BMJ:如何在后新冠时代重新定位护理专业?

2021
11/06

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The pandemic has laid bare the need to invest in nursing for global health and economic security. Howard Catton and Elizabeth Iro outline how the profession must transform to maximize its effect on patient care and outcomes

The effectiveness of healthcare is inextricably linked to the state of the nursing profession. The second report of the Independent Panel for Pandemic Preparedness and Response said, “The world was not prepared, and must do better,” arguing that “the covid-19 pandemic must be a catalyst for fundamental and systemic change in preparedness for future such events, from the local community right through to the highest international levels.”1

Frailties in healthcare systems, exposed by the covid-19 pandemic, reinforce the urgent need for all governments to invest heavily in nursing to bring about such fundamental change.23

In crisis situations, seizing opportunities to reflect, learn, and grow is critical. Countries have an opportunity to address the weaknesses that have been revealed in their healthcare systems and to ensure healthcare is available to everyone. The nursing profession must plan its next steps carefully to respond to the challenges the world now faces. The current context, and increased understanding of the state of nursing in the world, provides lessons that prompt consideration of nursing’s role and the form the profession should take in the future.

But these considerations must be viewed within a wider global context that includes gender equity45 and climate change6 as drivers of a new public health policy debate. And to reach universal health coverage by 2030 nurses must radically reframe their relationship with digital technology.7

A bold vision of the profession can stimulate investment for the fundamentally changed healthcare services needed in the decades after the pandemic. Strengthening nurse education and leadership and including a nursing voice in all decisions about the future of health systems and policies, will be essential if we are to create more equitable services and better outcomes for patients and their communities.8

Year of the nurse, year of the pandemic

The 72nd World Health Assembly designated 2020 as the international year of the nurse and the midwife.9 In April 2020 the World Health Organization, in partnership with the International Council of Nurses, (ICN), and the global Nursing Now campaign published The State of the World’s Nursing 2020. This report detailed the dimensions of the global nursing workforce and provided evidence based policy options to strengthen nursing education, jobs, and leadership.10

Activities were planned worldwide throughout 2020 to raise the profile of the nursing and midwifery professions, showing their important contributions to population health, achieving universal health coverage, and society. However, many were put on hold as nurses responded to the covid-19 pandemic. It was hoped that the advocacy for the nursing role, coupled with a compelling case for investment in nursing, would encourage a new generation into the profession11 and mobilise strategic partners and financiers around the world812 to address the chronic nursing shortages that can limit service delivery and undermine patient care.10 It is also clear that investment is needed to support nurses who are struggling to cope mentally and physically with the consequences of the pandemic and exhausted from the demands of working under extreme pressure over a prolonged period.31314

Despite disruption of planned activities because of the pandemic, 2020 raised the profile of nurses and nursing work around the world. The global media focused on overcrowded hospitals, inadequate protective equipment for the workforce, and desperate personal stories of dedication and compassion—and the world clapped in support. The past year has taught us that applause is not enough. It is essential and urgent to invest in and protect all those who safeguard our health and security. The year 2021 is fittingly designated the year of health and care workers with the campaign slogan, “Invest. Protect. Together.”15

Nurses in top level leadership

The pandemic has exposed the public to the realities of nursing: nurses’ advanced clinical skills, the complexity of their work, and their commitment to patient care. The public has also seen nursing’s frailties: too few nurses with the right skills and in the right place, insufficient plans to deal with a pandemic, and in many countries a lack of nursing leadership at government level to provide much needed direction.8101617

Although nurses take on leadership at all levels, globally nursing is least represented at the highest level in governments and ministries of health.8 During the pandemic it has been normal to see chief medical officers speaking alongside government ministers but rare to see chief nursing officers doing the same. The State of the World’s Nursing 2020 indicated that only 70% of countries have a government chief nursing officer position8; an ICN assessment found even fewer countries had a position with appropriate authority.18

For health to be a central tenet of all policy making, nursing leaders must take their seats at tables in every arena where health systems and health policy decisions are directed and driven. Senior nurses have roles as enablers of health not just in health ministries, but in organizations and institutions tackling matters that affect health, including education, the environment, and the economy. For government and industry leaders to recognize the value of nursing input across multiple sectors, nurses at all levels must continue to engage in informed dialogue and debate on a range of global challenges.

