Health Professions Networks Nursing & Midwifery Human Resources for Health. A Global Survey Monitoring Progress in Nursing and Midwifery

Transcription

1 Health Professions Networks Nursing & Midwifery Human Resources for Health A Global Survey Monitoring Progress in Nursing and Midwifery

2 A Global Survey Monitoring, Progress in Nursing and Midwifery (WHO/HRH/HPN/10.4) This publication is produced by the Health Professions Network Nursing and Midwifery Office within the Department of Human Resources for Health. This publication is available on the Internet at : Copies may be requested from World Health Organization, Department of Human Resources for Health, CH-1211 Geneva 27, Switzerland. World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel : ; fax : ; bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax : ; permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Edited by : Diana Hopkins, Freelance Editor, Geneva Switzerland. Design & layout by : (cover illustration Eric Scheurer, Switzerland).

3 Health Professions Networks Nursing & Midwifery Human Resources for Health A Global Survey Monitoring Progress in Nursing and Midwifery

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5 Contents Acknowledgements 4 Acronyms 6 Executive summary 12 Background 15 Introduction and purpose 17 Specific objectives of the study 18 Methodology 19 Findings 23 Data considerations 23 Responses : Regionally and globally 24 Key Result Area 1 : Health planning, advocacy and political commitment 25 Key Result Area 2 : Management of health personnel for nursing and midwifery services 38 Key Result Area 3 : Practice and health system improvement 45 Key Result Area 4 : Education of health personnel for nursing and midwifery services 47 Key Result Area 5 : Stewardship and governance 53 Millennium Development Goals 63 Challenges and limitations 66 Closing messages and thoughts 69 Reflections, conclusions and recommendations 69 References 75 Appendices 78 Appendix A : Survey 79 Appendix B : Tables 80 Appendix C : Key result areas for strengthening nursing and midwifery 95 Co-principal investigators 100 Co-investigators 100 Contents 3

6 Acknowledgements This study, A Global survey monitoring progress in nursing and midwifery is the result of a partnership involving the World Health Organization, the University of Toronto and the Federal Government of Canada and is part of an ongoing relationship aimed at addressing nursing and midwifery development. Along with the co-investigators, key collaborators from WHO regional offices, including many of those who compiled the data, promoted the completion of the survey, participated in the pilot study, and contributed to the study s validation and review process. The co-investigators acknowledge and extend their appreciation to the following individuals, national departments and organizations for their collaboration in the preparation of this study. The WHO Regional Advisers for Nursing and Midwifery who were pivotal in collecting the data in 2005 : Fariba Al-Darazi, Regional Office for the Eastern Mediterranean (EMRO); Kathleen Fritsch, Regional Office for the Western Pacific (WPRO); Silvina Malvarez, Regional Office of the Americas (AMRO); Margaret Phiri, Regional Office for Africa (AFRO); Prakin Suchaxaya, Regional Office for South-East Asia (SEARO); Lis Wagner (former), Bente Sivertsen, Regional Office for Europe (EURO) WHO Member States chief nursing and midwifery officers or governmental focal points who committed their time to the completion of this survey. Ministries of health, ministries of education, educational and financial departments, and boards and associations who supported it, as well as the individuals contacted throughout its progress. Sping Wang from the Nursing Health Services Unit, University of Toronto who contributed great expertise to the data elements. Susan Hicks, Senior Nursing Consultant, Health Policy and Communications Branch at Health Canada for her survey input and validation. Sandra Land, former Regional Nursing Adviser for the WHO Regional Office of the Americas for her insights during the peer review. Mwansa Nkowane, WHO Headquarters Office of Nursing and Midwifery, Department of Human Resources for Health in Geneva, for her technical contributions 4 A global survey monitoring progress in nursing and midwifery

7 Assistants Ellen Bonito, WHO Regional Office for the Western Pacific, Virgie Largado-Ferri, WHO Office of Nursing and Midwifery in Geneva, Freya Lilius and Amy Wimperis, Victorian Order of Nurses, and Joycelyn Reid, the Nursing Health Services Research Unit, University of Toronto, for facilitating the administrative aspects of the study. WHO Internship Programme summer students Christian Bergeron, Canada, Meraf Eyassu, the United States, for their help with data entry, and Nurse Scholar Yuling Zhang, China for her assistance with the final publishing processes of this report. Health Canada s Office of Nursing Policy, the Nursing Health Services Research Unit at the University of Toronto, and the WHO Department of Human Resources for Health, in particular the Office of Nursing and Midwifery, for their financial support to the study. Acknowledgements 5

8 Acronyms AFRO WHO Regional Office for Africa AMRO WHO Regional Office for the Americas ANOVA Analysis of variance BPG Best practice guidelines EMRO WHO Regional Office for the Eastern Mediterranean EURO WHO Regional Office for Europe GDP Gross Domestic Product HDI Human Development Index HRH Human resources for health HRHP Human resources for health planning KRA Key result area MDG Millennium Development Goal NHSRU Nursing Health Services Research Unit SDNM Strategic Directions for Nursing and Midwifery SEARO WHO Regional Office for South-East Asia UN United Nations UNDP United Nations Development Programme WHA World Health Assembly WHO World Health Organization WHOSIS World Health Organization Statistical Information System WPRO WHO Regional Office for the Western Pacific 6 A global survey monitoring progress in nursing and midwifery

9 List of figures and tables Figure 1 : Figure 2 : Figure 3 : Figure 4 : Figure 5 : Figure 6 : Figure 7 : Figure 7 a: Figure 8 : Figure 8 a: Health System and Health Human Resources Planning Conceptual Framework...16 Percentage of respondent Member States with human resources policies for nursing and midwifery, by HDI...26 Percentage of respondent Member States experiencing nursing and midwifery shortages, by HDI...26 Percentage of respondent Member States indicating a great to very great extent of nursing and midwifery shortage, by HDI...27 Percentage of respondent Member States with national recruitment guidelines for recruiting nurses from abroad, by HDI...28 Percentage of respondent Member States with national recruitment guidelines for recruiting midwives from abroad, by HDI...29 Percentage of respondent Member States with tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening nursing, by HDI...30 Percentage of respondent Member States showing moderate to significant impact of tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening nursing, by HDI..31 Percentage of respondent Member States with tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening midwifery, by HDI...32 Percentage of respondent Member States showing moderate to significant impact of tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening midwifery, by HDI...32 Figure 9 : Figure 9 a: Figure 10 : Percentage of respondent Member States with tools and approaches developed for advocating and building political alliances for nursing, by HDI...33 Percentage of respondent Member States showing a moderate to significant impact of tools and approaches developed for advocating and building political alliances for nursing, by HDI Figure Percentage of respondent Member States with tools and approaches developed for advocating and building political alliances for midwifery, by HDI...34 Figure 10 a: Percentage of respondent Member States showing a moderate to significant impact of tools and approaches developed for advocating and building political alliances for midwifery, by HDI...34 Figure 11 : Percentage of respondent Member States with evidence on nursing success stories developed and disseminated to policy-makers, by HDI...36 Acronyms List of figures and tables 7

10 Figure 11 a: Percentage of respondent Member States showing effectiveness of evidence on nursing success stories developed and disseminated to policy-makers, by HDI...36 Figure 12 : Percentage of respondent Member States with evidence on midwifery success stories developed and disseminated to policymakers, by HDI...37 Figure 12 a: Percentage of respondent Member States showing effectiveness of evidence on midwifery success stories developed and disseminated to policy-makers, by HDI...37 Figure 13 : Figure 14 : Figure 15 : Figure 16 : Figure 17 : Figure 18 : Figure 19 : Figure 20 : Figure 21 : Figure 22 : Figure 23 : Figure 24 : Figure 25 : Figure 26 : Percentage of respondent Member States with government/ nongovern-mental bodies that set nursing standards/policies to support initiatives on working conditions, by HDI...39 Percentage of respondent Member States with government/ nongovern-mental bodies that set midwifery standards/policies to support initiatives on working conditions, by HDI Percentage of respondent Member States reporting guidelines for employment policies on adapting working time and shift hours for nursing and midwifery, by HDI...42 Percentage of respondent Member States reporting guidelines for employment policies on reducing violence and increasing support at the workplace for nursing and midwifery, by HDI...43 Percentage of respondent Member States timeframe of last intervention to improve working conditions for nursing, by HDI Percentage of respondent Member States timeframe of last intervention to improve working conditions for midwifery, by HDI...45 Percentage of respondent Member States with best practice guidelines for nursing, by HDI Percentage of respondent Member States with best practice guidelines for midwifery, by HDI Percentage of respondent Member States with pre-registration/ basic competency-based education, by HDI...47 Percentage of respondent Member States with a system of registration or licence, by HDI Percentage of respondent Member States with mandatory continuing education, by HDI...49 Percentage of respondent Member States with approaches to build leadership capacity for nursing and midwifery, by HDI...50 Percentage of respondent Member States with regulated entry-topractice programmes for nursing, by HDI...51 Percentage of respondent Member States with regulated entry-topractice programmes for midwifery, by HDI A global survey monitoring progress in nursing and midwifery

11 Figure 27 : Figure 28 : Figure 29 : Figure 30 : Figure 31 : Figure 32 : Figure 33 : Figure 34 : Figure 35 : Figure 36 : Figure 37 : Table 1 : Table 2 : Table 2a : Table 3 : Percentage of respondent Member States with some or great improvements in the quality of education programmes in for nursing, by HDI...52 Percentage of respondent Member States with some or great improvements in the quality of education programme in for midwifery, by HDI...53 Percentage of respondent Member States with national human resources action plans for nursing and midwifery in 2005, by HDI...54 Percentage of respondent Member States with plans to develop national human resources action plans for nursing in 2005, by HDI...55 Percentage of respondent Member States with plans to develop national human resources action plans for midwifery in 2005, by HDI...56 Percentage of respondent Member States reporting the development of models/tools for educating nurses and midwives in the development of health policies, legislation and regulations, by HDI...59 Percentage of respondent Member States reporting effective to very effective models/tools identified for enhancing the involvement of nursing and midwifery in the development of legislation and regulations, by HDI...60 Percentage of respondent Member States reporting effective to very effective guidelines developed or strengthened for accrediting nursing and midwifery education programmes, and their implementation facilitated, by HDI...61 Percentage of respondent Member States reporting effective to very effective cost-effective models developed for improving the quality of nursing and midwifery practice, by HDI...62 Percentage of respondent Member States showing effective to very effective models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice, by HDI...63 Integration of WHO key result areas and Millennium Development Goals into the Health System and Health Human Resources Planning Conceptual Framework...72 Member States response rate, by WHO region and Human Development Index, as of March Member States, by WHO region, having submitted completed surveys, as of March Member States, by HDI and WHO region, having submitted completed surveys, as of March Percentage of respondent Member States with human resources policies for nursing and midwifery, by HDI...82 List of figures and tables 9

12 Table 4 : Table 5 : Table 6 : Table 7 : Table 8 : Table 9 : Table 10 : Table 11 : Percentage of respondent Member States experiencing nursing and midwifery shortages, by HDI...82 Percentage of respondent Member States indicating a great to very great extent of nursing and midwifery shortage, by HDI...82 Percentage of respondent Member States with national recruitment guidelines from abroad for nursing and midwifery, by HDI...82 Percentage of respondent Member States with national recruitment guidelines for importing and exporting nurses and midwives, by HDI...83 Percentage of respondent Member States with tools and approaches to support the strengthening of nursing and midwifery services, by HDI...83 Percentage of respondent Member States showing moderate to significant impact of tools and approaches to support strengthening nursing and midwifery services, by HDI Percentage of respondent Member States with governmental/ nongovernmental bodies that set nursing standards/policies to support initiatives on working conditions, by HDI Percentage of respondent Member States with governmental/ non-governmental bodies that set midwifery standards/policies to support initiatives on working conditions, by HDI Table 12 : ANOVA summary for national human resources policy (nursing)...85 Table 13 : ANOVA summary for national human resources policy (midwifery)...85 Table 14 : Percentage of respondent Member States reporting guidelines for employment policies for human resources for health for nursing and midwifery, by HDI...85 Table 15 : Table 16 : Table 17 : Table 18 : Table 19 : Table 20 : Table 21 : Percentage o f respondent Member States reporting somewhat to very effective guidelines for employment policies for human resources for health for nursing and midwifery, by HDI...86 ANOVA summary for regulatory bodies to set standards for improving nurses working conditions...86 ANOVA summary for regulatory bodies to set standards for improving midwives working conditions...86 Timeframe of rrespondent Member States last intervention to improve working conditions of the nursing and midwifery workforces, by HDI...87 Percentage of respondent Member States with best practice guidelines, by HDI...87 Percentage of respondent Member States with pre-registration/ basic competency-based education, by HDI...87 Percentage of respondent Member States with a system of registration or licence, by HDI A global survey monitoring progress in nursing and midwifery

13 Table 22 : Table 23 : Table 24 : Table 25 : Table 26 : Table 27 : Table 28 : Table 29 : Table 30 : Table 31 : Table 32 : Percentage of respondent Member States with mandatory continuing education, by HDI...88 Percentage of respondent Member States with approaches to building leadership capacity for nursing and midwifery, by HDI...88 Percentage of respondent Member States with regulated entry-topractice programmes, by HDI...88 Percentage of respondent Member States with authorities to regulate education for entry-to-practice, by HDI...88 Percentage of respondent Member States with great/some improvements in the quality of nursing education programmes in , by HDI...89 Percentage of respondent Member States with great/some improvements in the quality of midwifery education programmes in , by HDI...89 Percentage of respondent Member States with national human resources action plans for nursing and midwifery, by HDI...89 Percentage of respondent Member States with updated national action plans, by HDI...89 Percentage of respondent Member States with plans to develop national human resources action plans for nursing and midwifery in 2005, by HDI Percentage of respondent Member States reporting the development of models, tools and guidelines for the empowerment of nursing, by HDI Percentage of respondent Member States reporting the development of models, tools and guidelines for the empowerment of midwifery, by HDI...91 Table 33 : Percentage of respondent Member States showing effectively developed models, tools and guidelines for nursing, by HDI...91 Table 34 : Percentage of respondent Member States showing effective developed models, tools and guidelines for midwifery, by HDI...92 Table 35 : Linear regression summary for under-five mortality (nursing)...92 Table 36 : Linear regression summary for under-five mortality (midwifery)...93 Table 37 : Linear regression summary for infant mortality (nursing)...93 Table 38 : Linear regression summary for infant mortality (midwifery)...93 Table 39 : Linear regression summary for proportion of one-year olds immunized against measles (nursing) Table 40 : Linear regression summary for proportion of one-year olds immunized against measles (midwifery) List of figures and tables 11

