Digital APPG Triple Impact

A Report by the All-Party Parliamentary Group on Global Health
Triple Impact
How developing nursing will improve health,
promote gender equality and support
economic growth.
Better health
Triple Impact
of nursing
Greater
gender Stronger
equality economies
October 2016
Triple Impact of Nursing
Acronyms used
APPG All-Party Parliamentary Group on Global Health

DFID Department for International Development
EU European Union
HEE Health Education England
ICCHNR International Collaboration for Community Health Nursing Research
ICN International Council of Nurses
NGO Non-governmental organisation
NHS National Health Service
NMC Nursing and Midwifery Council
NP Nurse practitioner
QNI Queen’s Nursing Institute
RCM Royal College of Midwives
RCN Royal College of Nursing
RN Registered nurse
SDGs Sustainable Development Goals
THET Tropical Health and Education Trust
UHC Universal health coverage
VSO Voluntary Service Overseas
WHO World Health Organization
ZUNO Zambia Union of Nurses Organisation
This is not an official publication of the House of Commons or the House of Lords.
It has not been approved by either House or its committees. All-Party Parliamentary
Groups are informal groups of Members of both Houses with a common interest in
particular issues. The views expressed in this report are those of the group.
All-Party Parliamentary Group on Global Health: Triple Impact – how developing
nursing will improve health, promote gender equality and support economic growth;
London, 17 October 2016; http://www.appg.globalhealth.org.uk/
Contents
Preface
Key points and recommendations�� 3
1 Nurses and nursing globally�� 7
2 Today’s challenges�� 17
3 Workforce, professional education

and regulation�� 23
4 Opportunities and impacts�� 33
5 The UK’s contribution to health globally�� 42
Conclusions and recommendations�� 49
Acknowledgements�� 55
References....................................................................... 59
APPG on Global Health – October 2016 1

Preface
In September 2015 the nations of the world signed up to the ambitious goal of
ensuring that everyone in the world should have access to health care – universal
health coverage – and that nobody should be left behind.
This report makes the very simple point that universal health coverage cannot
possibly be achieved without strengthening nursing globally. This is partly about
increasing the number of nurses, but also crucially about making sure their
contribution is properly understood and enabling them to work to their full potential.
The report goes on to argue that strengthening nursing will have the triple impact of
improving health, promoting gender equality and supporting economic growth.
Much of what is said here will be familiar to nursing leaders, but they alone cannot
bring about the changes that are needed. Politicians, non-nursing health leaders and
others must work with them to create radical changes in how nurses are perceived
and in what they are permitted and enabled to do.
We urge the UK government to work with the Commonwealth, Europe, the World
Health Organization and others to take a leading role in raising awareness of
the opportunities and potential of nursing, creating political commitment, and
establishing a process for supporting the development of nursing globally.
Change will take years but a start can be made. The UK government – with its proud
record of international cooperation, development and support for gender equality –
has the opportunity to set the direction and lead.
Nursing and midwifery

This report does not cover the separate profession of midwifery except in as much
as many nurses worldwide are also midwives. We recognise, however, the central
importance of midwifery to achieving universal health coverage and the need for
it too to be strengthened. The full potential of midwifery needs to be understood
more widely and midwives also need to be able to work to the full extent of their
knowledge and skills.
Acknowledgements
We are very grateful to the many people who met us, responded to our call for
evidence and offered advice. There is a full list of acknowledgements at the end.
We particularly note here our gratitude to those who attended our witness sessions;
the Royal College of Nursing, which assisted us with the whole review, particularly
Susan Williams, Senior International Adviser; the International Council of Nurses,
which provided advice and support; and the Commonwealth Nurses and Midwives
Federation, which helped arrange many interviews.
Above all we are indebted to Johanna Riha, who led and undertook most of the
research for the report; Emily McMullen, who continued the work; and Hanadi
Katerji and Tajel Mehta, who supported them both. We are particularly grateful to
Jane Salvage, who has been our invaluable adviser and guide on nursing throughout
the whole review and report writing process.
Lord Nigel Crisp

(Chair of the APPG Review Board)
Maria Caulfield MP Baroness Caroline Cox
Dan Poulter MP Lord Bernie Ribeiro
Baroness Mary Watkins of Tavistock Lord Phil Willis of Knaresborough
2 APPG on Global Health – October 2016

Key points and recommendations
Triple impact
Nurses are by far the largest part of the professional health workforce and achieving
universal health coverage globally will depend on them being able to use their
knowledge and skills to the full. Yet they are too often undervalued and their
contribution underestimated.
There is enormous innovation and creativity in nursing – with, for example, nurse-
owned clinics in Africa, village ‘wise women’ in Central Asia and nurse specialists in
the UK – and the potential for much more. These sorts of development are needed
if countries throughout the world are to ensure that all their citizens have access to
health care.
Increasing the number of nurses, and developing nursing so that nurses can achieve
their potential, will also have the wider triple impact of improving health, promoting
gender equality and supporting economic growth.
Figure 1 The triple impact of nursing: better health, greater gender

equality and stronger economies
Better health
Triple
Impact
of nursing
Greater
gender Stronger
equality economies
The unique contribution of nurses

Nurses undertake different roles in different circumstances, but they all share in the
combination of knowledge, practical skills and values that makes them particularly
well placed to meet the needs of the future as well as those of today. While other
professions share some or all of these features, the nursing contribution is unique
because of its scale and the range of roles nurses play.
Nurses have many roles: they can provide and manage personal care and treatment,
work with families and communities, and play a central part in public health and
controlling disease and infection. Whatever their particular role, they can be guided
throughout by their professional education and knowledge and their person-centred
and humanitarian values.
Nurses are often the first and sometimes the only health professional that people
see and the quality of their initial assessment, care and treatment is vital. They are
also part of their local community – sharing its culture, strengths and vulnerabilities
– and can shape and deliver effective interventions to meet the needs of patients,
families and communities.

Nurses around the world, however, have shared concerns about staffing problems,
poor facilities and inadequate education, training and support. This can result in
poor quality care. Moreover, nurses report that they are frequently not permitted
to practise to the full extent of their competence; are unable to share their learning;
and have too few opportunities to develop leadership, occupy leadership roles and
influence wider policy.
Different areas of the world have different needs. Africa, for example, where nurses
provide care to a very wide range of people, often with little support or resources,
needs hundreds of thousands more nurses with good generalist skills – effectively
specialists in general nursing – as well as tens of thousands of speciality-based nurses.
The specific needs vary from place to place but the combination of knowledge, skills
and values that nurses offer is needed everywhere, and needs to be developed to its full.
Figure 2 The unique contribution of nurses
Intimate
hands-on
care
The unique
contribution of
nurses
Person-
centred and
Professional humanitarian
knowledge values
The UK contribution
The UK can play a leading role in developing nursing globally by working with its
partners in the Commonwealth, Europe and elsewhere as well as with international
agencies including the World Health Organization and the World Bank. It has
enormous influence globally through the work of the Department for International
Development; the NHS; and the UK’s universities, non-governmental organisations,
and health and life sciences industries – as well as through the great tradition
of nursing, education and research fostered by the NHS, universities, nursing
organisations and national agencies.
The vote to leave the European Union has, however, created a significant risk that the
UK will lose many of the European nationals employed in its health and care system
and will be unable to recruit more. The APPG believes that the UK needs both to find
methods for securing the continuing employment of EU citisens in the health and care
system, and to reassess and increase levels of nurse education to meet its own needs. It
needs also to maintain its commitment not to recruit health workers from countries
with major shortages.

Recommendations
This report argues that there is an urgent need globally to raise the profile of nursing
and enable nurses to work to their full potential if countries are to achieve universal
health coverage. Nursing can and must take the lead on these issues but cannot achieve
them without the support of politicians, policy-makers and non-nursing health leaders.
The APPG recommends that the UK government, together with the Commonwealth
Secretariat, the European Union, the World Health Organization and other
international agencies, works to:
1. Raise the profile of nursing and make it central to health policy. Nurses have
an enormous part to play in achieving universal health coverage, and nursing
should be central to global policy and plans.
a. Convene a high-level global summit on nursing, aimed particularly at

political and health leaders outside nursing, to raise awareness of the
opportunities and potential of nursing, create political commitment, and
establish a process for supporting development.
This should be part of a longer-term initiative that will embrace all the
following recommendations.
2. Support plans to increase the number of nurses being educated and

employed globally. The World Health Organization global strategy on human
resources for health, Workforce 2030, adopted by member states in 2016,
proposes a framework for making the most effective use of health workers and
developing country-specific investment plans to address workforce shortages.
a. Work with low and middle-income countries to develop and support

their workforce plans through funding and partnership schemes.
b. Reaffirm support for the WHO Global Code of Practice on the

International Recruitment of Health Personnel, publish a report on
UK progress in implementation since 2010, and provide support for
education and employment of health workers in their own countries.
c. Assess the impact of leaving the European Union on staffing in the UK

health and care system, and take mitigating action including finding
methods for securing the continuing employment of EU citizens in the
health and care system and reviewing and increasing the number of
nurses being educated in the UK to meet its needs.
3. Develop nurse leaders and nurse leadership. Experienced nurse leaders are
needed in the right places to help nursing deliver its potential and ensure that
the distinctive nursing perspective is included in policy-making and decision-
making.
a. Establish a large-scale new programme globally to develop nurse leaders

that will enable them to engage more effectively in policy-making and
decision-making. The International Council of Nurses has plans for
developing such a programme that could provide a template.
b. Ensure all countries have appropriate nurse leadership posts throughout

all their structures and organisations.

4. Enable nurses to work to their full potential. Nurses are too often not
permitted or enabled to fulfil their true potential. Cultural, regulatory and
legislative enablers and barriers need to be identified and removed and good
practice shared and acted on.
a. Develop new ways of sharing good practice – drawing on existing work

by nursing organisations, the Commonwealth Health Hub and others
– to create more coordinated and effective ways of identifying and sharing
good practice globally, and ensure they are brought to the attention of
policy-makers and other health leaders.
5. Collect and disseminate evidence of the impact of nursing on access, quality

and costs, and ensure it is incorporated in policy and acted upon. There are
many small-scale studies of the impact of nursing. These need to be brought
together with new evaluation and research to demonstrate impact at scale.
a. Commission research to bring together existing evidence and initiate new

studies on how and where nursing improves access, quality and costs and
what contribution nursing can make to universal health coverage.
b. Ensure that existing and future research findings are widely disseminated
and understood in order to influence both practice and policy.
6. Develop nursing to have a triple impact on health, gender equality and

economies. Developing and investing in nurses – the vast majority of whom
are women – will help empower them economically and as community
leaders. Improving health and empowering women will in turn strengthen
local economies.
a. Adapt development policy to bring together programmes and funding

to address simultaneously the three Sustainable Development Goals
focusing on health, gender equality, and inclusive and sustainable
economic growth (numbers 3, 5 and 8) and work with partners
throughout the world to develop nursing strategies that work towards
achieving all three goals.1
7. Promote partnership and mutual learning between the UK and other

countries. There are many partnerships between British organisations and
their counterparts abroad that bring mutual benefit and shared learning.
a. Expand the DFID Health Partnership Scheme and redesign it so as to

engage as many nurses as possible and promote mutual learning and
support between UK nurses, their organisations and their counterparts
abroad; and support UK agencies including Health Education
England, Wales for Africa, and the Scottish government’s international
development programme to promote the engagement of NHS and other
health and care organisations in global partnerships that bring mutual
benefits.

1. Nurses and nursing globally
This chapter describes the purpose and scope of this

review and provides an overview of the main issues.
It describes the wide variety of roles played by nurses

globally and the many different contexts in which
they work. It points to the common themes and
the similar roles they play, as well as the differences
between them.
The chapter goes on to discuss the rapidly changing

environment in which nurses work, and recent policy
responses. It concludes with some examples of
innovation and enterprise from around the world.
The purpose and scope of the review

The ambition to achieve universal health coverage (UHC) globally, as part of the
agreement of the Sustainable Development Goals (SDGs) in 2015, means that there
will be even greater demand for health workers.1 This will put particular pressure on
nurses, as they are the largest group of professional health workers globally and carry
out most direct patient care.
The All-Party Parliamentary Group on Global Health (APPG) therefore decided to
undertake a review, with the support of the Royal College of Nursing (RCN), of how
nursing needs to develop globally to cope with this and other challenges. The APPG
has not attempted to cover this very broad area in detail, but has concentrated on
identifying major trends and development needs, considering in particular what the
UK can do to support the development of nursing globally.
This report follows on from the APPG’s recent mapping of The UK’s Contribution to
Health Globally2, which identified the UK’s enormous ability to help improve health
globally, and its earlier report, All the Talents, on the development of new roles and
better teamwork in health.3
The APPG decided to focus only on nursing. It decided not to include midwifery,
although equally important for the achievement of UHC, because it is a separate
profession with its own distinct scope of practice. Nevertheless, many of the challenges
and issues described here also apply to midwives, who in many countries are also nurses.
This report is about the real lives of nurses, and concentrates on the experience and
needs of low and middle-income countries. It draws on discussions with nurses from
many countries, a call for evidence, a literature review, and meetings with policy-
makers and other experts with experience from around the world. The APPG panel set
up for this review (hereafter ‘the Review Board’) was particularly concerned to ensure
that the report accurately reflects insights and experience from low and middle-income
countries and that its findings are not dominated by Western views and concerns.
An enormous amount of change is happening in health and health care globally and
it is impossible to be certain how this will affect nursing, although some clear trends
are emerging. There is also a great deal of innovation under way in nursing, and each
chapter contains examples of enterprise and innovation from different groups and
countries that highlight aspects of how nursing is likely to develop in the next few years.

The real lives of nurses

There is enormous diversity in the education, experience and responsibilities of nurses
globally:
• Nurses in parts of rural Africa and elsewhere may be the only health worker
for miles around and provide a wide range of care and services for local people,
often going beyond their formal training and outside their legal scope of practice.
• Other nurses, in particular those working in hospitals in low and middle-
income countries, may not be allowed to utilise their training to the full but are
essentially ‘handmaidens’ of doctors and have no scope for development.
• Nurses trained to degree level in Cuba and elsewhere work alongside doctors
as equal partners and with equal status in looking after people in their
neighbourhood.
• Many nurses in the UK, the US and some parts of Europe are nurse
practitioners with very wide-ranging roles, able to diagnose, prescribe,
undertake a range of procedures, and develop and lead whole services.
• Nurses throughout the world take on wider leadership positions in
government, academia and health care organisations – leading, managing,
teaching, researching and shaping policy – as well as bringing their knowledge
and skills to bear in many settings including industry and humanitarian
programmes.
These examples illustrate how difficult it is to generalise about nurses and nursing.
There are many common issues and concerns facing nurses in all these situations,
as this report shows, but also important differences in education, training and
development needs in different environments.
These differences are reflected in how nurse leaders and policy-makers approach
the development of nursing. At one end of the scale, in Africa – the continent with
the lowest proportion of health workers to the population4 – there is a need to train
thousands more nurses with practical skills and personal resilience to deal with as
wide a range of issues as possible. They are effectively specialists in general nursing.
Africa also needs speciality-based nurses but the focus is different from high-income
countries like the US, which has the highest proportion of health workers and focuses
more on developing specialisms and extending the role and scope of practice.
Similar concerns
Despite these differences, nurses from different countries told the APPG about very
similar concerns – all constant themes throughout this report, discussed in chapters
2 and 3. They included:
• pressure caused by shortages of staff and poor or missing equipment;
• the ‘invisibility’ of nurses and underestimation of the nursing contribution;
• not being permitted and enabled to work up to the limit of their competence;
• migration of nurses from poorer to richer countries and, internally, from rural
to urban areas and from government services to disease-specific ones, non-
governmental organisations (NGOs) and private practice;
• lack of involvement in policy and planning; and
• inadequate training and development.

