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Erika Placella (February 2020)
Nurses as Change Agents
The World Health Assembly has designated 2020 the International Year of the Nurse and the Midwife. The WHO estimates that the world needs 9 million more nurses and midwives to achieve Universal Health Coverage (UHC) by 2030. The largest shortages of nurses and midwives are in Low and Middle Income Countries (LMICs).
Nurses play a critical role in health promotion, disease prevention and delivering emergency, primary and community care, both for communicable and non-communicable diseases (NCDs).
Nurses are often the first providers that people see when they seek care. They are uniquely placed to act as effective practitioners, health coaches, spokespersons, and knowledge suppliers for patients and their families.
Investing in nurses is considered as good value for money: investments in education and job creation in the health and social sectors result in a triple return of improved health outcomes, global health security, and inclusive economic growth. Quality and efficient primary health care services where most of the nurses work, are considered as cost effective and essential for achieving UHC.
The provision of appropriate and cost-effective promotive, preventive and curative services for NCDs requires a transformation of healthcare delivery models, with new roles and functions within multi-disciplinary teams. Nurses can definitely drive this change. As highlighted by a study carried out in the frame of a nursing education program supported by SDC in Kyrgyzstan, "transforming the family nurse's role from the doctor's assistant into an equal participant of the treatment and prophylactic processes with responsibilities on (…) NCDs" is crucial for this change to happen.
As the first point of contact, nurses are well positioned not only to detect, treat and refer patients with chronic conditions, but also to provide information, education and counselling on the prevention of NCDs. With their holistic approach to care and their focus on a person as a whole rather than on a disease, nurses are indeed well prepared to provide behavioral and lifestyle interventions that take into account the broad determinants of health and build on the strengths and resources of the individual and his/her community.
Empowering Nurses in Bosnia and Herzegovina
In Bosnia and Herzegovina (BiH), NCDs dominate the overall burden of disease and disability, accounting for 80% of the country's annual deaths. Addressing them is therefore the foremost public health priority in the country. Major risk factors for NCDs in BiH are high blood pressure, tobacco use, insufficient physical activity and unhealthy nutrition.
Due to the critical shortage of family doctors in primary health care settings and in remote or hard-to-reach areas of the country, preparing nurses for both leadership and expanded responsibilities is essential to address NCDs in a cost-efficient and effective manner.
Yet, expanding the role of nurses to address NCDs in BiH faces many obstacles such as slow reform processes, the lack of a conducive regulatory and legal framework for nursing, inadequate nursing education schemes, outdated standards of nursing practice, and resistance from doctors to task-sharing with nurses.
Since 2015, the SDC is supporting a project aiming at increasing the quality of and access to community nursing services in BiH. The objective is to improve the skills and competencies of nurses in identifying patients at high risk of developing an NCD and advising them on modifying risk factors such as smoking, obesity and high blood pressure. Patients are for example encouraged to increase their health literacy and empowered to become active participants in their own care. Community nursing services also include care for mothers with babies and for patients in terminal phases.
The project has made significant progress in regulating the nursing profession and aligning nursing education programs with EU directives and European standards. The access to higher education for nursing has been facilitated, with the provision of scholarships for Master's and PhD studies at 10 faculties. The capacities of nurses providing community services in 10 municipalities, for more than half a million population, have been also enhanced. Nursing services at primary health care level have been standardized and their quality enhanced. Finally, national nurses' associations have been empowered to promote the profession and protect its interests.
At the population level, the project has notably contributed to enhanced accuracy of data collection on NCDs and to improved diabetes and cardiovascular diseases monitoring and treatment. This has also contributed to increase the participation of the community in exercise and nutrition programmes; to reduce the need for amputations due to a diabetic foot or the number of hospital admissions for acute care; to integrate mental healthcare into primary healthcare; to improve sexual and reproductive health and rights among young people; and to provide care to the elderly/terminally ill patients thanks to improved skills in geriatrics and palliative care.
 Report of the UN High Level Commission on Health Employment and Economic Growth, 2016, https://www.who.int/hrh/com-heeg/reports/com-heeg_new-investments/en/
 Health Policy Analysis Center, Policy Research Paper, Addressing Underutilized Capacity for NCD Care: new role for Family Doctors/General Practitioners and Nurses?, Bishkek, 2015, p. 28.
 Wakefield MK, Nurse leadership in global health: New opportunities, important priorities. Int J Nurs Sci. 2017;5(1):6–9. Published 2017 Dec 14. doi:10.1016/j.ijnss.2017.12.002.
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