14 Executive summary Nursing and midwifery services are an essential part of any effective healthcare system and with the ageing population and the continuing growth in the world s population, there is a critical global need for increased numbers of qualified health-care personnel and increasingly more efficient healthcare systems. As indicated in the United Nations Development Programme Human development report 2007/2008 (UNDP, 2007), action to counteract the changes in the vulnerable global environment, and in the economic and political arenas, requires careful planning so that it serves those who have the greatest need of health-care assistance, especially given that these countries may also be those with the most limited access to resources. However, while the global demand for improved human resources for health planning (HRHP) is an established fact, to be as effective and cost-effective as possible, it must be carried out with care, and be based on up-to-date and reliable evidential data on populations health care needs and available resources. In May 2001, the World Health Assembly (WHA) announced resolution WHA54.12, which highlighted the crucial role that nurses and midwives play in reducing mortality, morbidity and disability, as well as in promoting healthy lifestyles. In addition, this resolution acknowledged that action was needed to maximize these professions contribution to health-care systems, and urged Member States to improve nurses and midwives utilization, education and regulation, working conditions, and involvement in the framing, planning and implementation of health policies. Later, in 2006, the Member States, through the WHA Resolution 59.27, supported the establishment of comprehensive human resources for health (HRH) programmes that would involve nurses and midwives, monitor progress towards implementing World Heath Organization (WHO) Strategic directions for nursing and midwifery services (2002), maintain up-to-date records on legislation and regulatory processes, provide the needed support for nursing and midwifery data collection at the country level, and establish ethical recruitment policies in order to strengthen nursing and midwifery services (resolution WHA59.27). In 2007, the WHO developed a framework of action in order to direct the improvement of health systems and outcomes, using six building blocks and priorities, including service delivery, health workforce, information, medical products, vaccines and technologies, and financing and leadership/governance. These priority areas provide for the development of a more effective role for the WHO to play at the country level and in international health. 12 A global survey monitoring progress in nursing and midwifery

15 In 2005, in response to the increasing emphasis being placed on the need for accurate information on global nursing and midwifery services, and deployment, WHO in collaboration with the University of Toronto and international stakeholders, developed a survey organized according to the five key result areas (KRAs) of the WHO Strategic directions for nursing and midwifery services ( ). These five KRA themes included human resources planning, management, education, practice, and leadership. The purpose of the study was to evaluate progress in strengthening the nursing and midwifery workforce using the five KRAs as the centre-piece, and establish a minimum baseline on standardized indicators of population health outcomes. All countries/territories, including the 192 WHO Member States were asked to participate in completing the survey. In total, 77 Member States returned a completed survey. The data from these surveys were analysed and grouped according to the Human Development Index (HDI), and analysis of variance (ANOVA) and regression analyses were used to compare and predict outcomes of the selected KRA expected results. It is evident from the data yielded by the survey that WHO Member States are making a strong effort toward achieving the global health targets and strengthening nursing and midwifery services as directed by resolution WHA For example, the majority of WHO Member States that responded to the survey did, in fact, have national human resources policies for nurses and midwives. Furthermore, many Member States also reported having tools in place to work with communities and policy-makers to raise awareness of the role and contribution nursing and midwifery services play in meeting health targets. But, as many Member States also indicated that they continue to experience a shortage of qualified nurses and midwives, it is clear that there is still room for further improvement. It is hoped that WHO Member States will continue moving forward with their efforts to create and implement much needed HRH policies for strengthening nursing and midwifery services. While efforts have been seen to date, an important next step for many WHO Member States is to collect and incorporate accurate data into working HRH models to guide future HRHP along the WHO framework of action. Given the steps towards improving the delivery of nursing and midwifery services that have already been observed, the application of such evidence-based practices to health-care systems and the global health workforce can only continue our shared progression towards a bright and sustainable future. Executive summary 13

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17 Background Traditionally, human resources for health planning (HRHP) has been defined in part as :...the process of estimating the number of persons and the kind of knowledge, skills, and attitudes they need to achieve predetermined health targets and ultimately health status objectives. Such planning also involves specifying who is going to do what, when, where, how, and with what resources for what population or individuals...this planning must be a continuing and not a sporadic process, and it requires continuous monitoring and evaluation (Hall & Mejia, 1978). Hall describes the HRH process as involving three major and inter-related steps : planning, production and management (Hall, 1988). The focus on one component at the expense of the others will do little to ensure an effective and efficient health system. While many articulate the goal of integrated workforce planning, it lacks a clear definition, a point that has been elaborated by O Brien-Pallas et al. (2001a) who noted : While strides have been made in resource planning, key themes that have emerged from an analysis of integrated resource planning worldwide, include: (1) there have been few empirical applications of the conceptual frameworks developed in the last years, (2) integrated and discipline specific empirical applications are ongoing but do not build upon conceptual and analytic advances, (3) discipline specific studies still dominate the literature, (4) labour market indicators, if collected, play an important role in planning for the workforce, (5) a link to outcomes is missing in many applications, (6) modest financial investments to build upon conceptual and analytic advances and data requirements may result in large payoffs that greatly exceed investments, and (7) the opportunity costs of not moving forward and relying on old methodologies need to be considered (continued reliance on primarily supply and utilization based approaches have led to cycles of over and under supply approximately every four to five years in the physician and nursing workforce). As we move into the 21st century, we need to make a concerted effort to shift from old and safe approaches and embrace conceptual and analytic complexity, with a focus on outcomes and integrated planning in order to provide an efficient and effective health service for future generations. Background 15

18 A concern in carrying out HRHP is that most supply databases do not contain the required elements to facilitate supply-based planning let alone comparability among WHO Member States. It is interesting to note that numerous reports reinforce the importance of HRHP and management, and comment on the need to establish and maintain data for planning that is of good quality, comprehensive and comparable. However, in many countries throughout the world, the amount of data being collected to meet these criteria is still limited. The Health System and Health Human Resources Planning Conceptual Framework (Figure 1), was designed to facilitate a better understanding of the complex interactions between population health needs and the human resources required to meet targeted outcomes. Figure 1 : Health System and Health Human Resources Planning Conceptual Framework POLITICAL GEOGRAPHICAL SOCIAL Supply Production (education and training) Health Outcomes Population Health Needs System Design ECONOMIC Planning & Forecasting Financial Resources Management, Organization and Delivery of Services across Health Continuum Resource Deployment and Utilization System Outcomes Provider Outcomes TECHNOLOGICAL Efficient Mix of Resources (Human & Non-Human) Source : O Brien-Pallas et al. (2005) (cited in Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources); adapted from O Brien-Pallas et al. (2001b) and O Brien- Pallas & Baumann (1997). The framework aims to obtain results for health systems and health outcomes programmes, and develop a more effective role for the WHO, both at the country level and in the international health systems agenda (WHO, 2007a). In order to gain insights into the impact of management and delivery 16 A global survey monitoring progress in nursing and midwifery

19 of health services on population health outcomes, planners and managers need to understand the number, type and distribution of providers they have in the workforce, their losses through migration, retirement, death, etc., and the potential number and demographics of the new recruits from educational systems and immigration. In May 2001 and 2006, the World Health Assembly (WHA) passed resolutions WHA54.12 and WHA59.27 for strengthening nursing and midwifery. Resolution WHA54.12 and its strategic plan of action, entitled Strategic direction for strengthening nursing and midwifery (SDNM), called for national policies and interventions to improve HRH planning, management, education, practice, and leadership of nurses and midwives (WHO, 2002). Resolution WHA urges Member States to confirm their commitment to strengthen nursing and midwifery by establishing comprehensive programmes for the development of human resources, actively involving nurses and midwives, ensuring continued progress toward implementation of WHO s strategic directions for nursing and midwifery, regularly reviewing legislation and regulatory process, to provide support for the collection and use of nursing and midwifery core data, and to support the development and implementation of ethical recruitment (WHO, 2006c). Continued international efforts and commitments being made towards improving global nursing and midwifery workforce strategies are important. It has been encouraging to see that, even before the publication of the present study, signs of this global commitment have been mounting, as evident by such publications and declarations as the recent Chiang Mai declaration (2008), Kampala declaration and agenda for global action (2008), and the WHO Regional Office for the Western Pacific Strategic plan for strengthening health systems (2008), both of which call for greater government commitment to improving the health-care workforce, and enhancing the collection and use of reliable HRH data in making informed policy decisions. With continued global backing for the improvement of the health-care workforce, it is hoped that international health outcomes will improve and global health targets will be met. Introduction and purpose This study reflects a joint plan for research, which started in mid-2005, and is being conducted by the Nursing Health Services Research Unit (NHSRU) at the University of Toronto, the Office of Nursing and Midwifery at the World Health Background 17

20 Organization and the Office of Nursing Policy of the Federal Government of Canada. The purpose of this study is to evaluate whether the key policy directions advocated by the Nursing and midwifery services : strategic directions (WHO, 2002), and country interventions and implementations based on these recommendations, have been carried out to strengthen nursing and midwifery. Resolution WHA54.12 also called for the development and implementation of systems and uniform performance indicators at country, regional and global levels to monitor, measure and report progress in achieving these strategic goals (WHO, 2001). Specific objectives of the study The specific research objectives were to : 1. establish a global baseline within five key result areas (human resources planning, management, education, practice and leadership) based on standardized indicators, monitor changes to this baseline in 2008; and 2. evaluate the impact of country interventions to improve nursing and midwifery services considering policy recommendations in Nursing and midwifery services : strategic directions and the goals set out in resolutions WHA54.12 and WHA Tracking implementation will facilitate cooperation within and among WHO Member States. Data collected informs the development and review of national action plans for strengthening nursing and midwifery. This progress report identifies issues for the exchange of information and experiences (e.g. culture, experience, demography, resources available to the health sector, etc.) with Member States in similar circumstances and/or for benchmarking progress through comparison with selected Member States/ regions with more developed nursing and midwifery services. The outcomes of the survey can be used as markers to assess progress towards ensuring that nurses and midwives contribute fully to achieving these objectives, the targets of resolutions WHA54.12 and WHA59.27, and the Millennium Development Goals (MDGs). The minimum dataset will be built upon with future surveys on nursing and midwifery. 18 A global survey monitoring progress in nursing and midwifery

21 Methodology Questionnaire The survey items were developed around five themes originating from the strategic directions of resolution WHA54.12 for nursing and midwifery, in which five key result areas (KRAs) were established. The five themes or KRAs include : (1) health planning, advocacy, and political commitment; (2) management of health personnel for nursing and midwifery services; (3) practice and health system improvement; (4) education of health personnel for nursing and midwifery services; and (5) stewardship and governance (Appendix C). In addition, the general demographics and status of each Member State, such as the number of nurses and midwives, were included. Several of the survey questions requested the participant to provide relevant documents, such as a HRH plan. The survey was drafted, reviewed and approved by several key members of the WHO Global Advisory Group on Nursing and Midwifery, the WPRO Standing Committee on Health Information, and selected technical officers from the Health Workforce Information team and the Human Resources for Health department at WHO in Geneva. Suggested changes and feedback were considered and integrated, and the instrument was evaluated for face and content validity. Following the completion of the pilot study and the finalization of the survey, the survey package, including a letter of introduction to the study, instructions for its completion, as well as an explanation and glossary of many of the survey terms were translated from English into three of WHO s official languages (French, Russian and Spanish). WHO headquarters then distributed the survey packages to the six WHO regional offices from where they were sent to 192 WHO Member States. They were delivered by both the conventional postal service and by electronic mail. Participants had a choice of returning the completed surveys to WHO headquarters using electronic means, conventional mail or the diplomatic pouch. See Appendix A for a copy of the final version of the survey entitled Monitoring Progress in Nursing and Midwifery - A Global Survey. The data collected informed the team about the development and review of national action plans, and assessed Member States progress towards strengthening nursing and midwifery. It was anticipated that the data collected would be data already collected by each country, and would thus represent a consolidation of secondary data. Background 19

22 Data analysis The WHO s Office of Nursing and Midwifery received the respondent data and performed the initial entry and verification, after which it was couriered to the NHSRU at the University of Toronto. The NHSRU validated and supplemented data as it was received and/or became available. The data was analysed using SPSS Inc. statistical software version 15 for quantitative analyses. Analyses were performed by the NHSRU. Individual Member State responses were grouped by HDI ratings, (low, medium or high), and descriptive statistics were completed to provide information on the status of each HDI group s achievement within each of the five KRAs. Between groups, ANOVA and regression modelling were used to examine the relationships among the KRAs and improvement in the MDGs. Sample All Member States were invited to participate by the WHO Office of Nursing and Midwifery through the WHO Global Advisory Group on Nursing and Midwifery and the WHO Regional Nursing Advisers. As of December 2005, 192 Member States had received copies of the survey. The respondents comprised individuals who lead nursing and midwifery in their country, and surveys were typically completed with the assistance of additional governmental and regulatory resources within their country/region. Data from WHO Member States are highlighted in this report. Ethical considerations WHO s Ethics Review Committee was consulted and indicated that an ethics approval certificate from the University of Toronto would satisfy the WHO s Ethical Review Committee criteria. The Human Subjects Review Panel at the University of Toronto reviewed the study. The University of Toronto Ethics Committee uses the criteria set out in the Tri-Council Policy Statement : Ethical Conduct for Research on Humans (section 1). The University s annual ethics certificate (originally approved in 2005) was last renewed in February The researchers were not aware of any risks to the participants either during or after the survey. While there were no direct benefits for the respondents, their participation may help to improve health systems performance, assist in policy development, and contribute to decreasing the global shortage of nurses and midwives. It is anticipated that the collective knowledge gained from this survey 20 A global survey monitoring progress in nursing and midwifery