These issues were not confined to the poorest countries. The World Health
Organization (WHO), for example, has cut its nursing activities in recent years, with
reductions in posts and funding in its six regions and at its headquarters. Meanwhile
Afaf Meleis, Dean of Nursing, University of Pennsylvania School of Nursing, United
States (US), told the APPG that only 10 US states permitted nurses to work to the full
scope described in the federal Nurse Practice Act.
Common features
There are also many common features in all the roles described here. In particular
nurses:
• are frequently the first and in some cases the only healthcare professionals with
whom patients come into contact;
• spend considerable amounts of time with their patients and, mostly, provide
very personal and intimate care as well as continuity throughout a period of
illness or treatment;
• work within a shared system of humanitarian and person-focused values; and
• are generally part of the local community and have a good understanding of
local issues and culture, which also affect them and their families.
All these important features contribute to the very wide-ranging roles that nurses
perform. Paul Magesa Mashauri, President, Tanzania National Nursing Association,
illustrated the holistic nature of nurses’ work when he told the APPG that nurses can
help people to live better: ‘Nurses meet many people when they are providing care.
They can meet the patient, they meet the family members, they meet the relatives,
(and) they meet friends. So they are in a good position to assist people to understand
how to live better.’
Belonging to their local community means that nurses can understand the local
culture, customs, belief systems and social norms. This cultural competency and
sensitivity is invaluable, whether in encouraging parents to vaccinate their children,
discussing family planning options with new mothers, or explaining the care associated
with managing diabetes.
One practical example comes from South Africa, where nurses in an HIV clinic
understood that local women were reluctant to be tested for HIV because of the
stigma attached to testing and diagnosis. They accordingly devised a system to make
any testing a routine part of antenatal care – so no one could tell who had been
tested and who had not, or who was HIV-positive and who was not. The success of
the whole programme for reducing mother to child transmissions depended on this
simple system: ‘It could all have failed at the last hurdle, however, if women attending
this clinic hadn’t been able to trust the nurses and if these nurses hadn’t been able to
understand the women’s worries and needs.’5
Nurses undertake different roles in different circumstances, but they all share in the
combination of knowledge, practical skills and values that makes them particularly well
placed to meet both present and future needs. While other professions share some or all
of these features, the nursing contribution is unique because of its scale and the range
of roles nurses play (Figure 1.1). This combination means that nurses are very well
positioned to respond to the growing need for more person and community-centred
care, and for a greater focus on health promotion and disease prevention.

Figure 1.1 The unique contribution of nurses
Intimate
hands-on
care
The unique
contribution of
nurses
Person-
centred and
Professional humanitarian
knowledge values
The definition of a nurse

The most commonly used definition of a nurse was created by Virginia Henderson and
adopted by the International Council of Nurses (ICN) in 1960: ‘The unique function of
nurses in caring for individuals, sick or well, is to assess their responses to their health
status and to assist them in the performance of those activities contributing to health
or recovery or to dignified death that they would perform unaided if they had the
necessary strength, will, or knowledge and to do this in such a way as to help them gain
full or partial independence as rapidly as possible.’6
More recently ICN widened this definition, adding: ‘The nurse is a person who has
completed a program of basic, generalised nursing education and is authorised by
the appropriate regulatory authority to practice nursing in his/her country. Nursing
encompasses autonomous and collaborative care of individuals of all ages, families,
groups and communities, sick or well and in all settings. Nursing includes the
promotion of health, prevention of illness, and the care of ill, disabled and dying
people. Advocacy, promotion of a safe environment, research, participation in shaping
health policy and in patient and health systems management, and education are also
key nursing roles.’7
These definitions embrace the whole of the nursing profession, whether nurses are
working in hospitals, clinics, community services, or in any of a vast range of other
settings including schools, factories, other workplaces, social services, residential homes
for people with dementia and long-term conditions, hospices, prisons, on the streets
with homeless people and sex workers, in the armed forces in conflict zones, or in
humanitarian organisations caring for the victims of conflict, refugees and internally
displaced people, and those affected by human and natural disasters.

The changing global context

Enormous changes in the global context are affecting nurses alongside all other health
workers. These include:
• changes in the burden of disease, with more long-term conditions and non-
communicable diseases affecting countries throughout the world;
• increased demand for health care from ageing populations in the North and
West and from increasingly affluent populations in the East and South;
• migration of people fleeing conflicts or seeking better futures, and of health
workers moving within a global market place;
• climate change and other environmental issues;
• changes in labour market composition and expectations;
• the increasing commodification of health, that places a premium on
measurable procedures;
• global and national policies that prioritise health and have helped make it the
largest sector in the global economy, and one of the fastest-growing;
• scientific and technological advances.
It is impossible to be certain of the long-term impact on health and health care of these
profound changes. Some trends, however, are already clearly established (Box 1.1).
Box 1.1 Some global trends

• There is demand for a big expansion in the health workforce.
• Work roles are changing as needs change.
• Some traditional models of delivery are disappearing – with a shift away
from hospitals and towards communities and homes.
• There is greater emphasis on disease prevention and health promotion.
• The engagement of patients and citizens alongside health workers is
increasingly seen as essential in improving access, quality and costs.
• Technology is beginning to play a more prominent part – as the internet
becomes the organising principle of the age.
• Knowledge of what works is at a premium as countries struggle to achieve
the goal of good access, high quality and value for money.
Gender equality and the changing roles of women

One other trend particularly important for nurses is the move towards gender
equality and the changing roles of women. Nursing should not be seen as a gender-
based profession, although the vast majority of nurses are women and this is likely to
continue for the foreseeable future. Global development policy from the SDGs onwards
emphasises the fundamental importance of promoting gender equality in social and
economic development. An important part of this in health is improving access for
women to high quality health care, as well as tackling the different genders’ differing
needs. Investing in nursing and raising its status will have the additional effects of
empowering more women socially, politically and economically, and helping establish
their status as important figures in their local communities.

Nursing policy and practice cannot of course change social trends by themselves but
can and should contribute through developing women in leadership roles, empowering
them economically and helping them reach their potential. James Buchan, Queen
Margaret’s University, Edinburgh, and others suggested to the Review Board that
investing in and developing nursing would have a triple impact as shown in Figure 1.2
– better health, greater gender equality and stronger economies. These three areas align
with the SDGs, especially Goal 3: Good health and well-being, Goal 5: Gender equality,
and Goal 8: Inclusive and sustainable economic growth. It is a theme to which we will
return.
The UN’s High-Level Commission on Health Employment and Economic Growth
has demonstrated the links between the employment of health workers and economic
growth.8 This report argues that the employment of nurses will also bring benefits in
health and gender equality.
Figure 1.2 The triple impact of nursing: better health, greater gender
equality and stronger economies
Better health
Triple
Impact
of nursing
Greater
gender Stronger
equality economies
Policy and practice development

There have been a number of important reviews of nursing in recent years. Others are
under way and policy is continuously being developed. Most recently, as this report was
being prepared, WHO published Global strategic directions for strengthening nursing and
midwifery 2016-2020.9 This focuses on four themes:
• accessibility, acceptability of safe and cost-effective nursing and midwifery care
based on population needs, addressing UHC and the attainment of the SDGs;
• optimising leadership and governance accountability;
• maximising capabilities and capacities of nurses and midwives at all levels
through collaborative intra- and inter-professional partnerships;
• mobilising political will to invest in building effective governance for nursing
and midwifery workforce actions founded on evidence.

The 2016 WHO Global Forum for Government Chief Nursing and Midwifery Officers
enthusiastically endorsed this approach and agreed to work on these four themes
individually and collectively. Other recent country-specific reviews addressing similar
issues include:
• Front Line Care, the report by the Prime Minister’s Commission on the Future
of Nursing and Midwifery in England, 2010.10
• The Future of Nursing: leading change, advancing health, the report of the
Robert Wood Johnson Foundation Initiative on the Future of Nursing, US,
2011.11
• Raising the Bar. Shape of Caring: a review of the future education and training
of registered nurses and care assistants, commissioned by Health Education
England, 2015.12
• The Lancet Commission on UK Nursing, launched in 2014, still under way.13
All these reviews were designed to address the changing context and find better and
more sustainable ways to provide nursing and midwifery care in the longer term,
locally and globally. Many other countries have also undertaken reviews. All have
common themes including considering whether nurse education remains fit for
purpose, how to improve leadership and motivation, and the relationship of nurses
to other health workers. Most recently, NHS England published Leading Change,
Adding Value – a framework for nursing, midwifery and care staff, which brings
together much current thinking about how nursing can develop in the UK.14 Some of
the broader issues raised are discussed in the following chapters.
The APPG notes, however, that no substantial commission or review has taken
a completely global approach to nursing and married together the insights
and experiences of people from all parts of the world. This is picked up in our
recommendations.
The APPG also recognises that nursing is affected by wider health policy and cannot
develop in isolation from the other professions, but is intimately connected with and
affected by developments in all of them.
The impact of nursing

There is considerable evidence, as described in Chapter 4, about the impacts of
nursing on quality, access and costs of treatment and about the relationships between
nursing education, workload and environment and reduced patient morbidity and
mortality. As nurse entrepreneur Heather Henry, co-chair of the New NHS Alliance,
says, ‘We need to market nursing as if it were a new drug or treatment.’15
“ We need to market nursing as if it were a new drug or treatment

”
Heather Henry, UK nurse entrepreneur
A new story of nursing

The nursing profession itself is changing and new approaches are needed. The need
to open up debate and engage the public and leaders outside the profession was
highlighted to the Review Board by three very senior nurses.

Maureen Bisognano, President Emerita and Senior Fellow, Institute for Healthcare
Improvement, US, said there were now four generations of nurses working together,
and policy, management and leadership needed to address their different needs.
The oldest group, the ‘baby boomers’, are concerned about retirement and pensions;
‘generation X’ believe money is less important but status and titles are more
important; ‘generation Y’, ‘the millennials’, are interested in recognition but not titles;
and the youngest, ‘generation Z’, see no distinction between work and personal life.
People from each generation are motivated differently and work and learn differently.
The modern workplace needs to reflect this diversity of perspectives and find ways
to recruit and retain all these generations. Moreover, research shows how engaging
health workers fully in decision-making helps improve health outcomes.16 Equally,
she said, there is a need to change relationships with patients and carers completely:
this can be empowering for both parties and helps improve outcomes.
Barbara Parfitt, former Dean of Nursing, Glasgow Caledonian University, and
Founding Principal, Grameen-Caledonian College of Nursing, Bangladesh, told a
workshop in 2014 that women are disadvantaged in countries in South and Central
Asia, which reduces their employment opportunities and has an effect on nursing.
Nursing is a low-status profession, she explained, with low salaries, poor working
conditions and little investment. ‘It is primarily controlled by doctors who make all
of the decisions around what nurses do, and in some cases, inhibit the development
of nursing … Nurses are considered “extra hands” for doctors and are not given
much agency.’
At the same time, she said, the environment is changing rapidly: ‘Educational
qualifications attract prestige, which can help improve the status of nursing and
of women. Younger nurses are more oriented to business and leadership; with the
proper support they could be transformational in health systems. The government
is issuing new policies toward the goal of improving nursing care, but sometimes the
top-down process is slow and difficult to implement.’
The focus is not only on rural health, she told the Review Board, but on equipping
intelligent young women from rural, disadvantaged areas to develop the skills
and expertise to be leaders and change agents for both women and for nursing in
Bangladesh. ‘In many ways for me this was even more important than persuading them
to return to their own communities. Influencing long-term policies to empower women
from rural areas and to empower nursing is critical for any sustainable change,’ she said.
“ Influencing long–term policies to empower women from rural areas and to

empower nursing is critical for any sustainable change
”
Barbara Parfitt, former Dean of Nursing, Glasgow Caledonian University, and
Founding Principal, Grameen-Caledonian College of Nursing, Bangladesh
Jane Salvage, APPG adviser and former WHO Chief Nurse, described the deep-
seated problems affecting nursing worldwide and said, ‘If nursing leaders could
solve them, they would already have done so; but these deep and broad social and
cultural realities and attitudes are too difficult to be tackled by nurses alone. We have
to help opinion-leaders and policy-makers within and beyond health and social care
to understand these issues, appreciate their gravity, and lend their weight to solving
them.’
Part of this campaigning approach involves the need to tell a new story of nursing,
she said: ‘Rooted in reality, yet able to reach for the stars, it will move away from the
stereotypical public image to reflect the diversity and richness of nursing work, and
the contribution to health and wellbeing made by everyone from newly qualified

staff nurses to clinical nurse specialists with PhDs. Health services fit for the future,
and responsive to the needs exacerbated by turbulent times, cannot be developed
without nurses at their heart, as leading actors in a new story of healthcare.’
Pointers for the future

Amid all the uncertainty, many innovative practitioners and programmes are finding
new ways for nurses to work effectively. The three examples in this section – wise
women, health promoters and entrepreneurs – are all very much focused on the
future. Community-based, they combine treatment with health promotion, and they
learn from the past while using the science and methods of the future.
Wise women – Tajikistan

Gulnar works as a family health nurse in Tajikistan, a Central Asian republic formerly
part of the USSR. Her innovative post arose from one of many programmes funded
by foreign donors to revitalise the country’s failing health system. The aim was to
develop a new approach to nursing education that would create skills and expertise
in primary health care, within a national service framework.
She undertook her initial nursing training in the Soviet system, starting in a
vocational programme at school when she was just 14. Nurses had very low status
and were expected to work only as doctors’ assistants. But she was intrigued by the
role of the feldsher, a middle-level practitioner who offered health education as
well as treatment and care. The feldsher is still often people’s first point of contact
with health services in small towns and rural villages across the Russian Federation,
Central and Inner Asia and elsewhere.
At a WHO workshop, Gulnar and other Central Asian nurses were encouraged to talk
about why they wanted to be nurses, and what they hoped to achieve – a question
they had never been asked before. She thought about the village where she grew up
in the remote Pamir Mountains, and its feldsher, who was the local ‘wise woman’, the
only person you could turn to with health problems apart from the shaman.
Equipped with her new knowledge, Gulnar knew that the feldsher’s advice and
practice had been based more on experience than on recent scientific evidence. She
also knew that women’s lives back in her village were still hard, and their health often
poor, especially from having many children. She found her voice in the workshop,
and said to everyone: ‘I want to return to my village and teach the women what
I needed to know for myself – family planning!’ And that is what Gulnar now does
as a family health nurse, a similar role to the feldsher but with additional knowledge
and expertise provided by her continuing nursing education.
Health promoters – Mozambique

A nurse-led project designed to improve women’s lives in Mozambique recruited
members of women’s groups as project leaders. They returned to their communities
after training and identified community development committees; collaborated with
them to identify priority needs; shared information; and worked together to address
the priorities. They were designated as ‘promoteras’ (promoters) of community
development and health.

