Will International Year of the Nurse and Midwife 2020 Bring Meaningful Change to Frontline Nurses’ Work Environments?
image credit EVAN EPPER
If you head west of the Kennedy Bridge along Boulevard de la Republique in Niamey’s rive gauche, past the Musée National Boubou Hama, then the new Radisson Blu Hotel and Conference Center on your right and turn south at the next roundabout, you find yourself at the entrance of Niger’s National Hospital. If you take this route, just before arriving at the roundabout, you will inevitably pass bereaved mourners congregating to claim the body of a deceased loved one from the hospital morgue to the left. Regardless of the direction one emerges from, everyone must go past the bustling market place right outside the hospital gate. There you can buy anything from an Airtel pre-paid mobile phone card to millet meal. Colorful plastic jugs and buckets for sale are strung to the frames of some of the stalls. Inside the gate, the mood is more somber than at the market. Patients linger as they await a test or consultation. Hospital personnel rushing to complete their responsibilities take determined steps around slow-moving vehicles and even slower-moving human traffic. Among them are nurses dressed in uniform sky blue smocks over white pants. In a darkened office around the corner from the bloc opératoire and across a narrow corridor from a shared bathroom at the far end of the male ward, the departing day nurse and incoming night nurse are huddled over a desk that takes up most of the space in the room. It is almost shift change. With almost 40 patients to hand off, the turnover report is incomplete. There are too many patients for one nurse to master essential details of their care in the allotted time. A large handwritten ledger on the oversized desk indicates that several patients registered an elevated blood pressure during the day. But, the hypertension was not addressed. Perhaps the next patient developed a more pressing need requiring an urgent response from the nurse. Or antihypertensive medications were ordered, but not available for any of a number of reasons. Through no fault of the nurse, who was overwhelmed by an unmanageable workload, the hypertension went untreated.
At first glance, it may appear that the nurse in Niamey shirked a fundamental responsibility to maintain vigilant surveillance of patients and initiate appropriate interventions in response to changes in patients’ conditions. But, research shows that nurses’ ability to execute timely and correct treatments is highly dependent on factors beyond their own individual traits. In fact, frontline nurses’ performance is tied to their participation in hospital affairs, support from managers, a nurse-centric foundation for quality of care, availability of staff and other resources, plus collegial relationships with physicians. Work environments in which one or more of these attributes are lacking are problematic because they impede exemplary nursing practice to the extent that quality of patient care suffers. Problematic work environments like the one described in Niger are not limited to low-income countries alone. Up to two-thirds of more than 30,000 nurses working in 488 facilities in 12 European countries endorsed in the RN4CAST survey that they left various patient care related tasks undone during their last shift because of time constrains and burdensome workloads. The tasks left undone ranged from providing treatments to talking with and comforting patients.
Far removed from the daily travails of nurses experiencing problematic work environments, in Geneva, Switzerland, Dr. Tedros Ghebreyesus, director-general of the World Health Organization (WHO), announced last May that the executive committee of the seventy-second world health assembly had designated 2020 as international year of the nurse and midwife. Welcomed as a watershed moment set to feature themed activities to raise the profile of nurses and midwives - who comprise half the health workforce and without whom achieving universal health coverage and other sustainable development goals will be impossible - 2020 also marks the release of an unprecedented report on the state of the world’s nurses and midwives. The report will “highlight areas for policy development for the next three to five years” with the aim of strengthening the two professions in WHO member states. Among the areas targeted for development should be each of the five attributes of practice environments known to positively influence nursing performance.
International year of the nurse and midwife comes on the heels of Nursing Now, the highly visible three-year campaign that also aims to raise the status of nurses globally by promoting their appointment to leadership roles and positioning them within policymaking axes. A brainchild of the United Kingdom (UK) All Party Parliamentary Group on Global Health, Nursing Now injected a large dose of glamor to nursing and nurses when it named the Duchess of Cambridge as its royal patron last year. This year, a new signature initiative was added to its roster of activities. The Nightingale Challenge is a clever way of enlisting buy-in from employers of nurses as key stakeholders to commit to developing the leadership potential of nurses. So far, 238 employers in 36 countries have pledged to send 10,451 nurses under 35 years of age to leadership training programs. In a broadcast to celebrate inception of the Nightingale Challenge, Elizabeth Iro, chief nursing officer at WHO, made the case for elevating nurses and midwives. “We must do more to attract and retain young people to these professions,” she said. “My message to employers is a simple one. Invest in the leadership potential of the next generation of nurses and midwives. They will change the world.”