23 data will inform future implementation of resolution WHA54.12, confirm resolution WHA59.27, help to identify policy initiatives that go beyond the timeframe of resolution WHA54.12, and help to pinpoint new targets for new strategic directions for strengthening nursing and midwifery. Only the NHSRU and the WHO have access to the database and raw data collected. Member States chief nursing officers, focal points, and nursing/ midwifery leaders will be given access to their countries response data, on request. The results of the current study will be summarized and disseminated through scholarly and public publications, and through presentations. As required by the University of Toronto s Office of Research Ethics, the original survey data will be stored for seven years in the NHSRU s locked data storage unit, after which time the material will be destroyed. Background 21

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25 Findings The results in this progress report are organized according to the WHO Member States HDI rankings. These results are presented in the order of the following five KRAs : health planning, advocacy and political commitment; management of health personnel for nursing and midwifery services; practice and health system improvement; education of health personnel for nursing and midwifery services; and 5. stewardship and governance of the Nursing and Midwifery Strategic Directions (WHO, 2002). Only selected KRA expected results are highlighted in this report, as additional data is required in certain areas for a more comprehensive analysis. Data considerations Only WHO Member States were included in the analyses for this study. It must be noted that researchers had received completed surveys from England and Scotland and, in this report; these countries are counted as one Member State, e.g. the United Kingdom of Great Britain. The demographics reported are weighted by the available HDI ranking for 2005, as established by the UNDP (2007). The HDI is a measure of human development that takes into consideration four indicators life expectancy at birth, adult literacy rate, gross enrolment ratio and gross domestic product (GDP) per capita (UNDP, 2007). Individual HDI rankings fall into three basic categories low, medium and high. Although the demographic data for this study was weighted on the HDI, it should be noted that it was not possible to obtain a HDI ranking for all Member States for the year 2005 due to the unavailability of data for certain countries. In total, there were four respondents (three from the WHO Western Pacific Region and one from the WHO African Region) lacking the Findings 23

26 appropriate data. As there is a strong correlation between the level of economic development and HDI (r = 0.827, p = 0.000), for the purpose of the current study, the researchers estimated the missing HDI rankings based on the respondents level of economic development. Researchers utilized these estimated data in their final analyses. An additional caution should be voiced regarding the HDI weightings, as the survey data shows statistically significant regional differences in the distribution of HDI rankings (contingency coefficient = 0.675, p = 0.000). This unequal distribution of HDI rankings between regions is an important consideration when reading the study s findings, as many of the differences between HDI groups contained in this report may ultimately be the result of factors other than HDI (e.g. geo-political climate, shared history, or cultural mores, etc.). For some results in this report, derived variables were created by calculating information from one or more fields that were not directly collected. For example, in this survey, respondent Member States reported their last intervention to improve working conditions of the nursing and midwifery workforce in the short-, mid- and long-term, whereas the data collected were categorized into six separate timeframes (Appendix A, Q 2.2). These six timeframes were collapsed into the three listed above for ease of reporting and interpretation. A final data consideration relates to data transformations completed prior to performing the statistical analyses. In order to meet the ANOVA requirements of normally distributed sample populations, the MDG indicators infant mortality, under-five mortality rate and proportion of one-year olds immunized data were transformed by calculating the square root of individual scores. This is a commonly used procedure to correct sample distributions, while maintaining the relative relationship of the individual data points. Variables were also combed for outliers, as regression analysis is particularly sensitive to this issue. Outliers were defined as values that were greater than three standard deviations from the variable s mean. When located, an outlier was replaced with the number from the dataset that was closest in value to the outlier, but that did not exceed three standard deviations from the mean. Responses : Regionally and globally As of March 2008, 77 of the 192 WHO Member States contacted had returned a completed survey (Appendix B, Table 1). The WHO South-East Asia Region had the highest rate of Member State responses (82%) with only two nonrespondents, while the WHO Region of the Americas had the lowest response 24 A global survey monitoring progress in nursing and midwifery

27 rate (20%) with 28 non-respondents. The WHO African Region was the only region that expressed responses from low HDI ranked Member States. Although 39% of the Member States from this region responded to the survey, over 50% of these respondents were from countries with low HDI ratings. A complete list of responding Member States by region and responding Member States by HDI can be found in Appendix B. (Table 2, Table 2a). Key Result Area 1 : Health planning, advocacy and political commitment Key Result Area 1 emphasizes the commitment to national policy planning and implementation of nursing and midwifery interventions to provide a stronger, more effective nursing and midwifery workforce. In the SDNM, the objectives outlined include strengthening policy development mechanisms that contribute to the maintenance of adequate levels of nursing and midwifery personnel, mobilizing individuals to support changes designed to strengthen nursing and midwifery services and enhance their contribution to health system performance, and foster an environment that enables nurses and midwives to make decisions and be directly involved in policy-making (WHO, 2002). KRA expected result : uniform indicators and systems established for monitoring human resources levels, shortage and migration In monitoring progress towards strengthening nursing and midwifery services, it is important to determine whether human resources policies targeted at nursing and midwifery have been adopted by WHO Member States of the different HDI rankings. If nursing and midwifery is a human resources concern for individual Member States, having national nursing and midwifery policies would be a starting point towards strengthening nursing and midwifery services. In effect, respondents reported slightly higher rates of national human resources policies for nursing than for midwifery (83% and 70%, respectively). Of the three HDI groups examined, the medium HDI category demonstrated the greatest proportion of respondent Member States with national human resources policies for both nursing (90%) and midwifery (73%). Contrary to what might be expected, respondents from the low HDI category showed a greater proportion of Member States with these policies than the high HDI group, with 86% of low HDI respondents indicating that they had these policies for nursing, whereas only 74% of high HDI respondent Member States reported that they had these national HRH policies (Figure 2; Table 3). Findings 25

28 Figure 2 : Percentage of respondent Member States with human resources policies for nursing and midwifery, by HDI 100 ursing Midwifery Total Low Medium High KRA expected result : tools developed for forecasting workforce shortages and migration Nursing and midwifery require more qualified providers in every HDI ranking, as over 75% of all respondent Member States reported that they were experiencing a shortage of nurses and midwives (Figure 3; Table 4). It is important to note, however, that this information is based on a self-report from the responding Member States set target numbers for nursing and midwifery staffing, and not the criteria for critical shortages as defined by the WHO. Figure 3 : Percentage of respondent Member States experiencing nursing and midwifery shortages, by HDI 100 ursing Midwifery Total Low Medium High 26 A global survey monitoring progress in nursing and midwifery

29 Across all HDI rankings, 81 92% of respondent Member States reported substantial nursing shortages. Across the three separate HDI groups, the proportion of respondent Member States that reported a shortage of a great to very great extent varied considerably, from 32% in the high HDI group to 75% in the medium HDI group. In both nursing and midwifery, the medium HDI group represented the greatest percentage of respondent Member States that indicated a shortage of a great to very great extent (Figure 4; Table 5). Figure 4 : Percentage of respondent Member States indicating a great to very great extent of nursing and midwifery shortage, by HDI 100 ursing Midwifery Total Low Medium High Of course, there may be a gap in these results as some respondent Member States may experience shortfalls in capturing the appropriate members of health personnel. There are also some Member States who do not collect certain data, such as in the Republic of Gambia where, for instance, Cuban doctors and other expatriate staff who are not paid from the Government payroll are not captured (Republic of Gambia, 2005), and for example, exchange programmes, as well as those who are not registered and working, or those who are registered but may have left the profession (O Brien-Pallas et al, 2007). According to the Republic of Gambia s HRH plans, there is an outflow of 24 36% of health personnel from developing countries, which supports the threat to system outcomes and the need for incentives, such as improved training and better working conditions to retain locally trained personnel (Republic of Gambia, 2005). KRA expected result : ethical guidelines developed for international recruitment Findings 27

30 WHO Member States were questioned about international recruitment in an attempt to understand the impact of immigration and international recruitment strategies in attracting nurses and midwives. No judgement about the ethical nature of interventions was made. Participants were asked, Does your country implement national guidelines to recruit nursing and midwives from abroad? (Appendix A, Q 6.3). On average, approximately one third of the respondent Member States reported the presence of these national recruitment guidelines for nurses or midwives. About 41% from the high HDI category reported having nursing recruitment guidelines while a low of 25% in the low HDI group reported having them (Figure 5; Table 6). Figure 5 : Percentage of respondent Member States with national recruitment guidelines for recruiting nurses from abroad, by HDI Guidelines Import Export The numbers were somewhat lower for midwifery, where 38% of respondents from the high HDI group, 23% in the medium HDI group and 31% in the low HDI group reported having midwifery recruitment guidelines (Figure 6). Of those reporting national recruitment guidelines for recruiting from abroad, the high HDI group comprised the most respondents reporting guidelines for the importation of both nurses and midwives (62% and 36%, respectively) (Figures 5, 6; Table 7). Low HDI respondent Member States had the lowest proportion of respondents with importation or exportation guidelines for both nurses and midwives (9% and 10%, respectively) (Figures 5, 6; Table 7). 28 A global survey monitoring progress in nursing and midwifery

31 Figure 6 : Percentage of respondent Member States with national recruitment guidelines for recruiting midwives from abroad, by HDI Guidelines Import Export While the recruitment rates of nurses and midwives from abroad are relatively low in the present sample, it is important to consider that the transfer of nurses and midwives, or any health personnel, between source and destination countries may not be an ideal practice for all Member States, as many factors need to be considered when planning recruitment strategies. Such examples for exportation include the protection and treatment of health care workers (WHO, 2006b) in not-so-ideal environments, expatriate training, as well as facilitating the return of the worker. When importing, Member States may need to consider reducing their dependency on migrant workers from industrialized countries (WHO, 2006b). A reliance on the importation of nurses and midwives could mean that Member States train fewer qualified workers than they need, and may involve agreements aimed at addressing the financial impact of migration, and may also result in the creation of bilateral agreements on the ethical and fair treatment of health-care workers (WPRO, 2007). One example of a bilateral agreement is the five-year agreement between the governments of the Republic of Namibia and the Republic of Kenya (2002)., where responsibilities and accountabilities for health personnel, including salaries, medical benefits, repatriation, etc., fall on both the sending and receiving countries governments. Findings 29

32 KRA objective 1.2 : to mobilize policy-makers, the general public, partners and health-care practitioners to support changes designed to strengthen nursing and midwifery services and to enhance their contribution to health system performance and outcomes In this section, Tables 8 and 9 highlight the resources and strategies to support strengthening nursing and midwifery that were examined in the current study. KRA expected result : tools developed for working with communities, politicians, and policy-makers in order to raise awareness regarding the role and contribution of nursing and midwifery services as core resources for achieving health targets Approximately 65% of respondent Member States reported having the necessary tools to work with communities and policy stakeholders to enhance the awareness of the role and contribution of nursing and midwifery towards achieving health targets (Figures 7, 8; Tables 8, 9). High HDI ranked respondent Member States had the highest percentage of these tools for both nursing and midwifery (79% and 77%, respectively),, whilst low and medium HDI ranked respondents had lower percentages for both nursing (54% and 53%, respectively), and midwifery (58% and 61%, respectively). Figure 7 : Percentage of respondent Member States with tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening nursing, by HDI Total Low Medium High 30 A global survey monitoring progress in nursing and midwifery

33 Figure 7 a: Percentage of respondent Member States showing moderate to significant impact of tools developed to work with communities, policymakers, etc. to raise awareness for strengthening nursing, by HDI Respondent Member States in the high HDI category were most likely to indicate that these tools had a moderate to significant impact on strengthening nursing and midwifery services and enhancing their contribution to health system performance and outcomes, whereas respondent Member States from the medium HDI category were least likely to indicate such an impact (Table 9). Interestingly, even though low and medium HDI groups reported almost equal percentages of respondents with resources developed for working with politicians and policy-makers to raise awareness of the role of nursing and midwifery in achieving health targets (Figure 8), a seemingly greater proportion of the low HDI group rated these resources as having a moderate to significant impact on health system performance (71% of low HDI compared to approximately 51% of medium HDI respondents) (Figures 7a, 8a). One possible interpretation of this finding is that, in addition to merely developing these tools, the context and the manner in which they are implemented may be critical in strengthening health services. Findings 31

34 Figure 8 : Percentage of respondent Member States with tools developed to work with communities, policy-makers, etc. to raise awareness for strengthening midwifery, by HDI Total Low Medium High Figure 8 a: Percentage of respondent Member States showing moderate to significant impact of tools developed to work with communities, policymakers, etc. to raise awareness for strengthening midwifery, by HDI Total Low Medium High KRA expected result : tools and approaches developed for advocating the strengthening of nursing and midwifery and the building of political alliances and support Political support is necessary to strengthen nursing and midwifery, and is garnered by establishing and maintaining effective relationships with com- 32 A global survey monitoring progress in nursing and midwifery

35 munities and policy-makers. To obtain support and encouragement from political alliances, quality tools and approaches that facilitate the communication and advocacy of nursing- and midwifery-related issues should be developed. A total of 61% of respondents globally reported having these tools in place for nursing and 63% of respondents indicated the existence of these tools for midwifery (Figures 9, 10; Table 8). Figure 9 : Percentage of respondent Member States with tools and approaches developed for advocating and building political alliances for nursing, by HDI Figure 9 a: Percentage of respondent Member States showing a moderate to significant impact of tools and approaches developed for advocating and building political alliances for nursing, by HDI Figure 10 Findings 33

36 Figure 10 : Percentage of respondent Member States with tools and approaches developed for advocating and building political alliances for midwifery, by HDI Figure 10 a: Percentage of respondent Member States showing a moderate to significant impact of tools and approaches developed for advocating and building political alliances for midwifery, by HDI The high HDI category reported the greatest proportion of respondent Member States with these tools for advocating and building political alliances (69% for both nursing and midwifery), whereas relatively fewer low HDI ranking respondent Member States reported the presence of such tools (46% for nursing and 42% for midwifery) (Figures 9, 10). Respondents with these tools 34 A global survey monitoring progress in nursing and midwifery

