Nursing now and always: evidence for the implementation of the Nursing Now campaign

Mendes, Isabel Amélia Costa; Ventura, Carla Aparecida Arena; Silva, Manoel Carlos Neri da; Lunardi, Valeria Lerch; Silva, Ítalo Rodolfo; Santos, Sara Soares dos

doi:10.1590/1518-8345.4553.3388

Isabel Amélia Costa Mendes Corresponding author: Isabel Amélia Costa Mendes. E-mail: iamendes@usp.br

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

Scholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.

https://orcid.org/0000-0002-0704-4319

Carla Aparecida Arena Ventura

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

Scholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.

https://orcid.org/0000-0003-0379-913X

Manoel Carlos Neri da Silva

Conselho Federal de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0002-3923-7473

Valeria Lerch Lunardi

Universidade Federal do Rio Grande, Departamento de Enfermagem, Rio Grande, RS, Brazil.

https://orcid.org/0000-0002-0380-1829

Ítalo Rodolfo Silva

Universidade Federal do Rio de Janeiro, Campus Macaé, Macaé, RJ, Brazil.

https://orcid.org/0000-0002-2882-1877

Sara Soares dos Santos

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0003-0712-0200

Corresponding author: Isabel Amélia Costa Mendes. E-mail: iamendes@usp.br

Associate editor: Pedro Fredemir Palha

Report of the High-Level Commission on Health Employment and Economic Growth-working for Health and Growth
Background
Commission established by United Nations Secretary General Ban Ki-moon in March 2016. Its task was to make recommendations to stimulate and guide the creation of at least 40 million new jobs in the health and social sectors and to reduce the lack of 18 million workers, especially in low and middle-income countries, by 2030. The results of this work reflect the partnership with the International Labour Organization (ILO), Organization for Economic Cooperation and Development (OECD) and WHO.
Scope of health professionals’ work
The Commission qualified the launch of its report as a unique opportunity to advance in the political commitment to achieve the SDG^* * SDG = Sustainable development goals , particularly SDG 1 (poverty elimination), 3 (health and welfare), 4 (quality education), 5 (gender equality) and 8 (decent work and economic growth), through investments in the local and global health workforce.
Potential of health professionals’ work
Acknowledgement of the health sector as a key economic sector and employment generator. Between 2000 and 2014, employment in health and social work grew by 48%, while jobs in the industry and agriculture dropped. The demand for health services is expected to grow, creating millions of new jobs. Economic development depends on healthy populations. Around a quarter of growth in low and middle-income countries between 2000 and 2011 resulted from improvements in health; the estimated return on investments in health is 9 to 1; one extra year in life expectancy raises GDP per capita by about 4%. In countries with a high fertility rate, bringing down the child mortality rate can positively influence family planning decisions, contributing to a faster demographic transition, associated with economic benefits called demographic dividends. Investments in health systems have multiplier effects that strengthen inclusive economic growth, also through decent jobs. Strategic investments in health systems are fundamental, including in the health workforce and in the promotion of economic growth, via cohesion and social protection, innovation and health security.
Challenges for health professionals’ work
The population is growing and the world faces a decrease in the number of health workers. The lack of skilled workers constrains job creation in the sector. Investments in health education/training are needed to promote more inclusive economic growth.
Recommendations
1. Job creation – stimulate investments in creating decent jobs in the health sector, especially for women and young people, with the necessary skills, in the right numbers and places. The Commission calls for urgent actions to develop job market policies to foster the demand for a sustainable health workforce. Government policies need to address systemic issues that result in recurring losses in the health job market. 2. Gender equality rights – maximize women’s economic participation, institutionalizing their leadership and addressing gender biases and inequalities in education and work. Women are the main care providers, including in humanitarian crises and conflicts. Hence, the health sector is an increasing employer for women and can contribute to gender equality. Gender inequalities, physical and sexual violence and harassment remain important challenges for health workers. 3. Education, training and skills – value high-quality, transformative education and continuing learning so that health workers have skills to face people’s health needs and work to their full potential. In that sense, countries can prioritize investments in education, focusing on building locally relevant competencies. Addressing geographical inequities is a priority, and demographic transitions present opportunities to strengthen youth education for health jobs. 4. Health service delivery and organization – Reform health service models concentrated on hospitals and focus on prevention and efficient delivery of high-quality, integrated, community-based and people-centered primary care, paying special attention to vulnerable areas. 5. Technology – explore the power of Information and Communication Technologies (ICT) that strengthen health education, people-centered health services and health information systems. The rapid technological changes are changing the nature of health services and new health professionals emerge with skills to handle the ICT. Digital technologies also provide opportunities to improve people’s access to health services and health systems’ response to the needs of individuals and communities. 6. Humanitarian crises – ensure investments in key international health regulations, including the skills development of health workers in humanitarian crisis and public health emergency situations, aiming to ensure the protection and security of health workers in different settings. Countries should build the capacity of their health workforce and health systems to detect and respond to public health risks and emergencies. In conflict settings, public health crises exacerbate the difficulties for offering basic care. 7. Financing and fiscal resources – raise adequate national and international funding from public and private sources and consider the funding of health reforms through investments in appropriate skills and decent working conditions. Societal dialogue and political commitment are crucial to drive appropriate macroeconomic reforms and health funding policies. 8. Partnership and cooperation – promote intersectoral collaboration at the national, regional and international levels, through the engagement of civil society, unions and other organizations of health workers and the private sector. Align international cooperation to support investments in the health workforce. 9. International migration – advance the international recognition of health professionals’ qualifications to optimize their skills use, increasing the benefits from and reducing the negative effects of health workers’ migration, safeguarding migrants’ rights. 10. Reliable evidence – undertake robust research on the health markets, using reliable methodologies to strengthen the evidence, reliability of the data and resulting actions.

