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| Josephine Etowa* | |
| Associate Professor & Loyer-Dasilva Research Chair in Public Health Nursing, Faculty of Health Sciences, University of Ottawa, Ontario, Canada | |
| Corresponding Author : | Josephine Etowa Associate Professor & Loyer-Dasilva Research Chair in Public Health Nursing Faculty of Health Sciences, University of Ottawa, Ontario, Canada Tel: 1 613 562 5800 E-mail: josephine.etowa@uottawa.ca |
| Received: November 05, 2014; Accepted: November 06, 2014; Published: November 10, 2014 | |
| Citation: Etowa J (2014) Painting the Landscape: Is the Invisibility of Nigerian Nurses in Research and Policy Development Arenas Ailing Healthcare in the Country?. J Preg Child Health 1:e105. doi: 10.4172/2376-127X.1000e105 | |
| Copyright: © 2014 Etowa J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. | |
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| Commentary |
| Strengthening capacity for health research is well recognized as an important unmet need in low middle income countries (LMICs). This has gained attention in both national and international agendas over the past two decades resulting in many proposals for restructuring the delivery of health care. These health care system redesign efforts seek to address the current global burden of disease. Nigeria is an LMIC that bears a significant proportion of the global burden of disease. For example, Nigeria has one of the highest rates of maternal mortality in the developing world and this translates to 10% of women dying from pregnancy and childbirth related complications whereas it accounts for 2% of world population. The country has with a reported maternal mortality ratio of 608 per 100,000 live births in 2008 (Hogan, 2010) [1]. Like many nations, Nigeria has made concerted efforts to initiate and sustain health sector reforms over the past decade to address this health crisis. However, there continues to be growing recognition of the urgent need to take action that will improve and set future agenda for better health care for Nigerians. |
| In acknowledgement of nurses’ steadfast commitment to high quality healthcare, this commentary raises the question; what contributions can nurses make to address the increasing demand for high quality and effective health care services?The US, Institute of Medicine (IOM, 2010) ‘the future of nursing: Leading change [2] report acknowledges that “nurses’ regular, close proximity to patients and scientific understanding of care processes… give them a unique ability to act as partners with other health professionals and to lead in the improvement and redesign of the health care system”. Nurses are untapped visionary leaders armed with the knowledge, skills, and attitudes that could be the missing link to implementation of positive change in healthcare. |
| As the largest group of health workers, nurses form the ‘backbone’ of the health care system in Africa and the western world. In 2008, there were 224,943 nurses in Nigeria compared to 55,376 physicians in the country, a ratio of 4 nurses to every 1 physician (WHO 2011). Nurses are well-positioned to play a leading role in improving health care for Nigerians especially in areas such as maternal and infant health, and HIV/AIDS. Nurses form an integral part of the health care system because: 1) they are at the forefront of patient care and have prolonged engagement with patients and their families. They work around the clock and thus have a realistic inside view of issues from patient and health care provider perspectives. It is this 24/7 presence that fosters rich opportunities for nurses to generate important practice and research ideas and solutions; 2) nurses know when and whom to call from other health professionals. They work across disciplines and sectors of the health system with potential for high yield of pertinent health services and policy design innovations, and they know how to utilize those that work in their everyday practice; and, 3) evidence-based approaches are highly relevant to nursing practice and nurses are engaged in designing new ways of working that might lead to improvements in the quality of care (Asuquo, Etowa, et al 2013, Darmstadt 2010) [3]. |
| Nurses as full partners in health research |
| Despite nurses’ pivotal role in the provision of health care services and in reaching vulnerable groups in underserved areas in Nigeria, nurses are typically not involved in funded research as investigators. Instead, they are primarily data collectors in medical research (Asuquo, Etowa et al). This limited representation has constrained the availability of nursing research and the ability for nursing-relevant research to inform healthcare and policy issues. Nurse-leaders need to act as full partners with other healthcare professionals, and must be accountable for their own contributions to high-quality health care while working collaboratively with leaders from other health professions (IOM, 2010). |