37 were also questioned on their perceived impact on strengthening nursing and midwifery services and enhancing their contribution to health system performance. Approximately two thirds of high HDI respondent Member States described these tools as having a moderate to significant impact in strengthening nursing and midwifery (Figures 9a, 10a; Table 9). Overall, only 53% (nursing) and 50% (midwifery) of all responding Member States reported a moderate to significant impact of these tools on improving services and enhancing their contribution to health system performance and outcomes. According to Dr Luis Gomes Sambo (2007), WHO Regional Director for Africa, a WHO African regional stakeholders consultation held in 2005 encouraged countries to band together, with governments, private sectors, civil society and other partners, in HRH development as HRH has become a high priority for many countries. Gomes Sambo adds that, these efforts must be done at a regional and international levels to support the country level as AFRO has while developing their HRH policies and plans. Gomes Sambo endorses the need to work together rather than taking a piecemeal approach with duplication and disjointed plans of action. He further recommends that when building much needed capacity in nursing and midwifery, the increased capacity in applying political advocacy should be done in a manner that demonstrates the aim to have a positive impact on HRH, services and population health, as seen in KRA expected result KRA expected result : evidence developed and disseminated to policymakers on success stories of the nursing and midwifery contribution to health systems goals As mentioned in the previous KRA expected result, in order to gain the support of officers and stakeholders, quality tools and approaches should be developed for advocating nursing and midwifery services. However, for these tools and approaches to be effective, their development should be based on solid evidence of the contribution nurses and midwives have made towards meeting health system goals and also must be communicated, disseminated and transferred to policy-makers. Similar to the previous findings, the greatest proportion of respondent Member States reporting the collection and dissemination of nursing and midwifery success stories came from the high HDI group (77% and 74%, respectively) (Figures 11, 12; Table 8). Respondents from the medium HDI group were comparatively less likely to report that they had collected and disseminated these success stories to policy-makers, and those from the low HDI group were the least likely to report such dissemination (46%). Findings 35

38 Figure 11 : Percentage of respondent Member States with evidence on nursing success stories developed and disseminated to policy-makers, by HDI Figure 11 a: Percentage of respondent Member States showing effectiveness of evidence on nursing success stories developed and disseminated to policy-makers, by HDI 36 A global survey monitoring progress in nursing and midwifery

39 Figure 12 : Percentage of respondent Member States with evidence on midwifery success stories developed and disseminated to policy-makers, by HDI Figure 12 a: Percentage of respondent Member States showing effectiveness of evidence on midwifery success stories developed and disseminated to policy-makers, by HDI Findings 37

40 Of all the respondent Member States that had reported collecting and disseminating success stories, approximately 60% reported this dissemination as having a moderate to significant impact on strengthening nursing and midwifery services (Figures 11a, 12a; Table 9). When these data are broken down by categories, it is revealed that the high HDI group had a relatively large number of respondent Member States reporting this degree of impact (78% for nursing and 76% for midwifery), whereas approximately one half of those from the medium and low HDI groups reported a moderate to significant impact. Key Result Area 2 : Management of health personnel for nursing and midwifery services Key Result Area 2 looks to improve the management of nursing and midwifery services in such areas as gender sensitivity, health and safe working conditions, financial rewards, and recognition of competencies in the hope of improving the quality of patient care and system accomplishments. A thorough assessment of this is resource intensive and further examination may be required to make a meaningful comment on the global progression towards these goals (WHO, 2002). KRA expected result : evidence collected and disseminated on the impact of employment policies on individual and organizational provider performance with specific reference to the nursing and midwifery workforce The impact of employment policies on individual or organizational provider performance in nursing and midwifery may be dependent on which governmental or nongovernmental body sets the standards for supporting initiatives on working conditions. The survey showed that, in nursing, just over one third of the respondent Member States surveyed relied solely on national standards, while 41% of all respondent Member States relied on a combination of national and institutional standards (Figure 13; Table 10). 38 A global survey monitoring progress in nursing and midwifery

41 Figure 13 : Percentage of respondent Member States with government/nongovernmental bodies that set nursing standards/policies to support initiatives on working conditions, by HDI ational Standards Institutional Standards Both For midwifery services, respondents from all three HDI categories reported that they relied primarily on national standards or a combination of national and institutional standards to support initiatives on working conditions (Figure 14; Table 11). The medium HDI ranked respondent Member States were most likely to rely on national standards alone, and only 4% reported that they relied solely on institutional bodies to set standards on workplace initiatives. Amongst the high HDI ranked respondent Member States, 53% relied primarily on combined national and institutional bodies to set these standards, whereas the medium HDI group tended to rely primarily on national standards alone to support initiatives on working conditions for midwives. The low HDI group appeared to rely equally on national standards alone, or a combination of national and institutional standards, at 40% for each. Findings 39

42 Figure 14 : Percentage of respondent Member States with government/nongovernmental bodies that set midwifery standards/policies to support initiatives on working conditions, by HDI ational Standards Institutional Standards Both In order to further examine the relationship between the presence of national human resources for health policies and the effectiveness of policies and standards for improving working conditions in both nursing and midwifery, a one-way between groups ANOVA was performed. This ANOVA compared the mean effectiveness ratings of employment initiatives given by respondent Member States that had national human resources policies for nursing or midwifery with those respondent Member States that had indicated they had no such national policies in place. The categories of employment initiatives that were rated for effectiveness were as follows : health and safety working hours (weekly/monthly) weekly rest paid annual holidays educational leave maternity leave sick leave social security entitlements/pensions. 40 A global survey monitoring progress in nursing and midwifery

43 An additional ANOVA was completed to examine group differences between respondent Member States that reported the presence of regulatory bodies (either government or institutional) to set standards and policies in support of improved working conditions versus those that had no such regulatory bodies. For this analysis, the mean effectiveness ratings were compared across four separate groups : respondent Member States with governmental regulatory bodies; respondent Member States with institutional regulatory bodies; Member States with both governmental and institutional regulatory bodies; and respondent Member States with no regulatory bodies to set standards and policies in support of improved working conditions. ANOVA results failed to reveal a significant effect of national HRH policies on the effectiveness ratings of any of the initiatives to improve working conditions examined. This means that respondent Member States with national HRH policies for nursing and midwifery reported having equally effective initiatives for improving the working conditions of nurses and midwives as those that did not have such policies in place. This finding was true for both the nursing and midwifery professions (Tables 12, 13). However, a highly significant main effect was observed when comparing respondent Member States with and without regulatory bodies to set standards and policies to support such initiatives. Overall, respondents without these regulatory bodies had less effective workplace standards and initiatives than those with these regulatory bodies (Tables 16, 17). Furthermore, in many cases the presence of institutional-only standards alone improved the effectiveness ratings of these initiatives. KRA expected result : innovative guidelines established on processes for reviewing, changing and developing employment policies for human resources for health As for the impact of employment standards on both nursing and midwifery, we see that, overall, 66% of respondents have standards on adapting working hours and shift hours (Figure 15; Table 14); and from this group a little over one third of respondent Member States found the policy effective in improving recruitment, retention and management of health personnel, such as nurses and midwives, with the highest percentage of respondents finding this policy effective originating from the high HDI group (Table 15). Findings 41

44 Figure 15 : Percentage of respondent Member States reporting guidelines for employment policies on adapting working time and shift hours for nursing and midwifery, by HDI The survey also looked at standards to reduce violence and increase support at the workplace, and found that 60% of all respondents had such a policy in place. As much as 75% of respondent Member States in the low HDI group reported having a workplace violence policy, while only 48% in the medium HDI group had such a policy (Figure 16, Table 14). For those who have policies on reducing violence, 38% of respondents in the high HDI category found this policy somewhat to very effective for improving recruitment, retention and management of nurses and midwives, whereas 22% in the medium HDI group found this policy effective. Despite the relatively high percentage of respondents from the low HDI category reporting the existence of a workplace violence policy, none of them rated this policy as being somewhat to very effective (Table 15). 42 A global survey monitoring progress in nursing and midwifery

45 Figure 16 : Percentage of respondent Member States reporting guidelines for employment policies on reducing violence and increasing support at the workplace for nursing and midwifery, by HDI In this 2005 survey, participants were asked about the timeframe in which their country last had a government intervention, including collective agreements, to improve working conditions for nurses and midwives. Responses were categorized into changes made in the short term (within the past 0 2 years), mid-term (within the past 3 5 years) or long term (within the past 6 10 years). The results show that just under one fifth of the respondent Member States had never had a government intervention to improve working conditions for nurses or midwives (17% and 19%, respectively) (Figure 17; Table 18). In the high HDI group, 31% of the respondents reported a government intervention to improve working conditions for nurses in the short term, while a substantially smaller percentage in the low and medium HDI groups reported such interventions in the short term (17% and 15%, respectively). Across all HDI levels, the most commonly reported timeframe for a government intervention for nursing was over the long-term period (i.e years ago), with one third or more respondents from each group reporting in this manner. Findings 43

46 Figure 17 : Percentage of respondent Member States timeframe of last intervention to improve working conditions for nursing, by HDI ever Long-term 6-10 yrs Mid-term 3-5 yrs Short-term 0-2 yrs For midwifery, 17% of low HDI ranked respondent Member States reported that there had been a government intervention to improve working conditions over the short term, 33% of them reported that the last intervention was made over the long term, and, of these, 33% reported never having had such an intervention (Figure 18; Table 18). As for the medium HDI respondents, 21% had never had an intervention. It should be noted that, although this group was less likely than the low HDI group to report an intervention in the short term (14%), respondents from this category were approximately twice as likely to report having had an intervention over the mid-term (32% compared to 17% for low HDI). In contrast, we see that relatively few respondents from the high HDI group reported that they had never had a government intervention to improve working conditions for midwives (13%), whereas approximately one third of them stated that there had been an intervention made in the short term (31%). Like the other two groups, however, the high HDI group s most frequently reported timeframe for interventions was in the long term (6 10 years ago), with approximately 35% of all Member States from this category reporting this way. Overall, it seems that many of the respondents have not had a recent government intervention to improve the working conditions for either nurses or midwives, with over half of all respondent Member States reporting the last intervention between 6 10 years ago, or longer. 44 A global survey monitoring progress in nursing and midwifery

47 Figure 18 : Percentage of respondent Member States timeframe of last intervention to improve working conditions for midwifery, by HDI Total Low Medium High ever Long-term 6-10 yrs Mid-term 3-5 yrs Short-term 0-2 yrs Key Result Area 3 : Practice and health system improvement Key Result Area 3 encourages the use of appropriate tools, information and guidelines in practice for system performance improvements. Best practice guidelines (BPG) for nursing and midwifery are one way of achieving KRA 3 (WHO, 2002). KRA objective 3.1 : to improve access to quality nursing and midwifery services as an integral part of health services aimed at individuals, families and communities particularly among vulnerable populations. This may be accomplished through the enhanced integration of successful nursing and midwifery service delivery models within health care systems In 2005, 68% of respondent Member States had developed or were developing evidence-based BPGs for nursing at a national level, and 61% of them had developed or were developing BPGs for midwifery (Figures 19, 20; Table 19). Where respondents from the medium HDI group indicated the lowest prevalence of these guidelines (60% for nursing and 56% for midwifery), those from the low HDI group reported a substantially greater percentage of BPGs either developed or in development (83% for nursing and 85% for midwifery). These percentages even exceeded the respondents Member States in the high HDI group, which reported having or developing BPGs (75% for nursing, and 60% for midwifery). Findings 45

48 Figure 19 : Percentage of respondent Member States with best practice guidelines for nursing, by HDI Figure 20 : Percentage of respondent Member States with best practice guidelines for midwifery, by HDI We see variance among responses that might be explained by the fact that some Member States may be developing BPGs at a local or institutional level. Denmark, for example, has indicated that clinical guidelines are continuously being developed locally instead of nationally. In examining selected guidelines sent by respondents, the researchers also noticed alliances or partnerships developed between countries for creating well-thought out guidelines, such as in the United Republic of Tanzania s case where their nursing practice standards are modelled on the Registered Nursing Association of Nova Scotia (Canada) Stand- 46 A global survey monitoring progress in nursing and midwifery

49 ard for Nursing Practice 1985 and International Council of Nurses Guidelines for Nurses Associations, Development of Standards for Nursing Education and Practice 1989 (the United Republic of Tanzania, 1997). This supports the progress being made in countries working together in order to strengthen nursing and midwifery, as mentioned by Gomes Sambo in KRA expected result Key Result Area 4 : Education of health personnel for nursing and midwifery services Looking at Key Result Area 4 in general, the target is to have competent workers with the appropriate skills and abilities in order to effectively deal with the challenges of nursing and midwifery practice. The present study found that many respondent countries have existing pre-registration/basic competency-based education curricula; representing, globally, 78% and 75% for nursing and midwifery, respectively (Figure 21; Table 20). Incidence rates across the three HDI categories showed that high HDI respondent Member States were most likely to report the existence of a pre-registration/basic competency-based education curriculum (88% nursing and 82% midwifery), followed by those from the medium HDI group (78% for nursing and 73% for midwifery), and finally, the low HDI group (50% for nursing and 55% for midwifery). A similar relationship was observed for respondent Member States indicating the presence of a system of registration or licence for nurses or midwives (Figure 22; Table 21). Figure 21 : Percentage of respondent Member States with pre-registration/basic competency-based education, by HDI ursing Midwifery Findings 47

50 Figure 22 : Percentage of respondent Member States with a system of registration or licence, by HDI Total Low Medium High ursing Midwifery KRA expected result : innovative models developed and disseminated for continuing education of nurses and midwives, including programmes that focus on quality of care In order to monitor the progress on models developed and disseminated for continuing education, the survey asked separately if continuing education was mandatory for nursing and midwifery. Much like the data for the previous two KRA targets, here we observed that a small majority of respondents from high HDI Member States indicated that continuing education was indeed mandatory (56% for nursing and 58% for midwifery), while the low HDI group had the lowest percentage of respondents requiring continuing education (27% for nursing and 30% for midwifery) (Figure 23; Table 22). 48 A global survey monitoring progress in nursing and midwifery

51 Figure 23 : Percentage of respondent Member States with mandatory continuing education, by HDI ursing Midwifery Perhaps the variance for this KRA arises from the term required in the survey question, Is continued education mandatory? (Appendix A, Q6.8) where some responding Member States may have answered no, as they may not require continued education, but encourage nurses and midwives to pursue this type of growth themselves or it may be province/territory/ state required versus a countrywide requirement, as the United States indicated in their survey. The goal of resolution WHA54.12 is to strengthen nursing and midwifery services and one method of accomplishing this is by having the right approaches to building leadership capacity for these professions (WHO, 2001). Two ways by which to achieve this goal are to implement policies specifically designed for career development and to strengthen leadership. Globally, two thirds of the respondent Member States reported having capacity building approaches to further nursing and midwifery careers. It was interesting to observe that the low HDI category reported the highest proportion of policies or interventions created to advance such careers (85%). In contrast, the lowest number of respondent Member States that reported approaches for career development was from the medium HDI group (54%) (Figure 24; Table 23). Findings 49

