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The need to involve nurses and midwives

The crucial contribution of nurses and midwives to improving the health outcomes of individuals, families and communities is well recognized but they have not always been included as key stakeholders at the health policy level.

For the future and moving towards universal health coverage and into the post 2015 development agenda for health, the involvement of the nursing and midwifery professions is critical to sustaining and strengthening the health, academic and regulatory systems. In order to ensure and maximise their contribution, nurses and midwives in the Eastern Mediterranean Region (EMR) have to be prepared to lead and also to teach and mentor the future generations.

Steps taken

In that regard, the draft Regional strategy for nursing and midwifery 2012–2020 was developed in line with the WHO Global strategic directions for strengthening nursing and midwifery 2011–2015 in order to help nurses and midwives in the Region enhance their contribution to improving the health agenda. However, taking into account recent challenges and trends in the Region, the EMR strategic directions needed to be reviewed, updated and expanded to 2025.

In late 2014, the Regional Office undertook the Eastern Mediterranean Nursing and Midwifery Survey as well as a desk review of WHO reports on missions to countries of the Region in the previous four years and data from the nursing country profiles provided by key informants from Member States. The overall aim was to assess the current status of nursing and midwifery in the EMR and to identify the key challenges facing these services. The survey was delivered as an online questionnaire and 20 of the 22 EMR member countries responded.

To follow up on these activities, report on the current status of nursing and midwifery in the EMR and identify the key challenges facing nursing and midwifery and propose actions to move forward, the Regional Office, under the patronage of HRH Princess Muna Al Hussein, WHO Patron for Nursing and Midwifery in the Eastern Mediterranean Region, organized the Regional nursing forum: the future of nursing and midwifery in the Eastern Mediterranean Region in Amman, Jordan on 24 April 2015.

The specific objectives of the forum were to:

share the current status of nursing and midwifery in the Eastern Mediterranean Region based on the findings of the Eastern Mediterranean nursing and midwifery survey;

present successful experiences and good practices in strengthening nursing and midwifery governance, education, practice and services;

identify and suggest solutions to constraints and bottlenecks impeding implementation of the nursing and midwifery strategic directions (2012–2020);

develop consensus on and, where necessary, update, the regional strategic directions for nursing and midwifery to guide actions related to nursing and midwifery resources and services development from 2015–2025.

The participants of the forum included key chief nursing and midwifery officers from Member States and from other regions, health and nursing advisers to HRH Princess Muna, key international nongovernmental organizations (International Council of Nurses, International Confederation of Midwives), international experts, WHO collaborating centres, representatives of the regulatory councils and accrediting bodies, representatives from the Gulf Cooperation Council nursing technical committee, field nursing officers from the United Nations Relief and Works Agency for Palestine Refugees in the Near East, staff from WHO headquarters and the Regional Office.

Challenges identified

The results of the Eastern Mediterranean Nursing and Midwifery Survey and the desk review had been distributed to participants before the forum, and a summary presentation delivered at the beginning of the meeting. The major findings were categorized across the three groups of countries in the Region . In view of the results, consensus was reached on the key challenges, which were categorized around the themes of education, nursing and midwifery workforce, practice and service development, regulation, governance, and information systems. Solutions addressing the challenges were proposed.

Education: Access to education is adversely affected by inadequate investment and the low priority given to nursing education. The poor education infrastructure is a result of the lack of a clear vision and mission. Specific educational strategies are not linked to outcomes and there is inadequate preparation of deans/school directors in educational leadership. There are few functioning accreditation/quality monitoring systems. Resources for recruitment are poor, leading to a teacher shortage: there is no preparation, curricula for preparing for the role of the educator are weak and there is no continuing professional development for faculty members.

Nursing and midwifery workforce: The nursing shortage is linked to the poor working conditions, the low levels of authority and the insufficient rewards/recognition/benefits. Additionally, an inadequate number of positions/staff are budgeted for. Distribution of nursing and midwifery services is inequitable, particularly urban/rural, public/private, general/ specialized, and for all levels of prevention. A further strain on the workforce is the migration of the best qualified nurses and midwives.

Nursing and midwifery practice and services development: Policies governing practice and service development are unclear. The profession suffers from the absence of a career structure, professional progression, clinical advancement and nursing and midwifery care models. Role definition and role recognition are unclear, particularly in regard to non-nursing responsibilities and duties. There is limited collaborative and multidisciplinary practice and limited training (statuary or mandatory). Working hours for the nursing and midwifery profession are generally inflexible and the benefits are not attractive enough to retain and motivate the workforce. A patient safety culture is absent or inadequate.

Regulation: Regulation and evaluation are important in safety and quality of health services; current processes are outdated and/or contradictory, however the situation is changing slowly. Legal requirements are limited in scope and implementation has been inadequately dealt with and not well organized. Legal terminology needs to avoid being prescriptive. Progress towards setting up a nursing and midwifery council has been slow.

Nursing governance: There have been problems with leadership and management capacity: nursing and midwifery leadership authority is limited and the position of nursing and midwifery leadership in the organizational structure is not clear. The management style has been traditional and non-supportive – involvement of nursing and midwifery staff in decision-making is restricted and the practice of shared governance is absent. Information systems were described as weak and fragmented, with little use of evidence in planning and policy analysis and development.