The promoteras assumed responsibility for conducting training, budgeting, field

supervision and compiling reports. Evaluation showed that the project had a positive
impact on the lives of people in the areas where the promoteras lived. A key lesson
was that development, like a tree, must grow from the ground upward and cannot be
imposed from above.
Entrepreneurs – Rwanda
A private franchised nurse-led network which links with the public health system and
the national health insurance scheme to ensure widespread coverage was founded in
2012 by Dr Gunther Faber and colleagues at One Family Health in Rwanda.
By the end of 2014 it had developed a franchise network of 92 clinics providing
services to about 4% of the population. These clinics are particularly innovative
because each franchise is owned and operated by nurses, who treat and prevent
the most common causes of community illness, such as respiratory infections
and parasites. They had seen almost 310,000 patients by the end of 2014. Backed
by international donors, One Family Health works in close partnership with the
Ministry of Health so that the nurse proprietors have access to the national health
insurance programme and can provide care in the poorest areas.17


2. Today’s challenges
Summary
This chapter describes what nurses told the APPG
Review Board about the challenges they faced.
Despite many differences between countries, there

was a great deal of consistency in the issues raised.
Nurses were concerned about staff shortages and
resources; the undervaluing of the workforce; not
being allowed to work to their full potential; and
challenges with recruitment, retention and return to
nursing, education and training, and leadership.
The chapter provides a brief overview of each area,

with staffing numbers and education and training
addressed in more detail in Chapter 3.
The main challenges

Although there are large variations between countries in resources, health systems
and population health needs, the Review Board heard about a consistent set of
challenges that nurses faced irrespective of setting. There were of course differences
of degree, for example with staff shortages in Malawi of a much greater scale than in
the UK or US. The main challenges (Box 2.1) are discussed in the following sections.
Nurses also told us about many more specific concerns that reflected their own
positions and circumstances.
Box 2.1 The main challenges facing nurses globally

• Staff shortages and lack of resources.
• Undervaluing of the nursing contribution and not being allowed to work
to their full potential.
• Poor quality and/or lack of education and training.
• Difficulties with recruitment, retention and return to nursing.
• Weak and, in some cases, reducing leadership.
Staff shortages and resources

Many respondents raised concerns about staff numbers and current and projected
shortfalls. This is a very serious problem globally and locally. The figures in Chapter
3 reveal both the scale of the shortfall against current and projected future demand,
and unequal distribution around the world. Most nurses were also very concerned
about lack of equipment, medicines and other resources. These concerns reflect the
pressures which health systems are experiencing around the world.

Undervaluing of the nursing contribution

Nurses throughout the world frequently expressed concern about the undervaluing
of the nursing contribution and not being allowed to work to their full potential.
They repeatedly told the Review Board that nurses and their contributions remain
largely invisible and undervalued, and that the low status of nursing extends beyond
clinical and health system settings to public opinion, policy circles and research and
education environments.
Anita Anand Deodhar, President, Trained Nurses Association of India, put it very
simply: ‘We [nurses] need to have more respect and recognition from society, from
doctors, from all other faculties.’
João Marçal-Grilo, Founding Director of Unity in Health, a UK-based NGO,
summed up many of the concerns and identified some of the barriers to greater
recognition. ‘The way in which nurses are perceived by other health professionals is
one which often hinders their confidence and assurance, perpetuating unfair systems
of strict pecking orders in which only some get to have a say in any form of decision-
making processes,’ he said.
‘In many regions, the role of the nurse remains undervalued and unrecognised;
in several countries there is no equivalent to a nursing council [i.e. regulatory
or professional body] and/or no legal representative of the profession, creating
significant obstacles to those trying to advocate for the rights and duties of nurses,’
he said. The absence of legal frameworks supporting the role of nurses and their
participation in the planning and delivery of care reinforced the difficulties and
challenges nurses experienced in low and middle-income countries.
This lack of respect and recognition is visible not just in terms of autonomy and
freedom to make decisions about patient management, but also in terms of pay
and financial recognition. Although these issues affect the nursing workforce as
a whole, the Review Board received several reports of advanced practice/specialist
nurses being particularly restricted in their scope to practise despite having extensive
qualifications and experience.
There are many contributing factors including the dominance of the medical
profession, which has high status and power and controls much of the health care
environment. The Review Board heard that more recently professional non-nurse
managers have taken over some of the planning and leadership functions previously
undertaken by senior nurses. The low status of nursing is also partly attributable to
the low status of women in many societies, and the undervaluing of forms of care
frequently associated with women, such as hands-on intimate care and emotional
support. Even among nurses, the higher-status, better-paid roles are very largely
those linked with medical specialities in high-tech environments, or management
roles with few if any clinical responsibilities.
Whatever the reasons, the very common complaint that nurses are not being
permitted to carry out the full range of the work they were trained for indicates
a waste of a valuable resource and of the opportunity to provide high quality care.
These concerns were also voiced by some doctors.
On the more positive side, ‘there is a large amount of evidence internationally that
enabling nurses to lead and shape delivery of care and health services not only
improves patient outcomes but promotes innovation and leads to better recruitment
and retention,’ as the RCN told the Review Board. The Buurtzorg district care model
in the Netherlands, for example, founded by a nurse in 2006, has reduced the costs of
care significantly by empowering frontline nurses to deliver care autonomously, and
delivers better patient care and satisfaction.18

Education and training

Nurses around the world are also concerned about education and training. They
described limited access to education, training and the continuing professional
development opportunities necessary to enable the workforce to deliver high
quality, compassionate and context-appropriate care. They cited many examples of
barriers to better education and training, including financial limitations; the lack of
availability of courses, particularly for nurses in rural areas; the shortage of teaching
and training staff; and, very frequently, heavy workloads.
There was also criticism of the shortcomings of current nursing curricula and
programmes, with respondents pointing to a disconnect between current education
and clinical practice. Some also deplored the very limited training available in
leadership, research, broader health determinants, and the development of a multi-
professional, multi-generational and multi-ethnic workforce. Others said that in
some countries doctors often do much of the teaching of nurses, despite having no
nursing experience or qualifications, as a consequence of the lack of training for
nurse educators as well as restrictive legislation.
These critical issues are discussed further in Chapter 3.
Recruitment, retention and return to nursing

Policy-makers and health service leaders, as well as nurses, are very concerned about
difficulties in recruiting nurses, retaining them and encouraging them to return
following a career break. Much of this is associated with poor morale and low job
satisfaction. Too often there are poor working conditions, increased workloads due to
staff shortages, and a lack of basic equipment and amenities. These are compounded
by factors already noted including low pay, undervaluing of the nursing workforce,
and limited professional development and career progression.
‘I have not heard of promotion since I came here,’ said a Ghanaian nurse working in
a rural area. ‘If you apply, they don’t call you… they told us in school it takes three
years to the next level. I have been working at this post for 12 years. The promotion
(is) too slow. I went for promotion interview last year, up till now no results, so we
are always demoralised.’
Many respondents also referred to the welfare and quality of life of nurses and their
families. In high-income countries this often related to inflexible rotas and shift
patterns that prevent many nurses from achieving a good life-work balance, as well as
a lack of child care facilities and family-friendly policies – which discouraged many
from returning to nursing after a career break. Poor accommodation; limited access
to good schools, amenities, basic necessities, and transport; and isolation were all
seen as contributing factors in low and middle-income countries.
These concerns about morale and satisfaction are important in themselves and their
immediate impact on the welfare and recruitment of nurses. Furthermore, there is
evidence of a strong correlation between staff satisfaction and patient outcomes.19
Several respondents described efforts to address these issues. Voluntary Service
Overseas (VSO), for example, says there is clear evidence that incentives represent
one of the main factors influencing health worker performance. Opportunities and
formalised government systems for continuing professional development, which
can then feed into a merit-based promotion system, were perceived as positive
and motivating in two VSO projects, Valuing Health Workers20 and Continuing
Professional Development for Health Workers.21

‘To improve nurse retention and motivation it is essential to examine non-monetary

incentives such as work autonomy, career development and flexible working hours/
shifts,’ VSO said. ‘In a study reviewing nursing in hospitals, work autonomy was
reported as a significant factor in explaining job satisfaction. It has also been
demonstrated that hospitals experience lower turnover rates where supportive
management structures are in place and nurses are more involved in decision-
making processes.’22
These challenges and concerns all argue very strongly for the need to improve
the management and operation of health services. There is also a need for greater
understanding of the potential workforce. As noted in Chapter 1, there are now four
different generations in the workforce with different expectations. As Emma Coyle,
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine,
told the Review Board, ‘There is a need for greater understanding of why people
choose to enter nursing and whether (or not) attrition rates are associated with pay,
working conditions, training, career development etc. The demographic factors
which affect nurse recruitment and retention will vary from country to country and
greater understanding of these is needed.’
Respondents from low and middle-income countries pointed to a shortage of
educated young people able to access nurse training, largely because of poor primary
and secondary educational systems. They also cited international and internal
migration as a problem. This is discussed in Chapter 3.
Leadership at all levels

The Review Board received overwhelming evidence that nurse leaders were not
sufficiently involved in policy-making and decision-making locally, nationally and
internationally, and this was essential for improving patient care and service design.
Paulette Cash, President, Nurses Association of the Commonwealth of The Bahamas,
said nurses were strategically positioned to be able to influence social, public
and health policies. ‘Therefore it’s so very important that we’re engaged, totally
engaged, within the design, the implementation, monitoring and evaluation of such
programmes [UHC]. Often they engage us at a level of implementation, but it needs
to go beyond that.’
‘It’s important that nurses are around the decision-making table and there when
initiatives are being designed – because nurses are often the gate-keepers, they are on
the front line and they understand the healthcare system at all levels, so it’s going to
be important that nurses are engaged at all levels. Nurses can represent nursing well
and health well. Nurses are leaders, nurses are innovative and nurses are drivers of
public health policy and decision-making,’ she said.
Nursing did not have a strong enough voice in many countries, said Ms Coyle.
‘Nursing needs to be on the political agenda at the highest level in all countries
and international agencies, on a par with medicine. Strong professional bodies (or
associations) and boards of nursing are needed to regulate and advocate for nursing.’
Respondents described occasions when nurse leadership and engagement had been
critical, such as tackling SARS in Taiwan, where nurse leaders played a prominent role. 23
Leadership and other aspects of the challenges described here came together in
evidence from Aisha Holloway and Pam Smith, University of Edinburgh. ‘The
nursing profession is severely challenged globally by its ability to be visible, credible
and influential in directly shaping and developing evidence based health and social
care policy within the political arena and across governments,’ they said.

Dr Holloway used evidence gathered during a leadership scholarship awarded by the

Florence Nightingale Foundation to conclude: ‘Nursing globally requires a critical
mass of nurses that have:
• capability and capacity to shape, develop, support and drive forward evidence-
based health and social care policy;
• political, strategic and advocacy skills to navigate, negotiate and influence
evidence-based health and social care policy;
• political leadership skills to secure and sustain a credible position at the
highest level of policy development within government;
• highest standards of research education to support the ability to frame the
evidence base within the relevant local, national and international political and
health and social care context;
• ability to identify, understand and work with key stakeholders both within
nursing, e.g. statutory bodies and professional organisations, and without
nursing, e.g. civil servants, special advisers, government, ministers,
international agencies including WHO and the UN, and NGOs.’
More pointers for the future

Nurses and other health professionals could take on greater leadership roles as ‘agents
of change’ - guiding developments, engaging patients and communities and making
best use of non-professional staff (such as health care support workers) and the new
technologies being developed around the world. The following three examples of
advanced nursing practice – nurse prescribing and nurse-led clinics, submitted by
the RCN, and developing nursing services, submitted by Sally Kendall, University of
Kent, illustrate different aspects of this.
Nurse prescribing in Botswana

Nurse prescribing delivers parity of outcomes with doctors. The Botswana Baylor
Children’s Clinical Centre of Excellence conducted a cross-sectional study in 2009
that compared the performance of nurse prescribers to doctors caring for HIV-
infected paediatric patients. Selected by stratified random sampling, 100 physician
and 97 nurse prescriber encounters were reviewed. The results showed that nurse
prescribers and doctors respectively correctly documented 96% and 94.9% of the
time. There was also evidence that nurses undertook a higher level of social history
documentation.
The findings led the centre to reaffirm its support for continued investment in
employing nurses to provide quality care and antiretroviral treatment services
to infected children. It is also advocating for this approach to be adopted across
southern Africa. Its report concluded that task-shifting to nurses continues to show
great promise for scaling up and sustaining adult and paediatric antiretroviral
treatment, particularly where provider shortages threaten rollout.24
Nurse-led clinics in Hong Kong

Advanced nursing practice began in Hong Kong in the 1990s. These nurses often
carry their own patient load, but may also see patients with specialty needs on other
wards. Their roles vary according to hospital and specialty, and have developed
significantly.

Hong Kong’s health system does not have significant primary health care capacity,
and people with serious problems are usually first seen in the emergency department.
Once diagnosed and stabilised to need no further inpatient treatment, they are
referred to a specialty outpatient clinic, but owing to the lack of such clinics, the
Hospital Authority developed the concept of nurse-led clinics, with specialist nurses
providing care and management. For example, a patient with chronic obstructive
pulmonary disease will go to a nurse-led COPD clinic.
These nurse-led clinics continue to expand and have demonstrated good
improvements in care. The nurses can manage up to 90% of patients for outpatient
disease-specific care. They practise independently or with some supervision,
adjusting medication and initiating diagnostics and treatments according to
protocols.25
Developing new services in England

Viv Marsh is a registered general nurse, sick children’s nurse and school nurse who
coordinated a school nursing service in the Midlands, England. Asthma, a common
long-term condition among young British people, is a frequent cause of hospital
admission. She inspired her colleagues to develop and implement a strategic policy
for asthma management in 110 schools, adopting a public health approach that
resulted in healthier children and probably saved lives.
With collaborative multiagency working between health, education and the
voluntary sectors, the programme covered the whole school population in the area,
raising awareness and knowledge to improve respiratory health and prevent acute
attacks and child mortality. Each school health advisor (mostly registered school
nurses) ensured the development and implementation of the asthma policy, trained
and worked closely with community health link workers, and had a caseload of
‘high need’ children.
Young people were actively involved, and could now access a well coordinated service
that enabled major reductions in emergency admissions. The introduction of a
generic emergency inhaler into schools kept children out of hospital and almost
certainly saved lives.
An independent evaluation, part of a larger study of nurses’ role in managing long-
term conditions, highlighted many positive outcomes. It said nursing education,
leadership, vision and the navigator role were key to success – the art and science of
navigating the health system and keeping children, schools and families at the centre.
Specialist professional associations provide advocacy and development opportunities
for public health nurses in the UK.26 27
Viv’s vision, persistence, leadership and knowledge were key, built on her sound
nursing education and specialist training. Her work demonstrates how nurses, when
trained and enabled to lead, and empowered to seize the opportunity, can develop
high quality, cost-effective systems of care that enact the principles of a primary care
system orientated to public health.28

3. Workforce, professional
education and regulation
Summary
This chapter describes the current shortfall in health
workers globally and the projections of still greater
shortages in future. It considers how WHO and its
member states propose to address this, and reviews
how education and regulation can contribute.
Nurses and midwives make up almost half the world’s

health workforce but are spread very unequally,
with the largest proportion working in urban areas in
high-income countries. This maldistribution is made
worse by internal and international migration and,
as significantly, by large numbers of nurses taking up
employment outside the health sector.
The biggest problem in terms of numbers, however,

is simply that not enough nurses are being trained,
and the estimated shortfall in nurses and other health
workers is therefore growing.
To mitigate these problems, countries around the

world are reviewing their approaches to education
and regulation, and looking for new ways to train and
deploy health workers.
Numbers of nurses, midwives and other health

workers
Nurses and midwives, taken together, are by far the largest professional group in
the health workforce globally. In 2013 there were over 42 million health workers,
according to WHO (Table 3.1).29 Among them were 9.7 million doctors, 19.7 million
nurses and midwives – just under half the total workforce – and 12.6 million health
workers from other professions or with some level of training.