52 Figure 24 : Percentage of respondent Member States with approaches to build leadership capacity for nursing and midwifery, by HDI Total Low Medium High Career Development Strengthening Leadership The pattern for strengthening leadership is comparable to that observed for respondent Member States reporting that they had invested in career development. Globally, 73% of these respondents indicated the presence of policies and interventions related to the strengthening of nursing and midwifery leadership. The low HDI group reported the highest percentage of respondents with policies for such strengthening with 77% and, although still relatively high, the medium HDI group showed the lowest percentage with 71% (Figure 24; Table 23). KRA expected result : tools developed and disseminated for different approaches to set and assess nursing and midwifery education standards The survey results determined that all respondent Member States regulate both nursing and midwifery education for entry-to-practice (Table 25). When divided by HDI levels, we see that respondent Member States across all HDI levels relied primarily on governmental authorities to regulate entry-to-practice, followed by nongovernmental regulating bodies. A minority of respondent Member States relied on a combination of both governmental and nongovernmental authorities to regulate nursing and midwifery entry-to-practice (Figure 25, 26; Table 25). It is interesting to note that all the responding Member States from the low HDI group indicated that the majority of the regulating authorities for nursing are either exclusively governmental or regulatory (not both) (Table 25). There 50 A global survey monitoring progress in nursing and midwifery

53 is a limitation in interpreting these findings, however, in that no distinction was made between private and public sector education, and it is not known if participants responses account for both private and public sectors, or if the responses encompass only one or the other. Figure 25 : Percentage of respondent Member States with regulated entry-topractice programmes for nursing, by HDI Government Regulatory Body Both Figure 26 : Percentage of respondent Member States with regulated entry-topractice programmes for midwifery, by HDI Government Regulatory Body Both Findings 51

54 At the end of the survey, participants were asked if they felt there had been improvements in the quality of education programmes in the past two years ( ) for nursing and midwifery. It was encouraging to discover that, globally, close to 90% of the respondent Member States reported seeing either some or great improvements in nursing education quality (Figures 27, 28; Tables 26, 27). In fact, 88% of the high HDI respondent Member States indicated that there had been some level of improvement for nursing programmes (Figure 27; Table 26), whilst 81% of them indicated that there had been some improvement in midwifery education programmes (Figure 28; Table 27). Figure 27 : Percentage of respondent Member States with some or great improvements in the quality of education programmes in for nursing, by HDI Some improvements Great improvements 52 A global survey monitoring progress in nursing and midwifery

55 Figure 28 : Percentage of respondent Member States with some or great improvements in the quality of education programme in for midwifery, by HDI Some improvements Great improvements For midwifery programmes, low HDI respondent Member States reported 63% improvement (Figure 28; Table 27). Overall, more than 90% of respondents rated midwifery programmes to have seen some or great improvements. It appears evident that education programmes for nursing and midwifery have improved globally between 2003 and 2005, although it also seems possible that the magnitude of the improvement may be mediated by a Member State s corresponding HDI level. Key Result Area 5 : Stewardship and governance Key Result Area 5 sees stewardship from governments, the community and health professions as essential to ensuring the safety of the public (i.e. patients), and the quality of care and health system performance. However, it has been recommended that this must be carried out through appropriate regulatory bodies with set standards for care (WHO, 2002). The following results come from survey items directly related to the participating Member States support, development and implementation of tools to assist in empowering nurses and midwives, and their regulatory bodies, to take an active role in setting standards that ensure the quality of patient care. Findings 53

56 KRA expected result : tools made available on different approaches for nursing and midwifery regulations and legislation (for example, in the areas of nurse prescribing and evolving roles) For KRA expected result 5.1, there is an emphasis on the development of strong health systems, stewardship and governance in nursing and midwifery. The current survey asked if the Member States had national action plans for nursing and midwifery. Respondents in the medium HDI category had the highest percentage of national action plans currently in place. This was found to be true for both nursing and midwifery (47% and 45%, respectively) (Figure 29; Table 28). Figure 29 : Percentage of respondent Member States with national human resources action plans for nursing and midwifery in 2005, by HDI Total Low Medium High ursing Midwifery Although only 23% of low HDI respondent Member States reported the presence of national nursing and midwifery action plans, 100% of these plans had been updated since 2000 (Table 29). The trend of updating existing plans was also seen globally with 89% of all nursing action plans and 93% of midwifery action plans being updated since 2000 (Table 29). For the respondents without national nursing action plans, the majority of low and medium HDI respondents indicated that they intended to develop plans at the time of responding to the survey (67% and 73%, respectively), and about one quarter of all respondent Member States reported that they were currently developing plans. High HDI respondents reported the largest proportion of Member States with no intention of developing a national nursing action plan (37%) (Figure 30; Table 30). 54 A global survey monitoring progress in nursing and midwifery

57 Figure 30 : Percentage of respondent Member States with plans to develop national human resources action plans for nursing in 2005, by HDI Do not intend Intend Currently developing As for midwifery, approximately one third of all respondent Member States without a national action plan were developing one at the time of the survey, and 45% of them stated that they were intending to develop one (Figure 31). Similar to the reported findings for nursing, high HDI ranked respondents had the greatest percentage of respondents that did not intend to develop a national action plan for midwifery (32%). However, this group also had the largest percentage of respondent Member States with a national action plan for nursing currently in development (37%) (Figure 30; Table 30). With regards to national action plans, we cannot speculate whether the respondent Member States without national action plans have no comparable national plans in place, or if they have employed a different approach to action plans for nursing and midwifery depending on the resources available (e.g. planning on a different level, such as local health authority, provincial/ state levels, or at the level of individual health-care facilities). The challenge with developing long-term action plans is that there is a danger in investing in training as, once training is complete, a lack of funding may cause low salaries, poor working conditions, and the risk of brain drain to another country, which may be able to more adequately meet the worker s needs and expectations. The dynamics may shift or political agendas may Findings 55

58 change, and unexpected work catastrophes may occur that require priorities to change, sometimes dramatically. Future studies may benefit from asking more open-ended questions about national or regional plans for the evolution of nursing and midwifery services. Figure 31 : Percentage of respondent Member States with plans to develop national human resources action plans for midwifery in 2005, by HDI Total Low Medium High Do not intend Intend Currently developing KRA expected result : evidence-based, cost-effective options for establishing or strengthening regulatory structures to support implementation of mechanisms, such as registration, licensing and certification of healthcare practitioners Responses to the survey revealed that 84% of all respondent Member States have systems of nursing registration or licensing in place, with nearly all the high HDI respondent Member States reporting these systems (95%). Those in the low and medium HDI groups indicated a lower prevalence of registration or licensing systems for nurses (69% and 79% respectively). In midwifery, approximately 81% of all respondent Member States surveyed reported the presence of registration or licensing practices, with the responding high HDI group indicating the largest percentage of respondent Member States with systems for midwifery registration (95%), followed by the medium and low HDI groups (72% and 69%, respectively) (Figure 22; Table 21). Before interpreting these data, the no responses of certain respondent Member States should be taken into consideration, as even though individual Member States 56 A global survey monitoring progress in nursing and midwifery

59 do not have a registration or licensing system themselves, they may require a licence from outside the country. Regardless, the high global percentage of Member States with registration practices is a positive sign that nations are moving towards meeting targets. KRA objective 5.2 : to empower nursing and midwifery professions and their regulatory bodies to assume responsibility for self-regulation and quality of care In examining KRA 5.2, a one-way between groups ANOVA was completed to compare respondent Member States with national policies and initiatives relating to nursing and midwifery and those without such policies on ratings of the effectiveness of empowerment initiatives. ANOVA results suggest that having a national human resources policy alone did not impact the perceived effectiveness of the empowerment models examined in the survey, nor did the presence of a national action plan for nursing, or the presence of regulatory bodies with set standards to support initiatives on improving working conditions. However, a significant effect of the national utilization of BPGs for nursing practice was observed, with the adoption of these guidelines being associated with higher effectiveness ratings for tools identified for educating nurses and midwives in the development of health policies, legislation and regulation; guidelines developed for programmes and services for nurses; and the development of cost-effective models for improving the quality of nursing practice. It should be noted, however, that despite the significantly greater ratings of effectiveness in these areas, respondent Member States with these guidelines only reported mean ratings of these survey items as 2.46, 2.85 and 2.28, respectively. This finding suggests that even though respondent Member States implementing BPGs reported significantly higher ratings of effectiveness in certain empowerment initiatives, these initiatives were still considered only somewhat effective tools for empowering nurses towards responsibility for self-regulation and quality of care. Analysis of factors contributing to the effectiveness of models and guidelines relating to the empowerment and increased self-regulation of midwifery revealed that the national use of BPGs for midwifery practice plays a significant role in improving the effectiveness of initiatives, such as the development of cost-effective models for improving the quality of practice, and the identification of models and tools for educating nurses and midwives in the development of health policies, legislation and regulations. Consistent with the pattern observed for nursing, the presence of a national action plan for midwifery did not significantly increase the perceived effectiveness of these Findings 57

60 guidelines, nor did the presence of a regulating body to set standards and policies on initiating workplace improvements. Interestingly, however, the factor associated with the greatest number of significant improvements on indices of empowerment was the presence of a national human resources policy for midwives. The presence of this policy was associated with improvements in three of the five empowerment models, tools and guidelines studied (Tables 31, 32). KRA expected result : models and tools identified for educating nurses and midwives in the development of health policies, legislation and regulations The results for this section examine the presence of models and tools for educating nurses and midwives in the planning and development of policies, legislation and regulations in nursing and midwifery, and their effectiveness. The presence of these related models and tools is globally impressive, with all respondent Member States reporting the existence of such tools for nursing and midwifery (72% and 81%, respectively) (Tables 31, 32). Prevalence rates varied across HDI levels, with high HDI respondents being the most likely to report having these models and tools for nursing (82%), followed by the low and medium HDI groups (67%). As for the presence of these tools and models for midwifery, again the high HDI respondents reported the largest percentage of Member States with these tools, followed by the medium HDI group (78%), and then the low HDI group (67%). Although an impressive percentage of high HDI respondents indicated that they have these resources, less than half of them rated these resources as being very effective (Tables 33, 34). Globally, only 36% of all respondents reported that these models and tools were very effective for improving the involvement of nurses and midwives in the development of health policies, legislation and regulations. For both nursing and midwifery, the low HDI group had the highest percentage of respondents describing these tools as being very effective (50%), whereas the medium HDI group had the lowest percentage of respondents describing them in this way (22%) (Figure 32; Tables 33, 34). 58 A global survey monitoring progress in nursing and midwifery

61 Figure 32 : Percentage of respondent Member States reporting the development of models/tools for educating nurses and midwives in the development of health policies, legislation and regulations, by HDI Total Low Medium High ursing Midwifery KRA expected result : models and tools identified for enhancing the involvement of nurses and midwives in the development of legislation and regulations These results vary across the HDI categories, where the number of respondent Member States with models and tools for enhancing the involvement of nurses and midwives is 71% and 77%, respectively (Tables 31, 32), with just over one third of these respondents describing them as effective (Figure 33; Tables 33, 34). The pattern of responses was somewhat different from that observed for the previous KRA expected result in that, although the percentage of Member States with these tools was greatest in the high HDI group, and appeared to get lower in the medium HDI and low HDI groups, the percentage of Member States reporting that these tools were effective was also greatest in the high HDI group (48% for both nursing and midwifery), followed by the medium HDI group (23% and 22%, respectively), and then the low HDI group (20% for both nursing and midwifery). Findings 59

62 Figure 33 : Percentage of respondent Member States reporting effective to very effective models/tools identified for enhancing the involvement of nursing and midwifery in the development of legislation and regulations, by HDI Total Low Medium High ursing Midwifery KRA expected result : guidelines developed or strengthened for accrediting nursing and midwifery education programmes and their implementation facilitated One of the targets for strengthening nursing and midwifery is the implementation of accreditation guidelines for educational programmes. Overall, approximately 80% of the respondent Member States indicated that these guidelines had been developed or strengthened, and their implementation facilitated for nurses and midwives. Low HDI respondent Member States were the most likely to report developing or strengthening these guidelines for both nursing and midwifery (83%), whereas the medium HDI group was most likely to report these guidelines for midwifery (86%). The high HDI group was least likely to report the development or strengthening of these guidelines for both nursing (77%) and midwifery (52%) (Tables 31, 32). From these totals, 65 63% of all high HDI respondents with these guidelines indicated that they were very effective (nursing and midwifery, respectively). Although over 80% of low HDI respondents reported that they had these guidelines, only 60% described them as very effective. Globally, respondents reported that their guidelines for accrediting nursing and midwifery programmes were very effective (57% and 60%, respectively) (Figure 34; Tables 33, 34). 60 A global survey monitoring progress in nursing and midwifery

63 Figure 34 : Percentage of respondent Member States reporting effective to very effective guidelines developed or strengthened for accrediting nursing and midwifery education programmes, and their implementation facilitated, by HDI Total Low Medium High ursing Midwifery Accreditation of programmes poses a common labour market issue where supply and demand is difficult to predict. If a programme or school does not meet accreditation standards and is disqualified until it is able to improve (Republic of Liberia, 2002), educators may go to work in another programme or school. This will be to the detriment of the programme in need as it will lose the time and income needed to build the programme back up to the standard. KRA expected result : cost-effective models developed for improving the quality of nursing and midwifery practice The importance of strengthening nursing and midwifery is often recognized. However, finding the financial means to do so can be difficult, especially for Member States with limited economic resources. Ensuring cost-effective models for improving nursing and midwifery practice is a target of KRA 5. The survey results show that, although approximately two thirds of all respondents indicated the presence of cost-effective models, only 23% (midwifery) and 27% (nursing) of them rate these models as being either effective or very effective (Figure 35; Tables 33, 34). It was also noted that relatively few of the low HDI respondent Member States, for which the presence of cost-effective models to improve the quality of nursing and midwifery practice is particularly important, described their current models as effective (14% for both nursing and midwifery). Findings 61