WHO Global Strategic Directions for Nursing and Midwifery (2021-2025) will be presented for consideration at the 74th World Health Assembly in May 2021. It includes policy options to tackle current challenges and strengthen nursing leadership.19 Implementation would create stronger and resilient health systems better prepared for future adversities.

Global shortage of nurses

The State of the World’s Nursing 2020 presented data from 191 countries. In 2018 there were almost 28 million nursing personnel; more than 19 million were classified as “professional nurses.”8 Nine out of 10 nurses globally are female, and one in six countries have fewer young nurses than nurses expected to retire within the next 10 years.8

These 28 million nurses translate to a global nurse density of 36.9 per 10 000 population. This figure masks vast disparities in the distribution of nurses around the world. For example, there are 10 times more nurses per 10 000 population in the Americas than in the African region (83.4 v 8.7/10 000). In short, some of the poorest countries in the world have the fewest nurses.8

The report highlighted a current global shortage of six million nursing jobs.8 A further 4.7 million nurses will be needed to replace those expected to retire over the next decade.8 Other analyses have identified a “covid-19 effect,” related to the mass traumatisation of the global nursing workforce,1619 which could result in up to 10% of nurses (2-3 million) leaving their jobs once the pandemic work is done.20 In effect, much of the current nursing workforce could need to be replaced in the next decade, a gap that requires urgent action.

Up to 255 million people have lost their jobs during the pandemic,21 creating a pool of potential candidates to become the new nurses we need. ICN has called on governments to make available dedicated additional “health education and retraining opportunity” funding to support education providers to increase capacity and to support people who have lost jobs to move into the health and care workforce.22

Nurse migration

The inequitable state of the global supply of nurses and migration has left many countries with too few nurses.16 Almost 90% of the six million shortfalls in nursing occurs in low and middle income countries. About one in eight, or 3.7 million, nurses are working in countries that are not where they were born or trained.8 In high income countries, foreign born or foreign trained nursing staff comprise 15% of the nursing workforce, compared with less than 2% in lower income countries, many of which can ill afford to lose nurses.

ICN’s migration report16 underscored the importance of having data on international mobility and migration by nurses and advocated for transparency in terms of each country’s reliance on international nurses. The WHO global code of practice on the international recruitment of health personnel is widely recognized as the universal ethical framework that links the international recruitment of health workers and the strengthening of health systems.23

In addition to full implementation of the code24 ICN advocates that countries employing nurses from abroad follow ethical recruitment principles; ensure working conditions are compatible with individual nurses’ qualifications, skills, and experience; and provide family friendly contracts that allow nurses the freedom to return home or bring their families with them.

Nurse leaders should position themselves in government ministries, to lead changes that build in education and recruitment to foster greater self-sufficiency by making nursing a more desirable and valued career choice.

Valuing nursing

Nurses are valued especially for “being there” for the patient and their loved ones during life’s most challenging moments.25 This has continued throughout the pandemic, with nurses often standing in for loved ones while patients died, providing comfort and compassion in their last moments.2627

Traditionally, this kind of care and compassion is associated with love,25 an aspect of nursing that is important to people, particularly when they are struggling to deal with complex, long term, and terminal illnesses.28 Compassion is a key aspect of healing29 and can affect the delivery of quality health outcomes.29 Nursing with compassion places people at the centre of care,30 but nursing is much more than this: it is both an art and a science, requiring intelligence, skill, knowledge, and, most importantly, high quality education.

The pandemic has highlighted the need for countries to increase investments in the health workforce, including nursing. The economic and social value placed on what nurses do is deeply rooted in gender norms, including pervasive gender segregation of the nursing profession.5 The challenges surrounding workforce planning during the covid-19 pandemic have highlighted an urgent need for fair pay,31 decent and safe working conditions, and gender equity in health leadership opportunities.832 These types of expenditures should be considered integral to national health security.33

As the demand for health services and nursing care continues to grow, having the right number of nurses with the right skills in every country in the world is an equity and health security imperative. Strategies to retain nurses and midwives, especially in rural, remote, and other underserved areas, are critical.34

Delivering and leading services

Nurses’ clinical skills span a wide spectrum of health service delivery, including public health, health promotion, community care (tackling the social determinants of health), primary healthcare, hospital care, infection prevention and control, antimicrobial resistance, mental healthcare, emergency care, and care in humanitarian and disaster settings.8 Nurses not only care for the sick, they promote health and wellbeing. In some parts of the world nurses are often the first, and sometimes only, healthcare workers that people have access to. After patients have had medical interventions, often using high-tech equipment in hospitals, nurses’ clinical competency is crucial because every member of the healthcare team is equally responsible and must provide an equally high level of care.35

