 ENGLISH 低中所得 27% 高中所得 61% 高所得 6% 低所得 6% アメリカ 43% ヨーロッパ 7% アフリカ 6% 東地中海 4% 西太平洋 22% 南・東アジア 18% 地域別 所得別 注：所得グル プーは、2018年の世界銀行の分類に基づく。 図 5.16 看護ストックの増加予測（2030年）（WHO地域別・所得グループ別） 2018年に見られた ストック（百万人） 2030年に予測されるストック WHO地域 シナリオ1： 高齢化と安定した 若年グル プー シナリオ2： 高齢化と 近年の卒業数 シナリオ3： 高齢化と2030年までに 卒業数50%増加 アフリカ 0.9 1.2 1.5 2.0 アメリカ 8.4 9.2 12.4 17.7 南・東アジア 3.3 4.7 5.0 6.1 ヨーロッパ 7.3 8.6 8.0 10.4 東地中海 1.1 1.9 1.5 1.7 西太平洋 6.9 10.3 9.0 11.2 世界全体 27.9 35.9 37.4 49.3 3つのシナリオのもとでの2018年から2030年に予測される看護職ストックのシミュレーション （WHO地域別） 表 5.11 60 State of the world’s nursing 2020　世界の看護 2020 注：不足数推計は、各国の年ごとの看護職ストック数を密度の水準と比較することにより算出した。 出典：「State of World Nursing Report 2020保健人材に関する世界戦略」2016年。世界レベルについては報告書「State of World Nursing Report 2020世界の看護の現状」。 現在の傾向が続いた場合、「State of World Nursing Report 2020世界の看護の現状」の2030年の看護職不足数の推計値は、「世界戦略」の推計値 と一致する（看護職570万人と560万人）。 図 5.17 2013年、2018年、2030年の看護人材不足数の推計 「保健人材に関する世界戦 略2016」 「State of World Nursing Report 2020世界の看護の 現状」 適用した補正係数： 1. 最新の割合データ（看護師・助産師合計のうち90%が看護職）を使用し、「世界戦略」で合わせて報告されている看護師と助産師のストックから助 産師分を削除。 2. データ改善による修正を行った結果、ストック推計値が増加し、不足数が減少。2018年の看護職2,780万人のうち440万人が、「世界戦略」から 改善されたデータの影響。 900 万人 看護師と助産師 820 万人 看護職 760 万人 看護師と助産師 690 万人 看護職 2030年の 不足の 推計値は一致 1 看護職のみに修正 2 データ改善による修正 570 万人 看護職590 万人 看護職 660 万人 看護職 2013 2018 2030 560 万人 看護職 イツ（高齢者の介護者と看護職を中心に、2030 年までに約 50 万人の保健医療従事者が不足） （268）、英国（2030 年までに108,000 人を超え る看護職が不足）（269）などでも報告されている。 5.8.4 2030 年までの看護職不足を補うた めに必要な養成数と費用 127. 2030 年までの看護職不足に全面的に対処するた めに必要な卒業者数と雇用数の増加を、さまざま な仮説のもとで推計した。 • 現在の傾向では、卒業者数を毎年平均約 10%（1.5% ～14.9%）増加させる必要が ある。 • 労働市場の新卒看護職の雇用能力が改善 すると考え、卒業者の労働市場雇用能力を 70% とすると、不足分に対処するための卒 業者数の年間平均増加率は 8.8%（0.2% ～ 13.4%）となる。 • 労働市場の雇用能力がさらに改善されたシ ナリオ（卒業者の 80%）では、2030 年ま での看護職不足に対処するために必要な卒 業者の平均増加率は、年間 8.1%（0.03% ～12.2%）となる。 128. 2030 年までの不足解消に必要な投資額を推計 するため、2018 年から 2030 年までに追加すべ き看護職数（卒業者の 80% が雇用されるシナリ オで予測）に、各国で看護職一人の養成にかか る平均コストをかけた（270）。低・中所得国の教 育費に関する査読付き文献その他をもとに、看 護職一人を養成するための平均コストに関して 3 つの異なる仮定（5,000 米ドル、10,000 米ドル、 20,000 米ドル）を用いた（271）。看護職不足を 解消するための追加投資額は、それぞれ平均で国 民1人あたり5.2 米ドル、10.5 米ドル、21米ドル となった11。仮定に対する感度分析とエビデンス の不十分さを考慮すると、具体的なシミュレーショ ンを行うためには、国民1人あたり約 10 米ドルの 中央推定値を採用するのが妥当である。 11.　これらの図は、全卒業生分の実習をカバーするのに予算が不足している国々に対する単発的な投資に関するものである。 61看護労働力に関するエビデンスとデータの現状 © WHO/Yoshi Shimizu 62 State of the world’s nursing 2020　世界の看護 2020 129. この報告書で明らかになった事実とそのエビデン スは、既存のフレームワークと先行文献（第 2、3、 4 章）および看護人材の現状分析（第 5 章）に 基づいており、より幅広い保健人材政策と保健シ ステム政策の一環として、看護人材の養成、配置、 管理、支援のあり方の根本的な変革を強く訴える ものである。 130. そのために必要な投資は相当な額になるが、何億 人もの健康状態の改善、何百万人もの適格な雇 用機会の創出（特に女性と若者にとって）、さらに 世界の健康安全保障の強化という形で、社会と 経済が受ける利益はさらに大きなものとなるであ ろう。 131. この可能性を生かすためには、地域、国、世界 レベルのさまざまなセクターを横断する協調的な 取り組みが必要である。この章では、世界規模で の議論と、本報告書のために集められたエビデン スによって明らかになった調査結果について説明 する。その上で、目的に合った、また実践に適し た看護人材を支援するための、持続可能な投資 を活発化させ、制度の構築、政策行動の促進に 必要な対策を概説する。 132. これらの政策オプションは、加盟各国と、必要に 応じてその他のステークホルダーに向けられたも のである。その適用性と妥当性は、それぞれの国 の保健システムの目標、基本的な条件、実施能 力に応じて検討する必要がある。 看護人材政策の 今後の方向性 6CHAPTER 63看護人材政策の今後の方向性 6.1 計画、モニタリング、説明責任のため　 　　　のエビデンスの強化 結果のまとめ 133. 本報告書は、看護職に特化した、最も包括的 な世界規模のデータとエビデンスを示している。 80% の国から少なくとも15 の指標の報告があっ た一方、欠損データが特定された。これは国ごと の保健人材情報システムの能力の差異を反映して おり、今後重点を置くべき貴重な点である。 134. 現役看護人材数（191か国）、年齢構成などの指 標（132 カ国）に関しては、非常に多くのデータ が得られたが、教育・財政面・保健労働市場のフ ローに関する指標は大幅に少なく、保健労働市場 の包括的な分析を実施するには十分ではなかった。 たとえば、看護人材数のみ把握され、養成能力、 求人率、雇用されていない人数、離職・退職等 の数値データがない場合、政策立案者は養成数 を増やすべきか、あるいはすでに適切なのか、判 断が難しくなる。政策立案者・策定者は、教育セ クターによる養成と保健労働市場での雇用が均一 にマッチしているか、または何らかの不均衡（人 材不足や過剰供給）があるのかを知る必要がある （スコットランドの保健労働市場に関する Box6.1 を参照）。 135. 各国におけるこれらのデータの供給・報告能力に 影響を及ぼす要因には、保健、労働、教育、財 政担当省庁間の連携の度合いや、看護職能団体 や看護基礎教育機関など、その他のステークホ ルダーの関わりなどが挙げられる。 政策オプション 136. 各国は、看護人材の個別の情報も含む、国家保 健人材統計の導入を速やかに進める必要がある。 特に急務なのは、国の保健労働市場の分析に不 Box 6.1 スコットランドの保健労働市場分析 国内での 2019 年 12 月、スコットランド政府は、スコットランドの保健福祉分野における包括的労働力計画 を発表した（272）。この計画には、入院ではなく在宅でのケアを可能にするというビジョンがあった。ただし それを実現するためには、地域の訪問看護師の人数を増やす必要がある。 スコットランド政府は、イギリス国民保健サービス・スコットランド情報サービス局のデータを使用して、追加 的に必要な看護学生の養成数を数理モデルで算出し、シナリオを作成した。また、看護以外の保健医療従事 者の供給と不足、その不足が提供すべきケアにどのように影響するか、どうすれば対処可能かを検討した。 データと調査結果は、看護師・助産師学生採用担当者グル プーおよびその他の関係者間で共有された。この 意見交換や議論により、訪問看護師養成に前向きにアプローチすることや、訪問看護師の教育と研修への投 資を増やし、現役訪問看護師もそうした教育と研修を受けられるようなスタッフ配置を検討するとの決定にい たった。 これは、スコットランド政府として初めて保健福祉分野の労働力問題に全国レベルで、また包括的に取り組ん だ事例であり、１つの職種のための人材確保計画から多職種チームベ スーのケアの計画に移行するための取り 組みであった。 64 State of the world’s nursing 2020　世界の看護 2020 可欠なデータの欠損・不足への対処である。これ は、保健情報システムのための人材確保や能力 強化と、システム構築に向けた包括的な取り組み を通じて達成されるべきである（273）。今回世 界の看護人材についての説明が可能になったの は、国家保健人材統計導入に向けた世界的な取 り組みと、さまざまなデータソースのおかげであ る。保健情報システムのための人材確保や能力強 化には、看護界のリーダーを含むステークホル ダーによる、データ使用のための明確なメカニズ ムの確立、データの供給、質、課題についての 議論、またデータの連結のための恒久的なメカニ ズムの確立が必要であろう。さまざまなセクター やステークホルダー間の調整もまた、データを収 集・共有し、そのデータを有意義な政策変更に 生かすためのチャンスとなる可能性がある。各国 は、保健労働市場分析に看護やそのほかの保健 人材のデータを活用して、国レベルでの政策決定 や投資決定の指針とすべきである（Box 6.2 看護 労働市場分析に国家保健人材統計指標を活用す る看護師リーダーチームを参照）。 6.2 看護職の国際的な移動 結果のまとめ 137. 約 370 万人の看護職（8 人に1人）が、自分の 出身国または看護教育を受けた国以外で働いて いる。この調査結果は看護職の国際的移動性が 高いこと、また国内での看護職養成数が不足して いる国が移住してきた看護職に強く依存している ことを示している。高所得国（15％を越える看護 職が、外国出身または外国で教育を受けたと報 告されている）での看護職の需要は、低所得国 で高い教育を受けた看護職を引き付け、集団の 健康に悪影響を及ぼす、医療の質やアクセスへの 格差を拡大するおそれがある（Box 6.3ドイツの 移住管理アプローチを参照）。 138. 大量の看護職が国外移住する場合（意図的な看 護人材輸出政策の結果は除く）、自国の労働条件 の魅力が低いと解釈できる。したがって政策とし ては、移住そのものだけではなく、看護職の労 働環境、支援システム、報酬の改善など根本的 な原因に対処する必要がある。また看護職の養 成においては、地域や一次医療の場で働くために 必要なスキルや能力と、収入を最大化し、より専 門的な、あるいはグローバルな環境で働くために 移住できるようなスキルを学ぶこととの間で、適 正なバランスをとる必要がある。 139. 移住する看護職の人数が大幅に増加しているため、 国民の安全を守るためにひとつの国だけで解決す るという典型的手法では不十分であり、システム 改革によって、世界的な解決方法を提供、強化す る必要がある（245、278、279）。