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

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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.