Triple Impact: how developing nursing will improve health, promote gender equality and support economic growth
Background
Report organized by the All-Party Parliamentary Group on Global Health in the United Kingdom. Its starting point was the goal countries signed in 2015, assuming the commitment to guarantee universal health access/coverage, adopting the view that “nobody should be left behind”. This report argues that universal health coverage cannot be achieved without strengthening Nursing; it highlights the need to increase the number, as well as the understanding that its contribution is understood, so as to enable nurses to work at their full potential. In that perspective, the report argues that the strengthening of Nursing will have a triple impact: improving health, promoting gender equality and supporting economic growth.
Scope of nursing work
Nurses play different roles, in varying circumstances and contexts, through a unique combination of people-centered competencies and humanitarian values; they provide and manage care, work with families and communities and play a central role in public health, disease and infection control. In diverse contexts, nurses are the primary or sole professionals people see in health care. Part of the community, they share its culture and are alert to social, individual and programmatic vulnerabilities.
Potential of nursing work
Nurses are the largest part of the professional health workforce. Achieving the goal of universal health coverage/access globally depends on these professionals’ comprehensive action. There is important innovation and creativity in nursing care, with great potential not yet used that will ensure that citizens have better access to health care. The increase in the number of nurses and the use of Nursing’s full potential will result in a triple impact of improving health, gender equality and economic growth.
Challenges for nursing work
In many contexts, Nursing remains undervalued and its contribution underestimated. These professionals still face problems in the team, poor infrastructure and inappropriate education and training. All of these factors can result in care of inferior quality; in this context, they are frequently unable to fully practice their skills and share their knowledge. They also get few opportunities to develop their leadership, hold leading functions and influence policy making.
Recommendations
1. Strengthen Nursing and make it central to health policies. A high-level global summit on Nursing should be convened, consisting of political and health leaders outside Nursing, to raise awareness of the opportunities and potential of Nursing, create political commitment and a establish a process for supporting development. This should be part of a long-term initiative that embraces all other recommendations. 2. Support plans to increase the number of nurses being trained and employed globally. The WHO Global Strategy on Human Resources for Health, Workforce 2030, adopted by member states in 2016, proposes a framework for making the most effective use of health workers, as well as investment plans to address their shortage. A) Develop plans in partnership with low and middle-income countries to support their health workforce; B) Reaffirm support for the WHO Global Code of Practice on the International Recruitment of Health Personnel, offering support for the training and employment of health professionals in their countries of origin; C) Assess the impact of health professionals’ leaving the European Union on health and the health system and take mitigation actions. 3. Develop nurse leaders and Nursing leadership. They are needed in the right places to ensure that the distinctive Nursing perspective is included in health policy-making and decision-making. A) Establish a global program to develop nurse leaders who are truly engaged in policy-making and decision-making. B) Ensure that countries have nurse leadership posts throughout their structures and organizations. 4. Enable nurses to work to their full potential. Cultural, regulatory and legislative barriers need to be identified and removed so that good practices are shared and applied. 5. Collect and disseminate evidence of the impact of Nursing on health access, quality and costs, aiming to ensure that it is incorporated in policies. It is important to undertake new assessments to demonstrate the impact of Nursing at scale. A) Develop research to join evidence and start new research on how and when the improvement of Nursing care contributes to universal health access. B) Ensure that existing and future research results are widely disseminated and understood in order to influence practice and policies. 6. Develop Nursing to have a triple impact on health, gender equality and economies. Investment in Nursing – the vast majority of whom are women – will help empower them economically and as community leaders, strengthening local economies. A) Adapt development policies to implement programs that simultaneously address SDG 3, 5 and 8, focusing on health, gender equality and inclusive and sustainable economic growth. 7. Promote partnerships and mutual learning between the United Kingdom and other countries. A) Expand the DFID Health Partnership Scheme, including more nurses.