さらに、多く の国が同時に移住元国であり移住先国にもなって いるため、将来的な保健人材計画を策定するに は、移住を管理し、その傾向について把握してお くことが不可欠である。しかしながら、「保健人材 の国際採用に関する WHO 世界実施規範」で規 定されている報告要件の1つである、外国出身ま たは外国で教育を受けた看護職が自国の労働力 に占める割合を報告しているのは、86 の加盟国 のみである。 政策オプション 140. 国と規制当局は、看護職を含む保健人材の国際 的な移動を管理する法規の実施を強化すべきで ある。移住先の国や地域の規制当局は、人々の安 全を守るため、移住してきた看護職の教育内容や 資格、また犯罪歴が、移住先で求められる資格・ 教育上の基準、倫理基準、行動規範を満たして いることを確認する必要がある。規制モデルを強 化することで、看護基礎教育課程への入学要件と、 看護職資格を取得・維持するために必要な教育 内容との一致による、移動性の促進が可能にな る。また各地域が看護職資格の相互承認に関す る協定を結ぶことで、将来的により広範な協定を 実現するための基礎が形成される。 141. 各国および国際的なステークホルダーは、保健 人材の国際採用に関する WHO 世界実施規範の 実施を強化すべきである。看護人材の国際的移動 を効果的に管理・規制するには、規制当局、保 健人材情報システム、雇用主、政府省庁、看護 職能団体などのステークホルダーの間での能力構 築、パートナーシップの活用、協力体制が必要と なる。国外移住による看護人材の過度の不足に 65看護人材政策の今後の方向性 Box 6.2 東部、中央部、南部アフリカ保健共同体：国家保健人材統計を用いた 　　　　　看護職データ集積の国家レベルの協力体制 東部、中央部、南部アフリカ保健共同体（ECSA-HC）は、保健に関する地域間協力を育み、促進するため の政府間組織である（274）。看護職不足はこの地域では一般的である。劣悪な労働条件と労働量の多さが原 因となり、看護職がこの地域で働くことのインセンティブが失われ、国外への移住率が高くなっている。教育 システムは、教員の能力不足によって崩壊しているケ スーも多く、教育スキルを備えた教員も不足している。 世界銀行グル プーは、Jhpiego、国際看護師協会、ECSA 看護大学と協力し、看護労働市場と看護教育市場 を評価するための研究に取り組んだ。その目的は、これらのシステムにおける課題の大きさを推計し、的を絞っ た公的・民間投資を通じて地域の看護教育拡大のための政策を特定することであった。この研究では、ガバ ナンスと法規の課題を考慮しつつ、教育システムと保健システムの相互作用が看護職の労働市場によっていか に仲介されるかを調査した。収集されたデータは、WHO が開発した保健人材登録の指標（273）と、地域で 収集された追加の定性的データである。各国で本調査のためのデータ報告の調整を行ったのは、国の看護職 リーダーシップ「クワッド」で、レビュー プロセスで WHO からさらなる支援を受けた（サブセクション 6.3.3 も 参照）。 その結果、不均衡な市場と、この地域における看護職の需要と供給の重大なアンバランスが明らかになった。 過去10 年間、看護職の供給は人口増加よりも速いペ スーで増加したが、同時に、多くの国において看護職の 公的医療機関等への雇用率が低く（多くの場合、非効率な採用または望ましくない労働条件が原因）、ニ ズー に対し大幅に不足していた。予測分析では、2019 年から 2039 年に需要が 33% 伸びると見ているが、それ でも公私の医療機関等で採用できない、または就職意欲のない看護職が 22 万人以上となる。対照的に、ニー ズに基づく看護職不足は 2030 年までに 841,000 人に達すると推測され、看護労働市場に現在見られる不 均衡はさらに拡大する。 この研究の結論は、ECSA 諸国で SDGs 達成に向け看護職の供給を増やすには、看護教育の拡大、看護教 育機関の質の向上（認証メカニズムの導入を含む）、看護職をこの地域の労働市場で雇用するために必要なリ ソ スーの増加が求められるというものである。これらは、物的・人的資源、看護職のガバナンス、法規、また 国が投資の影響をモニターできるようなデータの収集・分析能力育成への適切な投資によって、可能になるだ ろう。 66 State of the world’s nursing 2020　世界の看護 2020 直面している国は、給与（および賃金の公平性） と労働条件の改善、働きがいのある人間らしい仕 事の確保、そして正当な根拠がある場合は状況 に応じた定着のための対策を検討する必要がある。 6.3 看護人材の開発と支援 6.3.1 教育 結果のまとめ 142. 本報告書の調査結果は、看護職養成に関する複 雑な状況を示している。自国で養成した看護職の 割合が低かったのは、ヨーロッパと東地中海の各 地域、ならびに高所得国である。データによると、 中・高所得国が養成数を増やせない限り、高所 得国は国外からの看護職採用に依存し続ける可 能性があり、現在の不足状況の悪化、それに関 連する医療へのアクセスと公平性の問題を引き起 こす可能性がある。 143. 看護基礎教育課程の就学期間は、世界の各地域 によってかなりのばらつきが見られる。しかし、大 多数の国（回答国 169 カ国中 154 カ国）が、教 Box 6.3 ドイツの移住管理アプローチ 2018 年 11月 9 日、ドイツ議会は、病院、高齢者ホームの従業員、介護職員にとってヘルスケアと長期ケア をより魅力的にするための「ケア強化法」を可決した（275）。政府の新保健政策の中心にあるのは、こうした 施設での人員配置の改善であった。長年にわたり、ヘルスケアと長期ケアでは深刻な看護職不足に悩まされて おり、病院と高齢者ホームでの人員不足が広がっていた。定年退職と、不満のために保健サービスを離れる専 門職の数は、職業訓練修了による参入数よりも多かった。さらに、人員不足は職員の労働条件の悪化とケア の質の低下につながると認識されていた。2012 年、ドイツでは 2030 年までに看護ケア人員が 263,000 ～ 500,000 人不足すると予測された（276）。人員不足を軽減するため、ドイツでは、教育の拡大、新しい看護 職の創出、中央・南東ヨーロッパ出身看護職など移住保健従事者の国際的採用の適正化からなる多面的戦 略が採用された（277）。この最後の要素のために、ドイツは、移住元国での訓練や投資の機会を生み出す技 術協力や二国間協定などを通じて、保健従事者の国際的移住から移住元国も利益を得られるよう措置を講じ た（168）。 育・実習の内容と期間の基準があると報告してい る。一次医療や予防ケアサービス、災害、緊急事 態、紛争等への対応能力、リーダーシップスキル、 テクノロジーの適切な使用など、集団の健康ニー ズを満たすために必要な能力を学生に提供できる かどうかという点が、基準を設定する際きわめて 重要な検討事項である（Box 6.4 看護教育と実践 におけるテクノロジーを参照）。 144. また大半の国（89%）では教育機関の認証の仕 組みが整備されており、認証された機関のリスト があると報告している。このことは、多くの国が 認証において強化すべき点、つまり効果的で無理 のない費用のモデルや、集団の健康の優先事項 に対する説明責任や適切性などにフォーカスする 機会があることを示している。確実な認証の仕組 みがあれば、教育の内容、カリキュラム、学生の 臨地実習、教員の能力や質、多職種連携教育な どをカバーすることが可能である。今回の調査結 果で、回答国の 67% において多職種連携教育の 基準があることがわかったが、一部の地域ではま だ 20% 程度から半分未満と低い。 145. 対象集団の人口構成を反映したかたちで保健人材 を確保するには、看護基礎教育課程を卒業する 67看護人材政策の今後の方向性 学生にも多様性が必要である。本報告書の調査 結果によると、看護人材は依然大部分が女性で あり、特にアメリカ、西太平洋の各地域でその傾 向が顕著である。看護人材の構成の適正化には、 多様な集団からの学生の入学を増やすだけでなく、 一部の学生を看護教育から遠ざけている（中等教 育修了等の入学要件など）、または卒業を困難に する（費用負担など）、構造的・組織的な課題へ の対応が必要である（126）。看護基礎教育課程 の需要は、国によってはジェンダーによる職業選 択や看護職の社会的地位の低さに影響を受ける 場合もある。看護職を魅力的なキャリアにするた めにはこれらの課題への対応が必要であり、特に アメリカ地域のように人口に対する看護基礎教育 課程卒業者数が最も少ない地域では、積極的な 対応が求められる。 政策オプション 146. 各国は、看護職が基礎教育課程において、質が 高く包括的で人間中心のサービスを提供するコン ピテンシーを、確実に身につけられるようにすべ きである。優先性の高い課題としてあげられるの は、看護職のスキルミックスの状況の客観的な評 価、看護職のレベルと専門分野のタイプと保健シ ステムの目標との関連の判断、保健システムのニー ズと雇用能力に基づいて適切な数のポストを確保 することである。看護の高等教育プログラム（学士、 修士、博士課程）の新設や増設は、新しい教育 プログラムの開発、適切な能力を持った教員の配 置、また高等教育を受けた看護職の保健システム における明確な役割分担などに、影響を及ぼす。 147. 各国は、看護学生の人口動態的および地理的な 多様性を高めるためのメカニズムを検討する必 要がある。これは、男性、若者、また特定の民族 グル プーが看護職を選択することや、第二のキャ リアとして看護職を希望することにネガティブな 影響を及ぼす偏見への対応を意味する。場合に よっては、ジェンダーバランスの取れた入学を促し、 へき地や医療過疎地などから適切な人数の学生 の入学を促進するため、「パイプライン」の開発が 必要な場合もある。社会的に脆弱なグル プー、不 利な立場にある人々を対象とした財政支援や奨励 金の仕組みを活用して、教育の機会を増やすこと や、このような集団出身の教員を引き付けること も可能である。認証基準に社会的説明責任の対 策が強化されることも、このようなメカニズムの ひとつとなる。 148. 保健医療教育機関と規制当局は、能力に基づく カリキュラムを採用し、適切なテクノロジーを活 用すべきである。看護実践の質は、カリキュラム 全体に反映されるべきである。看護職は、臨床 の看護技術・知識に加え、多職種チームで働き、 患者への共感と思いやりを示し、適切な判断を行 い、学び続ける必要がある。カリキュラムは、看 護職の業務範囲と集団の健康ニ ズーの両方に適合 している必要がある。教育・実習内容のデジタル 技術を用いた提供により、従来の方法を効果的に 補完することが可能である。こうした「分散型学習」 の取り組みを成功させるには、カリキュラム設計 において、学生が最低限のデジタルヘルスリテラ シーを身につけ、臨地実習の指導を受けつつ、必 要な能力に関連するデジタル学習と遠隔学習を活 用し（285）、デジタルデバイスが活用できるよう になるために必要な、制度とインフラを整えるこ とが求められる（286）。 149. 政府とステークホルダーは、看護教育を推進す るため、部門間のパートナーシップと協力体制を 発展させ、活用すべきである。規制当局との協力 により、看護基礎教育課程への入学要件と、保 健システムにおける現在と将来の看護職の役割を 前提とした教育基準の見直しが容易になり、国際 的な標準の統一が促進される。認証機関との部 門横断的な協調は、認証過程の社会的説明責任 を明らかにすることにも役立つ。例としては、看 護基礎教育課程が、授業料と政府の補助金を通 して、組織の収入やステータスよりも、質の高い 医療サービスを提供できる看護職の養成を優先 するようにすることがある。関連省庁（教育、保 健）は、看護を理系（科学、技術、工学、数学） 分野として宣伝し、多様な生徒を看護職に引きつ けるメカニズムを導入するための、部門間調整を 強化する。官民パートナーシップは、プライマリ・ ヘルスケア環境での多職種連携の臨地実習に貢 献する。 150. 