64 Figure 35 : Percentage of respondent Member States reporting effective to very effective cost-effective models developed for improving the quality of nursing and midwifery practice, by HDI Total Low Medium High ursing Midwifery KRA expected result : models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice The last expected result for KRA 5 relates to models developed for whistleblowing legislation to protect practitioners from reporting malpractice. The percentage of all respondent Member States reporting that they had these models for nursing and midwifery was low at only 45% and 46%, respectively. Approximately one quarter of the respondents with these models rated them as being effective to very effective (Figure 36; Tables 33, 34). When separated by the different HDI categories examined, only 10% (nursing) and 11% (midwifery) of the medium HDI respondent Member States found their whistle-blowing models effective. The most likely HDI group to report the effectiveness of these models came from the high HDI category, 40% of which rated them as effective to very effective in both nursing and midwifery. 62 A global survey monitoring progress in nursing and midwifery

65 Figure 36 : Percentage of respondent Member States showing effective to very effective models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice, by HDI ursing Midwifery Millennium Development Goals In 2000, the United Nations (UN) member States committed to move towards internationally agreed targets and goals for various indicators, including maternal and child health, poverty and hunger, universal education and the environment, by 2015 (UN, 2000). Due to a lack of current data on all MDG indicators at the time of the survey, the focus of the current report will be on the reduction of under-five mortality, infant mortality, and increasing the proportion of one year olds immunized against measles. The rates of these indicators will be determined by using the applicable data in the World Health Organization s Statistical Information System (WHOSIS) database (WHO, 2007b). The researchers explored the relationship between various nursing and midwifery services revealed in the survey and these health indicators. Target 5 of MDGs : reduce child mortality The target for reducing the child mortality rate is to reduce it by two thirds between 1990 and 2015 (UN, 2007b). There is a commitment to reach the following three health indicators by 2015 : infant morality, under-five mortality and the proportion of one year olds immunized against measles. Findings 63

66 Indicator 13 under-five mortality Regression modelling was completed to examine factors that may contribute to reductions in under-five mortality rates. Analysis revealed a significant decrease in under-five mortality associated with the effectiveness ratings of several standards for improving working conditions for nurses and midwives. Specifically, decreased mortality rates were predicted by improved standards in health and safety, working hours, maternity leave, paid annual holidays and other leave, and social security entitlements for nurses. These items were then entered into a linear regression modelling equation, using forward entry. This is a commonly employed technique in which individual regression analyses are completed on the variables of interest, and each statistically significant variable is added to the regression model in the order of the strongest to weakest predictor. Predictors are added until the variables entered no longer demonstrate a significant relationship to the dependent variable. With regards to the current study, regression modelling indicated that decreased under-five mortality rates are best predicted by the use of a model consisting of effective health and safety workplace initiatives and improved social security entitlements for nursing. The individual regression analyses were also completed on midwifery data, with largely similar results. More effective workplace initiatives including health and safety, working hours, paid annual holidays, and social security entitlements were all individually associated with decreases in under-five mortality rates (Tables 35, 36). However, when these individual predictors were entered into a regression modelling equation, only health and safety remained significant predictors. Indicator 14 infant mortality According to the Millennium Development Goals report (United Nations, 2008), there has been a slower move toward increasing the child survival rates yet a decline in parts of the African region. In examining the infant mortality rate, using data from the 2005 Global Survey MDG data sheet (Appendix A) and the WHOSIS data (WHO, 2007b), the WHOSIS database was found to be a more reliable means of compiling complete data regarding the MDGs as it was not received or not included with the returned complete survey data. Regression analyses on infant mortality rates revealed significant relationships between the effectiveness ratings of several standards or policies for improving nurses working conditions. When analysed for their individual 64 A global survey monitoring progress in nursing and midwifery

67 contributions, the increased effectiveness of health and safety standards, working hours, paid annual holidays and other leave, and social security benefits for nurses were each associated with a decrease in infant mortality rates (Table 37). These individual predictors were then entered into a linear regression model equation in order to determine which items would best fit into an overall model for decreasing infant mortality rates. Following this analysis, only the health and safety workplace initiatives remained a significant predictor of decreased infant mortality rates. With few exceptions, these findings of the individual regression analyses described above were repeated in the midwifery data analyses (Table 38), and consistent with the data for nursing, the best predictor of decreased infant mortality was higher effectiveness ratings of workplace health and safety policies. The results of these analyses suggest that effective initiatives for improving the working conditions of both nurses and midwives serve to decrease infant mortality rates. Moreover, the workplace initiative with the strongest ties to decreasing infant mortality rates appears to be effective health and safety policies for nurses. Indicator 15 proportion of one-year olds immunized against measles In 2005, it was reported that about 4% of deaths in children under five-years old were ascribed to measles. Regressions were completed on the respondent Member States measles immunization rates data to examine whether a relationship exists between measles immunization rates in one year olds and the effectiveness of a Member States standards and policies for improving working conditions for nurses and midwives. More precisely, the effectiveness ratings of employment standards in the areas of health and safety, working hours, weekly rest, paid annual holidays and other leave, educational leave, maternity leave, and social security entitlements were regressed on 2005 measles immunization rates for one year olds. Of the employment standards investigated, only ratings of social security entitlements showed a trend towards a relationship to immunization rates, although this trend failed to reach statistical significance (p =.056) (Table 39). Additional regression analyses were completed to measure the impact of the respondent Member States initiatives to empower nursing and midwifery Findings 65

68 professions and their regulatory bodies to assume responsibility for selfregulation and quality of care. These regressions revealed that higher rates of measles immunizations in one year olds were associated with an increase in the effectiveness ratings of a respondent Member State s identification of tools for enhancing the involvement of nurses in the development of legislation and regulations (β =.32, p =.01). Put another way, respondent Member States that reported that the involvement of nurses and midwives in the legislative process effectively empowered these professions to assume responsibility for self-regulation and quality of care also tended to have high measles immunization rates in their one year olds. This finding was replicated in the analysis of the midwifery data (β =.3, p =.007). Although not significant, between groups, differences uncovered by ANOVA suggested that the presence of a chief nursing officer also positively influenced the number of one year olds immunized (p =.085). Contrary to expectations, however, there was a smaller proportion of immunizations in respondent Member States that reported having a national human resources policy in place for midwifery services (F(1,43) = 5.43, p =.007). Upon evaluating the dataset, it appears that this result is likely due to a combination of the small sample size and the inordinately high immunization proportions reported by respondent Member States with no national human resources policy for midwifery (four out of 13 respondent Member States reporting immunization rates of 99%). Challenges and limitations A study of this magnitude is resource intensive and this was shown in the data collection for Phase 1. Although the regional leader or focal point in nursing and midwifery for each Member State was invited to participate in completing the survey, many departments and consultants were required to complete the survey. Surveys were self-reported and may have been subject to bias. In one regional mailing, a draft spreadsheet database was accidentally sent to participants in place of the finalized version of the survey. This draft lacked certain contextual elements and explanations that would have allowed the Member States to respond accurately. This problem had been resolved as the correct survey was sent as part of a reminder. 66 A global survey monitoring progress in nursing and midwifery

69 Furthermore, this survey was developed so that it could be completed by hand or by using electronic means, such as Microsoft Word. There also appears to be different reporting systems in place for different Member States, such as in the case of Switzerland, which does not have a centralized health system. This made it difficult for respondents to reply on a macro-level to the survey questions covering their 26 cantons. As mentioned at the beginning of this report, the United Kingdom, as a respondent Member State, only contains two of the four countries that make up that Member State. As indicated by the WHO Regional Office for Europe, each country has a different reporting system and would be sending individual surveys. This proved a difficult analysis process for this report, but the United Kingdom was a unique case. Lastly, as previously indicated, the response rate for the current study was 40%, with 77 out of 192 WHO Member States submitting a completed survey. It is important to note that this low response rate may place significant limitations on the ability to generalize the study s findings. Findings 67

70 68

71 Closing messages and thoughts Reflections, conclusions and recommendations Although researchers had anticipated a greater response rate among WHO Member States, it is acknowledged that the resources necessary to answer the survey items may not have been readily available to all Member States, particularly those with low HDI rankings. There is hope that greater access to accurate data consisting of both process and outcome indicators will be made available for future studies, thus allowing for a more comprehensive review of global health planning and human resource commitments towards nursing and midwifery. Improved data strategies may involve ways of further streamlining data survey requirements and supporting survey completion by applying technologies, such as Internet conferencing, to enhance research capacities, data collection, analysis and application. Apart from the overall goal of being able to characterize and analyse global HRH trends, database maintenance and the availability of core domains and data elements will also better support intercountry (or cross-border) and subregional approaches to meeting workforce needs. There is evidence that we are moving forwards globally towards a shared databank allowing for more sophisticated HRH forecasting and intercountry HRH planning. In fact, the creation and maintenance of such a databank was one of the key points of Chiang Mai declaration (2008) and The Kampala declaration and agenda for global action (2008), which certainly suggests current governments and policy-makers are growing increasingly mindful of the importance of accurate and accessible data. Also, as pertains to the data used in this report, this study was initially designed to tell a quantitative story of nursing and midwifery human resources trends and initiatives, and their impact on the health outcomes in WHO Member States. Given the difficulty in obtaining this data, the researchers recommend that future studies include a qualitative analysis of interview questions focusing on how individual Member States are shaping their HRH policies and utilizing their resources to meet their population health needs. The inclusion of such an analysis could provide a valuable resource, as richer stories about the challenges and successes of nursing and midwifery may emerge through the carefully weighted combination of both quantitative and qualitative methods of investigation. We can learn from other s experiences and stories, successful and unsuccessful, and we anticipate that interview responses will allow Closing messages and thoughts 69

72 researchers and policy-makers to gain insights into approaches and techniques currently being used to strengthen nursing and midwifery. As reliable quantitative data may not have been collected or may not even exist for certain Member States, this method of combining quantitative and qualitative designs could allow future researchers to obtain a more complete, or inclusive, view of global trends in nursing and midwifery, thereby allowing for more generalized results. Although there is a clear need for continued research and monitoring in this area, the present findings suggest that efforts are being made to meet the mandated KRA and MDGs, as outlined in the Strategic directions for strengthening nursing and midwifery services (WHO, 2002). Specifically, as pertains to KRA 1.2, researchers found that over 60% of the respondent Member States surveyed indicated that they had tools in place to work with communities and policy stakeholders to enhance the awareness of the contributions made by nurses and midwives towards achieving health targets. Interestingly, there were fairly large disparities observed in the perceived impact of these tools on policy-makers, with the low HDI Member States reporting a moderate to significant impact in 71% of their Member States, while medium HDI Member States reported these tools as having a high level of impact in only 51% of their Member States. It may be worth investigating this finding further, as it is possible that the differences in the impact that these tools appear to have on policy-makers may be a result of variations in how these tools are implemented, or the level of governmental support they receive (both financial and legislative). There are encouraging aspects to these inter-group differences, however, as the HDI group with the lowest percentage of WHO Member States describing these tools as effective, was not from the lowest ranking HDI category. This finding suggests that the impact of these tools may not necessarily be mediated solely by the resources available or by the relative wealth of a Member State. Rather, it may be the manner in which their tools are implemented and perhaps the level of importance placed on them by their respective governments or stakeholders. An alternate interpretation, however, could be that medium HDI Member States are already adequately meeting their health and HRH targets and, as a result, experience a diminished benefit from the implementation of the tools investigated. As the precise mechanisms underlying these differences cannot be determined from the present study, further investigation is clearly warranted. An additional finding emerged from the statistical analyses of the data collected. Perhaps one of the more important findings was that there appeared 70 A global survey monitoring progress in nursing and midwifery

73 to be a relationship between the effectiveness of policies to improve working conditions for nurses and midwives, and certain MDG indicators. Specifically, higher effectiveness ratings of policies on workplace health and safety, working hours, paid annual leave and other leave, and social security entitlements were associated with decreases in infant and under-five mortality rates. This suggests that not only are improvements in HRH important for improving the working life of nurses and midwives, they also appear to have a direct impact on population health outcomes. This is an important point to address, as many of these initiatives may not be a high priority for government agencies and, thus, may be set aside as they are perceived irrelevant for moving the country towards the MDGs. Despite the apparent importance of having effective policies for improving the working conditions of nurses and midwives, over 50% of all respondent Member States surveyed indicated that they had not had a recent government intervention to improve working conditions for nurses and/or midwives (e.g. within five years of the survey). Given the observed link between improved working conditions and heath outcomes, it is recommended that more Member States initiate government interventions to improve the working conditions of the nurses and midwives in their country, thereby potentially enhancing their ability to meet the MDGs. The current study also revealed that while having a national human resources policy for nursing or midwifery alone did not significantly impact the perceived effectiveness of policies to improve the working conditions of these health-care providers, the presence of regulatory bodies that set standards to support initiatives on working conditions for nurses and midwives significantly improved ratings on the effectiveness of the workplace policies and initiatives investigated (e.g. policies on workplace safety, standardized leave, social security benefits, working hours, etc.). What this data suggests is that while it may be an important step to develop national human resources policies for nurses and midwives, their establishment is not enough to effect positive change in working conditions. Rather, what appears more important is the presence of regulatory bodies that monitor these working conditions and set standards. Furthermore, while these regulators may be either institutional or governmental, the greatest impact is observed when a Member State has a combination of both governmental and institutional organizations setting such standards. These data suggest that in order to improve working conditions for nurses and midwives, a greater commitment than merely creating national HRH policies is required. Countries must take the next step, and ensure that there are bodies in place to evaluate workplace initiatives and set standards, thereby providing workplaces with defined goals and known standards to work towards. Closing messages and thoughts 71

