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

越来越多的人一致认为，通过全民健康覆盖实现关于健康生活和福祉的可持续发展目标3需要重点关注卫生人力资源。在发展中国家，卫生工作者的短缺估计超过700万，最贫穷的非洲国家的短缺情况最严重。肯尼亚面临严重的卫生人力危机，各县公共部门的护理密度在每1000人1.2至0.008人之间，而国际建议的最低卫生人力门槛为每1000人2.5人。护士是卫生专业人员队伍的最大组成部分，被认为对提供安全有效的护理至关重要，应在促进和制定有效的卫生政策方面发挥关键作用。然而，我们认为护士往往被低估，她们的贡献被低估，她们在讨论主要HRH问题和护理质量（QoC）方面的“声音”往往缺乏。文献中与政策制定参与不足相关的一些障碍包括：缺乏对护士作为政策制定关键利益相关者的认识，护理“只是辅助职业”的负面形象，以及官僚程序。一个很少被研究的潜在重要方面是护理专业社会化如何影响他们的职业认同，可能会影响护士在卫生保健系统内调动权力和权威的能力。越来越多的优质信息被用来在政策和管理辩论中提供证据和宣传，而护理质量的衡量是一个特别的重点。衡量低收入和中等收入国家护理质量的努力几乎完全集中在护理的医疗方面。在初级保健一级，大多数护理实际上是由护士提供的。在较大的设施中，质量评估也侧重于医疗质量；然而，护士是提供临床干预措施（如治疗、营养干预等）和其他护士发起的干预措施的看门人，并在很大程度上负责整体护理，以满足更广泛的患者需求。然而，很少有人关注护理质量的措施和他们的潜力，以突出护理赤字对质量的影响。缺乏这些措施可能会进一步削弱护士影响政策和管理决策的能力。我们将以身份理论为视角，开始研究护士作为专业人士的身份是如何形成的，以及它对护士在管理和政策角色中行使权力和代理能力的潜在影响。我们还将探讨如何在非洲的背景下适应和实施更具体的护理质量衡量标准。能够更好地为旨在提供优质护理和全民健康覆盖的劳动力政策和管理决策提供信息的措施。实证研究将通过民族志、对关键利益相关者的访谈和利益相关者会议，探讨护士的职业认同及其在国家、县和医院层面的实践影响。在开发和预测试工具之前，我们将通过回顾文献来检查现有的测量错过护理的方法，这些工具与护理界共同设计，可以产生护理质量的指标，为政策和实践的辩论提供信息。这项工作计划将通过使用身份透镜来探索护理专业如何塑造和定义劳动力政策、角色和任务，从而提供重要的新思维。此外，我们将开发工具，提供通常缺乏的关于所提供护理的质量和数量的数据。作为应对全球劳动力挑战的更广泛努力的一部分，我们将着手寻找途径，使护士能够积极参与研究、改善护理和为政策提供信息。

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.