看護基礎教育課程は、教員の数や能力の不足、 インフラ上の制限を解消し、適切な臨地実習の 68 State of the world’s nursing 2020　世界の看護 2020 場を供給することなどにより、自身の能力を強化 すべきである（Box 6.5 より多くの看護職を養成 するパキスタンの取り組みを参照）。 質を維持し つつ教育者のポストを増やすには、教員の能力強 化プログラムへの投資が必要である。高所得国ま たは国外での求人に依存している国は、看護職の 国内での養成と配置を増やすべきである。 151. 各国は、労働市場の課題に対処するために、看 護教育の拡充や質の強化のための資金調達を検 討すべきである。資金調達は、学生、教員の多 様性、または看護基礎教育課程の定員を増加し、 現在の臨地実習課題解決に、大きな可能性があ る。卒後教育プログラムへの助成は、より高度な 看護実践のためのキャリアパスに活用されること もある。しかし政府は、看護教育への助成が費 用対効果の高い投資か、どのような状況・方法で、 乏しいリソースを公平性と効率性の実現に直接的 に寄与できる投資に優先的に利用するか、情報に 基づいて決定しなくてはならない（289）。たとえば、 労働市場分析によって、看護職が保健システムの ニーズに対し過少または過剰に養成されているの Box 6.4 看護教育と実践におけるテクノロジー テクノロジーが看護の教育と実践で果たす役割は、ますます重要度を増している。テクノロジーの活用は、アク セスの強化、遠隔ケア、プライマリ・ヘルスケア・サービスの提供、患者の意思決定支援、保健医療従事者間 での研修や相談を可能にする（280）。看護職は、デジタル知識を持ち、デジタル機器へのアクセス、インターネッ トのインフラなどをよく理解する必要がある（281）。 人工知能 (AI) であれ、拡張現実 (VR) やロボットなどであれ、デジタル技術はすでに看護と患者のケアに変革 をもたらしている（282）。個別医療とゲノミクスによって、患者ケアがもっと個人に合わせたものになる可能性 がある（283）。デジタルヘルスの最大の可能性のひとつは、生涯学習の機会にある。人工知能などのテクノロジー によって、学習も個人に合わせることができ、そのアップデートも可能となる。 保健医療従事者のプライマリ・ヘルスケアにおけるデジタルヘルス経験に関するコクラン系統的レビューによると、 看護職を含む保健医療従事者はケア提供におけるモバイルテクノロジーを評価しているが、課題にも直面してい る（284）。その利点には、互いの接点の増加、役割の創出、ケアの連携と質の向上、住民とのコミュニケーショ ンの向上、へき地住民へのアクセス向上などがある（284）。同時に、保健医療従事者については、個人（デ ジタルリテラシーの低さなど）、関係性（患者や同僚との直接的な接触を好む）、職業（自らの臨床スキルがデ ジタル臨床支援ツールによって脅かされていると感じる）、状況（患者に携帯電話を買う経済的ゆとりがない）、 インフラ（電気の欠如）に関わるものなど、複数の複雑な課題が挙げられている（284）。技術の進歩は多くの 恩恵をもたらす一方で、この系統的レビューに含まれる保健医療従事者の説明によると、保健システムの意思決 定者は、看護職を含む保健医療従事者が直面する課題を最小限に抑えるため、自らの事情に合わせてどのよう に実施されるべきか、慎重に検討する必要がある。 69看護人材政策の今後の方向性 かどうか、状況を特定する必要がある。養成数不 足は、入学を制限する状況の緩和や、必要に応じ た看護基礎教育課程への助成などの介入を行う 根拠となる。特に脆弱な集団に属する学生に対し、 一定期間プライマリー・ヘルスケアを行う公的保 健医療施設等で勤務する条件で、就学できる環 境を整えることなどが該当する（140）。 6.3.2 看護実践 結果のまとめ 152. 本報告書の調査結果によると、看護人材数は以 前の推計より多く、2018 年には約 2,800 万人に のぼり、看護師は約 69%、准（準）看護師は約 22% となっている。「保健人材に関する世界戦略」 の 2016 年の推計と比較して伸びが見られるのは、 より多くの正確な看護人材データが収集されたこ とと、実際の看護職数の増加によるものである。 153. 人数が増えても、看護職を含む保健医療従事者 の地理的な配置の不均衡は、世界的な課題であ る。本報告書では、国や地域の間、および国内・ 地域内で、看護職の配置に大きな差があることが 明らかになった。さらに本報告書の調査結果によ ると、回答国の 53% に高度実践看護師が存在す る。このような看護師は、医師が少ない国でより 多く見られる。これは、国のさまざまな保健人材 の課題に、看護人材が柔軟に対応していることを 示している。その方が効率性が高い場合、高度 実践看護職が、へき地に配置された方がよいこと もある。 154. 国内では、アクセスの公平性を改善するため、都 市部と地方の看護職の不均衡な配置への対処に、 引き続き重点を置く必要があることをデータが示 している。保健医療従事者の定着には、労働条件、 職場の安全、給与、非金銭的インセンティブなど、 さまざまな複雑かつ相互に関連する要因が関わっ ている。地域の状況に合わせた複数の政策介入の 結果、看護職が定着している場合もある。定着は、 看護職の労働条件や生活条件に関する文脈から 切り離して検討・対処されるべきではない。 政策オプション 155. 各国は看護職が、自身の受けた教育や訓練を 最大限に活用できるよう、支援する必要がある （180）。これは、プライマリ・ヘルスケアの場で多 職種連携チームを最大限活用する、全国的な取 り組みの一部であるべきだ（179）。優先領域であ るプライマリ・ヘルスケアの充実のためには、看 護職の最大限の貢献が不可欠である（Box 6.6 オ マ ンーの地域保健サービスへのアクセス拡大を参 照）。考えられるアプローチには、看護師のより 高度な役割、看護職主導の診療所の拡大、薬の 処方に必要な権限の付与や拡大と、そのために必 要な教育と実習の開発や強化などがある。高度 実践の資格を持つ看護職は、患者へのケア提供、 あるいは他の保健医療従事者へのリーダーシップ とマネジメントにおいて、その能力が適正に発揮 できる環境に置かれるべきである。高度な役割を 持つ、または看護職主導の診療所で勤務する看 護職は、必要に応じてメンターや同僚などからの 支援や、適切な物資や医薬品の提供を受け、実 践に関する明確な臨床・施設ガイドラインを持 ち、オンラインの資料や適切なテクノロジーなど にアクセスできる必要がある。必要な改革を教育、 保健、労働、その他の関連政策に組み込むには、 協力と調整の能力、組織的な支援の仕組みとリ ソース、リーダーシップと政治的意思、これらに 前向きな組織文化が必要である。業務範囲と能 力に基づく看護職の役割と機能を、他の保健医 療従事者や一般の人に正確に伝えることもまた重 要である。 156. 各国は、看護人材の効果的な配置と管理のため に、手順とメカニズムを適正化する必要がある。 雇用と配置の効率性、公平性、透明性は、適正 な働き方の実現に重要な要素である（16）。政策 立案者と行政官は、資格取得の 3 カ月後、6 カ月 後、1年後に雇用される新卒者の割合、卒業から 資格取得までの平均期間、資格取得から雇用ま での平均期間など、雇用プロセスの効率性と適時 性を評価するための、信頼性の高いデータを得る 必要がある。卒業生の低い雇用率は、労働市場 飽和の兆候である可能性もあるが、卒業、資格 取得、雇用の間のタイムラグが長すぎるのは、非 能率的な行政システムや官僚主義が原因の場合も ある。配置の手順もまた重要である。公的医療 70 State of the world’s nursing 2020　世界の看護 2020 機関等が全員の雇用を保証する場合を除き、高 い就職競争率と実力主義的評価によって、引き 続き選別が行われる（289）。キャリアアップと昇 進の機会もまた、年功序列（勤続年数）に基づく のではなく、実績と能力にリンクさせる必要があ る。その際は、他の職業グル プーと同様に、強 制配置とローテーションには限界があることを考 慮に入れる必要がある。看護職の配置は、可能 な限り自発的なキャリア選択と、勤務地希望に基 づいて行う必要がある。看護職の希望と、保健 システムのニーズ、特に地理的公平性に関連した ニーズとの一致は、困難な場合がある。地方への 配置と定着において希望とニーズが一致しない場 合は、有効性と労働者の権利の両方の観点から、 双方に利点のある幅広い戦略を取ることが望まし い（289）。 157. 各国は、看護職の定着に関する課題を明確か つ前向きに予測し、関連政策を整備すべきであ る。定着を強化するためのエビデンスに基づくア プローチには、リーダーシップ育成の機会、メン ターシップ（293、294）、非金銭的インセンティ ブ、生涯学習などがある。新卒者のためのプリセ プターシップは、実践への移行、臨床能力、仕事 の満足度、職業人としての自覚を向上させること ができ、これらすべてが新人看護職の定着に影響 を与える可能性がある（295）。プリセプターシッ プが新人看護職のコンピテンシーと定着に及ぼす 影響は、都市部でも地方でも変わらない（296）。 女性のリーダー職を増やし、ジェンダー差別に取 り組み、セクシャルハラスメントを防止するための 具体的な政策が整備されるべきである。セクシャ ルハラスメントは労働者の尊厳と権利の侵害であ り、また看護職の離職増加に関連している（122、 297、298）。 6.3.3 法規 結果のまとめ 158. 看護職の法規は、国民を保護し、変化する患者 や集団のニーズに保健システムが対応する上で、 不可欠な役割を果たしている。また、看護職の 専門性を高めるための枠組みを提供することもで きる（243、299）。本報告書の調査結果によると、 164 カ国の加盟国（86%）に、看護 教育・実 践の法規に責任を持つ政府機関がある。ただし、 施行されている法規の実効性については、各国レ ベルで検討する必要がある。たとえば、73% の 国には生涯学習を要件とする法規があるが、資格 試験や実践適性試験の法規がある国は、それよ りも少ない（64%）。 Box 6.5 看護職養成能力を高めるためのパキスタンの取り組み パキスタンは、100 万人の保健医療従事者の不足に対処しようとしている。2018 年には、保健人材のスキル ミックスと看護人材への対応を目的として、2030 年に向けた国の「健康実現のための保健人材ビジョン」が立 ち上げられた。保健セクターを支える人材とされる看護職はこのビジョンの鍵であり、2019 年がパキスタンで「看 護の年」であったこともあり、集団の健康への看護職の貢献が強調された（287）。「看護の年」を立ち上げる にあたってアルヴィ大統領は、年間 25,000 人の看護職養成を目指し、イスラマバードに看護大学を設立するこ とを発表した（287）。パキスタンは、全国的な看護職不足を克服するため、2 年間で看護セクターの規模を 2 倍にすることを計画している。国家保健サービス省の政務官であるハミッド博士は、看護職不足はユニバーサル・ ヘルス・カバレッジ達成の障壁であり、効果的な保健システムのためには十分な数の優秀な看護職が必要であ ると述べた（288）。 71看護人材政策の今後の方向性 159. 職業法規は、看護職の国際的な移動が高まる中 で、質の高いケアを維持するためにも重要であり、 移住してくる保健医療従事者が、集団のニーズに 見合った、人々の安全を損なわずに看護を実践で きるコンピテンシーを担保することができる。資 格情報を迅速に確認でき、現在の資格状況と職 歴をリアルタイムで照合できる Web システムは、 地域ベースの有用なツールとして生まれてきており、 世界的なソリューションに発展する可能性がある （168、300-302）。 政策オプション 160. 各国は、安全で、持続可能な、質の高い教育と 実践を支援するための法規を策定し、強化する 必要がある。看護職に関する法規に携わる政府機 関は、規制当局の役割と機能、看護教育と実践 のための規定と基準を定めた法律に基づき設立さ れる場合もある。法規による制限を最小限にしつ つ、望ましい公共保護の利益を実現するという適 切なバランスが必要性であるが、その実現には困 難を伴う（303–306）。