In many countries, nursing professionals have the main responsibility for immunisation programmes, and in some countries they are entirely responsible. With the covid-19 pandemic, nurses are participating in what will be the biggest immunisation event in history, with billions of doses administered in diverse locations worldwide. Many challenges are becoming evident, including supply chains, distribution problems, training, health education of the general public, availability of facilities and equipment for immunisation, the number of available vaccinators, misinformation, mistrust, and vaccine hesitancy.36 Coordinating valued and trusted nurse professionals to deliver on this task will move us closer to ending the acute phase of this pandemic.

At the clinical level, advanced nurse practitioners worldwide provide quality, cost effective care close to people’s homes,8 and these sorts of services can help to reshape the healthcare of the future.37 Advanced nurse practitioners create a huge opportunity to develop and grow strong health systems. They have a leading role to play in the prevention and containment of diseases, as well as in providing first contact and long term care, while benefiting vulnerable groups that other healthcare professionals may not reach.

However, some countries have regulatory restrictions that prohibit the potential expansion of the advanced nurse practitioner role. The ICN published its advanced nurse practitioner guidelines37 to support country-led approaches for advanced nursing practice that is safe, efficient, effective, and cost effective. Leadership by advanced practice nurses can help ensure nurses work to their full potential by designing and implementing nurse-led services.

Universal health coverage and inequalities

Achieving universal health coverage will require nurses to be involved in effective planning of primary healthcare services and strategic management of healthcare delivery.38 Much of the mortality burden for covid-19 has been borne by people with existing vulnerabilities, especially preventable comorbidities, and often within communities already at high risk of communicable and non-communicable diseases.3940 Tackling these inequalities falls firmly within the scope of nursing, and nurses need to be enabled, through high quality education, safe and supportive workplaces, effective leadership, and collaboration in multidisciplinary teams to fulfil this element of their practice.

Optimizing the contributions of nurses to universal health coverage through evidence based policy approaches is a clear priority for countries around the world.

Key recommendations

  • Nurses should be leaders in the design of healthcare systems, not just in delivery of care

  • Health should be considered in every government policy, with senior nurses present at the top of all health system organizations and government departments

  • Governments should lead implementation of globally endorsed strategies as appropriate for their health workforce and nursing professions

  • Countries should adopt long term workforce plans, striving for self-sufficiency in the supply of their health workforces, including nurses

  • Investment in nursing jobs, education, leadership, and service delivery should be viewed as an investment in every citizen’s safety, security, and peace

全文翻译(仅供参考)

大流行暴露了为全球健康和经济安全投资护理的必要性。Howard CattonElizabeth Iro概述了该行业必须如何转型以最大限度地提高其对患者护理和结果的影响

医疗保健的有效性与护理专业的状况密不可分。大流行准备和应对独立小组的第二份报告称,“世界没有做好准备,必须做得更好”,并认为“covid-19 大流行必须成为对未来此类事件的准备工作发生根本性和系统性变化的催化剂,从当地社区一直到最高的国际水平。” 1

由 covid-19 大流行暴露的医疗保健系统的脆弱性加剧了所有政府对护理进行大量投资以实现这种根本性变革的迫切需要。2 3

在危机情况下,抓住机会进行反思、学习和成长至关重要。各国有机会解决其医疗保健系统中已暴露出的弱点,并确保每个人都能获得医疗保健。护理行业必须仔细规划下一步,以应对当今世界面临的挑战。当前的背景以及对世界护理状况的日益了解,提供了一些经验教训,促使人们考虑护理的作用以及该职业在未来应采取的形式。

但必须在更广泛的全球背景下看待这些考虑因素,其中包括性别平等4 5和气候变化6作为新的公共卫生政策辩论的驱动因素。为了到 2030 年实现全民健康覆盖,护士必须从根本上重构他们与数字技术的关系。7

该专业的大胆愿景可以刺激对大流行后几十年所需的根本改变的医疗保健服务的投资。如果我们要为患者及其社区创造更公平的服务和更好的结果,就必须加强护士教育和领导力,并在有关卫生系统和政策未来的所有决策中加入护理声音。8

护士年,大流行年

第 72 届世界卫生大会指定 2020 年为国际护士和助产士年。9 2020 年 4 月,世界卫生组织与国际护士理事会 (ICN) 和全球护理现在运动发布了《2020 年世界护理状况》。该报告详细介绍了全球护理人员的各个方面并提供了证据加强护理教育、就业和领导力的政策选择。10