| The growth of evidence-based health service delivery and the move of nursing education into institutions of higher learning in many countries demand enhanced research capacity in nursing. The movement of nursing scholars into universities represents a major upheaval for those involved as this is usually associated with new expectations and competing demands which leave some people feeling overwhelmed. There are fundamental differences in resources, cultures and the skill base between long-established academic disciplines and those professions like nursing which are still adjusting to the transition from hospital-based training to university education. University nursing institutions have expectations to actively engage in research as an integral aspect of their role while still maintaining existing clinical and teaching commitments (Cook) [4]. The nursing profession also faces additional challenge in terms of negotiating its financial needs and competing agendas within the wider institutional, professional and political arenas. Health professionals have diverse backgrounds which influence the kinds of research questions they ask and the dimensions of a problem, they can illuminate. While all health professionals share some common knowledge (e.g. biological sciences) on the basis of their professional education, there are also key points of divergence that influence the types of research questions they ask. It is not the case that one type of research question is inherently better than another. Rather, when scientific investigation draws on multidisciplinary perspectives, this strengthens the breadth and depth of evidence available to successfully respond to complex, multi-faceted problems (Edwards et al. 2009) [5-7]. |
| As frontline providers who have everyday presence with patients and families, nurses’ work provides fertile ground for important clinical research questions. The investigation and adoption of evidencebased approaches are highly relevant to nursing practice and patient outcomes, and to the quality and cost-effectiveness of health services (Forster et al.) [8]. The full engagement of nurses in researching critical health services issues is likely to lead to service delivery and policy recommendations that are both pragmatic and evidenceinformed (Edwards et al ,) [5]. Ultimately, developing nursing research capacity can make a significant contribution to positive patient health outcomes as their practice will be evidence based. |
| Edwards and Roelofs [7] exemplified the benefits of nurseled maternal-child health research in a Canada-China project which made a significant contribution to health outcomes in the region with over 30% reduction in under-five mortality rate. This five year project targeted maternal and child health workers’ training using interventions based on community based participatory research approaches in the Yunnan, China, a province with 2.2million people, mostly ethnic minorities. Innovations from this project have been integrated intoother local and international including a recently completed nurseled five country program to strengthen nurses’ capacity in HIV policy development in Sub-Saharan Africa and the Caribbean. This program of research effectively trained and mentored nurses from LMICs, some of whom have been able to successfully obtain international research funds for spin-off projects (Edwards et al.) [6]. This program uses a participatory process and a range of capacity-building mechanisms such as leadership hubs to engage nurses in study countries; Kenya, Uganda, South Africa and Jamaica. |
| Nigerian nurses need the opportunity to join this kind of promising global networks of nurse-researchers to realize their full potential as leaders in healthcare research and policy development. Without a supportive environment, very few nurses are likely to conduct this kind of innovative inquiry which is necessary to ensure evidence-based healthcare. Healy [9] argue that nursing research capacity development is essential to address contemporary issues related to clinical nursing practice, nursing service delivery, and global health policy issues. Nursing research capacity building efforts require appropriate infrastructure and knowledge translation support in order to convert nursing knowledge gained into viable healthcare policies. |
| Nurses’ involvement in health policy |
| Although nurses are well-prepared educationally and often play a leadership role within various areas of the health care system, their contribution to health research and policy process is limited in African countries, and specifically in Nigeria (Asuquo, Etowa et al. 2013). Nurses are constrained in engaging in health research and policy processes because of a lack of research training and mentoring, limited experience with effective knowledge transfer strategies, and few opportunities for dialogue with researchers and policy makers (Edet et al.) [10]. In the face of these challenges, nurses are largely not involved in the development of health care and health system policies that impact on their practice (WHO, 2011). There have been numerous calls for greater nursing involvement in local, national, and international policy and decision making arenas to improve the health of people in Africa (PAHO 2004; Edwards, Kahwa et al.) [5]. Nurses have an important role to play in knowledge generation and the provision of evidence to inform and influence policies and practice relevant to health care delivery (IOM, 2010). The literature points to the significance of not only increasing research productivity but also of using research evidence in decision-making and health system |