各国は、多様なレベルの 看護職が自分の役職に適した学習機会に触れら れるようにするため、生涯学習の要件を検討する 必要がある。看護実践をするにあたり、最低レベ ルの基礎知識を持っていることを評価する資格試 験が、益々一般的となっている（255、307）。さ まざまなアプローチの相対効果に関する、より強 力なエビデンスは必要である。しかし、様々な看 護実践の場で必要とするコンピテンシーを、有効、 公平かつ独立したかたちで評価することの必要性 は、既にコンセンサスが得られている。 161. 各国は、看護教育と実践の質を強化・促進する 法的枠組みに投資すべきである。重要なのは、規 制当局が保健システムや他のデータベースと相互 接続可能な最新の登録情報を保有することであ る。その方法のひとつは、再登録または再資格 の取得を義務付けることである。これは生涯学習 を奨励するだけでなく、規制当局の収入にもなる。 また、看護に関する法規担当官の個々の能力も強 化する必要がある。一般的に、看護に関する法 規担当官は、その役職につく前に職業法規に関す る正式な研修をほとんど、または一切受けていな い可能性がある。法規担当官は、法規枠組みの 強化に成功した他の国の経験や地域レベルの取り 組みから学べる（アフリカ保健人材法規共同体に 関するボックス 6.7 を参照）。 6.3.4 働きがいのある人間らしい仕事 結果のまとめ 162. 適正な労働条件の確保は全ての保健人材にとって 重要かつ必要なものであるが、看護職は特有の課 題に直面している。大半を女性が占め、一部の地 域において伝統的に従属的な役割を担ってきたと いう負の遺産を考慮すると、看護人材は、もとも と職場でジェンダーの偏見や差別に直面しやすい 傾向がある。看護職はまた、長時間労働、一部 の状況では攻撃のリスク、セクシャルハラスメン ト、移住労働者としての不当な扱いなどを受けが ちである。労働時間と労働条件は 94%、社会保 護は 91%、最低賃金は 89% の国が「法規がある」 と報告している。しかし、これらの内容の妥当性 や執行のレベルについてはあまり分かっていない。 計 55 カ国（36%）、主に南・東アジアと東地中 海の各地域で、保健医療従事者への攻撃防止策 が報告された。 政策オプション 163. 各国は、働きがいのある人間らしい仕事に向け、 看護職の労働条件改善に投資すべきである。不 可欠な要素としては、適正な報酬、社会的保護、 公正な労働条件、妥当な労働時間、職場の安全、 非金銭的インセンティブ、透明性の高い成果主 義のキャリアアップ機会などがある。これらの条 件は、看護職の定着に密接に関連しており、ジェ ンダー、社会的背景、出身国、出身地域、民族、 言語にかかわらず看護職に適用すべきであり、明 確な説明責任メカニズムを通じて施行されるべき である。保健医療従事者による争議やストライキ は、適切な給与と適正な労働条件を含む保健医 療従事者の権利を理由としたものが多い。（Box 6.8 保健医療従事者のストライキを参照）。 164. 各国は、人道的危機の影響を直接受けている看 護職を保護し、支援しなければならない。保健省、 72 State of the world’s nursing 2020　世界の看護 2020 看護職能団体、NGO は、関係各所と協力して、 著しいリソース不足や過酷な状況下（難民キャン プや避難所など）でケアを提供している可能性の ある看護職や、自身が国外避難民であり、所有す る看護資格が認められない地域で働いている看 護職を、確実に保護・支援する必要がある。これ により、あらゆる状況で、すべての保健医療施設 の保健医療従事者、特に危機において攻撃やハラ スメントに遭いやすい女性の、安全を確保できる。 6.3.5 ジェンダーと女性の権利 結果のまとめ 165. 世界の看護人材の約 90% は女性で構成されてい る。看護におけるジェンダーの課題は、複雑な報 酬パタ ンーにつながり、多くの国で「ジェンダー賃 金格差」を生じている。ただし、エビデンスが得 られたのは主に高所得国からである（21）。ジェン ダー賃金格差政策の効果的な実施とモニタリング は、保健人材のジェンダーの均衡化を慎重に推し 進め、ジェンダーの偏見などによって看護職の仕 事を過小評価してきた経緯を克服するために必要 である（121、232）。WHO の分析によると、世 界の保健分野のリーダーの地位はこれまで男性に 占められており、女性が占めるのは 25% のみで ある（21）。Nursing Now キャンペ ンーから委託 された、看護におけるリーダーシップの阻害要因 と促進要因の調査では、女性にとっての「ガラス の天井」だけでなく、男性にとっての「ガラスのエ レベーター」についても説明している（122）。こ れは、保健システムの全レベルに浸透し、看護人 材管理全体に影響を与える、根深いジェンダー不 均衡の可視化された一例にすぎない。 政策オプション 166. 各国は、女性看護職に影響を与えるジェンダー 賃金格差に対処する必要がある。一部の国で は、看護職の給与に関し他の職業と比較してジェ ンダーによる不均衡が生じている。この問題に は、国の給与水準の分析と、保健医療従事者に おける、ジェンダー格差のないより公平な給与体 系の実施から取り組むことができる。そのために Box 6.6 オマーンにおける地域保健サービスへのアクセス拡大 オマ ンーは、看護師と助産師の教育方針を見直し、一次医療のコンピテンシーに力を入れた例を示している。 一次医療のコンピテンシーは、WHO 東地中海地域委員会第 66 回会議（2019 年 10 月）で採択された看 護人材強化に求められる対策のひとつであった（290）。 オマ ンーでは、人口と平均寿命が急速に伸びている。また社会経済の発展に伴い、慢性疾患の負荷が増加し ている。この集団の健康問題に対処するため、政府はコミュニティーヘルスナ スーへの投資を決めた（291）。 保健省の看護・助産局は、16 週間の実地研修プログラムを立ち上げ、最初は首都マスカットで試験的に実施し、 その後他の州に拡大した。その役割は、一次医療施設で提供されるサービスに沿った形で、プライマリ・ヘル スケア構造に取り入れられた（292）。 最終的に、16 週間の研修は地域保健サービスに重点を置く看護学士号に変わり、その後さらに、地域保健 を専門とする資格となった（291）。この専門プログラムは、国の一次医療サービスのニ ズーを満たすための、 コミュニティーヘルスナ スーの継続的な養成に貢献している。 73看護人材政策の今後の方向性 は、保健医療従事者の給与に対する適切な政策 と、財源の見直しが不可欠である。経済状況が 給与水準に影響を与えることは認識しつつ、ジェ ンダー賃金格差に対処する法や政策は、必要に応 じて民間にも適用されるべきである。給与の公平 性と政策策定の評価は、看護界のリーダーも参画 しなくてはならない。 167. 各国は、看護および保健人材全体におけるセク シャルハラスメントと差別に対する政策を、優先 して実施する必要がある。これには、暴力、言葉 によるハラスメント、身体的ハラスメント、セクシャ ルハラスメントを決して容認しない政策と、女性 としてのニーズ変化に対応する、看護職の柔軟な 労働時間など、女性にとって適正な労働環境を創 出する政策と、看護人材における女性のリーダー シップ育成の機会を含める必要がある。 6.4 効果的なガバナンスのためのキャパ 　　　シティー ・ビルディングとリーダーシッ 　　　プスキルの構築 結果のまとめ 168. 80 を超える国が、保健と看護に関する政策決定 に関与する、看護職の国レベルのリーダー的役 職があると報告している。政府の看護行政責任 者は、他の保健医療職のリーダーと全面的に協 力し、保健サービスの計画、ケアの提供、労働 条件に関する戦略的決定を行う必要がある（316）。 優先事項を特定した上で、教育能力を強化し、雇 用を創出し、エビデンスに基づいた看護職の定着 対策を開発するには、労働市場と財政状況の分 析、労働力の政策・計画・ガバナンスにおけるキャ パシティーが必要である。本報告書の調査結果 によると、回答国 76 カ国のうち 53% に、国が 実施する看護職のリーダーシップ育成プログラム がある。ただし、プログラムがある国の大多数は WHO のアフリカ地域と東地中海地域に属し、世 界的には不均衡である。 169. 適切な看護・保健政策の立案・実施には、保健 を越えた広い視野での政府の対策に、看護人材 の優先事項を組み入れるための制度、メカニズム、 政策手順も必要である。本報告書の調査結果で は、看護行政責任者の役職と看護職のリーダー シップ育成プログラムの存在は、より強力な看護 関連法規があることと関連している。しかし、看 護行政責任者の存在とリーダーシップ・プログラ ムの有無には、関連があるわけではない。これは、 リーダーシップ・プログラムが看護職能団体によっ て、所属メンバー向けサービスや職能団体の収入 を目的として運営されてきたためである。 © Kieran Dodds 74 State of the world’s nursing 2020　世界の看護 2020 政策オプション 170. 看護職のリーダーシップは、国、地域、世界の すべてのレベルで育成されなくてはならない。看 護職には、リーダーシップの可能性を伸ばし、意 思決定の場に参加する機会が必要である。看護 職は、ほかの保健医療専門職と同様に、自治体 等だけではなく、中央や地方政府のリーダー的役 職への任命を検討されるべきである。この取り組 みには、看護職のリーダーシップ育成を目的とし た予算配分が必要である。国による表彰制度の 創設などにより、ユニバーサル・ヘルス・カバレッ ジ推進に対する看護の貢献を認め、若手看護職 にロールモデルとして示すことができる（Box 6.9 西太平洋地域のリーダーシップ・フェローシップ・ プログラムを参照）。 171. 国の保健システムの政策決定の場に、看護職の 視点を取り入れるべきである。政策決定において は、看護職がすべてのレベルの議論に参加し、主 要な保健システム上の決定と集団の健康政策立 案に発言権を持てるようにすべきである。また、 臨床上の意思決定、すなわちガイドラインの開発 やレビューに看護職を参加させ、提言の実現可能 性や容認性について看護の研究成果や知見を反 映させるようにすべきである。 6.5 看護職養成のための投資の促進 結果のまとめ 172. 本報告書は、ユニバーサル・ヘルス・カバレッジ 達成に向けた保健医療従事者への投資の根拠と なる、看護職養成の重点化に関するデータを提 供する。ここ数年改善傾向ではあるが、看護職 の養成と雇用が大幅に増加しない限り、看護職 人口は今後10 年間でほとんどの地域でごくわず かに改善するのみとなり、低・中所得国、特に WHO のアフリカ、南・東アジア、東地中海地域 では、ニーズに対する大幅な不足が続くであろう。 173. 教育、スキル、雇用創出、採用、配置と定着の 政策、資格や認証に関連する機関などの能力開 発への投資に十分な財源を確保するためには、部 門横断的な政策対話が必要となる。保健労働市 場の拡大は、特に女性の雇用機会を生む。看護 の仕事の拡大は、女性の労働力への参入（世界全 体で、男性の 75% に比べ、女性はわずか 48%） と女性の雇用率を高める（326、327）。看護職 養成への投資は、健康、ジェンダー平等、開発と いう「3 分野への配当 (triple devidened)」に有 効であることが、強いエビデンスによって裏付け られている（21）。 政策オプション 174. 各国は、看護職養成のために、複数部門によ る対策と持続可能な財源を検討する必要がある。 ほとんどの国では、現状の財源の中で人件費の伸 びを効率的に管理することで、今後必要とされる あと 590 万人（現在の不足分を埋めるために必要 な人数のみ）の新しい看護職のポストを創設する ことが可能となる。国の計画立案者は、他の職 業グル プーと比較して看護職への投資の効率性を 検討し、適切なインセンティブと管理システムを 通じて、現在および将来の看護人材の養成数を 適正化すべきである。多くの高・中所得国では、（安 定した経済成長があり保健政策を優先すると仮定 した場合）公的資金を医療従事者の継続的な必 要経費に当てることが可能である（328）。