74 In completing this study, it was also noted with some interest the ease with which the KRAs and MDGs examined fitted into the Health System and Health Human Resources Planning Conceptual Framework put forward by O Brien- Pallas, et al. (2005). For example, KRA expected results and could easily be superimposed over the framework s Production component. Likewise KRA expected results 1.2.2, 2.1.2, 3.1, etc. all appear to fit nicely with the concept of Management, Organization, and Delivery of Services across the Health Continuum. The MDG health targets, of course, find a suitable home in the Health Outcomes component of the framework (Figure 37). Figure 37 : Integration of WHO key result areas and Millennium Development Goals into the Health System and Health Human Resources Planning Conceptual Framework Population Health Needs SOCIAL System Design HDI ECONOMIC POLITICAL KRA 1.1.4, KRA KRA Supply Financial Resources Production (education and training) Planning & Forecasting KRA Level of Economic Development HDI KRA 4.1.5, KRA KRA 5.2.1, KRA KRA 3.1 Resource Deployment and Utilization Management, Organization and Delivery of Services across Health Continuum HDI KRA 1.2.2, KRA 2.1.2, KRA 3.1, KRA 5.1.1, KRA 5.1.2, KRA 5.2.1, KRA 5.2.2, KRA GEOGRAPHICAL MDGs Health Outcomes KRA KRA MDGs System Outcomes MDGs, KRA Provider Outcomes KRA KRA TECHNOLOGICAL Efficient Mix of Resources (Human & Non-Human) HDI Source : O Brien-Pallas, Tomblin Murphy, Birch, 2005 (as cited in Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources, 2005); adapted from O Brien-Pallas et al. (2001b); and O Brien-Pallas, Baumann (1997). The observed compatibility of components with the Health System and Health Human Resources Planning Conceptual Framework (O Brien-Pallas et al, 2005) suggests that it might be useful to apply it more rigorously when countries and organizations engage in HRH planning to meet population health needs. The use of this framework for these applications may have the dual effect of providing a workable foundation from which countries 72 A global survey monitoring progress in nursing and midwifery

75 can build HRH strategies to address health needs and realize health targets, as well as providing a real world testing ground to explore how the framework functions across a diverse group of cultural, political and economical backdrops. Lastly, from the data collected, 70% of the respondent Member States indicated that they were experiencing a shortage in both the nursing and midwifery sectors. This is an alarming figure. It indicates a clear need for global improvements in nursing and midwifery HRH practices, particularly with regards to training, recruitment and retention initiatives. It is our sincere hope that the data obtained during the course of this study will provide future governments and policy-makers with some guidance in taking the next step towards ensuring the availability of a valuable resource. Closing messages and thoughts 73

76 74

77 References Chiang Mai Declaration (2008). Nursing and midwifery for primary health care, International Conference on New Frontiers in Primary Health Care : Role of Nursing and Other Professions. Chiang Mai, Thailand, 4 6 February 2008 ( Chiang_Mai_Declaration.pdf, accessed 1 June 2009). Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (ACHDHR), eds. (2005). A framework for collaborative pan-canadian health human resources planning. Ottawa, Health Canada. El-Gilany A, Al-Wehady A, (2001). Job satisfaction of female Saudi nurses. Eastern Mediterranean Health Journal, 7(1/2) : Global Health Workforce Alliance (2008). Health workers for all and all for health workers the Kampala declaration and agenda for global action. First Global Forum on Human Resources for Health. Kampala, Uganda, 2 7 March 2008 ( final.pdf, accessed 1 June 2009). Gomes Sambo L (2007). Message of the Regional Director on the occasion of World Health Day 2006 : working together for health. Africa Health Monitor, 7(1) :1 3. Hall TL (1988). Guidelines for health workforce planners. World Health Forum, 9(3) : Hall TL, Mejia A, eds. (1978). Health manpower planning : principles, methods, issues. Geneva, World Health Organization. Ministry of Health and Social Welfare (2002). Accreditation guidelines for the Liberia Board for Nursing and Midwifery. Monrovia. O Brien-Pallas L, Baumann A (1997). Health human resources in nursing in Ontario (unpublished). O Brien-Pallas L et al (1997). Strengthening nursing and midwifery a global study. Geneva, World Health Organization (WHO/HDP/NUR- MID/97.2). O Brien-Pallas L et al. (2001a). Integrating workforce planning, human resources, and service planning. Human Resources Development Journal, 5(1 3) :2 16. References 75

78 O Brien-Pallas L et al. (2001b). Framework for analyzing health human resources. In : Future development of information to support the management of nursing resources : recommendations. Canadian Institute for Health Information, Ottawa. O Brien-Pallas L et al. (2007). Health human resources modelling : challenging the past, creating the future. Ottawa, Canadian Health Services Research Foundation ( OBrien-1_3_25.pdf, accessed 1 June 2009). O Brien-Pallas L et al. (2008). Integration of WHO key results areas and Millennium Development Goals into the Health System and Health Human Resources Planning Conceptual Framework (unpublished). The Republic of Namibia Ministry of Health and Social Services and the Republic of Kenya Ministry of Health (2002). Memorandum of understanding on technical cooperation in health. The Republic of the Gambia Department of State for Health and Social Welfare (2005). Human resources for health : 15-year human resources plans and training schedules for the health sector of the Gambia. Banjul. The United Republic of Tanzania Department of Nursing Services and the Tanzania Nurses and Midwives Council (1997). Minimum standards for nursing practice in Tanzania. Dar es Salaam. United Nations (2000). United Nations Millennium Declaration. General Assembly of the United Nations, New York, 6 8 September, 2000 ( accessed 1 June 2009). United Nations (2008). The Millennium Development Goals report. New York ( accessed 1 June 2009). United Nations Development Programme (2007). Human development report 2007/2008 : fighting climate change : human solidarity in a divided world. New York, United Nations ( hdr /, accessed 1 June 2009). Webster s new encyclopedic dictionary, 2nd ed. (1995). New York, Black Dog and Leventhal Publishers Inc. World Health Organization (2001). Strengthening nursing and midwifery services. Geneva (A54/VR/9). 76 A global survey monitoring progress in nursing and midwifery

79 World Health Organization (2002). Strategic directions for strengthening nursing and midwifery services. Geneva ( LinkFiles/Resources_Anglais.pdf, accessed 1 June 2009). World Health Organization (2005). Health and the Millennium Development Goals. Geneva (WA 530 :1). World Health Organization (2006b). Fact sheet N301 : migration of health workers. Geneva ( accessed 1 June 2009). World Health Organization (2006c). Resolution WHA Strengthening nursing and midwifery. In : Fifty-ninth World Health Assembly, Geneva, 27 May Resolutions and decisions. Geneva. ( ebwha/pdf_files/wha59/a59_r27-en.pdf, accessed 1 June 2009). World Health Organization (2007a). Everybody s business : strengthening health systems to improve health outcomes : WHO s framework for action. Geneva (W84.3). World Health Organization (2007b). World health statistics Geneva (WA 900.1). World Health Organization Western Pacific Region (2007). Pacific code of practice for recruitment of health workers and compendium (unpublished). World Health Organization Western Pacific Region (2008). Strategic plan for strengthening health systems in the WHO Western Pacific Region, Manila ( 80D4-067CFB7757B6/0/StratPlan2.pdf, accessed 1 June 2009). References 77

80 Appendices Appendix A: Survey Appendix B: Tables Appendix C: Key result areas for strengthening nursing and midwifery 78

81 Appendix A : Survey Monitoring progress in nursing and midwifery A copy of the global survey evaluation entitled Monitoring Progress in Nursing and Midwifery may be requested by nmoffice@who.int or from our web site : MONITORING PROGRESS IN NURSING AND MIDWIFERY A GLOBAL SURVEY Health Professions Networks Nursing & Midwifery Human Resources for Health World Health Organization Geneva, Switzerland 2005 Appendix A : Survey 79

82 Appendix B : Tables Table 1 : Member States response rate, by WHO region and Human Development Index, as of March 2008 WHO regions Total (No.) Low (No.) Medium (No.) High (No.) Response rate (%) AFRO (African) AMRO (Americas) SEARO (South-East Asia) EURO (European) EMRO (Eastern Mediterranean) WPRO (Western Pacific) Total Table 2 : Member States, by WHO region, having submitted completed surveys, as of March 2008 AFRO AMRO SEARO Member States Benin, Cape Verde, Comoros, Congo, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea, Guinea-Bissau, Liberia, Madagascar, Mali, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, South Africa, United Republic of Tanzania, Zambia Canada, Dominica, Dominican Republic, Panama, Paraguay, Peru, United States of America Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste Total No. by WHO region EURO Armenia, Belgium, Denmark, Hungary, Ireland, Lithuania, Poland, Portugal, Slovenia, Sweden, Switzerland, United Kingdom a 12 EMRO WPRO Djibouti, Egypt, Iran, Islamic Republic of, Oman, Pakistan, Sudan, Tunisia Brunei Darussalam, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Lao People s Democratic Republic, Malaysia, Mongolia, Niue, Papua New Guinea, Philippines, Republic of Korea, Samoa, Singapore, Solomon Islands, Viet Nam 7 18 a England and Scotland 80 A global survey monitoring progress in nursing and midwifery

83 Table 2a : Member States, by HDI and WHO region, having submitted completed surveys, as of March 2008 WHO region Low Medium High AFRO Benin, Democratic Republic of the Congo, Ethiopia, Guinea-Bissau, Guinea, Liberia, Mali, Niger, Nigeria, Rwanda, Senegal, United Republic of Tanzania, Zambia Cape Verde, Comoros, Congo, Equatorial Guinea, Gabon, Gambia, Madagascar, Namibia, Sao Tome and Principe, South Africa Seychelles AMRO Dominica, Dominican Republic, Paraguay, Peru Canada, Panama, the United States EMRO Djibouti, Egypt, Iran, Islamic Republic of. Pakistan, Sudan EURO Armenia Belgium, Denmark, United Kingdom a, Hungary, Ireland, Lithuania, Poland, Portugal, Slovenia, Sweden, Switzerland SEARO Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste Oman WPRO Cambodia, China, Cook Islands, Fiji, Kiribati, Lao People s Democratic Republic, Mongolia, Niue, Papua New Guinea, Philippines, Samoa, Solomon Islands, Viet Nam Brunei Darussalam, Japan, Malaysia, Republic of Korea, Singapore Total a England and Scotland Appendix B : Tables 81

84 Table 3 : Percentage of respondent Member States with human resources policies for nursing and midwifery, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 4 : Percentage of respondent Member States experiencing nursing and midwifery shortages, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 5 : Percentage of respondent Member States indicating a great to very great extent of nursing and midwifery shortage, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 6 : Percentage of respondent Member States with national recruitment guidelines from abroad for nursing and midwifery, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery A global survey monitoring progress in nursing and midwifery

85 Table 7 : Percentage of respondent Member States with national recruitment guidelines for importing and exporting nurses and midwives, by HDI Type of recruitment guidelines Total (%) Low (%) Medium (%) High (%) Import nurses Export nurses Import midwives Export midwives Table 8 : Percentage of respondent Member States with tools and approaches to support the strengthening of nursing and midwifery services, by HDI Professions Nursing Midwifery Tools/approaches Tools developed to work with communities, policy-makers, etc. to raise awareness Tools and approaches developed for advocating and building political alliances Evidence on success stories developed and disseminated to policy-makers Tools developed to work with communities, policy-makers, etc. to raise awareness Tools and approaches developed for advocating and building political alliances Evidence on success stories developed and disseminated to policy-makers Total (%) Low (%) Medium (%) High (%) Appendix B : Tables 83

86 Table 9 : Percentage of respondent Member States showing moderate to significant impact of tools and approaches to support strengthening nursing and midwifery services, by HDI Professions Nursing Midwifery Moderate to significant impact Tools developed to work with communities, policy-makers, etc. to raise awareness Tools and approaches developed for advocating and building political alliances Evidence on success stories developed and disseminated to policy-makers Tools developed to work with communities, policy-makers, etc. to raise awareness Tools and approaches developed for advocating and building political alliances Evidence on success stories developed and disseminated to policy-makers Total (%) Low (%) Medium (%) High (%) Table 10 : Percentage of respondent Member States with governmental/nongovernmental bodies that set nursing standards/policies to support initiatives on working conditions, by HDI Type of standards Total (%) Low (%) Medium (%) High (%) National Institutional Both Table 11 : Percentage of respondent Member States with governmental/nongovernmental bodies that set midwifery standards/policies to support initiatives on working conditions, by HDI Type of standards Total (%) Low (%) Medium (%) High (%) National Institutional Both A global survey monitoring progress in nursing and midwifery

87 Table 12 : ANOVA summary for national human resources policy (nursing) Effectiveness ratings ME F p Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions Table 13 : ANOVA summary for national human resources policy (midwifery) Effectiveness ratings ME F p Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions Table 14 : Percentage of respondent Member States reporting guidelines for employment policies for human resources for health for nursing and midwifery, by HDI HRH employment guidelines Total (%) Low (%) Medium (%) High (%) Adapting working time and shift hours Reduce violence, increase support at the workplace Appendix B : Tables 85

88 Table 15 : Percentage o f respondent Member States reporting somewhat to very effective guidelines for employment policies for human resources for health for nursing and midwifery, by HDI Effective HRH employment guidelines Total (%) Low (%) Medium (%) High (%) Adapting hours Reduce violence/ increase support Table 16 : ANOVA summary for regulatory bodies to set standards for improving nurses working conditions Effectiveness ratings ME F p Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions Table 17 : ANOVA summary for regulatory bodies to set standards for improving midwives working conditions Effectiveness ratings ME F p Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions A global survey monitoring progress in nursing and midwifery

89 Table 18 : Timeframe of rrespondent Member States last intervention to improve working conditions of the nursing and midwifery workforces, by HDI Professions Nursing Midwifery Timeframe Total (%) Low (%) Medium (%) High (%) Never Long-term Mid-term Short-term Never Long-term Mid-term Short-term Table 19 : Percentage of respondent Member States with best practice guidelines, by HDI Professions Nursing Midwifery Best practice guidelines Total (%) Low (%) Medium (%) High (%) Yes/in process No Yes/in process No Table 20 : Percentage of respondent Member States with pre-registration/basic competency-based education, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 21 : Percentage of respondent Member States with a system of registration or licence, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Appendix B : Tables 87

90 Table 22 : Percentage of respondent Member States with mandatory continuing education, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 23 : Percentage of respondent Member States with approaches to building leadership capacity for nursing and midwifery, by HDI Capacity-building approaches Total (%) Low (%) Medium (%) High (%) Career development Strengthening leadership Table 24 : Percentage of respondent Member States with regulated entry-topractice programmes, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 25 : Percentage of respondent Member States with authorities to regulate education for entry-to-practice, by HDI Professions Authorities regulating entryto-practice education Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Government Regulatory body Both Government Regulatory body Both A global survey monitoring progress in nursing and midwifery