Strategic Directions for Nursing and Midwifery – 2016-2020
Background
In 2000, the 54^th World Health Assembly, by resolution WHA54.12 on Strengthening Nursing and Midwifery, requested the Director-General to prepare a plan of action for strengthening Nursing and Midwifery. As a result, the first Strategic Directions for Nursing and Midwifery were published in 2002 and updated in 2011. Since then, other resolutions on strengthening Nursing and Midwifery services have been passed by the World Health Assembly. The strategic directions provide decision makers, nurses and other stakeholders at every care level with a comprehensive reference framework for collaborative action to strengthen the capacity for Nursing and Midwifery development. In that context, WHO continued to act on that commitment: in May 2014, the 67th World Health Assembly adopted resolution WHA 67.24 on the Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage. In paragraph 4(2) of that resolution, the member states requested the Director-General of WHO to present a new global strategy for human resources for health – The Global Strategy on Human Resources for Health Workforce 2030, which provided the foundation for the elaboration of these Strategic Directions. The Strategic Directions were developed through an extensive consultative process, including experts from all WHO regions, academicians, educational teaching institutions, government Chief Nursing Officers, policy-makers, WHO Collaborating Centers for Nursing and Midwifery Development, students, NGOs and professional associations. The document builds on the following guiding principles: ethical action – planning and offering care based on equity, integrity, fairness and respectful practice in the context of human rights; relevance – development of education programs, research, services and systems guided by health needs, evidence and strategic priorities; ownership – adoption of a flexible and strategic approach that ensures effective leadership, management and capacity building, as well as transparency, engagement and involvement mechanisms of all beneficiaries; partnership – joint work on common objectives; quality – adoption of mechanisms and standards based on evidence and best practices, through education and research.
Scope of nursing work
The global disease burden is increasing and gaining complexity, including emerging and re-emerging noncommunicable diseases. Nursing is critical in the delivery of essential health services and thus strengthens the health systems. Acting as individuals, members and coordinators of interprofessional teams, nurses bring people-centered care closer to the communities where it is needed most, improving the health outcomes and service effectiveness. They are active in promoting and maintaining the health and wellbeing of the elderly population. At the same time, they contribute to reductions in newborn, infant and maternal mortality. They are responsible for a wide range of hospital services, ranging from accident and emergency to palliative care. They are core in crisis and post-crisis situations, contributing to risk communication, response planning and multisectoral participation aspects of different programs, providing services ranging from trauma management to mental health.
Potential of nursing work
Nurses and midwives constitute more than 50% of the health workforce. In that scenario, there is demonstrable evidence supporting the contribution of Nursing to the strengthening of health systems through increased patient satisfaction, decreased morbidity and mortality rates, stabilization of financial systems through the reduction of readmissions and length of stay, among other conditions such as hospital-acquired infections, providing an overall contribution to patient wellbeing and safety. The utilization of the nursing workforce is cost-benefit. Nurses are the first responders to complex humanitarian crises and disasters, protecting and advocating for the community; and serve as team coordinators. Nursing interventions in the treatment of chronic conditions stimulate improved treatment adherence. Studies also show that family planning and maternal and child health interventions can avert a total of 83% of maternal and neonatal deaths.
Challenges for nursing work
There is continued need to strengthen the quality of nursing education, in response to unhealthy lifestyles, risk factor reduction and provision of different disease and infection-related interventions. Nursing education and practice takes place in an environment of constant technological changes, and its promotion is an important element for the future. Technological advancement can support transformational outcomes of more integrated, high-quality and knowledge and evidence-based approaches. In response to the challenges nursing and midwifery face, the document emphasizes that robust leadership, governance and accountability are essential. Strategic planning based on collecting and monitoring data and country indicators can contribute to effective education and recruitment, as well as to the retention and effective management of the nursing workforce.
Recommendations
1. Ensuring an educated, competent and motivated Nursing workforce within effective and responsive health systems at all levels and in all service settings. Objectives: to educate, recruit and retain a sufficient number of nurses with appropriate competencies, equipped with the necessary resources and governed by professional regulation. Strategies: to align investments and coordinate plans for the development of nursing in workforce coordination; in continuing education; regulation and in guaranteeing healthy practice environments. 2. Optimizing policy development, effective leadership, management and governance. Objectives: to favor the active participation of nursing leaders at every level of policy formulation, program planning development and implementation, including evidence generation for informed decision-making. Strategies: to prepare Nursing leaders to meet the challenges of health systems, ensuring their competence in all aspects of Nursing development, including policy development and evidence generation, in order to improve the quality of education and Nursing service provision. 3. Working together to maximize the capacities and potentials of Nursing through interprofessional collaborative partnerships and continuing professional development. Objectives: to optimize the impact of Nursing on health systems at all levels through intra- and interprofessional collaboration. Strategies: to delineate, monitor and evaluate roles, functions and responsibilities of the Nursing workforce to advance collaborative education and practice. 4. Mobilizing political initiatives to invest in effective scientific evidence on Nursing workforce development. Objectives: to establish structures that enable the empowerment of nurses in order to achieve effective engagement and contribute to health policy development, aiming to increase the quantity and quality of nursing workforce services. Strategies: to build political support and the highest levels of health systems and with civil society to ensure that the policies created are in line with the achievement of the universal health coverage and Sustainable Development Goals.