一部の 高・中所得国は、保健医療従事者の養成数や雇 用の制限を撤廃し人材不足に対処することで、国 際的に移動・移住してくる看護人材への過度の依 存を減らすことができる。128. 開発パートナーは、 看護職の教育と雇用のための公的な開発援助を、 国の保健人材や保健セクターの戦略と整合させる 必要がある。一部の低・中所得国は、財源不足 により、看護職の雇用を創出する上で課題に直面 するだろう。ドナーや開発パートナーの支援を統 一・整合させることによって、保健・福祉の労働 力を強化するための持続可能な財源の拡大と、人 件費全体の増額が可能になり、ユニバーサル・ヘ ルス・カバレッジの進展を加速できるようになる （Box 6.10 人的資源への投資を参照）。低所得 国や、紛争等によって脆弱な状況にある地域など、 中長期的な国内財源不足が予測され、状況が許 す場合は、資金プールの取り決めなどを検討する ことも可能である。 75看護人材政策の今後の方向性 175. 開発パートナーは、看護職の教育と雇用のため の公的な開発援助を、国の保健人材や保健セク ターの戦略と整合させる必要がある。一部の低・ 中所得国は、財源不足により、看護職の雇用を 創出する上で課題に直面するだろう。ドナーや開 発パートナーの支援を統一・整合させることによっ て、保健・福祉の労働力を強化するための持続可 能な財源の拡大と、人件費全体の増額が可能に なり、ユニバーサル・ヘルス・カバレッジの進展 を加速できるようになる（Box 6.10 人的資源へ の投資を参照）。低所得国や、紛争等によって脆 弱な状況にある地域など、中長期的な国内財源 不足が予測され、状況が許す場合は、資金プー ルの取り決めなどを検討することも可能である。 176. 各国は、国内外の労働市場の状況を鑑み、看護 職の報酬に関する課題に取り組む必要がある。政 策立案者や規制当局は、よくある落とし穴を慎重 に回避する必要がある。落とし穴には、継続的 な低すぎる報酬体系（意欲の喪失、離職の増加、 違法な対応などにつながる可能性あり）、継続的 な高すぎる報酬体系（賃金インフレーションと人 件費全体の持続可能性の問題につながる可能性 あり）、またジェンダーによる報酬格差の固定化な どが考えられる。支払い方法も重要である。通常、 看護職は報酬として固定給を支払われ、兼業によ る収入は他の職業よりも少ない。国の優先事項に 合致しない、持続可能ではない、特定の疾患や プログラムだけでの報酬の上乗せは、避ける必要 がある。また政策立案者は、看護職になること で不利益が生じないよう、保健専門職全体の報 Box 6.7 アフリカ保健人材法規共同体（African Health Professions 　　　　　Regulatory Collabolative: ARC） ARC は、各国の看護師と助産師の法規の更新を支援し、HIV 患者のケアと治療が安全で持続可能になるよう な看護主導モデルを促進するために設立された。この共同体には、東部・中央部・南部アフリカ看護大学の メンバー国の大半からなる 17 カ国が参加している（308）。 ARC は、各国政府の看護行政責任者、全国の看護職能団体会長、学術界のリーダー、看護師・助産師評 議会の登録担当者を招集し、各国が特定した法規課題の優先順位付けと協力体制作りを支援した。各国で取 り組みを率いるチームは、自ら「クワッド」と名乗り、年に一度、法規の優先事項（HIV 関連を含む業務範囲、 HIV コンテンツの継続的な専門能力開発要件など）に共に取り組んだ。クワッドは、各国内で頻繁に会合を開 いたのみならず、同様の優先事項に取り組む地域関係者と頻繁に会合を行った。進捗状況は定期的に、また さまざまな方法で測定された（309）。 2011 ～ 2016 年の 5 年間で、看護師および助産師の法規は強化され、クワッドはリーダーシップスキル、組 織の能力、および各国の看護師・助産師組織間の協力体制の大幅な向上を報告した（310）。ARC は寄付 金によるイニシアチブであったが、「クワッド」の配置は東部・中央部・南部アフリカ看護大学で制度化されて おり、看護師と助産師のリーダーシップを活用して国の保健上の優先事項に取り組むための継続的なメカニズ ムとして機能している。 76 State of the world’s nursing 2020　世界の看護 2020 酬の一貫性を考慮する必要がある。看護職には、 国のニーズに合った人数が、意欲を持って定着で きるレベルの報酬が与えられるべきである。 6.6 研究とエビデンスの展望 177. 本報告書は、看護人材に関する過去に例のない 豊富なデータとエビデンスをもたらし、加盟国や ステークホルダーに向けて政策の策定を可能にし た。同時に、政策の策定は、データとエビデン ス双方の有効性において限界もあった。以下に述 べるのは、データとエビデンスの欠損部分であり、 今後の研究テーマの一部になると考えられる。 178. 看護に関する定量的・半定量的エビデンス。本 報告書で明らかになった最も重要な点の1つは、 データそのものではなく、データの状況に関する ものである。看護人材を包括的に理解し、保健 労働市場の分析（特に養成能力、離職、賃金レ ベル、雇用など）に必要な情報が、大幅に不足 している。これらのエビデンスの照合、分析、活 用を支えるシステムの強化が必要である。国家保 健人材統計の実施には、複数部門の強力な関与 が必要だが、これによって、看護の発展のための、 持続可能な投資に関する政策対話と意思決定を 支援することができる。 179. プライマリ・ヘルスケアとユニバーサル・ヘルス・ カバレッジにおける看護人材の有効性に関する エビデンス。本報告書では、さまざまな臨床や 集団の健康分野における看護職の貢献に関する エビデンスをまとめた。最も強力なエビデンスは、 一次医療における看護職による介入の有効性を 示した18 件の系統的レビューから得られた（30）。 ただし、18 件のうち17 件は高所得国で実施され ており、中所得国は1 件、低所得国での調査は 皆無だった。また、抗レトロウイルス療法、禁煙、 Box 6.8 保健医療従事者のストライキ 世界中の多くの国で、労働者は公民権としてストライキを行う権利がある（311）。しかし保健医療従事者の 場合、この権利の行使は複雑である。権利の行使によって、患者や市民がケアを受ける、またユニバーサル・ ヘルス・カバレッジを受ける権利を侵害され、死亡率増加につながる場合がある（311–314）。それにもかか わらず、看護職を含む保健医療従事者のストライキは、世界中で行われている（313、314）。低所得国のス トライキを分析したところ、2009 年から 2018 年の間に、23 カ国で、保健医療従事者が 875 営業日にわ たりストライキを実施したことが明らかになった（311）。この調査によると、ストライキは数日から数ヶ月に及 び、数ヶ月間または数年の間に再発したケ スーもあった（311）。これらのストライキにつながった第一の原因は、 報酬額とその支払い遅延に関する不満であり、続いて以前の合意内容の不履行への抗議、または保健セクター のガバナンスと政策に対する抗議、労働条件と安全問題に関する苦情であった。保健医療従事者のストライキ を減らすには、複数のステークホルダーによる、多面的、多部門的なアプローチが必要である（311、314、 315）。和解に向けてだれがどのように関与すべきかについては、地域全体のパタ ンーや個人的な要因などの、 さらなる調査が必要である（311）。しかし、保健医療従事者のストライキの要因に対処するためには、政治 的指導者の支援と共に、保健その他の複数セクターによる対策が必要である（314）。安全で適切な労働環 境を保証する、保健医療従事者の労働条件への投資は、ユニバーサル・ヘルス・カバレッジの実現と、カバレッ ジを受ける権利の保護に不可欠である（314）。 77看護人材政策の今後の方向性 が低所得国、15 件が低・中所得国の調査であっ た（31、33、34）。また概説においても、気候変 動など健康の社会的決定要因に関する看護介入や、 複雑な緊急事態における看護介入など、有効性に 関するエビデンスが欠けているテーマが示されて いる。 180. さまざまな研究の場と方法論の活用。前述のレ ビューは看護介入の有効性を確立する上で不可欠 なものであるが、研究の状況によっては、一般化 やグローバルな適用は制限される。さらに、実験 的・準実験的な調査では、大半のケースで看護 職を他の保健専門職と比較している。これは有用 な知見をもたらすかもしれないが、多職種連携で の取り組みによる、質の高いヘルスケア提供の成 功のプロセスを十分に理解するためには適さない。 量的（実験的および非実験的）研究、質的研究、 混合研究、フィー ルド記述型事例研究などの幅広 い研究によって、世界全体の看護政策の課題への 包括的な理解が促進される（Web 付属文書を参 照）。しかしこのエビデンスの大半は、研究課題 の優先順位（330）を含め、高所得国で実施され た研究によるものであった（30、329）。 181. 低・中所得国での看護介入の文書化を進め、看 護学の発展を支援するためには、さらに多くの措 置を講じる必要がある。これにより、看護職自身 が保健サービス提供における自らの経験に基づ き、自らの研究を推し進められる。看護職はすで に、革新的な研究法を開発したり、これらの方法 を使って調査したりすることで、世界の健康改善 に多大な貢献をしている（331）。低・中所得国の 保健医療従事者の実践力を向上させるには、効 果的な戦略に関するエビデンスが不足している （332）。看護研究への投資は、業績数の増加だ けでなく、看護学の質の向上にも重点を置く必要 がある。それが、保健人材に関するの知識全体 に貢献するからである。 182. 看護の役割を適正化するための効果的な政策と システム支援に関するエビデンス。本報告書では、 教育、法規、配置、実践、定着など、多様な分 野における看護職の貢献とインパクトを最大化す る政策についてのエビデンスを多数取り上げてい る。一方、その他の分野のエビデンスは不足して いる。たとえば、看護職と幅広い保健人材への © Janice Mullings-George メンタルヘルス、性的暴力などについても、コク ランとキャンベルの系統的レビューが実施されて いる。これらのうち、1 件はランダム化比較試験 のみだが、他のレビューは比較試験（ランダム化・ 非ランダム化）、前後比較試験、コホート研究（前 向き・後ろ向き）、分割時系列研究など、実験 的・準実験的研究の両方を含んでいるため、ケー スとコントロールの比較が可能となった（31、33、 34）。キャンベルのレビューは米国と英国での実 践に限定しており、調査結果もこれらの国に限定 された。抗レトロウイルス療法に関するレビュー は、アフリカの調査のみであった。禁煙に関する レビューはすべて高所得国、主に米国で行われて いた。メンタルヘルスに関するレビューは、7 件 78 State of the world’s nursing 2020　世界の看護 2020 © WHO/Yoshi Shimizu 投資利益率については、看護職によるケアの費用 対効果調査（特に低・中所得国の一次医療におけ る）などによってもっと理解が可能であるし、さ まざまな状況や政策の文脈の中で研究されるべ きである。また、看護職の定着のための有効な 政策介入、看護職が一次医療サービスにおいて 業務の全範囲をカバーできるようにするための法 規やガバナンスのアプローチ、また民間部門の教 育と実践を規制する効果的なメカニズムなどのエ ビデンスも、さらに必要である。移住によるネガ ティブな影響に対する政策をきちんと評価するこ とで、移動する保健人材に対する、より適切で現 実的な政策策定が可能となる。これらすべてにわ たり、明確なジェンダー平等の視点を持った分析 が必要である。レビューされた研究の多くは対象 期間が短期であるため、長期間の縦断的研究を 行えば、調査結果と実際の政策との関連性も明ら かになると考えられる。 79看護人材政策の今後の方向性 © WHO/Yoshi Shimizu Box 6.9 西太平洋地域におけるリーダーシップ・フェローシップ WHO 西太平洋地域の保健システムは、非感染性疾患と感染性疾患の二重の課題を抱えると同時に、深刻な 社会・経済・環境の課題にも直面している。