Building a qualified global nursing workforce

The World Health Organization (WHO) estimates that there is a global shortage of over 4 million health care workers (WHO 2006). The situation is particularly acute in sub-Saharan Africa where new resources are available for the roll-out of anti-retroviral medications and the treatment of TB and malaria. Governments are seeking quick solutions to build up the health workforce. Unfortunately, most of the massive build-up is directed toward developing the new cadre of community health workers. Significant resources are being devoted to training this new group of health workers instead of exploring strategies to scale-up nursing education. Governments, agencies and donors are paying little attention to the capacity building required within nursing, or to the potential for nursing to expand its workforce and scope of practice to address the shortage of health care workers. I suggest that we will continue to see a lack of support for building nursing education and may be developing a cadre of workers who are unable to provide safe patient care. Under WHO leadership, several countries are moving quickly to develop community health workers. This cadre has no agreed upon standards of quality, required level of primary or secondary education, or legal scope of practice. Significant resources are being devoted to preparing community workers with minimal basic education, and only several weeks to months of training, to serve as front line health care workers in the management of anti-retrovirals, assessment of patient and family conditions, and as the communicator between patients and health care workers. WHO has offered the concept of task shifting as a strategy to prepare community health workers. Task shifting is defined as ‘the process of delegation in which tasks are moved, where appropriate, from more to less specialized health workers’ (Samb et al. 2007). There is nothing inherently wrong with the concept of task shifting. In fact, the success in quality, cost, and patient satisfaction of task shifting from one highly qualified health worker to another highly qualified health worker has been documented. Research by Sherwood et al. (1997) and Horrocks et al. (2002) demonstrated that diagnostic and management tasks can be competently shifted from medicine to advanced practice nurses. Samb et al. (2007) in their recent article cite task shifting of physician diagnostic and management skills to highly trained nurse practitioners as an example that task shifting can work. It should be noted that task shifting to advanced practice nurses occurred between two licensed professions, each with separate yet complementary regulatory bodies and approved scopes of practice. There is almost no evidence that supports task shifting primary care skills to marginally qualified health workers. I believe that those in leadership positions who scaling up the training of community health workers have not paid sufficient attention to understanding the levels of nursing education. Nor do they appreciate the potential to utilize new resources to both accomplish the need for front line community workers, perhaps within the scope of practice of nursing assistants, and also to strengthen nurse training programs across all levels. A review of the research on community health care workers is promising, although mixed, and the studies were conducted primarily from programs that operated in resource wealthy nations (Lewis et al. 2005). To make the community health worker viable, governments are establishing entirely new structures of trainers, supervisors, salary scales, and career mobility systems. These independent structures are outside of nursing education, which desperately needs an infusion of resources. The International Council of Nurses (ICN) has articulated five levels of nursing: nursing assistant, enrolled nurse, registered nurse, specialist nurse, and advanced practice nurse (ICN 2008). Separate competencies were developed for each level. ICN did not link education requirements to levels in order to allow each country to integrate the model into their own educational system. Health planners at national levels might consider developing a more sustainable model of health worker in countries with significant shortages by adopting the ICN model of levels of nursing. I urge governments, donors, and foundations to consider bringing together nursing leadership from the national nursing organization, the nursing regulatory body, the chief nurse in the Ministry of Health (MOH), and university leadership to conceptualize and implement a coherent national plan across the continuum of levels of nursing. Through such strategic planning, nursing education at all levels in a particular country might be strengthened. Communities would not be left with community health workers who may have less than primary schooling, no career mobility opportunities, and be challenged by health care needs beyond their ability or training. National planning groups would also need to include other governmental agencies, representatives from civil society, consumers, and industry to provide broad input and support. Recently, the MOH in Tanzania rewrote their diploma nursing education curriculum in four months, reducing the time required for graduation from three to two years and including significant HIV content. Some critics state that it would take too long to prepare nurses given the urgent need for health care workers. I would suggest that these critics do not understand that nursing has a continuum of levels of scope of practice, and the length of training varies according to the level. Furthermore nursing students provide direct patient care in hospitals and clinics during their training period. If a nation provided the resources to double the number of nurse trainees at all levels of education, it would immediately double the number of health care workers giving health care to their citizens. Other critics of nursing education and training state that qualified registered nurses will leave the country once they have completed their training. Proponents of this statement do not understand international migration as articulated in the book Nurses on the Move: Migration and the Global Health Care Economy (Kingma 2005). Global data suggest that most nurses do not wish to migrate and leave their families. If conditions were better at home, many more would choose to stay actively employed in their own communities. Today migration is recognized as a normal activity of civil society. Health workforce planners are charged to develop plans for a national self-sustainable work force in all professions. Governments are challenged to provide safe and quality working environments with adequate compensation for nurses. The challenge of out migration can be creatively addressed. One solution includes requiring physicians, nurses, and other health care workers to provide two to four years of service in their country if they were educated with governmental funds. The experiment by the United Kingdom's foreign aid agency, DFID, to augment health worker salaries in Malawi will be important to monitor. Why don't governments and donor agencies see the potential of developing nursing education as a significant strategy to solve the emergency work force shortage? Why are governments and donors devoting significant new resources to non-sustainable training programs while nursing education is receiving so little attention? Perhaps nurse leaders have not been cooperative in such planning processes. Perhaps governments wish to dismantle nurse worker unions. Perhaps leaders lack the vision to make the link between the extreme lack of resources being provided for nursing education and the challenge of developing a qualified nurse work force. Perhaps this is another example of gender inequality as articulated in the Millennium Development Goals. Is a gender bias operating that supports the subordinate status of nurses to physicians, of women to men, and that hides nursing's potential to contribute to the global shortage of health workers? William L. Holzemer RN, PhD, FAAN is Professor and Associate Dean for International Programs and the Lilian and Dudley Aldous Chair in Nursing Science at the School of Nursing at the University of California, San Francisco.