Table 3.1 Stock of health workers globally, 2013
Medical Nurses/ All other

Medical Nurses/ All other doctors midwives cadres Total per
doctors midwives cadres 1 Total 2 per 1000 per 1000 per 1000 1000 2
Region
Africa 225,120 1,039,709 620,315 1,885,144 0.27 1.22 0.73 2.22
Americas 2,025,041 4,629,099 2,637,289 9,354,429 2.09 4.85 2.73 9.68
Eastern 785,629 1,295,020 979,097 3,059,747 1.26 2.08 1.57 4.91

Mediterranean
Europe 2,909,059 5,314,157 3,308,690 11,531,897 3.20 5.84 3.64 12.68
South-East Asia 1,062,373 2,776,662 2,093,276 5,932,311 0.57 1.50 1.13 3.20
Western Pacific 2,721,036 4,624,862 2,959,246 10,305,145 1.49 2.54 1.62 5.66
Income 3
Low 144,826 399,478 323,979 868,284 0.19 0.51 0.41 1.11
Lower-middle 1,977,455 4,475,914 3,543,241 9,996,609 0.77 1.75 1.39 3.91
Upper-middle 3,880,669 6,603,520 4,259,087 14,743,276 1.61 2.74 1.77 6.12
High 3,725,300 8,263,597 4,471,607 16,460,504 2.92 6.48 3.51 12.91
World 4 9,728,249 19,742,509 12,597,914 42,068,673 1.38 2.81 1.79 5.99
1
Refers to the seven other broad categories of the health workforce as defined by the WHO Global Health Workforce Statistics Database,
i.e. dentistry personnel, pharmaceutical personnel, laboratory health workers, environment and public health workers, community and
traditional health workers, health management and support workers, and other health workers. A cadre multiplier was determined by
taking, for each World Bank income region, with non-missing “all other cadres” values, the average number of “all other cadres” relative to
medical doctors/nurses/midwives. This yielded the following workforce multiples: 0.595 (low): 0.549 (lower-middle): 0.406 (upper-middle): and
0.373 (high). Multiplying the total medical doctors/nurses/ by this cadre multiplier yielded the estimated number of “all other cadres” for that
region.
Counts and rates may not equal row/column totals due to rounding or to missing data in income or region.
2
3
Income-specific “all other cadres” multipliers are as indicated under note (1) above.
4
Comprises 210 countries for which the United Nations publishes population estimates, at a total estimated population in 2013 of
7,024,094,223
Table 3.1 estimates that in 2013 (latest available data) the global health workforce was slightly over 42 million,
including 9.7 million physicians, 19.7 million nurses/midwives, and approximately 12.6 million other health
workers. The global nurse/midwife to physician ratio was 207.
WHO estimates there is a shortage globally of more than 7.2 million health workers,
based on current demand, and that this will increase to 12.9 million by 2035.30
Demand for health care is growing globally for a variety of reasons, including
increased demand from high-income countries as their populations age, and from
low and middle-income countries as they progress towards UHC. Health care
is already a $7.2 trillion a year industry, equivalent to 10.6% of global domestic
product. It is growing at 5.2% annually – with Asia and Australia expected to see
growth of 8.1% a year – and may reach $9.3 trillion by 2018.31
This growth in demand is in turn generating a need for health workers that far
outstrips current supply. On current trends the number of nurses and midwives
in Africa will grow from 1.0 million to 1.5 million between 2013 and 2030, but the
shortfall in the number required to meet the need will grow from 1.8 million today

to 2.8 million by 2030.32 In other words, the shortage is growing faster than the
increase in supply.
Governments and health policy-makers everywhere, as described below, are looking
to innovative models of service delivery and staffing to mitigate the problems these
shortages cause, for example through greater engagement of patients, better use of
technology and changes to skill mix.
The distribution of health workers

Shortages in many countries are made worse by maldistribution of health workers.
Most nurses, like other health professionals, work in richer countries and in urban
areas where there are better opportunities in terms of income, training, career
progression, work environment, employment and access to services and amenities.
This uneven distribution across and within countries often means that the people
most in need do not have access to health services.
Table 3.1 also shows the distribution of health workers and nurses and midwives
across the six WHO regions. The quality of the data provided to WHO is patchy and
in some cases poor; however, it is sufficiently good to reveal the scale of differences
between countries. Europe, the region with most nurses and midwives, has 5.84 per
1000 population while Africa, the region with the least, has 1.22 per 1000. These
regional averages mask greater differences, for example between African countries
such as Mozambique, Ethiopia and Kenya, which have respectively 0.34, 0.28 and
0.79 nurses and midwives per 1000 population, and the UK, US and Norway with
respectively 6.9, 9.4 and 14.2.33 Thus the UK has around 20 times more nurses and
midwives in proportion to its population than Mozambique and Ethiopia, the US
about 30 times as many, and Norway 40 times as many.
“ The UK has around 20 times more nurses and midwives in proportion to its
population than Mozambique and Ethiopia, the US about 30 times as many,
and Norway 40 times as many
”
Most countries in the Organization for Economic Co-operation and Development
(OECD) report nurse shortages despite their relative advantage in numbers;
Australia, for example, predicts a shortfall of 85,000 by 2025.34 Recently 83% of
organisations surveyed in the UK reported shortages of qualified nurse supply.
Paradoxically, qualified nurses in some countries are unable to find work, a problem
in some countries for many years according to ICN. It arises both from a mismatch
in supply and demand and because governments often lack the funds to employ the
nurses who have been trained.35 The government of Zambia told the Review Board
that many newly qualified nurses were unemployed in 2016 for this reason, but it
plans to rectify this.
Migration of health workers

The international migration of nurses to countries offering better opportunities
occurs at both global and regional levels and disadvantages the poorest countries.
Many nurses from Zambia and Zimbabwe, for example, migrate to South Africa
where salaries and work environments are better. In Trinidad and Tobago, local
nurses leave for opportunities in the US and the UK while the government of
Trinidad and Tobago in turn recruits nurses from the Philippines, Cuba and other
islands in the Caribbean to cover the deficit.

Even more significantly in terms of the numbers involved, there is also migration
within countries, from rural to urban areas and from government health services
to NGOs, for-profit organisations and project-based work. Many health workers
in low and middle-income countries move to work for ‘vertical programmes’ for
specific health conditions, such as those funded through the Global Fund to Fight
AIDS, Tuberculosis and Malaria, the Global Alliance on Vaccines and Immunization
(GAVI), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). Many
others work outside the health sector for a range of reasons including lack of jobs,
low pay and poor working conditions. This internal migration contributes to
shortages in general health services, which are mostly provided by governments, or
locally-based charities in some countries.
There is also migration from the countryside to urban areas. Less than 55% of people
globally live in urban areas, but more than 75% of doctors, over 60% of nurses and
58% of other health workers. Populations in rural, periurban and inner-city slums
are often in most need but are generally the least well served.
Migration and the resulting global and national maldistribution of nurses cause
major problems for governments. Paul Magesa Mashauri, President, Tanzania
National Nursing Association, told the Review Board that it was not just about
numbers but also about who chose to leave – ‘especially those nurses who are more
competent are the ones who leave.’ Others described how they were working on
these problems by providing incentives to retain nurses and ensure their distribution
nationally mirrored population health needs. Nurses working on some of the smaller
islands in the Bahamas, for example, receive additional benefits and allowances as
they are considered to be working in hardship areas.
A range of approaches is taken in Ghana, Kwansa et al report. ‘Like many countries in
sub-Saharan Africa, Ghana is faced with the simultaneous challenges of increasing its
health workforce, retaining them in-country and promoting a rational distribution
of staff in remote or deprived areas. Recent increases in both public sector doctor
and nurse salaries have contributed to a decline in international out-migration, but
problems of geographic maldistribution remain.’36
Proposed non-fiscal incentives in Ghana included clearer terms of contract detailing
length of stay at a post, and transparent procedures for transfer and promotion;
career opportunities for all cadres of nursing; and benefits such as better on-the-job
housing, better mentoring and more recognition from leaders. ‘An integrated set of
recruitment and retention policies focusing on career development may improve job
satisfaction and retention of nurses in rural Ghana,’ they say.
The UK has long been a major beneficiary from inward migration: many nurses from
Ireland, for example, worked in UK institutions before the foundation of the NHS.
In the early 1950s the UK actively recruited nurses from the Caribbean and doctors
from India to support the expanding NHS. More recently it has benefited from large
numbers of European Union (EU) health workers coming to the UK, but this trend
is likely to disappear and perhaps reverse. UK withdrawal from the EU will probably
lead to pressure for increased recruitment from other countries.
Since 2000 the UK has worked to reduce the number of trained health workers
coming from countries with severe shortages. It signed a series of agreements,
starting with a bilateral one with South Africa, followed by a Commonwealth
concordat, and the WHO Global Code of Practice on the International Recruitment
of Health Personnel in 2010.37 This code seeks not only to safeguard countries with
major shortages from active recruitment by other countries, but also to uphold the
rights of migrants and ensure they are treated appropriately.

These agreements have contributed to large reductions in immigration to the UK

from the countries with the greatest shortages. For example, the number of Africans
registering with the Nursing and Midwifery Council (NMC) for the first time has
fallen, from a peak of over 2000 a year at the turn of the century to below 200. Other
factors have also played their part, including free movement of labour within the
EU and the boom and bust cycle of nurse training and workforce planning, with its
alternating peaks and troughs in UK nurse numbers. UK withdrawal from the EU,
as noted above, could increase these flows.
Many nurses raised concerns about migration in interviews and written evidence.
The APPG therefore recommends that the UK reaffirms its support for the WHO
code, and publishes a report on its progress on implementation since 2010. In
particular it should monitor and report annually on data on inflow and source
countries, and demonstrate how it will meet the commitment in the 2016 WHO
global strategy to reduce reliance on international recruits by half.
The emigration of health workers is a very significant issue for low and middle-
income countries and needs to be tackled. However, dealing with migration alone
is only a part of the problem. For example, it has been estimated that if every African
health worker who had received some level of health worker training and then
emigrated were to return home, this would only address about 10% of the shortage
in the continent.38 There are many interconnected problems but in numbers terms
the single biggest factor is that not enough nurses and other health workers are
trained in the first place.
The WHO global strategy on human resources for health

WHO, its member states and partners have developed a global strategy on human
resources for health, Workforce 2030, adopted by the 2016 World Health Assembly of
member states. It has four main objectives to address these fundamental issues, by
securing investment in increased numbers of health workers and also by improving
the ways in which they work and are managed and deployed:
• optimise performance, quality and impact of the health workforce through
evidence-informed policies on human resources for health, contributing to
healthy lives and wellbeing, effective UHC, resilience and health security at all
levels;
• align investment in human resources for health with the current and future
needs of the population, taking account of labour market dynamics, to enable
maximum improvements in health outcomes, employment creation and
economic growth;
• build the capacity of institutions at subnational, national and international
levels for effective leadership and governance of actions on human resources
for health;
• strengthen data on human resources for health for monitoring and
accountability of the both national strategies and the global strategy.39
UHC will be won or lost with nursing and midwifery, the Review Board heard
from Jim Campbell, Director, Health Workforce Department, WHO and Executive
Director, Global Health Workforce Alliance, who led the development of the strategy.

“ Universal health coverage globally will be won or lost with nursing and
midwifery
”
Jim Campbell, Director, Health Workforce Department, WHO, and Executive
Director, Global Health Workforce Alliance
The strategy provides a global framework within which countries should develop
their own plans. It provides a comprehensive overview but recognises that
investments and policies have to be determined nationally in the light of local
priorities, circumstances and resources. As noted in Chapter 2, many countries
are reviewing their strategies for nursing and considering its future contribution.
Developments in professional education and regulation are central to these
approaches.
The challenges to governments

APPG co-chair Lord Crisp met many nursing and government health leaders in
Zambia during this review. The Permanent Secretary of its Ministry of Health is
leading the country’s approach to strengthening its health system and working
towards UHC – and the development of nursing is seen as an important part. The
challenges, familiar to other countries, include:
• decisions about the level of education needed for nurses – with increases in the
proportion of registered nurses (RNs);
• how best to train nurses to be able to work independently in rural areas
without immediate access to doctors – with an accompanying extension of
their scope of practice to include prescribing and other elements;
• the need to train specialist nurses as the country develops services for cancer
and other conditions;
• training increased numbers of community health workers in rural areas, and
health care assistants in hospitals.
Every country in the world is likely to face broadly similar issues as they grapple with
moving towards UHC or, in the case of many European countries, work to maintain
and improve existing services and systems. These commonalities suggest there is
much that countries can learn from each other and considerable scope for sharing
good practice and learning.
These discussions and decisions are taking place at the same time as far-reaching
developments in the education and training of health professionals, their regulation,
and the concept of professionalism itself. Full consideration of these issues goes far
beyond the scope of this report, but some key features to note here include:
• the continuing shift towards competency-based and system-based education
and training;
• the related approach to competency-based regulation;
• new approaches that embrace greater teamwork and the full engagement of
patients, carers and communities.
Before looking at the differences between countries, it is worth noting that if nurses
in any country are to fulfil the potential of the combination of knowledge, practical
skills and values described in Figure 1.1, Chapter 1, both their education and their
employment need to support it. This means that every country needs a strong cadre

of well-educated RNs who can work as team leaders, navigators and facilitators, and
that their employment must enable them to work to the full extent of their training
and potential.
As the APPG notes, there is good evidence of a positive correlation between quality
of care and outcomes, including mortality, and the proportion of RNs in the
workplace with nursing-related degrees.40 The APPG therefore supports the WHO
aspiration that an undergraduate (bachelor’s) degree in nursing should become
the entry qualification for all RNs. This will also help the profession to attract the
recruits it needs. This aspiration will take years to achieve in many countries, and
countries will find their own routes towards it.
Differences between countries