西太平洋地域では看護職がケアの約 78% を提供しているため （317）、人々の健康の改善に必要な能力を得られる教育が非常に重要である。しかし、西太平洋地域にはリー ダーシップ・プログラムがなく（318、319）、保健専門職向けのプログラムもごくわずかで（320 ～ 322）、 しかも既存のプログラムは地域の文化に適合していなかった（317、323、324）。 シドニー工科大学は 2009 年から2017 年にかけて、南太平洋看護・助産行政官連盟と提携して、リーダーシッ プとメンターシップのプログラムを実施した（318）。このプログラムでは、保健人材、集団文化、メンターシッ プ教育、政策の実施、ユニバーサル・ヘルス・カバレッジとのリンクに重点が置かれた。プログラムの評価には、 14 カ国の 300 名を超えるステークホルダーとプログラム参加者が関わった（318）。 初回の評価によると、リーダーシップ・モデルの参加者の 85% が大幅にキャリアアップし、看護・助産の上級 の役職に就いた。また参加者は自国において、若手育成、専門能力開発、法規、卒後教育などの分野でプロジェ クトを実施した（319）。もうひとつの大きな成果は、これらの専門職が世界規模の会合に参加し、政策に影 響を与えていることである（325）。リーダーシップ・プログラムを修了した 9 名の参加者は、第 72 回世界保 健総会に出席した。6 名は自国政府の看護行政責任者に、2 名は自国の保健大臣となった。 80 State of the world’s nursing 2020　世界の看護 2020 Box 6.10 人的資源への投資 ユニバーサル・ヘルス・カバレッジ達成の基本である質の高いプライマリ・ヘルスケア・サービスへのアクセス を増やすには、インフラ（医療施設など）と関連する人的資源（知識と技術を持った保健医療従事者）への 大幅な投資が必要である（14、328）。多くの人的資源への取り組みは、それを必要とする国が健康、栄養、 質の高い教育と技術の向上に、より多く、より効果的に投資することに重点を置いている。 · 世界銀行は、特にアフリカに重点を置き、低・中所得国での人的資源改革を支援するために 150 億米ド ルの投資を約束し、63 カ国が署名した。 · 国際通貨基金は、社会のための支出を目的とするすべてのプログラムを強化している。社会のための支出、 社会保護、教育、健康の分野で追加的な支援を提供している。 · ヨーロッパ投資銀行とWHO は、ユニバーサル・ヘルス・カバレッジの実現に向け、ヨーロッパ投資銀行 による投資と、保健セクターの教育、技術向上、雇用に的を絞った支援を結びつける金融商品の開発を 通じ、人的資源に関する課題でパートナー関係を結んでいる。 · OECD、WHO、ILO は、国連マルチパートナー信託基金を設立し、変容する教育、スキル、雇用創出に 関連する「保健の雇用と経済成長に関する国連ハイレベル委員会」からの勧告を実施するための財源を 確保している。 81看護人材政策の今後の方向性 © AKDN/Christopher Wilton-Steer 82 State of the world’s nursing 2020　世界の看護 2020 183. 本報告書は、ユニバーサル・ヘルス・カバレッジ をはじめとする国と世界の保健目標に向け、保 健人材のなかで看護職が中心的役割を果たして いることを明確に示している。看護職は推計約 2,800万人の最大の職業グル プーであり、世界の あらゆる国で、プライマリ・ヘルスケアと保健シス テムの中心的な要素である。 184. 本報告書で収集されたデータとエビデンスは、 これまでになく強力なものである。看護人材の ストックについて報告したのは計191カ国と過去 最大の数であり、2018年に発表されたデータか ら53%の増加となった。今回初めて80%の国が、 様々な政策面の最低15の指標に関するデータを WHOに提供した。分析によると、2018年の時点 で世界では590万人の看護職が不足しているが、 それはおもにアフリカ、南・東アジア、東地中海の 各地域に集中している。これは、「保健人材の世界 戦略」で示されたベースラインの状況と比べ、看護 人材が不足している国々でのストックが改善して いることを示している。 185. 本報告書は課題も浮き彫りにしている。低・中所 得国およびアフリカと東地中海の各地域では、大 幅な人手不足への対応を急ぐ必要がある。看護職 の人数に最大の不足が生じているのは、依然とし て南・東アジア地域である。アメリカとヨーロッパ の各地域は、看護人材の高齢化という新たな脅威 に直面している。アメリカ、ヨーロッパ、東地中海 の各地域の複数の高所得国は、移住した看護職に 過度に依存している。 186. 各国政府は、必要に応じて国内外のパートナーか らの支援を得て、次のような取り組みを加速し、 主導する必要がある。 • 教育、保健、雇用、ジェンダーなどの分野にお ける看護人材のリーダーシップ、財務管理、運 営能力の構築。 • 看護人材の教育、適正な労働、配置、実践、生 産性、法規、定着に必要な政策導入による、看 護職への投資の最大化。 結論 7CHAPTER 83結論 • 保健人材、その一部である看護職への大規模 投資と、それによる、雇用創出、ジェンダー、若 者のエンパワーメントなど複数の開発目標の 達成。 187. 本報告書のエビデンス、推奨される政策、戦略的 方向性を実現するには、政府部門間の調整とス テークホルダーとの協力が必要である。提示され た調査結果とデータをもとに、各国では、重要な ステークホルダーによる政策対話を開始し、健全 でエビデンスに基づいた政策の策定と適切な投資 を引き出すべきである。 © WHO/Yoshi Shimizu 84 State of the world’s nursing 2020 いまこそ 看護職の 教育、労働、 リーダーシップに 投資し、 2030年の SDGｓ達成に貢献しよう 1 . 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Lancet Global Health . 2018;6:e1163–75 . doi:10 .1016/s2214- 109x(18)30398-x . 99参考資料 付属文書1 . 看護職とは誰を指すのか 看護職は、専門病院から診療所、 地域社会まで、あらゆる保健医療 の場において、人々に多種多様な サービスを提供する。看護職には 多様な職名、役職、教育経路が ある。最も一般的な看護職の職名 は、登録看護師、看護師、認定実 践看護師、高度実践登録看護師、 ナース・プラクティショナー、看護 助手の 6 つである。しかしながら、 たとえ職名が同一であっても、役 割が国によって異なる場合がある。 このため、世界レベルでの分類と 分析の手法として職名を使用する ことは不適切である。 本報告書で目指しているのは、ILO 2008 国際標準職業分類（ISCO- 08）によって定義され、WHO 加盟 国によって報告および検証された、 看護人材に関する入手可能な最良 の、そして国際的に比較可能なデー タを提示することである。この目 標の達成を助けるため、「国家保健 人材統計」では、保健医療従事者 の分類に ISCO-08 システムを使 用している。各国は、自国の看護 人材を2つの主要なISCO-08コー ド、すなわち「看護師（ISCO コー ド 2221）」と「准（準）看護師（ISCO コード 3221）」のいずれかに分類 するよう求められた。本セクション では、前述のように定義された職 業グル プーとしての看護職について 報告するが、「看護ケア」では、看 護職は多数職種からなる保健シス テム内に置かれるため、本セクショ ンで説明されていないその他複数 の職業が関わることに注意された い。たとえば、ISCO 分類と ISCO に準拠した国のシステムでは、「看 護助手」は、より広い支援的職業 グル プーであるヘルスケアアシスタ ントとして分類される12。 ISCO ガイダンスは、どの保健医 療従事者をどのカテゴリーに分 類すべきかについて、詳細な説 明を提供する（BoxA1.1）。要約 すると、看護師は、患者の看護 の計画と管理に責任を負い、自 律的に、または医師らとチーム で働く。准（準）看護師は、基 本的な看護とパーソナルケアを 提供し、一般に医療、看護また はその他の医療専門職の監督下 または支援のもとで働く。 しかしながら、一部の国では、 看護師と准（準）看護師の区別 が曖昧である。同様に、看護の 準専門職と看護助手の違いも必 ずしも明確ではない。したがっ て、こうした場合、国のステーク ホルダーによる判断が求められ た。各国に対しては、ある職業 グループを看護師と准（準）看 護師のどちらに分類するか、あ るいは看護職に分類しないかを 決定する際には、役割と責任、 養成教育の期間を考慮するよう 助言された。たとえば、原則と して、看護師は少なくとも 3 年 間の養成コースを修了している。 国が使用カテゴリーを決定でき なかった場合、国家保健人材統 計には「看護職：詳細な定義な し」のオプションが含まれており、 一部の国では、看護職の一部ま たはすべてをこのカテゴリーに分 類することを選んだ。このカテ ゴリーは、看護師または准（準） 看護師には当てはまるが、看護 助手には当てはまらない。後者 はヘルスケアアシスタントの職業 グル プーに属しており、本報告書 の分析の対象とはなっていない。 12.　ILO 国際標準職業分類：https://www.ilo.org/public/english/bureau/stat/isco/　 100 State of the world’s nursing 2020　世界の看護 2020 看護師の業務は以下を含む： 准（準）看護師の業務は以下を含む： · 患者への看護ケアを企画、提供、評価する · 他の保健医療専門職と相談して患者のケアを調整 する · 他の保健医療専門職と協力して、患者の治療のた めのケア計画を作成、実施する · パーソナルケア、治療法を計画、提供する（薬物 の投与や、治療またはケアに対する反応のモニタリ ングを含む） · 傷を洗浄し、保護する · 患者の痛みと不快感を観察し、鎮痛薬を含むケア を提供する · 健康教育プログラム、健康増進、看護教育活動を 計画し、それに参加する · 患者や家族からの質問に回答し、疾病の防止、治 療、ケアに関する情報を提供する · 他の保健医療従事者の仕事を監督、調整する · 看護の実践と手順に関する研究を実施する · 保健医療専門職によって設定されたケア計画に 従って、患者への看護ケア、治療上・健康上のア ドバイスを提供する · 患者への投薬やその他の治療を実施し、患者の状 態と治療への反応を観察し、必要に応じて特別な ケアのために患者とその家族を保健医療専門職に 紹介する · 傷を洗浄し、保護する · カルテ上の、患者の状態と治療に関する情報を更 新する · 個々の患者のケアの計画と管理を補助する · 緊急時の応急処置を補助する ISCOによる看護職の定義Box A1.1 注：看護師と准（準）看護師の区別は、上で指定した業務に関連して行われる作業の性質に基づいて行う必要がある。看護職の養成プロセスは国によって 大きく異なり、国内でも時と共に変化しているため、個人が保持する資格や国において一般的な資格は、この区別を行う主な要素とはならない。 出典：ISCO-08から翻案。 101付帯資料 1 付属文書2 . 方法 本報告書で使用された指標 WHO 加盟国は、2019 年 7 月から 2019 年 11 月までの間に、36 の 指標（国家保健人材統計からの 30 指標および 6 つの追加の固有指標） を通じて、看護人材に関する最新の 入手可能なデータを提出するよう要 請された（表 A2.1のリストを参照）。 30 の指標は国家保健人材統計ハン ドブック 13 で定義されており、この ハンドブックは各指標の詳細な定義 とメタデータも提供している。 データ収集プロセス 国家保健人材統計は、保健人材の データの入手可能性、質、利用を 段階的に改善するための継続的な プロセスである。