计划在 2020 年在全球范围内开展活动,以提高护理和助产专业的形象,展示他们对人口健康、实现全民健康覆盖和社会的重要贡献。但是,由于护士应对 COVID-19 大流行,许多人被搁置。希望对护理角色的倡导,加上对护理投资的令人信服的案例,将鼓励新一代进入该行业11并动员世界各地的战略合作伙伴和金融家8 12解决可能限制长期护理短缺的问题服务提供和破坏患者护理。10同样很明显,需要投资来支持那些在精神上和身体上都在努力应对大流行的后果并因长期在极端压力下工作而精疲力竭的护士。3 13 14

尽管由于大流行而中断了计划中的活动,但 2020 年提高了世界各地护士和护理工作的知名度。全球媒体关注人满为患的医院、劳动力防护设备不足,以及绝望的奉献和同情心的个人故事——全世界都鼓掌支持。过去的一年告诉我们,掌声是不够的。投资和保护所有维护我们健康和安全的人是必不可少且紧迫的。2021 年被恰当地指定为卫生和护理工作者的一年,竞选口号是“投资。保护。一起。” 15

护士在高层领导

大流行使公众了解了护理的现实:护士的高级临床技能、工作的复杂性以及对患者护理的承诺。公众也看到了护理的弱点:拥有合适技能和在合适位置的护士太少,应对大流行的计划不足,而且在许多国家,政府层面缺乏护理领导来提供急需的指导。8 10 16 17

尽管护士在各级担任领导职务,但在全球政府和卫生部的最高级别中,护士人数最少。8在大流行期间,看到首席医疗官与政府部长一起讲话很正常,但很少看到首席护理官这样做。《2020 年世界护理状况》指出,只有 70% 的国家拥有政府首席护理官职位8;ICN 的一项评估发现,拥有适当权限的国家更少。18

为了使健康成为所有政策制定的核心原则,护理领导者必须在指导和推动卫生系统和卫生政策决策的每个领域的桌子上就座。高级护士不仅在卫生部,而且在处理影响健康的事务(包括教育、环境和经济)的组织和机构中都扮演着促进健康的角色。为了让政府和行业领导者认识到跨多个部门的护理投入的价值,各级护士必须继续就一系列全球挑战进行知情对话和辩论。

世卫组织护理和助产士全球战略方向(2021-2025 年)将提交 2021 年 5 月第 74 届世界卫生大会审议。其中包括应对当前挑战和加强护理领导力的政策选择。19实施将创建更强大、更有弹性的卫生系统,为未来的逆境做好更好的准备。

全球护士短缺

《2020 年世界护理状况》提供了来自 191 个国家/地区的数据。2018年护理人员近2800万人;超过1900万人被归类为“专业护士”。8全球每 10 名护士中有 9 名是女性,六分之一国家的年轻护士人数少于预计在未来 10 年内退休的护士人数。8

这 2800 万护士意味着全球护士密度为每 10 000 人 36.9 人。这个数字掩盖了世界各地护士分布的巨大差异。例如,美洲每 10 000 人口中的护士数量是非洲地区的 10 倍(83.4 v 8.7/10 000)。简而言之,世界上一些最贫穷的国家拥有最少的护士。8

该报告强调了当前全球缺少 600 万个护理工作岗位。8还需要 470 万名护士来取代预计将在未来十年退休的护士。8其他分析已经确定了“covid-19 效应”,这与全球护理人员的大规模创伤有关,16 19一旦大流行工作结束,这可能导致多达 10% 的护士(2-300 万)离职。完毕。20实际上,当前的大部分护理人员可能需要在未来十年内被替换,这一差距需要采取紧急行动。

在大流行期间,多达 2.55 亿人失业,21创造了一个潜在候选人库,以成为我们需要的新护士。ICN 呼吁各国政府提供专门的额外“健康教育和再培训机会”资金,以支持教育提供者提高能力并支持失去工作的人进入医疗保健队伍。22

护士移民

全球护士供应和移民的不公平状况导致许多国家护士太少。16在 600 万护理短缺中,几乎 90% 发生在低收入和中等收入国家。大约八分之一,即 370 万名护士在并非他们出生或受训的国家工作。8在高收入国家,外国出生或接受外国培训的护理人员占护理人员的 15%,而在低收入国家则不到 2%,其中许多国家无法承受失去护士的代价。