There are obvious differences in needs between countries. As the many examples in
this report show, low and middle-income countries like Zambia need large numbers
of nurses with very good generalist skills so that they can cope with all the different
situations they face, in hospital wards as much as community settings. In effect,
they need to specialise as general nurses. These countries also need speciality-based
nurses, and richer countries also need generalists, but in a different proportion and
often with substantially different skill sets from colleagues in high-income countries.
The entry requirements, academic units, type of training and duration of training for
each group vary from country to country and sometimes between institutions within
a country. There is also a growth in some countries of unregulated private providers
offering professional training in nursing and medicine. The proportion of nurses in
each group also varies between countries: in Cuba and the UK, to take two examples,
all nurses are educated to degree level while in Rwanda, as in many countries in
sub-Saharan Africa, the majority of the nursing workforce is trained to enrolled
nurse or nursing auxiliary level.41 42 In addition, the relationship between nursing and
midwifery education and training varies from country to country.
There is a clear trend across countries of upgrading the nursing workforce, with
many aiming to train most RNs to degree level.43 Not only are there strong policy and
quality arguments for this, as noted above, but this shift is also driven by demand,
with more nurses choosing to get a degree instead of a diploma/certificate. Zambian
nurse leaders said there was no point in training enrolled nurses any more as so
many applied for RN training as soon as they qualified.
Funding for education also varies. In some countries the government pays most of
the costs, while in others students depend entirely on government loans or private
and charitable sources. Similarly, nurses have many different employers across the
range of health services, whether public, private, faith-based or NGOs. Although
government is the main employer in many low and middle-income countries,
funding for staff salaries can come from a variety of sources including the private
sector and bilateral and multilateral aid.29 Moreover, nurses working in the public
sector often supplement their income by taking on additional work in private
practice or outside nursing, or working extra hours through nurse banks or other
systems.
Competency-based and system-based education

There is a long-term movement towards basing professional education on acquiring
competency rather than on completion of a prescribed and profession-specific
course of instruction, a movement from specifying education attainment by inputs
to measuring achievement in terms of outputs. As defined by Epstein and Hundert,

‘competency is the habitual and judicious use of communication, knowledge,

technical skills, clinical reasoning, emotions, values and reflection in daily practice
for the benefit of the individual and community being served.’ 44
The Lancet Commission on the Education of Health Professionals for the 21st
Century argued in 2010 that education should be based not only on competency
but also on understanding systems. As epidemiological trends have changed and
awareness of the wider determinants of health has risen, there is a need for better
understanding of systems and for professionals, including nurses, to develop
leadership roles and lead improvement and development of services as ‘change
agents’. As a professional it is not enough to know what needs doing, you also need to
know how to get it done within a health system.45
The commission also emphasised how professionals and ideas about professionalism
needed to change. ‘Professionals…have special obligations and responsibilities to
acquire competencies and to undertake functions beyond purely technical tasks
- such as teamwork, ethical conduct, critical analysis, coping with uncertainty,
scientific inquiry, anticipating and planning for the future, and most importantly
leadership of effective health systems,’ it said.
This bringing together of education for the different professions, while maintaining
their distinctive roles, describes and reinforces the way in which practice is already
developing. Many of the skills, knowledge and attitudes of practitioners cut across
professional boundaries; for example, all need some knowledge of applied anatomy
and physiology, good communication skills, and emotional literacy. Moreover,
learning these together at the outset makes sense, not least in creating a shared,
holistic understanding of health, health care, people and communities, and laying
a foundation of mutual respect for each specific contribution.
Competency-based regulation
The regulation and registration of professionals is vital for providing protection for
the public, and providing assurance about the competence, integrity and values of
professionals. Just as with education, there is a move towards a competency-based
approach.
Regulation varies from country to country. In the UK, for example, acts of
parliament in 1902 (for midwives) and 1919 (for nurses) established independent
regulation for nursing and midwifery. The NMC ‘sets standards of education,
training, conduct and performance so that nurses and midwives can deliver high
quality healthcare throughout their careers’. In education, it:
• sets education standards, which shape the content and design of programmes
and state the competences of a nurse and midwife;
• approves education institutions and maintains a database of approved
programmes;
• delivers quality assurance of its approved programmes;
• registers nurses and midwives when they have successfully completed their
courses;
• assesses and ensures the quality of practice placements for students.

The NMC provides a very clear link between regulation and education and ensures
that both operate on the same principles. In some countries, however, such as
the former Soviet countries and many others worldwide, nursing regulation has
comprised little more than legislation that specifies lists of tasks nurses are entitled to
perform. Many countries still have no independent regulatory body for nursing.
The scope of practice of a profession will change as governments or independent
regulators decide to change, expand or extend roles and practice, just as the
government of Zambia is currently considering. It is helpful to separate the concepts
of role and scope of practice because the role may be very wide – as described in the
definition of nursing in Chapter 1 – while the scope of practice may vary from time
to time as needs and circumstances dictate.
The complaints from nurses in Chapter 2 about not being able to practise to the
extent of their competence partly arise from their particular country having a very
limited scope of practice, and partly, as in the example of the US in Chapter 1, from
not being allowed to practise to its full extent. The development of nursing globally
will embrace both aspects – enabling nurses to do what they are competent to do
today, and extending the boundaries of the scope of practice for the future.
Pointers for the future – nurses as change agents

Nurses act as change agents in many ways, as illustrated in the following two studies
submitted by the RCN.
Tackling AIDS in Andra Pradesh, India

Andhra Pradesh is the fifth largest state in India, with a population of around
80 million (73% of whom live in rural areas). It is also among the six Indian states
with the highest prevalence of HIV/AIDS, estimated among adults at 1%, or 21%
of all people living with HIV/AIDS in India. The decentralisation of HIV/AIDS
services to regional level has been critical for people living in rural and remote areas,
especially for access to counselling and testing services, which provide a gateway for
the entire range of HIV/AIDS treatments.
A pilot project was launched through a novel task-shifting model whereby nurses
were trained for extended roles as counsellor, lab technician and outreach worker.
The programme was stringently monitored and evaluated, including the supervision
of nurses by medical officers and nurse supervisors. In 2009 nurses in primary
health care were assessed: 80% were rated as excellent, while the remaining 20%
needed upgrading. A subsequent evaluation indicated more positive results for the
programme, particularly with respect to the nurses’ roles.46
Improving TB services in the Republic of South Africa

In 2000, the Lung Institute at the University of Cape Town developed a series of
innovative packages to train nurses in rural, underserved areas to lead in screening
patients at high risk of tuberculosis (TB) and other respiratory diseases. Over a
period of 14 years, a randomised trial cluster of 40 clinics with over 200 nurses
showed a substantial improvement in early detection of TB. A follow-up programme
was developed following this success, which extended the training of clinic nurses
to include HIV/AIDS screening and referral to doctors for diagnosis and initial
prescribing of treatment, with patients then returning to nurses for monitoring.

A second cluster of randomised trials for this extended programme again confirmed
a substantial positive impact on case detection of TB and HIV. There was also a
surprising improvement in successful outcomes for retreatment of patients with TB,
suggesting that the training had a positive impact on nurse–patient relationships.
The trials also found that nurse-led care of HIV/AIDS caseloads resulted in patients
being managed as effectively as they would have been in doctor-led programmes.
Qualitative evaluations alongside these trials also showed that front-line clinic
staff felt empowered by their training, allaying fears that responsibility for clinical
diagnosis and treatment would be overpowering and result in burnout.47

4. Opportunities and impacts
Summary
The first three chapters of this report reviewed the
current situation and described many long-standing
problems. The final three chapters look forward,
towards opportunities and possibilities.
This chapter starts by considering evidence of the

positive impact of nurses on quality, access to care
and costs. There are many small-scale studies of this
impact, and even more examples and anecdotes,
but few large-scale studies, and most research is
limited to high-income countries.
It goes on to look at how nurses can be enabled to

fulfil their potential and take on new roles, making an
even greater impact as a result, and at how sharing
good practice, task-shifting and task-sharing can
help.
The chapter concludes with the triple impact of

nursing on improving health, promoting gender
equality and strengthening economies.
The impact of nursing

Many studies show the beneficial impact of nursing across the different settings of
homes, communities and hospitals, and in public health as well as clinical care. This
section looks in turn at impacts on improved quality, access and value for money;
patient outcomes; and service design and policy-making.
Quality, access and value for money

Several organisations have brought together existing research about the impact
of nurses in high-income countries. These include the Institute of Education,
University College London, which in 2010 did a rapid systematic review of reviews
of the socioeconomic value of nursing and midwifery;48 the Department of Health
and Public Health England; WHO;49 and ICN50. Many of these studies make
comparisons between nurses and doctors. The results all show that there are no
easy generalisations about impact. All describe positive impacts on quality, access
to services and value for money in particular circumstances and for specific ranges
of patients – and not for others. The Institute of Education, for example, reviewed
32 systematic reviews conducted in OECD countries and concluded as follows:
• Interventions provided by specialist nurses or led by nurses were shown to
have a beneficial impact on a range of outcomes for long-term conditions
when compared with usual care. While there was little evidence of a difference

in clinical benefit of such interventions, there was persuasive evidence that

specialised cancer nursing produced benefits in terms of patients’ ability to
cope with their condition.
• Enhanced nursing care for respiratory conditions may result in fewer visits
to accident and emergency departments, though there was little evidence of
benefit for other outcomes. There may be cost savings associated with nurse-
led hospital at home care.
• General practice nurses may have some benefit in reducing some of the risk
factors for heart disease when compared with usual or no care. While cost
estimates were provided, overall cost-effectiveness was unclear.
Individual studies show benefits from nurse-led care including reduced costs,51
higher patient satisfaction,52 shorter hospital admissions,53 better access to care, and
fewer hospital-acquired infections. Nurse-led interventions for chronic conditions
such as HIV and diabetes have resulted in patients making more informed decisions
about their care and being more likely to adhere to treatment.54
Advanced nurse practitioners (NPs) not only improved access to services and
reduced waiting times, but also delivered the same quality of care as doctors for a
range of patients, including those with minor illnesses and those requiring routine
follow-up, according to an evaluation by the OECD across high-income countries.55
“ An OECD evaluation… found that advanced practitioners not only

improved access to services and reduced waiting times, but that they
also delivered the same quality of care as doctors for a range of patients,
including those with minor illnesses and those requiring routine follow-up
Department of Health and Public Health England ”
A systematic review of comparison of NPs with physicians in primary health care
settings in Canada, the UK and the US showed low to moderate quality evidence
that patient health outcomes were similar for NPs and physicians, but that patient
satisfaction and quality of care were better for NPs.56 Similarly, an English study
showed that in a comparison of care effectiveness and cost effectiveness of general
practitioners and NPs in primary health care, outcome indicators were similar for
nurses and doctors, but patients cared for by nurses were more satisfied. NPs were
slightly more cost-effective than general practitioners.57
Globally, home-based, nurse-led health promotion and case management offer
clinical benefits across a number of important health dimensions for older people
(benefits in mortality, functionality, self-perceived health status, and caregivers’
mental health), the International Collaboration for Community Health Nursing
Research (ICCHNR) told the Review Board. ‘Home-based early intervention
delivered by community nurses is effective in preventing obesity in children, reducing
mental health problems in mothers and children, promoting parenting self-efficacy
and in providing access to basic primary care in remote and rural areas where other
health services are not available,’ it said.
By being embedded within communities, many respondents pointed out, nurses are
able to promote public health and disease prevention. They can educate their local
populations to make healthy choices, empower patients and families with knowledge
and skills to encourage individual ownership of health, and help to build health
resilience in their communities. In the current global climate of increasing burdens
of more complex and chronic conditions, a nurse’s role as a culturally attuned health
promoter is invaluable.

As ICCHNR argued, ‘The foundational characteristics of many of these services

provided by community nurses include a patient-and family-centred approach,
a proactive orientation, an emphasis on promoting self-care skills and independence,
and cross-organisational relationships with other providers and institutions.’
Nurses working in primary care settings have a critical role in supporting patients to
self-manage their long-term conditions, taking an assets-based and health coaching
approach and making use of opportunities for social prescribing, said Crystal
Oldman, Chief Executive, Queen’s Nursing Institute (QNI). ‘Nurses make up the
majority of health practitioners who support people among the most vulnerable in
society, such individuals and families who are homeless,’ she told the Review Board.
The outcome studies are mainly from Europe and the US, although there are some
from other countries. In studies in the Republic of Korea, primary care services
provided by nurses were of the same quality as those provided by physicians,
and also more cost-effective. Furthermore, ‘many of these nurses function as
community development agents, working not only to improve the health status of
the community but also to improve the quality of the environment and the standard
of living.’58
Patient outcomes and safety

Several studies show the relationship between the number of nurses on a ward, their
workload, education and the environment on the one hand, and inpatient morbidity,
mortality and safety on the other. 59 60 61 62
The RN4CAST Collaboration was set up to investigate these linkages further and
provide better evidence for the deployment of nurses in hospitals. It started from the
basis that ‘current human resources planning models in nursing are unreliable and
ineffective as they consider volumes, but ignore effects on quality in patient care’. The
project aims at innovative forecasting methods by addressing not only volumes, but
also quality of nursing staff and quality of patient care.63
The first major RN4CAST observational study obtained discharge data for 422 730
patients aged 50 or older who underwent common surgical procedures in 300
hospitals in nine European countries. It drew some clear conclusions. ‘An increase
in a nurse’s workload by one patient increased the likelihood of an inpatient dying
within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031–1·106), and
every 10% increase in bachelor’s degree nurses was associated with a decrease in
this likelihood by 7% (0·929, 0·886–0·973). These associations imply that patients
in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for
an average of six patients would have almost 30% lower mortality than patients in
hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an
average of eight patients.’64
‘Nurse staffing cuts to save money might adversely affect patient outcomes. An
increased emphasis on bachelor’s education for nurses could reduce preventable
hospital deaths,’ the study concluded. The collaboration is continuing its work in
Europe and the US; however, there are as yet no comparable studies for low and
middle-income countries or for primary health care and community settings.
“ Nurse staffing cuts to save money might adversely affect patient

outcomes. An increased emphasis on bachelor’s education for nurses could
reduce preventable hospital deaths
”
Linda Aiken and colleagues, RN4CAST Collaboration

Service design and policy-making

There are great benefits in involving nurses and other health workers in both service
design and policy-making and, as the following paragraphs show, great dangers from
not doing so.
The Ebola virus disease outbreak in West Africa killed many health workers and
became known to some as the ‘caregivers’ disease’. It also led to many health workers
and their families being stigmatised and shunned in their local communities. The
European Federation of Nurses Associations, reviewing the extent of involvement of
health workers in preparedness for Ebola and other infectious diseases, was surprised
to find that ‘health professionals do not feel they are being consulted enough on the
equipment and protocols they are to use, and are not adequately briefed from their
organisation.’
Its report, aptly called We are not prepared unless we are all prepared, argued that
‘overall, awareness-raising initiatives are imperative in improving preparedness
for Ebola and other infectious diseases of high consequences (IDHC); nurses have
first-hand knowledge and experience of the reality of caring for patients with IDHC
and Ebola, can give valuable contributions and consequently need to be involved in
the decision-making, selection of material, development of protocols, as well as the
design of policies and procedures which are “fit for practice”.’65
“ We are not prepared unless we are all prepared

”
European Federation of Nurses Associations
The comment that nurses have first-hand knowledge and experience of the reality of
caring for patients has great relevance in many different situations. ICN summed up
the many ways in which nurses can play a vital role in making decisions about how
services are delivered and improvements introduced, saying that nurses as a force for
change have opportunities to improve efficiency and reduce waste. In collaboration
with other health professionals and decision-makers, it said, nurses and other health
professionals can:
• improve prescribing guidance, information, training and practice;
• educate individuals and communities on detection and surveillance of
counterfeit medicines;
• develop and implement clinical and evidence-based best practice guidelines;
• implement task-shifting and other ways of matching skills to needs;
• adhere to and champion infection control procedures;
• improve hygiene standards in hospitals;
• provide more continuity of care;
• undertake more clinical audits;
• monitor hospital performance and use the data to guide clinical decisions;
• reduce administrative burdens;
• evaluate and incorporate into policy evidence on the costs and impact of
interventions, technologies, medicines, and policy options.

