Role of Nurses in the delivery of quality care: understanding the workforce deficit

There is growing consensus that achieving Sustainable Development Goal 3(SDG 3) on healthy lives and well-being through universal health coverage (UHC) requires a critical focus on human resources for health (HRH). In developing countries the shortage of health workers is estimated to be over 7 million, with the worst shortages experienced in the poorest countries in Africa. Kenya faces a severe health workforce crisis with nursing densities in the public sector ranging between 1.2 to 0.008 per 1000 population across counties, compared to an internationally suggested minimum health workforce threshold of 2.5/1000 population. Nurses form the largest component of the health professional workforce and are recognized as essential to the delivery of safe and effective care and should be key players in promoting and shaping effective health policy.

However, we suggest nurses are often undervalued and their contribution underestimated with their 'voice' in discussion on major HRH issues and on quality of care (QoC) often lacking. Some of the barriers associated with poor involvement in policy development in the literature include: lack of recognition of nurses as key stakeholders in policy development, a negative image of nursing as 'only an assisting profession', and bureaucratic processes. A potentially important aspect that has rarely been examined is how nursing professional socialization influencing their professional identity may influence the ability of nurses to mobilize power and authority within the health care system.

Increasingly availability of good information is used to provide evidence and advocacy in policy and management debates with measures of quality of care being of a particular focus. Efforts to measure quality of care in LMIC have focused almost exclusively on medical aspects of care. At primary care level most of this care is actually delivered by nurses. In larger facilities too, quality assessment focuses on medical quality of care; yet nurses are gate keepers of the delivery of clinical interventions (e.g. treatments, nutrition interventions etc.) and other nurse initiated interventions as well as being largely responsible for holistic care to address wider patient needs. However, little attention has been paid to measures of nursing quality and their potential to highlight the impact of the nursing deficit on quality. The absence of such measures may further undermine the ability of nurses to affect policy and management decisions.

We will begin work using an identity theory as a lens to examine how the identity of nurses as professionals is created and its potential influence on their ability to exert power and agency in management and policy roles. We will also explore how measures of quality that are more specific to nursing care might be adapted and implemented in an African context. Measures that can better inform workforce policy and management decisions aimed at providing quality care and universal health coverage. Empirical research will explore nurses' professional identity and their influence in practice at national, county and hospital levels through ethnography, interviews with key stakeholders and stakeholder meetings. We will examine existing approaches to measuring missed nursing care by reviewing literature before developing and pretest tools, co-designed with the nursing community, that may produce metrics of nursing quality to inform debate on policy and practice.

This programme of work will contribute essential new thinking by using an identity lens to explore how the nursing profession shapes and defines workforce policy, roles and tasks. In addition, we will develop tools that provide the often lacking data on quality and quantity of nursing care delivered. We will embark on work to identify avenues through which nurses can be actively engaged in research, improving care and informing policy as part of broader efforts to tackle the global workforce challenge.

There is growing consensus that achieving Sustainable Development Goal 3(SDG 3) on healthy lives and well-being through universal health coverage (UHC) requires a critical focus on human resources for health (HRH). In developing countries, the shortage of health workers is estimated to be over 7 million, with the worst shortages experienced in the poorest countries in Africa. In Kenya, nursing densities in the public sector range between 1.2 to 0.008 per 1000 population across counties, compared to an internationally suggested minimum health workforce threshold of 2.5/1000 population. Nurses form the largest component of the health professional workforce and are recognized as essential to the delivery of safe and effective care and should be key players in promoting and shaping effective health policy. However, we suggest nurses are often undervalued and their contribution underestimated with their 'voice' in discussions on major HRH issues and on quality of care (QoC) often lacking.

Increasingly availability of good information is used to provide evidence and advocacy in policy and management debates with measures of quality of care being of a particular focus. We will explore how measures of quality that are more specific to nursing care might be adapted and implemented in an African context. We will develop and pretest tools, co-designed with the nursing community, to produce metrics of nursing quality to inform debate on policy and practice. We will use identity theory as a lens to examine how the identity of nurses as professionals is created and its potential influence on their ability to exert power and agency in management and policy roles and how it also influences the quality of nursing care delivered.

Evidence to inform policy and practice: This work is prompted by initial findings from the on-going Health Services that Deliver for Newborns (HSRI grant MR/M015386/1) work examining the quality of newborn care specifically in Nairobi County and exploring task shifting as a possible solution to HRH challenges. The work highlights much wider gaps in the understanding of nursing care and its contribution to quality service delivery. It has also highlighted the paucity of academic nursing capacity in Kenya and 'medical dominance' in the policy making process. Expected findings on current staffing norms gaps and practice and how this might influence quality of care (QoC) will begin to develop a new and broader area of research with important implications for evidence based and informed decisions on the health workforce. The findings will potentially address the passive role played by nurses in the decision making process at local, county, national and even international levels on issues regarding HRH policy and management with implications for nursing practice and health in general. A deeper understanding of how nurses are 'encultured' into practice through training and how this influences power and agency more broadly of the nursing profession within wider health systems will help inform approaches for enhancing engagement of nurses in policy development and implementation.
The use of quality indicators of nursing care has been shown to improve the quality of nursing practice and they are associated with patients' outcomes in high income countries. Our findings and experience on developing and testing nursing quality of care indicators will provide initial steps towards broader measurement that can then strengthen the 'voice' of nurses and inform HRH policy and practice decisions in Kenya and elsewhere. In addition, tools developed for data collection, data entry and data management approaches using non-proprietary or open-source software and accompanying standard operating procedures will be made freely available to encourage wider utilization cross the country and beyond.

Collaboration: The partners on this work include the Kenyan Ministry of Health at county and national levels with whom the KEMRI-Wellcome Trust Research Programme in Kenya has a long standing relationship. We will build new collaborations with Schools of Nursing in Aga Khan University, Kenyatta University, AIC Kijabe College and internationally with Oxford Brookes University, Oxford, UK, to support the development of much needed nursing research in LMICs. These collaborating partners from the nursing community will engage with senior health systems and social scientists offering opportunities for wider work on nursing and service delivery.

Practitioner engagement and co-production of research: We will be working with key stakeholders from national, county and front-line levels who are involved in policy development and implementation of HRH activities. In addition, we will engage with key academic stakeholders responsible for nursing training to guide identification of the technical aspects of nursing care that can be measured. The direct impact on these stakeholders include increasing their knowledge on development of nursing metrics, prioritization of indicators for measuring care and development of tools for routine assessment of nursing QoC. The development of an approach for measuring nursing care delivered will create an increased interest in and focus on quality of care assessment that is expected to help identify gaps and consequently enhance quality improvement initiatives.

Capacity building: We will directly build capacity for nurses and other stakeholders involved in this work by improving their understanding and conduct of research. Additionally, the lead PIs (early career post-doctoral researchers) will be mentored to develop future independent work in nursing research based on the collaborations developed in this grant application.