このプロセスの一 環として、各国は、データ提出前に 内部で検証を行うため、すべての 保健人材のデータに関するマルチス テークホルダー作業部会を設置す るよう奨励され、多くの国で設置 された。本報告書の作成は、標準 化されたデータのモニタリングと報 告の改善という世界規模の取り組み を加速させた。各国は担当者を指 名するよう求められ、この担当者に は、データの入力と検証のための国 家保健人材統計オンラインプラット フォームへのアクセス権限が与えら れた。さらに、OECD、ユーロスタッ ト、WHO ヨーロッパ地域事務局 共同のデータ収集質問票で得られ た OECD 諸国のデータは、国際機 関への重複報告を避けるために自動 入力され、担当者はこのデータを 確認・検証するよう助言された。各 国の人口の年次推移は、国連経済 社会局の「世界人口推計」の 2019 年改訂版から抽出された 14。少数 の国の情報を補完するため、ガバ ナンスと政策環境を評価する指標 と、教育と研修の期間についての追 加データを、シグマデータベースと NCBSN データベース15 から収集し た。 データ収集を支援するため、WHO は 6 つの地域すべてにおいて地域 国家保健人材統計ワークショップ を実施し、複数言語でツールと情 報を提供した。約 80 カ国から計 250 人を超える代表がこの能力構 築イベントに参加した。データは 2019 年 7 月から11月の間に提出 され、データのクリーニングと分析 は 2019 年 10 月から12 月の間に 行われた。本報告書は、2019 年 12 月17 日現在の国家保健人材統 計オンラインプラットフォームから のデータセットに基づく。 国家保健人材統計担当者は、看護 指導者や他のステークホルダーを 関与させるよう助言された。WHO の国と地域の事務局は、関連デー タの収集、報告、検証を含む、国 家保健人材統計の実施と報告のプ ロセスを支援した。 報告されたデータ 194 カ国 の WHO 加 盟 国 のうち 193 国が、国家保健人材統計プラッ トフォーム経由で直接、または地域 事務局およびその他の国際プロセス （OECD、ユーロスタット、WHOヨー ロッパ地域事務局による「非金銭的 ヘルスケア統計についての共同デー タ収集」など）を通じて、データを 報告した（191カ国がストックにつ いて報告）。図 A2.1は、80% の国 が 36 の選択指標のうち少なくとも 15 の指標についてデータを提供し、 23% の国が少なくとも 25 の指標 のデータを提供したことを示してい る。 主なデータ欠落は、賃金、看護教 育への支出、およびその他の教育 関連問題の指標に関するものであっ た。教育と研修の期間、賃金、能 力の指標など、一部の選択指標に ついては、国家保健人材統計デー タを補足するための代替ソースが特 定された。たとえば、国際看護名 誉協会であるシグマは、世界の看 護教育のステータスに関するデータ ベースを管理しており、そこにはさ らに約 50 カ国の基礎レベルの賃金 や教育プログラムの期間に関する 指標も含まれている。看護職の実 践と教育の政策と法規に関連する 一連の二択式指標については、資 格試験が必要な国と法規機関が存 在する国を特定するために、世界 法規アトラスが使用された。 191カ国のうち、83% が 2017 年 または 2018 年の看護職数のデー タを提供した。その他の国が提供 できたのは、それ以前の年（2013 年から 2016 年）のデータのみで あった。このような場合、入手可能 な最新の年の密度を 2018 年の人 口に適用して、2018 年の人数を推 計した。人数が報告されなかった 4 カ国に関しては、対応する地域での 密度が 2018 年の人口に適用された。 多くの国（特に西アフリカ、中央ア フリカ、中央アジア）が複数指標 のデータを提供できなかったという 13.　「国家保健人材統計：実装ガイド」。ジュネ ブー：WHO。2018 年。 14.　経済社会局人口部。「世界人口推計 2019」、オンライン版、改訂 1。ニューヨーク、アメリカ合衆国：国際連合。2019 年。 15.　シグマデータは https://www.sigmanursing.org/advance-elevate/research/research-resources から抽出。 　　NCSBN データは https://www.ncsbn.org/national-nursing-database.htm から抽出。 102 State of the world’s nursing 2020　世界の看護 2020 30の指標は国家保健人材統計ハンドブックに由来し、6つは本報告書のために特別に作成された。 指標名 （国家保健人材統計での略称） 国家保健人材 統計番号 2019年 12月17日時点の 回答率 看護職労働力のストックと配分 看護職密度（種類・レベル別） 1-01 98% 看護職密度（地方レベル） 1-02 31% 看護職配置（年齢グル プー別） 1-03 55% 女性の看護人材 1-04 68% 看護職配置（施設の所有者別） 1-05 47% 看護職配置（施設の種類別） 1-06 34% 外国出身の看護職の割合 1-07 35% 外国で教育を受けた看護職の割合 1-08 46% 教育と訓練 認証を受けた教育機関のマスターリスト 2-01 88% 教育と研修の期間 2-02 56% 教育と研修の応募数 2-03 12% 資格を持つ教員に対する看護学生の割合 2-05 10% 教育と訓練の規則と認証 教育の期間と内容の基準 3-01 87% 教育機関の認証メカニズム 3-02 84% 多職種間連携教育の基準 3-06 80% 継続的な専門能力開発 3-08 82% 教育の財政 看護教育の卒業者一人あたりの支出 4-05 7% 保健労働市場の変動 1年以内に実務を始める卒業者 5-01 14% 国内の取り組みによる補充率 5-02 45% 外国人看護職の参入率 5-03 11% 保健労働市場からの自発的な退出率 5-04 9% 失業率 5-06 8% 雇用の特性、労働条件 パートタイム契約の保健医療従事者 6-02 6% 労働時間と労働条件の法規 6-03 86% 最低賃金の法規 6-04 86% 社会的保護の法規 6-05 86% 保健医療従事者への攻撃予防策 6-09 80% 看護人材の支出と報酬 基礎レベルの賃金と給与 7-05 42% ジェンダーによる賃金格差 7-07 3% 様々なケアモデルのための スキルミックスの構成 高度実践看護職の有無 8-06 79% 「世界の看護2020」のために 追加された指標 国の主任看護官（または同等）の役職 – 84% 国のリーダーシップ開発機会 – 76% 国の資格取得前学生のための協会 – 76% 看護職を法規する機関 – 98% 教員資格の基準 – 68% 実践適性試験または資格試験 – 92% 本報告書に使用された36の指標のリスト表 A2.1 注：国家保健人材統計指標の詳細については、メタデータを含む詳細情報が国家保健人材統計ハンドブックで入手可能。 https://www.who.int/hrh/documents/brief_国家保健人材統計_handbook/en/　 追加の6つの非国家保健人材統計指標のメタデータは、SOWN2020@who.intへの要請により提供可能。 103付帯資料 2 事実は、これらの地域の保健医療 情報システムのための人材を引き続 き強化する重大な必要性があるこ とを示している。 収集されたすべてのデータが本報 告書で示されたわけではない。か なりの数の国が統計を報告した指 標のみが分析され、提示された。 さらなるデータが、国家保健人材 統計データへのアクセスのための パブリックポータルを通じて段階 的に利用可能となる。 セクション 5.4 および 5.6 の教育 法規と労働条件に関する集成値 分析の大半は純然たる記述的性質 のものであり、主にパーセンテー ジに焦点を絞っているが、教育法 規と労働条件の指標の概要説明に は集成値が使用された。どちらの 値も、答えが「はい」であったす べての指標について 1 ポイントが 国に与えられ、答えが「部分的に」 であった場合は 0.5 ポイント、答 えが「いいえ」であった場合は 0 ポイントとなり、その後値を集計し て、集成値が決定された。したがっ て、想定される最大値は 9、最小 値は 0 であった。情報が欠落して いる指標については「いいえ」と見 なされたため、0 ポイントとなった。 セクション 5.4 および 5.6 の教育 法規と労働条件の多重対応分析 教育と実践の法規に関する指標は、 高いレベルの関連性を示している。 一方に「はい」と答えた場合、他の 指標にも「はい」と答えている確率 が高い。このようなパタ ンーをより よく理解するために、多重対応分 析が行われた。これによって、多く の変数間の関連が 1つの 2 次元グ ラフ内に単純化される（図 A2.2）。 この分析によって、2 つの次元（x 軸と y 軸）の抽出が可能となっ た。第一「次元」（x 軸）は、右側 が法規の欠如に関連する要因、そ れに対して左側が法規の存在に関 連する要因として解釈できる。第 一次元によって、変数間の 79.7% の変動が説明される。第二次元（y 軸）は、上方向が認証メカニズム の欠如を示すのに対し、軸の下方 本報告書のために世界で報告された指標の数図 A2.1 0 1,000 2,000 3,000 4,000500 km 5未満 5～9 10～14 15～19 20～24 25以上 報告なし該当なし 注：30の国家保健人材統計指標と、能力に関する6つの質問を含む。 出典：国家保健人材統計 2019年。 104 State of the world’s nursing 2020　世界の看護 2020 向が教育法規の欠如を示すものと 解釈できる。この次元では、指標 間の変動が 2.1% であると説明され る。このグラフには、各地域がより 密接に関連している指標を強調す るため、地域も含まれている。分 析の結果、南・東アジア、東地中海、 西太平洋の各地域がグラフの右側 に位置し、これ らの地域が低水準 の看護教育法規に関連している可 能性が高いことが確認された。 多重対応分析から明らかなように、 労働条件に関する指標には強い関 連性があった（図 A2.3）。強い関 連性を示す 2 つの指標が、攻撃防 止策と高度実践看護職の役職の存 在であり、これは、より危険な環 境では、困難な状況下でも患者の ケアを継続できるよう、看護職が より高位の職業的自律性を与えら れる可能性があることを示している のかもしれない。ヨーロッパ地域 は他の地域とは異なるパタ ンーを示 し、保健医療労働者への攻撃を防 ぐための対策が少なく、高度実践 看護職の役割も少ないことを示して いる。 2030 年までのストック予測 2030 年までの看護職ストックを評 価するために、次の 3 つのシナリ オを作成した。 • シナリオ 1：高齢化（看護人材 の高齢化の影響のみ）。予測 では、国ごとの年齢分布と 35 歳未満の安定した年齢グルー プを使用し、この最低年齢カ テゴリーの10 分の1 の人数 の補充を考慮した。55 歳以 上の看護職グループの10 分 の1の人数が退職するものとし て、労働力の高齢化を考慮し た。このシナリオでは、看護 学校卒業者の統計を考慮せず、 若年齢層の割合は今後も一定 であるものとみなした。 • シナリオ 2：補充：シナリオ1 と同様に高齢化を伴うシナリ オであるが、セクション 5.5 で 計算した地域ごとの最新の卒 業率を使用しており、OECD 図 A2.2 複数対応分析が示す教育指標の関連 SEAR EUR AMR EMR AFR WPR ???? ? 2.1?? 第一次元（79.7%） 4 3 2 1 0 -1 -2 -3 -4 -5 0 1 2 3 4 5-2 -1 No-M2-01 No-M3-02 No-M3-01No-NN2 No-NN3 No-M3-08 No-M3-06Yes Yes Yes Yes Yes Yes Yes 分析のタイプ：看護教育システムの法規に関する変数の多重対応分析。地域は独立変数として表示。 本グラフで要約される変数：M2-01：認証教育機関のマスターリスト、M3-01：教育の期間と内容に関する基準、M3-02：教育機関の認証メカニズム、M3- 06：多職種間連携教育の基準、M3-08：継続的な専門能力開発、NN2：実践適性試験、NN3：教員資格の基準。 