91 Table 26 : Percentage of respondent Member States with great/some improvements in the quality of nursing education programmes in , by HDI Level of improvement of nursing education programmes Total (%) Low (%) Medium (%) High (%) Some improvements Great improvements Table 27 : Percentage of respondent Member States with great/some improvements in the quality of midwifery education programmes in , by HDI Level of improvement of nursing education programmes Total (%) Low (%) Medium (%) High (%) Some improvements Great improvements Table 28 : Percentage of respondent Member States with national human resources action plans for nursing and midwifery, by HDI Profession Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Table 29 : Percentage of respondent Member States with updated national action plans, by HDI Professions Timeframe Total (%) Low (%) Medium (%) High (%) Nursing Midwifery Before or later Before Appendix B : Tables 89

92 Table 30 : Percentage of respondent Member States with plans to develop national human resources action plans for nursing and midwifery in 2005, by HDI Profession Nursing Midwifery Intention to develop HR action plans Total (%) Low (%) Medium (%) High (%) Not intending to develop Intending to develop Currently developing Not intending to develop Intending to develop Currently developing Table 31 : Percentage of respondent Member States reporting the development of models, tools and guidelines for the empowerment of nursing, by HDI Models/tools/guidelines being developed for nursing Models/tools educating nursing in development of health policies, legislation and regulations Models/tools identified for enhancing the involvement of nursing in the development of legislation and regulations Guidelines developed or strengthened for accrediting nursing education programmes, and their implementation facilitated Cost-effective models developed for improving the quality of nursing practice Models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice Total (%) Low (%) Medium (%) High (%) A global survey monitoring progress in nursing and midwifery

93 Table 32 : Percentage of respondent Member States reporting the development of models, tools and guidelines for the empowerment of midwifery, by HDI Models/tools/guidelines being developed for midwifery Models/tools educating midwifery in development of health policies, legislation and regulations Models/tools identified for enhancing the involvement of midwifery in the development of legislation and regulations Guidelines developed or strengthened for accrediting midwifery education programmes, and their implementation facilitated Cost-effective models developed for improving the quality of midwifery practice Models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice Total (%) Low (%) Medium (%) High (%) Table 33 : Percentage of respondent Member States showing effectively developed models, tools and guidelines for nursing, by HDI Effective models/tools/guidelines developed for nursing Models/tools educating nursing in development of health policies, legislation and regulations Models/tools identified for enhancing the involvement of nursing in the development of legislation and regulations Guidelines developed or strengthened for accrediting nursing education programmes, and their implementation facilitated Cost-effective models developed for improving the quality of nursing practice Models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice Total (%) Low (%) Medium (%) High (%) Appendix B : Tables 91

94 Table 34 : Percentage of respondent Member States showing effective developed models, tools and guidelines for midwifery, by HDI Effective models/tools/guidelines developed for midwifery Models/tools educating midwifery in development of health policies, legislation and regulations Models/tools identified for enhancing the involvement of midwifery in the development of legislation and regulations Guidelines developed or strengthened for accrediting midwifery education programmes, and their implementation facilitated Cost-effective models developed for improving the quality of midwifery practice Models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice Total (%) Low (%) Medium (%) High (%) Table 35 : Linear regression summary for under-five mortality (nursing) Predictor B SE B β Health and safety * Working hours (weekly/monthly) * Weekly rest Paid annual holidays/leave * Education leave Maternity leave * Sick leave Social security entitlements/pensions * * p <.05 Source : WHO, 2007b 92 A global survey monitoring progress in nursing and midwifery

95 Table 36 : Linear regression summary for under-five mortality (midwifery) Predictor B SE B β Health and safety * Working hours (weekly/monthly) * Weekly rest Paid annual holidays/leave * Education leave Maternity leave Sick leave Social security entitlements/pensions * * p <.05 Source : WHO, 2007b Table 37 : Linear regression summary for infant mortality (nursing) Predictor B SE B β Health and safety * Working hours (weekly/monthly) * Weekly rest Paid annual holidays/leave * Education leave Maternity leave Sick leave Social security entitlements/pensions * * p <.05 Source : WHO, 2007b Table 38 : Linear regression summary for infant mortality (midwifery) Predictor B SE B β Health and safety * Working hours (weekly/monthly) * Weekly rest Paid annual holidays/leave * Education leave Maternity leave Sick leave Social security entitlements/pensions * p <.05 Source : WHO, 2007b Appendix B : Tables 93

96 Table 39 : Linear regression summary for proportion of one-year olds immunized against measles (nursing) Predictor B SE B β Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions * p <.05 Source : WHO, 2007b Table 40 : Linear regression summary for proportion of one-year olds immunized against measles (midwifery) Predictor B SE B β Health and safety Working hours (weekly/monthly) Weekly rest Paid annual holidays/leave Education leave Maternity leave Sick leave Social security entitlements/pensions * p <.05 Source : WHO, 2007b 94 A global survey monitoring progress in nursing and midwifery

97 Appendix C : Key result areas for strengthening nursing and midwifery Key result areas and their objectives and expected results (WHO, 2002) Key result areas 1 : HEALTH PLANNING, ADVOCACY AND POLITICAL COMMITMENT Objectives 1.1 To strengthen those mechanisms relating to human resources policy intervention and planning in order to contribute to the maintenance of adequate levels of nursing and midwifery personnel so that health systems may function more effectively. 1.2 To mobilize policy-makers, the general public, partners and health care practitioners to support changes designed to strengthen nursing and midwifery services and to enhance their contribution to health system performance and outcomes. Expected results Staffing norms developed for specific health care contexts Guidelines developed for health workforce distribution and combinations of skills Models developed on causes of workforce shortage and migration within and between countries Uniform indicators and systems established for monitoring human resources levels, shortage and migration Tools developed for forecasting workforce shortage and migration Best practices collected, adapted and disseminated for human resources policy intervention, assessment and planning Ethical guidelines developed for international recruitment Tools developed for working with communities, politicians, and policy-makers in order to raise awareness regarding the role and contribution of nursing and midwifery services as core resources for achieving health targets Tools and approaches developed for advocating the strengthening of nursing and midwifery services and the building of political alliances and support Evidence developed and disseminated to policy-makers on success stories of the nursing and midwifery contribution to health system goals. Appendix C : Key result areas for strengthening nursing and midwifery 95

98 Key result areas 1 : HEALTH PLANNING, ADVOCACY AND POLITICAL COMMITMENT Objectives 1.3 To foster an environment that enables nurses and midwives to make decisions and be directly involved in policy-making (including the allocation of funds) at all levels and thus support more efficient health outcomes. Expected results Mechanisms established or strengthened to ensure that nursing and midwifery expertise is included in the development of health policies and programmes at all levels, including those at WHO Political support strengthened for the adoption of effectivenursing and midwifery models of care that focus on HIV/ AIDS, Making Pregnancy Safer (MPR), Roll BackMalaria (RBM), Adolescent Health and Development (ADH), Mental Health, and tuberculosis (STOP-TB). Key result areas 2 : MANAGEMENT OF HEALTH PERSONNEL FOR NURSING AND MIDWIFERY SERVICES Objectives 2.1 To promote healthy and safe working environments and conditions that are conducive to recruiting and retaining nursing and midwifery personnel. Expected results Evidence collected and disseminated on the impact of employment policies on individual and organizational provider performance with specific reference to the nursing and midwifery workforce Innovative guidelines established on processes for reviewing, changing and developing employment policies for human resources for health The impact examined of reform, privatization, and emergency situations on health-care practitioners, with specific attention to nursing and midwifery personnel, and lessons learned disseminated Interdisciplinary and multisectoral collaboration established or strengthened at global, regional and national levels to develop, apply and monitor employment policies that are equitable and gender sensitive. 96 A global survey monitoring progress in nursing and midwifery

99 Key result areas 3 : PRACTICE AND HEALTH SYSTEM IMPROVEMENT Objectives 3.1 To improve access to quality nursing and midwifery services as an integral part of health services aimed at individuals, families and communities particularly among vulnerable populations. This may be accomplished through the enhanced integration of successful nursing and midwifery service delivery models within health-care systems. Expected results Innovative approaches identified, adapted and disseminated to bridge gaps between the health system and the needs of the community, specifically in terms of home-based care, palliative care, health promotion, disease prevention, rehabilitation and emergency care A comprehensive research agenda developed to strengthen nursing and midwifery services Evidence base further developed with partners on cost effective nursing and midwifery services and their impact on priority diseases, such as HIV/AIDS, ADH, MPR, Mental Health, TB and Malaria Guidelines established on the utilization of nurses and midwives to improve health outcomes in selected priority areas Models identified, adapted and disseminated for evaluating nursing and midwifery services Development supported for setting standards for nursing and midwifery practice and access facilitated to tools for assessment Models of decision-making identified and promoted that optimize the contribution of nursing and midwifery expertise. Appendix C : Key result areas for strengthening nursing and midwifery 97

100 Key result areas 4 : EDUCATION OF HEALTH PERSONNEL FOR NURSING AND MIDWIFERY SERVICES Objectives 4.1 To strengthen the core skills of nursing and midwifery practitioners in order to meet changing population and practice needs. Expected results Models and approaches developed and disseminated for integrating core competencies and updating curricula Core competencies developed and disseminated for nursing and midwifery practice at pre-registration and post registration levels A framework of shared competencies established that shows the value of collaboration between nursing and midwifery with other disciplines Innovative approaches developed and disseminated in all aspects of education, optimizing the use of technology Innovative models developed and disseminated for continuing education of nurses and midwives, including programmes that focus on quality of care Development supported of effective approaches for building leadership capacity in nursing and midwifery, and access to them facilitated Tools developed and disseminated for different approaches to set and assess nursing and midwifery education standards Development of teaching capacity supported, with a focus on methodologies that link theory to practice and education to services Educational institutional capacity developed through twinning of nursing and midwifery schools; South South and North South collaboration; faculty development Interdisciplinary and multisectoral collaboration promoted at global, regional and national levels to support networking and collaboration between disciplines and institutions. 98 A global survey monitoring progress in nursing and midwifery

101 Key result areas 5 : STEWARDSHIP AND GOVERNANCE Objectives 5.1 To support governments in the development of sound health systems stewardship and governance, with a particular focus on nursing and midwifery services. 5.2 To empower nursing and midwifery professions and their regulatory bodies to assume responsibility for self-regulation and quality of care. Expected results Tools made available on different approaches for nursing and midwifery regulations and legislation (for example, in the areas of nurse prescribing and evolving roles) Evidence-based, cost-effective options identified for establishing or strengthening regulatory structures to support implementation of mechanisms, such as registration, licensing and certification of health-care practitioners Tools and mechanisms developed to ensure that legislative reforms are informed by and reflect the contribution and scope of nursing and midwifery services Tools and databases developed to assess the magnitude of organizational and individual provider errors and their implications for health care Approaches and mechanisms established for the prevention of organizational and individual provider errors Professional input facilitated in international trade agreements that have an impact on the legislation and regulation of health- care practitioners Models and tools identified for educating nurses and midwives in the development of health policies, legislation and regulations Models and tools identified for enhancing the involvement of nurses and midwives in the development of legislation and regulations Guidelines developed or strengthened for accrediting nursing and midwifery education programmes, and their implementation facilitated Guidelines developed or strengthened for accrediting nurses and midwives, and their implementation facilitated Cost-effective models developed for improving the quality of nursing and midwifery practice Models developed for whistle-blowing legislation to protect health-care practitioners who denounce malpractice. Appendix C : Key result areas for strengthening nursing and midwifery 99

102 Co-principal investigators Linda O Brien-Pallas, RN, PhD, FCAHS Professor and CHSRF/CIHR National Chair, Nursing Human Resources Principal Investigator, Nursing Health Services Research Unit (University of Toronto site). Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. Jean Yan, RN, MA, PhD Chief Scientist, Nursing and Midwifery, Office of Nursing and Midwifery, Department of Human Resources for Health, World Health Organization Geneva, Switzerland. Co-investigators Judith Shamian, RN, PhD Chief Executive Officer, Victorian Order of Nurses, Ottawa, Ontario Co-Investigator of Nursing Health Services Research Unit, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. Judith Oulton, RN, M.Ed Chief Executive Officer, International Council of Nurses Geneva, Switzerland. Kathleen Fritsch, RN, MN Regional Adviser in Nursing, World Health Organization, Regional Office for the Western Pacific, Manila, Philippines. Gail Tomblin Murphy, RN, PhD Science Lead, Canadian Institute for Health Research, Institute for Health Policy Research, Professor, School of Nursing, Dalhousie University, Halifax, Nova Scotia. Co-Investigator of Nursing Health Services Research Unit, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. Sandra MacDonald-Rencz, RN, CHE Executive Director, Office of Nursing Policy, Health Policy and Communications Branch Health Canada, Ottawa, Canada. Fadi El-Jardali, MPH, PhD Assistant Professor, Department of Health Management and Policy Faculty of Health Sciences American University of Beirut, Beirut, Lebanon. Karen Smith, HBA Research Officer, Nursing Health Services Research Unit, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. R. Daniel Laporte, MA Research Officer, Nursing Health Services Research Unit, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. 100 A global survey monitoring progress in nursing and midwifery

103

104 WHO/HRH/HPN/10.4 In 2002, the World Health Organization (WHO) issued resolution WHA54.12, calling attention to the global shortage of nurses and midwives, and urging Member States to take action towards improving nursing and midwifery services. Later that year, the WHO went on to publish Strategic directions for strengthening nursing and midwifery services, which provided a framework of five key result areas to guide Member States in enhancing their support of nurses and midwives. Specifically, this document recommended improvements in the areas of human resources and planning, management of personnel, evidence-based practice, education and stewardship. The current report summarizes information gathered from Member States about their progress towards meeting the WHO s targeted objectives, and provides a preliminary analysis of the influence that initiatives are having on the effectiveness of certain policies as well as several population health outcomes. Responses from 77 Member States were collected and categorized according to Human Development Index ratings. Results showed that many respondent Member States have made efforts to meet the key results areas and Millennium Development Goals outlined in the Strategic directions for strengthening nursing and midwifery services. Progress was not limited to high HDI ranked Member States, but was also evident in many medium and low HDI ranked Member States. Despite their efforts, however, over 70(%) of survey respondents indicated that their country was experiencing a shortage of nurses and midwives, suggesting a continued need for intervention and improvement of these services. Health Professions Networks Nursing & Midwifery Human Resources for Health World Health Organization Department of Human Resources for Health 20, avenue Appia 1211 Geneva 27 Switzerland