Nursing Now campaign goals	Recommendations of the documents analyzed
1. Expand investments in improving the teaching, professional development, standards, regulations and employment conditions of nurses.	Recommendation 1 High Level Commission Report. Job creation; Recommendation 2 High Level Commission Report. Gender equality rights; Recommendation 3 High Level Commission Report. Education, training and skills; Recommendation 4 High Level Commission Report. Health service delivery and organization; Recommendation 5 High Level Commission Report. Technology; Recommendation 6 High Level Commission Report. Humanitarian crises; Recommendation 7 High Level Commission Report. Funding and fiscal resources. Recommendation 8 High Level Commission Report. Partnerships and cooperation. Recommendation 9 High Level Commission Report. International Migration. Recommendation 2 Triple Impact Report. Support plans to increase the number of trained and employed nurses globally. Recommendation 4 Triple Impact Report. Enable nurses to work to their full potential. Thematic Area 1 Strategic Directions. Ensure an educated, competent and motivated nursing workforce in effective and responsive health systems at all levels and services.
2. Increase and improve the dissemination of effective and innovative practices in nursing.	Recommendation 10 High Level Commission Report. Reliable evidence. Recommendation 5 Triple Impact Report. Collect and disseminate evidence on the impact of nursing on access, quality and costs, in order to ensure its incorporation into policies. Recommendation 6 Triple Impact Report. Develop nursing to have a triple impact on health, gender equality and economies. Thematic Area 4 Strategic Directions. Mobilize political initiatives for investments in effective scientific evidence on the development of the nursing workforce.
3. Intensify the influence of nurses and midwives on the global and national health policy as part of more broad-ranging efforts to ensure that human resources for health are more engaged in decision-making processes.	Recommendation 1 Triple Impact Report. Raise the profile of nursing, making it central to health policies. Thematic Area 3 Strategic Directions. Work together to maximize nursing skills and potentials through interprofessional partnerships and collaborations and continuous professional development. Thematic Area 4 Strategic Directions. Mobilize political initiatives for investments in effective scientific evidence on the development of the nursing workforce.
4. Enhance leadership positions occupied by nurses and multiply development opportunities at all levels.	Recommendation 1 Triple Impact Report. Raise the profile of nursing, making it central to health policies. Recommendation 3 Triple Impact Report. Develop nursing leaders and leadership in nursing. Thematic Area 2 Strategic Directions. Optimize policy-making, effective leadership, management and governance.
5. Provide an expanded evidence base for decision makers and policy makers on how and when nursing can have the greatest impact and what prevents nurses from reaching their potential to manage these obstacles.	Recommendation 2 High Level Commission Report. Gender equality rights - maximize women’s economic participation by institutionalizing their leadership and dealing with gender biases and inequalities in education and the job market. Recommendation 10 High Level Commission Report. Reliable evidence - develop robust research and analyses on health markets, using reliable metrics and methodologies to strengthen evidence, reliability of data, and resulting actions. Recommendation 5 Triple Impact Report. Collect and disseminate evidence on the impact of nursing on access, quality and costs, in order to ensure its incorporation into policies. Thematic Area 4 Strategic Directions. Mobilize political initiatives for investments in effective scientific evidence on the development of the nursing workforce.

[1] Corresponding author: Isabel Amélia Costa Mendes. E-mail: iamendes@usp.br

Brasil

Brasil

Nursing now and always: evidence for the implementation of the Nursing Now campaign^* * This article refers to the call “Nursing Now and Nursing in the Future”.

Objective:

Method:

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Conclusion:

Brasil

Brasil

Nursing now and always: evidence for the implementation of the Nursing Now campaign* * This article refers to the call “Nursing Now and Nursing in the Future”.

Objective:

Method:

Results:

Conclusion:

Nursing now and always: evidence for the implementation of the Nursing Now campaign^* * This article refers to the call “Nursing Now and Nursing in the Future”.