AFR =アフリカ地域、AMR =アメリカ地域、SEAR =南・東アジア地域、EUR =ヨーロッパ地域、EMR =東地中海地域、WPR =西太平洋地域。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能なデータ。 105付帯資料 2 諸国で見られる卒業者数と現 役労働力への参入数の差にな らい、新卒者の 60% が保健 医療セクターで仕事を見つける ものと想定し、0.6 の補正係数 を適用した。 • シナリオ 3：補充の加速：シナ リオ 2 と同様のシナリオである が、2030 年まで 1年あたりの 卒業者の数を増やすという卒 業率と吸収率の加速を考慮し、 2018 年から 2030 年で各国 の卒業能力を 50% 増加する （年間 3.44% の増加に相当） ものと想定する。このシナリオ でも、保健労働市場への吸収 率を 60% と想定している。 これらのシナリオから、2030 年の 「国連人口推計」の推計値を使用し て、2030 年の推定予測密度が算 出された。 シナリオ 3 の影響を評価するため、 卒 業 者 25% 増 加、50% 増 加、 100% 増加（養成量が倍増）と、 卒業者の増加数に幅のあるさまざ まなシミュレーションが行われた（図 A2.4）。これによって、看護学校卒 業者数の伸び率の違いは、2030 年の推定ストックに劇的な影響を与 えないことが示され、全体の伸び 率 25%、50%、100% に対し、予 測されるストックはそれぞれ 3,800 万人、3,970 万人、4,280 万人と なる。 予測値を解釈する際の注意事項 予測値を解釈する際は、いくつかの 制限について考慮する必要がある。 1. データの可用性に関して、シ ナリオ1で使用された年齢と、 シナリオ 2 で使用された卒業 率については、すべての国が報 告できたわけではない。分析 の結果、シナリオ 1と 2 で同 様の結果が示されたため、新 卒者の労働市場への参入率が 改めて確認された。 2. 55 歳以上の看護職の離職率に ついて、いくつかの仮定がなさ れた。これは地域によって差が 出る可能性があり、退職年齢 が最大 65 歳になることを考慮 していることから楽観的なもの となる可能性がある。同様にこ の分析では、OECD 諸国にお ける資格を持つ看護職に対す る実践看護職の割合に基づき、 実践を始める卒業者を追加す 図 A2.3 多重対応分析が示す労働条件指標の関連性 12 10 8 6 4 2 0 -2 -4 -6 0 1 2 3 4 5 6-3 -2 -1 SEAR EUR AMR EMR AFR WPR No-M6-03 No-M6-04 No-NN1 No-M6-09 No-M8-06 Yes-M6-09 Yes-M8-06 Yes Yes Yes ???? ? 2.6?? 第一次元（80.1%） 分析のタイプ：労働条件の法規に関する変数の多重対応分析。地域は独立変数として表示。 本グラフで要約される変数：M6-03：労働時間と労働条件に関する法規の有無、M6-04：最低賃金の法規、M6-09：攻撃防止策の有無、M8-06：高度実 践看護職の役職の有無、NN1：看護職能団体の有無。 AFR =アフリカ地域、AMR =アメリカ地域、SEAR =南・東アジア地域、EUR =ヨーロッパ地域、EMR =東地中海地域、WPR =西太平洋地域。 出典：国家保健人材統計 2019年。2013年から2018年の間に国によって報告された最新の入手可能なデータ。 106 State of the world’s nursing 2020　世界の看護 2020 る際に 0.6 の比率を適用した。 ただし、これは地域によって 異なる可能性がある。基盤と なるすべての仮定がシナリオ1 ～ 3 に及ぼす影響を調べるた め、一連の感度分析が行われ た。その結果わずかな変化し か見られず、結論はほとんど 変わらなかった。 3. 予測は最近の傾向のみを反映 しており、看護人材のストック の軌道の幅広い理解をもたら すものである。今後、より多 くのデータが入手可能になる につれ、改訂していく必要が ある。また、これらの予測は、 国レベルのモデリングから導 き出された結論に代わるもの ではない。国レベルのモデリ ングでは、保健労働市場全体 のより広範な保健医療従事者 指標およびその他の指標、な らびに財政余地を含む、より 詳細な経済統計が考慮されて いる。 不足数の推計 看護職不足数の推計では、「保健 人材に関する世界戦略」で説明さ れている方法と同様の方法に従っ た。しかしながら、データが更新 されているため、不足数を「世界 戦略」での推計値と直接比較する ことはできない。 分析が示すところによると、「世界 戦 略」の推計は、2009 年から 2013 年のストック値が入手可能 な102 カ国の数値に基づいてお り、残りの国については、それ以 前のデータまたはインピュテーショ ン・データが用いられた。本報告 書で入手できた最近のデータに基 づくと、174 カ国が 2013 年のス トックのデータまたはそれ以前の 5 年間のストックのデータを保有し ており（うち130 カ国が 2013 年 のデータを保有）、2013 年の看護 職ストックの修正値は 2,320 万人 と推計された。2018 年のストック 値は、2013 年から 2018 年まで の191カ国のデータに基づいてお り、うち 89% が 2017 年と 2018 年のデータであった。したがって、 本報告書で報告された 2018 年の ストック値もまた、非常に確実な 推計値とみなすことができる。 不足数を推定するために、2018 年と 2030 年の密度を、「保健人 材に関する世界戦略」で用いられ たベンチマーク値と比較した。そ 「現状のまま」のシナリオと3通りの「新卒看護職の養成数増加」シナリオのもとでの 世界の看護職ストック数の進化（2018-2030年）（単位：百万人） 図 A2.4 看護職ストック数 （卒業者数は現状のまま） 20.0 25.0 30.0 35.0 40.0 45.0 2016 2018 2020 2022 2024 2026 2028 2030 2032 看護職ストック数 （卒業数数25%アップ） 看護職ストック数 （卒業者数50%アップ） 看護職ストック数 （卒業数数100%アップ） ???????? ????? 注：「看護職ストック」には、看護師および准（準）看護師が含まれる。 使用した補正係数、地域固有：高齢化係数（2018年の55歳以上の年齢グル プーの10分の1が毎年引退する）、看護実践以外の就業者を考慮するため、セ クション5.5の分析の卒業率を0.6で修正（OECDの免許取得者に対する実践者の割合）。 107付帯資料 2 の後、人口 1,000 人あたりの医師、 看護師・助産師 4.45 名というベン チマークを、看護職のベンチマー ク値に変換した。 • まず、「世界戦略」での看護師 と助産師の割合をこのベンチ マークに適用した。2013 年の 人口 1 万人あたり、看護師と 助産師は 20.7人、医師は 9.8 人であったため、ベンチマー クは人口 1,000 人あたり看護 師と助産師 3.02 人と修正さ れ た（4.45 x（20.7 /（9.8 + 20.7）））。 • 次に、看護職のみのベンチ マーク値を算出するため、看 護師と助産師の総数に占める 看護職の割合（直近の年では 90.7%）がこのベンチマーク に適用され、人口 1,000 人あ たり看護職 2.74 人というベン チマーク値が得られた。 • 保健医療従事者の密度は人 口 1 万人あたりで表されるた め、人口 1 万人あたりの看護 職 27.4 人の値をベンチマーク として使用した。 • 次に、このベンチマーク値を 2018 年の密度と比較し、3 つのシナリオのもとで 2030 年に向けた数値が予測され た。 2030 年までに推計される不足数 は、上記の 3 つの予測シナリオの もとで推計され、どのシナリオに おいても低・低中所得国の不足数 が依然として高いことを示している （表 A2.2）。 卒業者一人あたりのコスト 不足が最も多く見られた低・低中 所得国における卒業者 1人あたり のコストについては、多種多様な ソースが特定された。これらは、 マダガスカルの 5,180 米ドル、世 界銀行 ECSA 分析の 5,589 米ド ル 16、モザンビークの 5,656 米ド ル、ガーナの19,794 米ドル 17 と 幅がある。このため、コストの計 算は、卒業者 1人あたり 5,000 米 ドルの低コストシナリオ、10,000 米ドルの中コストシナリオ、および 20,000 米ドルの高コストシナリオ で実施された。これらのコストに 関する入手可能なデータはアフリ カ諸国から得たものであり、卒業 者 1人あたりのコストがはるかに高 いことが公表データで示されてい る高所得国への転置はできないこ とに注意されたい。 所得グループ 2018 2030 高齢化と 安定した 若年グループ 高齢化と 近年の卒業数 高齢化と 2030年までに 卒業数50%増加 低所得 1.34 1.80 1.54 1.26 低中所得 3.91 3.44 2.81 1.54 高中所得 0.67 0.45 0.25 0.12 高所得（参照として使用。 すべて密度がしきい値を超えている） – – – – 世界全体 5.91 5.69 4.60 2.92 「世界戦略」のしきい値を下回る国の看護職不足の推計値（百万人）（所得レベル別）：2018年と2030年 （3つのシナリオによる） 表A2.2 注：「看護職」には、看護師および准（準）看護師を含む。所得グル プーは、2018年の世界銀行の分類に基づく。 16.　Araujo EC、Garcia-Meza AM。「東部アフリカ、中央部アフリカ、南部アフリカの 16 か国における看護職労働市場分析（Nurse labour market analysis in 16 countries in east, central, and southern Africa）」（予備調査結果、未発表）。ワシントン（DC）：世界銀行。 2020 年。 17. Beciu HA、Preker AS、Ayettey S、Antwi J、Lawson A、Adjey A.「ガーナの保健医療従事者教育を拡大する（Scaling up education of health workers in Ghana）」。ワシントン（DC）：世界銀行 ; 2009 年 108 State of the world’s nursing 2020　世界の看護 2020 「世界の看護 2020」教育、労働、リーダーシップへの投資は、国立研究開発法人 国立国際医療 研究センター 国際医療協力局による仮訳である。仮訳には、国立国際医療研究センター国際医療 研究開発費 20A4（フランス語圏アフリカにおける臨床看護師のコンピテンシー評価、研究代表者 永井真理）を用いた。なお翻訳は、多職種にわたる有志の国際医療協力局員によって行われた。 ｜翻訳者｜ 駒形　朋子　　田村　豊光　　永井　真理 ｜翻訳協力者｜ 池本めぐみ　　伊藤　由衣　　江上由里子　　及川みゆき 神田　未和　　菊池　識乃　　菊地　紘子　　清原　宏之 小土井　悠　　虎頭　恭子　　森山　潤　　　宮﨑　一起 　　　　（50 音順） ｜発行｜ 2020 年 11 月 国立研究開発法人 国立国際医療研究センター 国際医療協力局 〒 162-8655 東京都新宿区戸山 1-21-1 Tel: 03-3202-7181　Fax: 03-3205-7860 Email: koho@it.ncgm.go.jp http://kyokuhp.ncgm.go.jp/index.html 教育、労働、 リーダーシップへの投資 STATE OF THE WORLD'S NURSING 2020 2020 In vestin g in edu cation , job s an d leadersh ip S T A T E O F T H E W O R L D ’S N U R S IN G 2020 看護 世界の 日本語版作成　国立研究開発法人 国立国際医療研究センター 国際医療協力局