Nurses hold a wealth of knowledge about health and health systems that needs
to feed into decisions about service design and policy-making. Due to their roles,
the intimate care they frequently provide, and their mostly belonging to the same
community and culture as their patients’ nurses often understand patient needs
better than doctors and policy-makers.
The point was made to us very powerfully by Peggy Vidot, Principal Secretary,
Ministry of Health, Republic of Seychelles, describing how nurses can contribute to
policy. ‘People tend to believe that policies are done at a high level. But for policies
that are generated at that level, one requires the information, the evidence from
further down and I think this is where nursing can contribute. Nurses know what it is
that we need to address in their communities, what services we need to bring, or how
those services can be given more effectively so that we can be looking at attaining the
different goals and health targets in those goals.’
“ People tend to believe that policies are done at a high level. But for
policies that are generated at that level, one requires the information, the
evidence from further down and I think this is where nursing can contribute
Peggy Vidot, Ministry of Health, Republic of Seychelles ”
The quality of the evidence
This brief review of the evidence shows that it is not very extensive and that some
is of poor quality. However, the APPG also noted both that existing evidence was
often ignored and not acted on and that it was very difficult to undertake research
on nursing in low and middle income countries. Moreover, many of the services
provided by nurses are invisible and the impact of this evidence is therefore low, as
the ICCHNR told the Review Board. However, available evidence does illustrate two
key points:
• There are many opportunities for nurses to have an even bigger impact on
improving health and health care.
• Better evidence needs to be collected and disseminated to enable countries to
make their own business cases for where and how investing and developing
nursing in their country will have significant benefits.
More generally, many respondents told the APPG about small-scale initiatives
undertaken by nurses – innovative, sometimes experimental, patient-focused and
practical. There is a large reservoir of talent available that could have greater impact
in the future. Despite the paucity of evidence, there is already enough for action to be
taken. More evidence is needed but existing evidence needs to be used.
Current potential and future possibilities

Looking forward, this evidence and the discussions in earlier chapters show that
there is enormous potential to enable nurses to realise their full current potential
and to develop still further. This section looks briefly at four actions to help begin to
make this happen – each of which will influence the others and all of which need to
be undertaken.

First, this will require systematically removing barriers and changing mind-sets.
This is very difficult and can only be achieved with high-level leadership linked
with practical actions taken locally. The first APPG recommendation is that the UK
government, working with partners, is very well placed to help make this happen –
and should initiate a process to do so.
Second, political and non-nursing leadership is important in making this happen
but nursing leadership is also crucial. Earlier chapters show that in many countries
and in WHO there has been a reduction in nurse leadership roles, rather than a
strengthening. This needs to be reversed.
As the Department of Health and Public Health England report quoted earlier
argues, ‘What this reinforces is a need to build and strengthen leadership at all
levels for the long term – including within health service providers and ministries
and enhancing the role of chief nursing and midwifery officers. Maintaining and
enhancing this positive influence remains a challenge in the UK countries as well as
more resource poor countries.’66 As part of this, the APPG believes there needs to be
major investment globally in leadership programmes which will help nurses engage
in policy-making as well as in service design and organisational leadership. It notes
that ICN is in the process of developing a programme that could potentially meet
this need with the right support and funding.
Third, there need to be better ways of sharing and learning from good practice and
from research locally, nationally and globally. There are already a number of ways in
which this happens within particular communities – with, for example, both ICN
and RCN using their extensive networks to do so. However, little of this evidence is
seen outside nursing circles and many respondents saw a need for this to be more
extensive and better supported by ministries and non-nursing leaders. The APPG
suggests that the Commonwealth’s newly created Health Hub may have a useful role
here.67
Finally, the development of nurses needs to be undertaken as part of a balanced
approach to the whole health workforce. The WHO strategy described in Chapter 3
provides an overall framework and there is a great deal of recent research and policy
development on teamwork and skill mix, including, for example, guidelines on task
shifting and task sharing from WHO and the World Health Professions Alliance.68 69
The global shortage of health workers and the need to achieve the best possible
value for money are leading policy-makers to look at many different options for how
services will be delivered, health workers deployed and professionals educated in
future. A very common approach is to look to skill-mix change, task-shifting or task-
sharing, approaches through which tasks traditionally performed by one group of
health workers are undertaken by another or by patients and their carers. In Zambia,
as noted in Chapter 3, the Ministry of Health is both enhancing the roles and scope
of practice of nurses working alone in country areas and introducing health care
assistants in hospitals. In England work is under way to pilot proposals for a new
nursing support role, the ‘nursing associate’.
In some cases, this approach is about extending the scope of practice, for example
of nurses; in others, about creating new roles or cadres; and in yet others about
supporting patients to do more for themselves.
There are many excellent and successful examples of each, including:
• Extended scope of practice. Nurse prescribing in England has worked
successfully. Similarly, the enabling of nurses to initiate ARV therapy in South
Africa played a major part in bringing down HIV/AIDS deaths.

• Creating a new cadre. The creation of ‘tecnicos di cirurgia’ to undertake

obstetric surgery in Mozambique – many previously trained as nurses –
contributed enormously to improving maternal and child mortality and
morbidity.70
• Self-care. The introduction of patient-managed dialysis in hospitals in Sweden
– not just in their homes – improved quality and satisfaction and reduced
costs.
The Lancet Commission on the Education of Health Professionals for the 21st
Century describes how these approaches relate to the earlier discussion on
competences and professionalism. ‘Individual professions might have distinctive and
complementary skills that could be considered the core of their special niche. But
there is an imperative for bringing such expertise together into teams for effective
patient-centred and population-based health work. Moreover, the walls between task
competencies of different professions are porous, allowing for task-shifting and task-
sharing to produce practical health outputs that would not be possible with sealed
competencies.’45
There are risks with this approach. In part these arise from staff not following
guidelines described above with, for example, tasks of intimate physical care, or care
for people with mental illnesses or learning difficulties, being undertaken by people
who may not be properly trained for the task or able to follow the patient’s care plan.
This can result in the delivery of poor care and these assistants being mistaken for
nurses by patients, the public and the media.
On the other hand, there are also risks when NPs and other specialist nurses take on
tasks performed by doctors. This is partly about workforce planning. ‘Task shifting
from medicine to nursing needs to be evaluated for its impact on the provision of
nursing care,’ Emma Coyle told us. ‘The development of new cadres of health care
workers to fill the shortage left by too few nurses and doctors could take away from
those who would normally enter nurse education. If there is a finite human resource
for nursing, then fragmentation of that resource may not be conducive to achieving
universal health coverage.’
Furthermore, the distinctive and wide-ranging role of the nurse should not be lost by
becoming more focused on specific processes and procedures. As Heather Henry put
it, nurses should not just be used as a cheap way to plug gaps in services – nursing
must remain distinct from medicine, ‘maxi nurse not mini medic’. 71
An earlier APPG report, All the Talents, identified five groups of factors consistently
present in successful examples of task-shifting but absent where it failed.72 These
success factors are individually very obvious and simple-sounding but collectively
quite hard to deliver. Many low and middle-income countries lack resources to do
all these things all the time, such as provide supervision in remote areas. The more
of these factors that are in place at any time, the more likely any change is to be
successful.
The upward spiral in Figure 4.1 illustrates how these factors reinforce each other
when building from a sound basis of planning and leadership, with the full
engagement and leadership of local teams. Turning the spiral upside down, it is
easy to see why many such examples fail – poor planning without engaging those
who will actually do the work, recruiting the wrong people, inadequate training, no
supervision and no authority or ability to refer are all major contributors to failure.

Figure 4.1 Success factors in changing skill mix
Recognition and teamwork
Supervision and referral
Formal training and progression
Job design and recruitment
Leadership and planning
Recognition and teamwork

All health workers should receive adequate recognition for their work and
be supported to work in teams with other professionals, lay workers and
patients.
Supervision and referral

Supervision and clear referral pathways – involving all groups of health
workers – are essential to ensure the best quality of care.
Formal training and progression

Formal training is needed to develop skills, and opportunites for
progression can be important in enabling individuals to achieve their
potential.
Job design and recruitment

Tasks must be defined and recruitment targeted accordingly.
Leadership and planning

Success is based on careful preparation and planning – with a leader,
institution or government taking responsibility for all aspects of planning
and implentation.
Triple impact
This chapter has concentrated on nurses’ impact on health, but it is also important
to recognise how investing in and developing nursing promotes gender equality and
strengthens economies – the other two aspects of the triple impact.
Nursing is not and should not be seen as an exclusively female profession. Yet women
currently make up the vast majority of the nursing workforce, and the way nurses
are treated in a particular society is often a reflection of how women are treated.
Becoming a nurse provides many girls and women around the world with access
to formal education, training programmes and eventually licensure, a job, and an
income, facilitating their economic independence. Through this experience nurses
gain confidence and respect in their local communities and can act as role models

and mentors to other women and girls. In addition, a qualified, empowered and
competent nurse empowers other women indirectly by helping to improve their
health and well-being.
The Grameen Caledonian College of Nursing, Dhaka, Bangladesh, created in
partnership between Grameen Bank and Glasgow Caledonian University, is a fine
example. It educates girls from the rural communities of Bangladesh to a high and
appropriate standard of nursing and midwifery practice, with a focus on rural public
health. Their education is paid for by a low-interest social loan that is then repaid
when they start working in rural community health. ‘This creates a sustainable
training model, equips the students with skills that have a real impact on the health
of rural communities, and raises their social status and income, benefiting their
family and community.’73
As founding principal Barbara Parfitt says, ‘Our students will be equipped with
the skills, knowledge and attitudes that will change their lives and the lives of their
communities forever.’ It gives young women opportunities and prepares them to
be leaders and change agents in health care for the future, adds Muhammad Yunus,
Nobel laureate and Chancellor, Glasgow Caledonian University.74
“ Grameen Caledonian College of Nursing gives young women

opportunities and prepares them to be leaders and change agents in health
care for the future
”
Muhammad Yunus, Chancellor, Glasgow Caledonian University
Turning to economic growth, there has long been an understanding that better
health contributes to economic growth and, conversely, that ill health is an economic
cost to a country and affects educational attainment and productivity.75 Additionally,
nursing contributes to economic growth by being a major source of long-term
employment and contributing to national and international labour markets.
Moreover, there is evidence that health sector employment has significant growth-
inducing effects on other economic sectors, as employed health workers spend their
income across a wide range of areas.76 This causes a cascade effect, with money
circulating across the economy and spurring economic growth.
The UN High-Level Commission on Health Employment and Economic Growth
was established in 2016 precisely to describe this interface between health worker
employment and economic growth.77 Its report notes that: ‘First, good health
contributes to economic growth. Second, there are important additional pathways
by which investments in the health system have spill-over effects that enhance
inclusive economic growth, including job creation. Third, new evidence suggests that
expenditures on health are not dead-weight drags on the economy, but rather can
be associated with productivity gains in other sectors.’78 It goes on to argue for the
importance of investing in health worker employment as a means of ensuring there
is inclusive growth.
While the details will vary from country to country, this triple impact provides a
compelling case for developing nursing globally.

5. The UK’s contribution to
health globally
Summary
This chapter describes the UK’s contribution to health
globally and its potential to do much more to support
the development of nursing globally.
It also outlines the role of partnerships and the scope

for mutual learning between nurses in the UK and their
counterparts abroad. It concludes by highlighting
some existing partnerships.
The UK’s contribution to health globally

In 2015 the landmark APPG report, The UK’s Contribution to Health Globally,79
mapped the contribution to global health of actors across four sectors in the UK
– government, academia, commerce and not-for-profit activity. It showed that the
UK is a world leader in health, with enormous scope both to help improve health
worldwide and to continue to develop research, industry and activities that benefit
the UK.
The report made little mention of nursing – partly because its contribution is
largely small-scale and ‘invisible’, but also because its potential is unrecognised and
unrealised. Yet, with its world-class universities and research institutions, cutting-
edge life science, a diverse not-for-profit sector and acknowledged strengths in health
care and international development, the UK is very well positioned to contribute
significantly to supporting the development of nursing globally.
There are many government bodies and public authorities that can play major roles,
including:
• The UK government itself through its international relationships, particularly
with the Commonwealth, Europe and countries supported by the Department
for International Development through partnerships. The next chapter
contains recommendations on how the government can use these great
strengths to support the development of nursing globally.
• The NHS in the four countries of the UK, through sharing expertise; creating
mutually beneficial relationships with partners in other countries; and
strengthening and developing nursing in the UK. Examples of partnerships
between UK organisations and others abroad are described below.
• Regulatory and public bodies, such as the NMC, the National Institute for
Health and Care Excellence (NICE) and the authorities responsible for public
health and education and training in the UK’s four countries, can influence the
future of nursing in the UK and work with others abroad on global issues.
The UK also has nursing organisations that are themselves world leaders, building
on the great traditions of UK nursing and able to influence and partner with others.
The RCN, for example, internationally recognised as both professional body and
trade union, can play an important role in influencing policy and developments;
helping to strengthen national nurses’ associations; and collecting and sharing good
practice and evidence of impact. It also provides some training and development
opportunities for nurses from other countries – its partnership with the Zambia

Union of Nursing Organisation (ZUNO) is described below. The Royal College of

Midwives (RCM) undertakes similar work overseas with midwives as well as nurses
who work in maternity care. In addition Unison, Unite and other trades unions play
a role in bilateral projects and through Public Services International.
Many academic institutions in the UK train nurses and other health workers.
They can and do play an important role in education and providing continuing
professional development opportunities to overseas nurses, and supporting research
by nurses in low and middle-income countries. The UK also has many of the leading
nursing and health journals globally which disseminate evidence and best practice.
Looking ahead, both the not-for-profit sector and the commercial sector in the UK
can also play a larger part in supporting nurses through research and innovation in
practice.
The UK will only be able to play this important role, however, if its health and care
system is on a sound footing – and if there is no suggestion that it will be competing
with low and middle-income countries for health workers and other resources. The
vote to leave the EU has, however, created a significant risk that the UK will lose
many of the European nationals employed in its health and care system and will be
unable to recruit more. The Review Board believes that the UK needs both to find
methods for securing the continuing employment of EU citizens in the health and
care system and to re-assess and increase levels of nurse education to meet its own
needs. It needs also to maintain its commitment not to recruit health workers from
countries with major shortages.
Real-life experience and opportunities