Information systems: Limitations were noted in the nursing information system and in national human resources policies/workforce planning processes. Available data are of limited accuracy and reliability and data integration are absent: there is no shared minimum data set. Pertinent research and monitoring and evaluation are also inadequate

Other: The diversity of the Region was taken into consideration in the survey analysis. There are some cross-cutting issues such as those related to the governance of nursing and midwifery and the availability of accurate and reliable information about nurses and midwives that are common to all the three groups of countries. There also are challenges that are specific to a particular group of countries such as dependence on expatriate nurses in Group 1 countries, dual practice and deployment issues in Group 2 countries and critical shortages and issues related to the use of the title of nurse or midwife in Group 3 countries. It was emphasized that actions should be targeted for each group of countries within the context of universal health coverage and the sustainable development goals.

The way forward

The meeting concluded with participants agreeing on the priority challenges facing nursing and midwifery and the identification of several feasible and appropriate solutions to tackle the obstacles that are impeding progress in these professions.

It was recommended that an expert group be convened to finalize the strategic directions for nursing and midwifery development in the EMR based on the outcomes of the forum.

This follow-up meeting was held on 29 May 2015 in Geneva, Switzerland. The primary aim was to define a clear action plan/roadmap to address the key challenges with short- and long-term actions and a time frame for implementation. Experts in the field of nursing and midwifery from within and outside the Region, as well as relevant WHO staff, participated in the meeting.

After this meeting, the proposed framework for action on strengthening nursing and midwifery in the Region for 2015–2025 was developed (shown at the end of this report) and will be presented at the pre-session to the Sixty-second session of the WHO Regional Committee for the Eastern Mediterranean being held in Kuwait on 5–8 October 2015.

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¹This article is based on the report of the Fourth Seminar on Health Diplomacy held in Cairo, Egypt from 2 to 5 May 2015. The complete report is available on the Regional Office web site at: http://applications.emro.who.int/docs/IC_Meet_Rep_2015_EN_16400.pdf

Framework for action: Strengthening Nursing and Midwifery in the Eastern Mediterranean Region

2015-2025

Domain 1: Governance

Strategic Direction 1: Nurses and midwives will play a major role in the governance of nursing and midwifery services to meet the national health priorities.

Priority 1: Establishment or strengthening of the Nursing and Midwifery Department/Directorate at the Ministry of Health.

Priority 2: Establishment of reliable nursing information system (NIS) that is operational and is linked to the health workforce information system.

Strategic Direction 2: Nurses and midwives are regulated through legal bodies, such as a Council or Board, which are mandated to assume responsibility for professional regulation through implementing sustainable, and robust regulatory policies and practices.

Priority 1: Establishment and or strengthening of National Nursing and Midwifery Council/Board, either on its own or with other health professions regulatory bodies.

Priority 2: Effective implementation of key regulatory processes.

Priority 3: Establishment of partnerships and collaborative relationships with national health workforce departments and with regulatory bodies in other countries.

Domain 2: Nursing and Midwifery Workforce

Strategic Direction 3: Human resources policy and nursing and midwifery workforce planning focus on maintaining adequate levels , distribution and an appropriate skill-mix to meet national health priorities.

Priority 1: Countries have a national nursing and midwifery workforce plan as part of the national health workforce plan.

Priority 2: Increase pool of potential recruits.

Priority 3: Introduce flexibility in management and deployment of nurses and midwives.

Priority 4: Apply retention strategies.

Domain 3: Nursing and Midwifery Practice and Services

Strategic Direction 4: Nurses and midwives practice to the full extent of their education and scopes and standards of practice to ensure safe and quality health and nursing services for all populations.

Priority 1: Development of a model of nursing/midwifery care and practice standards that is adaptable and adoptable at country level, capable of responding to changing health priorities, incorporating primary health care ,non-communicable and infectious disease management and control, and emergency and disaster preparedness, response and recovery

Priority 2: Introduce expanded or advanced practice nursing and midwifery roles.

Priority 3: Introduce a quality improvement system for nursing and midwifery services.

Priority 4: Expand capacity and capability of currently employed nurses and midwives.

Domain 4: Access to Quality Nursing and Midwifery Education

Strategic Direction 5: Increase resource allocation to improve access to quality nursing and midwifery education.

Priority 1: Invest in nursing and midwifery education.

Priority 2: Establishment of essential national curriculum requirements for nursing and midwifery.

Priority 3: Greater use of flexible learning models including part-time and distance learning modes, use of bridging programmes and the incorporation of more Information Communication Technology (ICT) education methods as common modes of programme delivery.

Priority 4: Develop the capacity of persons holding the educator role and those engaged in educational planning, management and leadership.

Priority 5: Improved quality of programme delivery and clinical teachers and preceptors.

Priority 6: Establishment of accreditation system for nursing and midwifery education.

Domain 5: Research responsive to health priorities

Strategic Direction 6: Nurses and Midwives are engaged in research that is responsive to health priorities and that informs health, nursing and midwifery policies.

Priority 1: Enhancing the wellbeing of individuals, families and populations by translating nursing and midwifery research evidence into clinical practice, nursing governance, education and service development.

Priority 2: Incorporating Nursing/midwifery health research into national health planning.