The narrative that ushering young nurses into halls of influence will correspond to future health gains is taking hold. World Innovation Summit for Health, an affiliate of the Qatar Foundation with an interest in supporting nursing leadership development, sponsored 24 nurses from 18 countries to spend five days this summer at the world health assembly in Geneva attending meetings with the director-general, chief nursing officer and Nigel Crisp, co-chair of Nursing Now and a member of the UK House of Lords. Undoubtedly, as international year of the nurse and midwife gets underway, more of these galvanizing opportunities will become available to nurses fortuitously coming of age at such an exciting time for the profession. But, progress should not be quantified solely in terms of the proportion of nurses ascending to positions of leadership. Because frontline nurses count on their managers to eliminate, or at least minimize, undesirable attributes of problematic work environments, which serve as distractions that compel nurses to divert their attention away from patient care activities, the principal measure of impact deserves a definition that is characterized in terms of the effect on work environments. The proposed measure should reflect the ability of a newly bolstered nursing leadership to transform work environments into supportive ones so that frontline nurses who interface daily with patients can in turn deliver necessary interventions to optimize patient outcomes while encountering as few barriers as possible. Troubling evidence indicates that for many nurses, a chasm exists between them and nurse managers, and that discourse taking place at the national and international levels fails to yield actions that rectify their harsh practice realities.
Dissonance between nurses and their managers can partly be explained by a nursing leadership whose titles connote authority, but confer insufficient power to produce meaningful change from the perspective of frontline nurses. In six of the twelve European countries participating in the RN4CAST study, more than half of nurses reported perceptions that their chief nursing officer was not in equal standing with other hospital executives (range: 58% in Belgium to 69% in England). Elsewhere, discord between nurses and their managers is attributed to a lethargic response by the leadership to predicaments encountered by frontline personnel, which is seen to exacerbate rather than relieve problems and instills mistrust. In Tanzania, one-third of mid-level providers, including nurses and midwives, revealed to researchers that they received their salaries late or when they opened their paycheck it contained only a partial amount that was sometimes less than half the expected remuneration. They described going to great lengths to resolve payroll discrepancies, including taking time off from work and borrowing money to fund travel spanning a significant distance to local health authority headquarters. These efforts did not always yield positive results and some respondents perceived that salary discrepancies were resolved faster for managers. One nurse midwife stated that “... those seniors [in authority], even if he went [to district authorities] last week, this week he will just be paid. But for those who have been waiting for six months we get told that there’s no money. But for him, there is no problem because he is the boss ...” In the same study, respondents also reported that their managers utilized obscure criteria to assign opportunities for in-service training and fewer than half were offered opportunities commensurate with skills necessary for their job. Similarly, nurses in Vietnam referred to their “chief nurse” as an important gatekeeper who decided which nurses were eligible to take advantage of opportunities to attend professional meetings. The Vietnamese nurses also spoke of wide hierarchical distances between them and physician colleagues that effectively prohibited their input on patient care even when their silence put the patient at potential risk for harm. Researchers evaluating practice environments encountered by mid-level providers in three districts in Malawi found that “inadequate management support and a sense of not being valued by their managers was another strong feature of the environment.”
How nurse managers bridge the divide between them and frontline nurses to create more supportive work environments will depend on their local health system contexts and the specific challenges those contexts present. What is clear, regardless of the strategy employed, is that their stance needs to lean heavily in favor of frameworks that optimize conditions in which nurses deliver care. As the upcoming international year of the nurse and midwife shines a serendipitous spotlight on the profession, the collective nursing leadership has an opportunity to capitalize on ensuing goodwill to advance a nurse-driven agenda. Still, it is difficult to ignore extreme factors within some health systems that allow the most worrisome attributes of work environments to prevail, but whose purview is not exclusive to nursing leadership. For example, in Niger, where the nurse at the National Hospital was assigned to 40 patients, there is one nurse or midwife for every 10,000 people, which is far below the recommended level to ensure universal coverage of essential health services by health personnel. With such low levels of nursing stock, it is unrealistic to expect that nurse managers in Niger can achieve optimal nurse-to-patient ratios to ensure the most favorable patient outcomes. Similarly, in Tanzania where development assistance accounts for more than 40% of total health expenditure and fluctuates from year-to-year, available funds may differ from budget forecasts and partially contribute to the payroll discrepancies experienced by frontline nurses further downstream. However, even when the circumstances are austere, nurse managers can institute smaller scale changes that convey their commitment to the wellbeing of frontline staff. A little recognition goes a long way. We should not accept as the norm sentiments such as the one expressed by a South African nurse when they stated, “we get much more from the patient than from anybody else. We don’t get that [appreciation] from managers.” Studies conducted in South Africa and Uganda suggest that creating a comfortable physical space for nurses to complete their work, providing tea with sugar and clean staff toilet facilities boosts morale.
The decision to commemorate 2020 as international year of the nurse and midwife confers much deserved recognition on our profession, but also a great responsibility to ensure that the opportunity to engage meaningfully on a global stage will reap benefits for all nurses, particularly those working in the most difficult environments.