A great deal of partnership and development work is under way and there are
opportunities for much more, as many respondents said. The following examples,
taken from interviews and responses to the APPG call for evidence, reveal some of
the complexities, including both risks and benefits.
Dr Oldman gave some historical context. After the Second World War, the QNI
played an important role in training district nurses from countries all over the world,
including Greece, Malta, Nigeria and Singapore. Some of them returned home while
others stayed to work in the UK. At the same time British Queen’s Nurses, trained by
the QNI as district nurses, were appointed abroad to support overseas community
nursing services. ‘The QNI is keen to continue this historic relationship with nurses
from all over the world and to support the development of global nursing practice,
particularly in community and primary care settings,’ she said.
Looking forward, she argued that the NMC-approved Specialist Practitioner:
District Nursing qualification is vital to support nurses to develop the unique skills
and knowledge required to lead and manage a team of multi-skilled professionals
to deliver excellent nursing care to people in their homes and local communities.
‘Adopting similar programmes in other countries would help to build the expert
clinical, management and leadership skills required to coordinate care provided by
the district nursing service in people’s homes and communities,’ she said.
The RCM argued for strengthening the UK role and placing it in a wider context,
pointing out that the UK is an important hub for medical, midwifery and nursing
research. ‘Our government needs to utilise UK expertise to support global health
research, and to commit to integrating the UK’s health professional education system
into a landscape of global learning, acknowledging that the UK has much to learn
from other countries and health care systems and facilitating this learning to help the

UK face the changing landscape of healthcare in the future (particularly in utilising

global expertise in non-communicable diseases and new epidemics),’ it told the
Review Board.
The RCM said world-renowned UK health professional journals have a key role
in providing evidence on the effectiveness of midwifery and nursing. ‘The UK
government needs to better utilise this research, in particular the research on the
components of quality care…. (it) also has an important role to play in influencing
the prioritisation of midwives and nurses in national health care plans, and in raising
the status of midwives and nurses through raising the status of women.’
“ …commit to integrating the UK’s health professional education system into

a landscape of global learning
” Royal College of Midwives, UK
Taking a global perspective, João Marçal-Grilo, Unity in Health, spoke of the

‘enormous potential for both the UK government and UK-based organisations to
support the development of nursing globally.’ His NGO is developing programmes
in Sri Lanka and Nepal, focusing on training nurses in community mental
health nursing skills. In both programmes, UK-trained nurses and other health
professionals support local educational bodies and teaching staff in delivering
theoretical and practical courses for nurses – ‘support with the planning and
designing of course curriculums and course materials, with identifying and creating
placement opportunities with local health care services and NGOs, and with the
teaching of specific course modules.’
Several respondents spoke of the debt the UK owed to other countries. ‘The UK
government and NHS have relied on nurses from other countries over significant
years and this has on the whole been a positive experience and brought value to the
NHS. I believe it is time to give back support for the development of nursing from
vocational to professional nursing in some of the third world countries,’ said Joyce
Fletcher, deputy director of nursing, Black Country Partnership NHS Foundation
Trust. ‘So there is a role for the UK in proactively sharing our experiences, expertise,
systems and processes across the globe and of course learn from other more
advanced countries. Development of an exchange system to allow ease of movement
of nurses across the globe.’
Nurses in many countries are requesting international support, including Eva Said of
the College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq. She
sent the APPG a very moving statement which included the following: ‘The door has
been found and left ajar – the door leading to the global nursing community which
has shown time and time again that solidarity among nurses has no boundaries.
Communication leading to partnerships and cooperation has enormous potential to
support self-development of the nursing profession in regions like ours.’
‘Nurses in Kurdistan need and want to learn,’ she continued. ‘Many of those in
clinical practice, education, administration and policy development crave guidance
and support that will allow them to develop themselves and their profession.
International nursing experience and expertise is vital for nursing in the region to
consolidate its strengths, face the challenges of healthcare during the time of conflict,
and prepare for post-conflict era of restoration and growth. By doing so, nursing in
the region can not only continue to develop but contribute to the efforts of global
nursing community to face current and future challenges.’

Nurses from outside the UK generally welcomed these approaches but said they need
to be done in the right way – if they are not, they will not be sustainable. Michael
Koroma, chief executive officer, St John of God Catholic Health Services, Sierra
Leone, worked in the Northern Province of Sierra Leone during the Ebola outbreak
and noted the challenges of foreign intervention: ‘They often dictate and don’t allow
us to be innovative and sometimes their focus does not meet the needs of the local
context. They also need to work more with the local populations and ensure projects
are sustainable.’
‘Since the British left, you realise that the impact has not been there,’ he added. ‘After
millions of pounds spent you see it again as if nothing was done. But you realise that
the money was not with the government, the money was with the British NGOs. You
don’t see any impact again. They left us in misery. I don’t think the tax-payers will
be very happy because they want to give their money to make a change, not to come
back to them to ask them again for help.’
This critique is of fundamental importance in pointing to the need to ensure that
development work and partnership schemes are undertaken in the right way –
professionally, with proper preparation, clear ground rules and mutual respect. Very
importantly, funding should not just support the foreign organisation but should go
towards building capacity in the country.
The underlying point is that richer countries like the UK, US and others need
to approach this work with the humility of understanding that everyone has
something to teach and everyone has something to learn. The top-down processes of
international development where ‘the West knows best’ often fail because they ignore
local circumstances and culture – and because they underestimate and often ignore
or dismiss local knowledge and skills. There is a need to go beyond aid into a new
world of co-development and mutual learning.80
“ Communication leading to partnerships and cooperation has enormous

potential to support self-development of the nursing profession in regions
like ours
” Eva Said, Hawler College of Nursing, Kurdistan Region, Iraq
Mutual learning
Many respondents told the APPG that partnerships and overseas volunteering
benefited the UK as well as the recipient countries, and argued for more
opportunities. In an earlier report, Improving Health at Home and Abroad, the APPG
identified four areas of benefits from volunteering – benefits for the country in
health services, training and outcomes; benefits to the UK in leadership development;
shared benefits from shared innovation; and benefits in international relations and
enhancing the UK’s soft power.81
The report noted that working in resource-poor settings was particularly valuable
for health workers in building leadership skills such as communication and self-
knowledge. The ingenuity and adaptability required for projects in host countries
led to first-hand opportunities to develop these skills in ways that few courses
could compete with. This fits with a growing appreciation of the value of real world
challenges, as opposed to classroom learning, in the field of leadership development.
Clinical staff in particular, the APPG heard, returned with new interests in
redesigning pathways of care, service integration, and commissioning and teamwork
– all key competencies identified as priorities for improvement in the NHS.

The Improving Global Health Fellows Scheme run by the Thames Valley and Wessex
Leadership Academy One uses overseas volunteering with the explicit intention of
developing its workforce’s leadership skills. It places doctors in training and more
experienced nurses, midwives, managers and allied health professionals in partner
organisations in Cambodia and South Africa for periods of 4–6 months.
The fellows receive initial induction and training, and work on projects that have
been identified locally and are therefore designed to be both appropriate and
sustainable to provide ‘an unparalleled personal and leadership development
experience to staff ’ and ‘create a cadre of skilled clinical leaders with quality
improvement skills who can make a real difference to the NHS on their return’.
Three years in, an independent evaluation found that ‘without exception fellows
reported outstanding personal development, often described in terms such as “life
changing”… The majority emerged with a greater appreciation of the value of audit,
teaching, management and their significance for clinicians, and with an enthusiasm
for leading service improvement in the NHS.’ Such benefits have been recognised
both nationally and more locally.
“ A period overseas can broaden experiences and thinking in a whole host

of new ways. ‘It changes people forever’ is the quote that we hear directly
back from people. It can revitalise people and helps them realise just how
fortunate we are to have the NHS
”
Ian Cumming, Chief Executive, Health Education England
A range of organisations including the Tropical Health and Education Trust (THET),
Health Education England (HEE) and Wales for Africa support partnership schemes
where the priority is to deliver benefit to the receiving country, and where the
incidental benefit to the UK is both acknowledged and welcomed. The Global Health
Exchange has been set up in association with HEE to facilitate this mutual learning
and co-development and explore how best to support the English NHS by workforce
and education transformation through global learning.82
“ Members of staff return from international work highly motivated, with

increased work ethic and renewed vocation for the NHS. They are more
adaptable and open-minded, innovative in their approach to service delivery
and capable of leading change
”
Sheffield Health and Social Care NHS Foundation Trust
Pointers to the future – partnerships

Examples of partnerships involving UK organisations are mentioned elsewhere in
this report. Many are small scale, relating to individual specialities or small groups
of people. Nurses from Brighton and Sussex University Hospitals NHS Trust,
for example, work alongside Zambian colleagues to improve critical care at the
University Teaching Hospital, Lusaka, and have helped develop the country’s first
paediatric nursing course.83 The examples below illustrate the wide range of possible
partnerships, whether in professional associations, research, education or public
health.

Developing a professional organisation

The RCN is working in partnership with ZUNO to influence nursing policy and
improve nursing practice in Zambia. The project focuses on building ZUNO’s
capacity as a professional association to advocate for better policy and practice
at local, district and national levels, and supports it to demonstrate influence on
nursing practice at institutional level. As part of this, ZUNO with RCN support
is leading a small pilot project at the University Teaching Hospital, Lusaka, on use
of the WHO Surgical Safety Checklist. This takes a multi-disciplinary approach,
encouraging nursing, surgical and anaesthesia staff to work together as a team.
A research partnership
The International Collaboration for Community Health Nursing Research
(ICCHNR) aims to advance and share knowledge of community health care nursing
practice through research.84 Dr Oldman told the APPG that ‘greater investment in
networks like the ICCHNR is required, both to develop forums for sharing learning
internationally, and to support research to improve the global evidence base for
nursing practice in the community and primary care.’
Professional education
The Grameen Caledonian College of Nursing, already mentioned in this report,
was established in 2010 in Dhaka, Bangladesh. This visionary college offers students
nursing education and clinical practice to international standards. It raises the status
of the profession in Bangladesh and provides opportunities, education and training
to women from impoverished backgrounds. It celebrated its inaugural graduation
in 2013, when 38 graduates were awarded a Diploma in Nursing and Midwifery
approved by the Bangladesh Nursing Council.74 The impact of its work in health and
on gender equality and the economy were noted above in Chapter 4.
Technology to support accessible training programmes

Partnerships extend beyond the public sector and may involve the creation of
products and tools that enhance training programmes. For example, as part of
the response to the Ebola outbreak in West Africa, the Masanga MENTOR Ebola
Initiative brought together experts from public and private sectors to create a digital
tool kit to augment traditional training using a blended approach. It is accessible on
a tablet that can be adapted to reflect different cultures and languages. The Initiative
developed this innovation jointly with Plymouth University Peninsula Schools
of Medicine and Dentistry, with funding from donations to The Telegraph 2014
Christmas appeal. The US government then supported its further development to
support safe triage practice in the aftermath of the outbreak.
Public health
Public Health England is promoting the role of nurses and midwives in public health
and working towards designation as a WHO collaborating centre for public health
nursing and midwifery. It aims to:
• collaborate with WHO to provide information on models for nurse/midwife
practice/service delivery;
• support WHO by providing information about nursing and midwifery
education and regulation;

• assist WHO to develop research in the field of nursing/midwifery person-

centred public health practice and service delivery and development;
• participate in jointly planned and implemented research about integrating
health promotion, improvement and prevention through the life course into
service/care delivery;
• collaborate with WHO to provide specialist conferences, training and
education on the nurse/midwife role and contribution on the social
determinants of health.

Conclusions and
recommendations
Summary
This chapter brings together the discussion from
earlier chapters and makes seven recommendations
about how the UK can support the development of
nursing globally.
It sets out each recommendation in turn and

summarises the main arguments that support them.
At the outset, the chapter notes that nursing leaders

cannot by themselves achieve the development that
is needed. Politicians, policy-makers and non-nursing
health leaders need to work with nurses to make this
happen.
Moreover, if the UK is to play a leading role globally,

it needs to apply the findings and recommendations
of this report to the UK itself: raising awareness of
the potential of nursing, investing in education and
training, supporting nurse leadership and ensuring
that nurses, with all their depth of experience, are fully
involved in policy-making.
Leadership
The APPG believes strongly that major change is needed if nurses are to be enabled
to play their full role in improving health and health services globally, and to help
achieve UHC. This is not simply a technical matter of adjusting health policies, but
requires fundamental change in how nurses are regarded and treated. In turn this
relates both to the position of women in societies around the world, and the power
and dominance of the medical profession and the biomedical model of health care.
Most of what is said in this report is not new and much of it will be very familiar to
nursing leaders. For example, 50 years ago a WHO Expert Committee on Nursing
described the rapidly changing social, political and scientific environment in which
nursing was operating. It asked whether planners were preparing for a future where
women had different roles, where there was mass demand for health care, and where
nurses took on tasks traditionally done by doctors and in turn passed on some tasks
to others. ‘In order to cope with this and other challenges, nursing must break with
some of its traditions as well as alter existing stereotypes,’ it said.85
Much has changed in 50 years, including the huge growth in degree-level nursing
education, but more is needed – in particular, action to change the stereotypes.
Nurses simply do not have the power and leverage to achieve this by themselves.

This is why this report proposes that the UK government not only takes a leading
role in raising the profile of nursing, but also does so in the context of achieving a
triple impact of improved health, greater gender equality and stronger economies.
The UK has a very strong tradition as a pioneer in nursing, and in health more
generally, and enormous strengths on which to build. However, it is essential that
the findings and recommendations of this report are taken up within the UK if
it is to play a leading role in nursing globally. This will involve raising awareness
of the potential of nursing, investing in education and training, supporting nurse
leadership, ensuring that nurses with all their depth of experience are fully involved
in policy-making, and much more.
Change will take years but a start can be made: the government has the opportunity
to set the direction and lead.
Recommendations
The APPG recommends that the UK government, together with the Commonwealth
Secretariat, the European Union, the World Health Organization and other
international agencies, works to:
1. Raise the profile of nursing and make it central to health policy. Nurses have
an enormous part to play in achieving universal health coverage, and nursing
should be central to global policy and plans.
a. Convene a high-level global summit on nursing, aimed particularly at

political and health leaders outside nursing, to raise awareness of the
opportunities and potential of nursing, create political commitment, and
establish a process for supporting development.
This should be part of a longer-term initiative that will embrace all the
following recommendations.
The main arguments for this recommendation are that:

• Universal Health Coverage cannot be achieved without strengthening
nursing, the largest part of the health workforce globally.
• There is enormous waste in educating and training nurses and not then
allowing them to work to their full potential and, often, failing to retain
them in the workforce.
• Much of what nurses do is necessarily small-scale, intimate and invisible
to the wider world and their collective impact, capability and potential
needs to be much better understood.
• Politicians and non-nursing leaders need to work as partners with
nurses because nurse leaders alone do not have the power and influence
to make the changes needed, in light of the lower status of women and
the dominance of the medical profession and the bio-medical model of
health care.
• Nurses are very well positioned, thanks to their education, skills and
values, to address the needs for more holistic and bio-psycho-social
approaches to health which are arising from changing epidemiology and
new understanding of the social determinants of health.

