Post-Covid future for nurses: focus on leadership for long-term change

Kidest Nadew and Enrique Castro-Sánchez, nurses and members of Primary Care International (PCI) Clinical Associate network, share their thoughts and experiences for International Nurses Day on what nurses globally need to thrive.

COVID-19 has brought home the key role of frontline health workers and the importance of a strong and supported primary care team: and 2021 has rightly been declared the year of the Health and Care Workers. In particular, the pandemic has highlighted the work that nurses do across the health system, and in fact the global declaration for 2020 as the year of nurses and midwives was bordering on prophecy. However, despite these special ‘years’ being declared, as we approach the next ‘International Nurses Day’ on May 12th, nurses around the world are struggling to cope, let alone thrive.

Globally there are 27.9 million nurses – but this still leaves a shortfall of 5.9 million nurses , and 89% of this gap is concentrated in so called low and middle-income countries.

Particularly in primary care settings with less money and equipment, whether that be an urban health centre in conflict-affected Libya or a small clinic in rural Ethiopia, support for nurses is often neglected in both policy and practice. Task-shifting is being done in an ad-hoc way due to necessity rather than as a strategic goal – as a trickle-down process rather than real reconfiguration of tasks taking place. This has resulted in many missed opportunities for the patients and high stress level and job dissatisfaction for the nurses.

One of the main clinical challenges being faced by nurses in these primary care settings is caring for the increasing number of people with chronic diseases. Non-communicable diseases (NCDs), such as diabetes, high level of blood cholesterol, cardiovascular diseases and hypertension, are now the leading global causes of morbidity and mortality, affecting 71% of the population between the ages of 30-69 years.

However, NCDs can be invisible compared to other diseases until it’s too late, especially if health workers are not trained to recognise and manage them. This is exacerbated by the lack of resources allocation and financing from governments, as NCDs are still not usually viewed as the most pressing issues.

As a result, primary healthcare providers, who are often nurses (many countries have next to no doctors at primary care level), are struggling to implement and integrate health promotion, disease prevention and management of chronic diseases into their practice.

The advent of COVID-19 further shifted attention and resources away from essential health services, in particular NCDs, to emergency management set up at the primary health care level. This has been even more of a challenge in settings that rely on donor funding and imported medical supplies. In addition to existing systemic challenges, the living environment where these nurses work are often less than ideal, exacerbating the stress level.

There are examples of progress in supporting nurses that we can build on.

In Ethiopia, it is estimated that NCDs account for 42% of deaths, and disability-adjusted life years are increasing – along with the associated economic burden this brings. This has been due in part to the poor coordination of national response and the negligible total health spending per capita for NCDs .  Recently however, NCDs prevention and control had started to receive more attention at both the policy and programme level and the Ministry of Health incorporated NCDs prevention and control activities in its Health Sector Transformation Plan and other health sector strategies such as the essential health service strategy and revised Health Extension Worker packages. In addition, the de-centralised health system in Ethiopia had adopted task shifting of the care of NCDs from physicians to nurses at the primary care level. Through support of NGOs in collaboration with the regional health bureaus and district health management, nurses were provided training, job resources and supportive site supervision in areas such as cardiovascular diseases management. As in most healthcare settings, the early phase of the COVID-19 pandemic saw resources being pulled away and suspension of services. But we must look to the long term. Given the evidence of how some chronic health problems, such as obesity and diabetes, influence COVID-19 outcomes – support to nurses to better manage, and also prevent, NCDs would also trickle down to impact on COVID-19 outcomes.

As well as training in knowledge and skills on NCDs (and beyond), including being able to access information to support complex cases and understanding issues around the supply chain, nurses also need to be skilled up to lead the design and evaluation of programmes, and to work strategically, as leaders. Nurses need to better be able to influence policymakers and government officials. Currently these kind of roles are put in place but with no support, budget or remit – meaning they remain tokenistic.

Primary Care International have placed strengthening leadership for primary care workers at the heart of their work. They are currently working with GIZ in Libya to promote a strengthened primary health workforce. In consultation with health workers and key stakeholders, the team will be developing an in-service training plan to create structured opportunities for both doctors and nurses in primary healthcare, which includes consideration of leadership skills. This will maintain and enhance these health workers skills to deliver quality services to their clients and the communities they serve, as well as stepping up as primary care leaders to ensure more long-term change.

Our partners at Action for Global Health are strongly behind this call for stronger leadership for long- term change: “Nurses are the critical backbone of the health workforce and health systems globally – and need to be supported to take leadership roles and elevate their perspectives into health decision-making. As this International Nurses’ Day looks to the future, leaders around the world must also learn important lessons from the pandemic and invest in building the nurse workforce to fill global shortages and achieve universal health coverage.” (Katie Husselby, Coordinator, Action for Global Health)

It is likely that shortages of healthcare workers, including nurses, are not going to be resolved soon. Nor is increased remuneration likely in the near future. So it becomes ever more crucial that existing workers are retained and re-trained to make optimal use of skills, reforming legislative frameworks to facilitate task shifting or role configuration in a systematic and strategic way – and ensuring that nurses can meaningfully contribute to policymaking.

The 2021 International Nurses’ Day seeks to highlight the ways nurses are innovating and will also explore what nursing may look like in the future. Well the future for us is about ensuring that nurses, as an essential part of the primary care team globally, are better supported both clinically and with leadership skills. This will then support transformation at a policy level and long-term change for the better.

What can you do

For those of you based in the UK: take action today by signing and sending this letter from Action for Global Health to your MP to ensure that health for all is prioritised at this year’s G7 Summit.  By raising the profile of this issue, we will show the UK’s continued commitment to creating a healthier, safer world, through standing in solidarity with other countries, at a time when it matters the most.