| planning. Lack of evidence-based policies has been identified as a key factor influencing the health and health care crisis in Africa (Salmon & Rambo,) [11]. According to Schryer-Roy and Campbell [12,13], “a strong evidence base, indicating efficiency, effectiveness and cultural appropriateness on any given issue, has not always informed the decision-making process” in this region. Similarly, Sitthi-amorn, and Somrongthong [14] assert that research and its publications do not necessarily translate into improved health outcomes unless they are interpreted into tangible practices and policies. Knowledge capacity is determined by the ability to manage, identify, use and apply relevant knowledge in health planning, decision-making and system development.” Given the significant impact of policy on health outcomes, policies developed without nursing involvement may lack crucial information about system gaps and strengths (Edwards et al., ) [5] |
| The International Council of Nurses developed a policy-based interventions framework to address the global nursing shortage (Buchanan and Calman,) [15]. The elements of this ICN framework include addressing health human resource issues in nursing such as recruitment and retention, deployment and performance, and utilization and skill mix. The report suggests that stakeholder involvement and leadership must be part of a sustainable response to the health human resource crisis, and that this involves building leadership capacity among nurses. This is consistent with recommendations from both WHO (2011) and the Pan American Health Organization (PAHO, 2004) [16,17]. Despite numerous recommendations from international and regional bodies (PAHO) to include nurses as participants at all levels of health system, their involvement is still quite rudimentary. Poor working conditions, lack of professional status, and the imbalance between supply and demand for nurses have contributed to the absence of nurses from health systems decision-making (Phalaze, 2003). Nurses’ absence in these arenas is a concern because nurses have the potential to be one of the foremost inks between the various governance systems and clinical practice settings (Edwards et al.) [5-7]. |
| Walker and Gilson [18,19] described nurses as “street-level bureaucrats” capable of influencing national health policies, such as the introduction of the “free care” policy in South Africa. While the “free care” policy aimed to improve equitable access to health services, it led to significant and unanticipated negative consequences (work hours, morale, and pay) for nurses providing health services. These negative consequences might have been prevented if nurses were actively involved in the policy development process. Another study by Gilson, Erasmus, Kamuzora et al. [20] identified the effect of implementation-resistance from nurses and other health workers on equity-oriented policies. Similarly, a Nigerian nursing study revealed the marginal representation of nurses in policy making arenas and the negative impact this may have in policy formulation (Asuquo, Etowa et al ). |
| This study showed that only3.3% of the 120 nurses in the study were involved in policy making. Increasing nursing involvement in policy development and research productivity will raise awareness is necessary to ensure consistent use of research evidence in clinical practice thereby improving health outcomes. To be effective in contemporary health care, nurses need to see policy as something they can shape rather than something that happens to them. Nurses need to have a voice in health policy decision making and be actively engaged in implementing policies relevant to health care sector redesign. Nurses also should serve on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care (IOM, 2010). |
| In conclusion, the demands of contemporary healthcare call for more active engagement of nurses especially in LMICs like Nigeria. Innovation in today’s healthcare requires not only more evidence but new kinds of evidence. Nurses’ holistic approach to healthcare and social science research will shed light to old problems and uncover new ways of addressing health challenges. As WHO (2011) [21] states, nurses’ presence within the scientific foundation for making decisions on healthcare policies, programs, and resource allocations can improve equity, quality, and efficiency of health systems. The time is ripe for the many dynamic nurse leaders in Nigeria and Africa as a whole to mobilize the global nursing networks and intellectual capital to tackle the current health situation in the country and to fulfill their potential as leaders in healthcare. Nigerian nurses need to take their rightful place in the boardrooms and international platforms where healthcare research and policy decisions are taking place. |
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