• Globally nurses themselves describe their not being permitted to work to

their full potential as one of their greatest problems and sources of low
job satisfaction.
• The UK has enormous influence globally and can strengthen its own
global role still further by establishing a major new initiative on nursing.
2. Support plans to increase the number of nurses being educated and

employed globally. The World Health Organization global strategy on human
resources for health, Workforce 2030, adopted by member states in 2016,
proposes a framework for making the most effective use of health workers and
developing country-specific investment plans to address workforce shortages.
a. Work with low and middle-income countries to develop and support

their workforce plans through funding and partnership schemes.
b. Reaffirm support for the WHO Global Code of Practice on the

International Recruitment of Health Personnel, publish a report on
UK progress in implementation since 2010, and provide support for
education and employment of health workers in their own countries.
c. Assess the impact of leaving the EU on staffing in the UK health and care
system, and take mitigating action including finding methods for securing
the continuing employment of EU citizens in the health and care system
and reviewing and increasing the number of nurses being educated in the
UK to meet its needs.

• There are very large shortages of health workers globally – not all of
which can be ameliorated by finding more effective ways of deploying
staff and delivering services;
• The needs of countries must be determined and very largely funded
locally but the UK and other high income countries can assist with
expertise – for example in education and management – and, in some
cases, funding;
• Emigration of health workers remains a very serious problem for many
low and middle income countries;
• Migration to the UK in the past – and the perception that the UK is still
encouraging it – can damage relationships with partner countries;
• There is a significant risk that since the referendum many European
nationals working in the UK’s health systems will leave the country and
not be replaced – raising the fear that it may return to recruiting more
health workers from low and middle income countries;
• Action globally to deal with these problems appears to have slowed down
and needs to be given new emphasis and momentum.
3. Develop nurse leaders and nurse leadership. Experienced nurse leaders are
needed in the right places to help nursing deliver its potential and ensure that
the distinctive nursing perspective is included in policy-making and decision-
making.

a. Establish a large-scale new programme globally to develop nurse leaders

that will enable them to engage more effectively in policy-making and
decision-making. The International Council of Nurses has plans for
developing such a programme that could provide a template.
b. Ensure all countries have appropriate nurse leadership posts throughout

all their structures and organisations.
The main arguments for this recommendation are that more nurse leaders
need to be appointed and developed to:
• improve the visibility of nursing and ensure that non-nursing leaders
understand how nursing can contribute;
• inform and contribute to policy – and they are particularly important in
understanding how policy impacts on practice and outcomes in reality;
• lead this very large workforce operationally, Improve its management and
ensure that nurses are well educated, motivated and supported;
• deliver and develop education, training and research.
4. Enable nurses to work to their full potential. Nurses are too often not
permitted or enabled to fulfil their true potential. Cultural, regulatory and
legislative enablers and barriers need to be identified and removed and good
practice shared and acted on.
a. Develop new ways of sharing good practice – drawing on existing work

by nursing organisations, the Commonwealth Health Hub and others
– to create more coordinated and effective ways of identifying and sharing
good practice globally, and ensure they are brought to the attention of
policy-makers and other health leaders.

• There are very many small scale innovations in nursing, sometimes
initiated by individual practitioners, which need to developed and learned
from more widely;
• There are a number of existing networks for sharing good practice and
learning within nursing which need to be opened up and used by non-
nurses;
• Similarly, existing networks outside nursing need to take far greater
recognition of the role that nursing can play and engage them in their
work.
5. Collect and disseminate evidence of the impact of nursing on access, quality

and costs, and ensure it is incorporated in policy and acted upon. There are
many small-scale studies of the impact of nursing. These need to be brought
together with new evaluation and research to demonstrate impact at scale.
a. Commission research to bring together existing evidence and initiate new

studies on how and where nursing improves access, quality and costs and
what contribution nursing can make to universal health coverage.

b. Ensure that existing and future research findings are widely disseminated
and understood in order to influence both practice and policy.
• There are many smaller-scale evaluations and studies which identify
impacts but very few at scale which can help identify where and how
nursing can have the greatest beneficial impact
• These studies need to be championed and disseminated outside nursing
• New studies and analysis of impacts will help countries make business
cases for investment in nursing and inform global policy making and
planning.
6. Develop nursing to have a triple impact on health, gender equality and

economies. Developing and investing in nurses – the vast majority of whom
are women – will help empower them economically and as community
leaders. Improving health and empowering women will in turn strengthen
local economies.
a. Adapt development policy to bring together programmes and funding

to address simultaneously, the three Sustainable Development Goals
focusing on health, gender equality, and inclusive and sustainable
economic growth (numbers 3, 5 and 8) and work with partners
throughout the world to develop nursing strategies that work towards
achieving all three goals.1

• There is clear overlap in Sustainable Development Goals 3, 5 and 8.
• UK DFID has prioritised work on gender equality and economic
development as well as health, and can realise synergies and benefits from
bringing its three programmes in these areas together.
7. Promote partnership and mutual learning between the UK and other

countries. There are many partnerships between British organisations and
their counterparts abroad that bring mutual benefit and shared learning.
a. Expand the DFID Health Partnership Scheme and redesign it so as to

engage as many nurses as possible and promote mutual learning and
support between UK nurses, their organisations and their counterparts
abroad; and support UK agencies including Health Education
England, Wales for Africa, and the Scottish government’s international
development programme to promote the engagement of NHS and other
health and care organisations in global partnerships that bring mutual
benefits.

• There is a great deal of scope for mutual learning and co-development
between UK organisations and their counterparts abroad.

• Partnerships and volunteering abroad, when well organised and

supported, bring benefit to the recipient country but also offer scope for
personal and leadership development to participants, help all parties to
share in innovation, and promote good international relationships and
the UK’s soft power.
• Greater benefit will come from supporting partnerships at a greater scale.

Acknowledgements
The Review Board is very grateful to the many people who were interviewed or
provided evidence for the review, as listed below. It is particularly grateful to James
Buchan, School of Health Sciences, Queen Margaret University, Edinburgh, and
Susan Williams and Christian Beaumont, both of the Royal College of Nursing, who
read and commented on sections of the report. It is also very grateful for the work
of Johanna Riha, who undertook many of the individual interviews, and of Jane
Salvage, who provided advice and support and helped with the preparation of this
report.
The Review Board also wishes to record its thanks to Janet Davies and colleagues
from the RCN; Frances Hughes and colleagues from ICN; Jill Iliffe and colleagues
from the Commonwealth Nurses and Midwives Federation; Jill Rogers Associates
and participants at the NET2016 conference; and the Global Advisory Panel on the
Future of Nursing and Midwifery.
The speakers at a public seminar on

24 February 2016
Jim Campbell Director, Human Resources for Health Department,
WHO, and Executive Director, Global Health
Workforce Alliance
Francesca Colombo Head, Health Division, OECD
Richard Horton Editor-in-Chief, The Lancet
Duncan Selbie Chief Executive, Public Health England
The people who attended public witness sessions

James Buchan Queen Margaret University, Edinburgh
Frances Hughes Chief Executive, International Council of Nurses
Donna Kinnair Royal College of Nursing
Rachel Mwansa Zambia Nurses Association
Anne Marie Rafferty Professor, King’s College London
Judith Shamian President, International Council of Nurses
Susan Williams Royal College of Nursing
People interviewed
Maureen Bisognano Institute for Healthcare Improvement
Paulette Cash The Nurses Association of the Commonwealth of
The Bahamas
Isatu Daramy Kabia Datin
Paduka HJH Abdullah Retired nurse and midwife
Anita-Anand Deodhar The Trained Nurses Association of India
Andre Gitembagara Rwanda Nurses and Midwives Union
Heather Henry New NHS Alliance

Chris Hopson NHS Providers

Michael Musa Koroma St John of God Catholic Health Services,
Sierra Leone
Sunita Lawrence Madhya Pradesh branch, Trained Nurses
Association of India
Gwendolyn Lobbie-Snaggs Trinidad and Tobago Registered Nurses Association
Salome Madithapo
Masemola Democratic Nursing Organization of South Africa
Paul Magesa Mashauri Tanzania National Nurses Association
Nga Manea Cook Islands Nurses Association
Afaf Meleis University of Pennsylvania
Judy Mewburn International Development Committee, Association
of Surgeons of Great Britain and Ireland
Njoki N’gan’ga International Organization for Women and
Development
Francis Omaswa African Centre for Global Health and Social
Transformation
Anthony Peters Trinidad and Tobago Registered Nurses Association
Mala Rao Dept of Primary Care and Public Health, Imperial
College London
George Saliba Malta Union of Midwives and Nurses/ CNMF
Board Member, European Region
Peggy Vidot Ministry of Health, Republic of Seychelles
People and organisations who submitted evidence

Heather Alcock VSO
Jerome Babate Beta Nu Delta Nursing Society
Andrea Bennett Your Healthcare
Fleur Blakeman NHS Eastern Cheshire Clinical Commissioning
Group
Mary Chiarella University of Sydney
Emma Coyle Centre for Maternal and Newborn Health,
Liverpool School of Health and Tropical Medicine
Graeme Chisholm THET
Joyce Fletcher Black Country Partnership Foundation Trust
Emma Forster North East and Cumbria International Health
Links Network
Steven Fouch Christian Medical Fellowship
Finbar Gibbons Public Health England
Elizabeth Hall Public Health Wales
Christine Hancock
and Pat Hughes C3 Health

Aisha Holloway University of Edinburgh

Claire Johnston Camden and Islington NHS Foundation Mental
Health Trust
Peter Jones Lancaster University
Joy Kemp Royal College of Midwives
Sally Kendall International Collaboration for Community Health
Nursing Research
Brenda Longstaff Northumbria Healthcare Trust
João Marçal-Grilo Unity in Health
Anne Moger Nursing Directorate, NHS England
Daniel Mortimer NHS Employers
Tom Murray Nurse
William Nkata Mental health practitioner
Crystal Oldman Queen’s Nursing Institute
Eva Said Hawler University, Kurdistan Region, Iraq
Fiona Sanders NHS Stockport
Michael Stark Educators International
Fiona Stephenson International Training Coordinator, Nepal
Pam Smith University of Edinburgh
Dawn Tillbrook-Evans Faculty of Intensive Care Medicine,
Royal College of Nursing
UK Critical Care Nursing Alliance and Intensive
Care Society
Bethan Twigg WaterAid
Richard Walker Department of Medicine, North Tyneside General
Hospital
Roger Watson Professor of Nursing, University of Hull
Silvia Cassiani, Joint submission from Pan American Health
Maria del Carmen Organization, Colombian Association
Gutierrez Agudelo, of Schools of Nursing (ACOFAEN) Collaborating
Jacqueline Molina Center for the Development of Innovative
de Uriza, Methodologies in the Teaching-Learning in
Nathaly Rozo Gutierrez, Primary Health Care, Escuela Nacional de
Rosa Zarate, Enfermería y Obstetricia de la Universidad
Laura Morán, Nacional Autónoma de México Collaborating
Lynda Wilson, Center for the Development of Professional
Doreen Harper Nursing, Latin American Association of Nursing
Schools, University of Alabama at Birmingham
School of Nursing


Sponsors
The APPG is extremely grateful to its sponsors whose logos are shown below for their
continuing and very valuable support.

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Notes

Design Ark:London
All-Party Parliamentary Group (APPG) on Global Health
Coordinator: Emily McMullen, Office of Lord Crisp

Fielden House, 13 Little College St, London SW1P 3SH
info@appg-globalhealth.org.uk
+44 (0)20 7219 3873
Contact: Elaine Bryce, Office of Dan Poulter MP

House of Commons, London SW1A 0AA
elaine.bryce@parliament.uk
+44 (0)20 7219 7038

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A Report by the All-Party Parliamentary Group on Global Health

APPG All-Party Parliamentary Group on Global Health

Key points and recommendations�������������������������������� 3

1 Nurses and nursing globally���������������������������������������� 7

3 Workforce, professional education

4 Opportunities and impacts��������������������������������������� 33

5 The UK’s contribution to health globally������������������ 42

Conclusions and recommendations��������������������������� 49

APPG on Global Health – October 2016 1

Nursing and midwifery

Lord Nigel Crisp

2 APPG on Global Health – October 2016

Key points and recommendations

Figure 1 The triple impact of nursing: better health, greater gender

The unique contribution of nurses

APPG on Global Health – October 2016 3

Figure 2 The unique contribution of nurses

4 APPG on Global Health – October 2016

a. Convene a high-level global summit on nursing, aimed particularly at

2. Support plans to increase the number of nurses being educated and

a. Work with low and middle-income countries to develop and support

b. Reaffirm support for the WHO Global Code of Practice on the

c. Assess the impact of leaving the European Union on staffing in the UK

a. Establish a large-scale new programme globally to develop nurse leaders

b. Ensure all countries have appropriate nurse leadership posts throughout

APPG on Global Health – October 2016 5

a. Develop new ways of sharing good practice – drawing on existing work

5. Collect and disseminate evidence of the impact of nursing on access, quality

a. Commission research to bring together existing evidence and initiate new

6. Develop nursing to have a triple impact on health, gender equality and

a. Adapt development policy to bring together programmes and funding

7. Promote partnership and mutual learning between the UK and other

a. Expand the DFID Health Partnership Scheme and redesign it so as to

6 APPG on Global Health – October 2016

1. Nurses and nursing globally

This chapter describes the purpose and scope of this

It describes the wide variety of roles played by nurses

The chapter goes on to discuss the rapidly changing

The purpose and scope of the review

APPG on Global Health – October 2016 7

The real lives of nurses

8 APPG on Global Health – October 2016

APPG on Global Health – October 2016 9

Figure 1.1 The unique contribution of nurses

The definition of a nurse

10 APPG on Global Health – October 2016

The changing global context

Box 1.1 Some global trends

Gender equality and the changing roles of women

APPG on Global Health – October 2016 11

Policy and practice development

12 APPG on Global Health – October 2016

The impact of nursing

“ We need to market nursing as if it were a new drug or treatment

A new story of nursing

APPG on Global Health – October 2016 13

“ Influencing long–term policies to empower women from rural areas and to

14 APPG on Global Health – October 2016

Pointers for the future

Wise women – Tajikistan

Health promoters – Mozambique

APPG on Global Health – October 2016 15

The promoteras assumed responsibility for conducting training, budgeting, field

Key points and recommendations�� 3

1 Nurses and nursing globally�� 7

4 Opportunities and impacts�� 33

5 The UK’s contribution to health globally�� 42

Conclusions and recommendations�� 49

APPG on Global Health – October 2016 1

2 APPG on Global Health – October 2016

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4 APPG on Global Health – October 2016

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6 APPG on Global Health – October 2016

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8 APPG on Global Health – October 2016

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10 APPG on Global Health – October 2016

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12 APPG on Global Health – October 2016

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14 APPG on Global Health – October 2016

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16 APPG on Global Health – October 2016

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18 APPG on Global Health – October 2016

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20 APPG on Global Health – October 2016

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22 APPG on Global Health – October 2016

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24 APPG on Global Health – October 2016

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