ICN 的移民报告16强调了护士国际流动和移民数据的重要性,并倡导每个国家对国际护士的依赖程度的透明度。世卫组织关于卫生人员国际招聘的全球行为守则被广泛认为是将卫生工作者的国际招聘与加强卫生系统联系起来的普遍道德框架。23

除了全面实施守则24 ICN 还倡导从国外雇用护士的国家应遵循道德招聘原则;确保工作条件与个别护士的资格、技能和经验相匹配;并提供家庭友好合同,让护士可以自由回家或带家人一起去。

护士领导者应将自己定位于政府部门,引领教育和招聘方面的变革,通过使护理成为更理想和更有价值的职业选择来促进更大程度的自给自足。

重视护理

护士尤其受到重视,因为在生命中最具挑战性的时刻,为患者及其所爱的人“在那里”。25在整个大流行期间,这种情况一直在持续,护士经常在患者死亡时替所爱,在生命的最后时刻提供安慰和同情。26 27

传统上,这种关怀和同情与爱有关,25护理的一个方面对人们很重要,尤其是当他们努力应对复杂的、长期的和绝症时。28同情心是治愈29 的一个关键方面,可以影响提供高质量的健康结果。29富有同情心的护理将人置于护理的中心,30但护理远不止于此:它既是一门艺术,也是一门科学,需要智慧、技能、知识,最重要的是,需要高质量的教育。

大流行凸显了各国增加对包括护理在内的卫生人力的投资的必要性。护士工作的经济和社会价值深深植根于性别规范,包括护理行业普遍存在的性别隔离。5在 covid-19 大流行期间围绕劳动力规划的挑战凸显了对公平薪酬、31体面和安全的工作条件以及卫生领导机会中的性别平等的迫切需求。8 32这些类型的支出应被视为国家卫生安全的组成部分。33

随着对卫生服务和护理的需求不断增长,在世界上每个国家拥有适当数量的具有适当技能的护士是公平和健康安全的当务之急。留住护士和助产士的策略至关重要,尤其是在农村、偏远和其他服务欠缺的地区。34

提供和引领服务

护士的临床技能涵盖广泛的卫生服务提供,包括公共卫生、健康促进、社区护理(解决健康的社会决定因素)、初级卫生保健、医院护理、感染预防和控制、抗菌素耐药性、精神卫生保健、紧急护理,以及人道主义和灾难环境中的护理。8护士不仅照顾病人,还促进健康和福祉。在世界的某些地方,护士通常是人们可以接触到的第一个,有时也是唯一的医疗保健工作者。在患者接受医疗干预后,通常在医院使用高科技设备,护士的临床能力至关重要,因为医疗团队的每个成员都负有同等责任,必须提供同样高水平的护理。35

在许多国家,护理专业人员对免疫计划负有主要责任,而在一些国家,他们完全负责。随着 covid-19 大流行,护士们正在参加历史上最大的免疫活动,在全球不同地点接种了数十亿剂疫苗。许多挑战变得越来越明显,包括供应链、分销问题、培训、公众健康教育、免疫设施和设备的可用性、可用疫苗接种者的数量、错误信息、不信任和疫苗犹豫。36协调有价值和值得信赖的护士专业人员来完成这项任务将使我们更接近结束这一流行病的急性阶段。

在临床层面,世界各地的高级执业护士在人们家附近提供优质、具有成本效益的护理,8而这些类型的服务有助于重塑未来的医疗保健。37高级执业护士为发展和壮大强大的卫生系统创造了巨大的机会。他们在预防和控制疾病以及提供首次接触和长期护理方面发挥着主导作用,同时使其他医疗保健专业人员可能无法触及的弱势群体受益。

然而,一些国家的监管限制禁止高级护士执业角色的潜在扩展。ICN 发布了其高级护士从业者指南37,以支持国家主导的安全、高效、有效和具有成本效益的高级护理实践方法。高级执业护士的领导可以通过设计和实施护士主导的服务来帮助确保护士充分发挥其潜力。

全民健康覆盖和不平等

实现全民健康覆盖将需要护士参与初级医疗保健服务的有效规划和医疗保健服务的战略管理。38 covid-19 的大部分死亡负担由现有脆弱性的人承担,尤其是可预防的合并症,并且通常在已经处于传染性和非传染性疾病高风险的社区内。39 40解决这些不平等问题完全属于护理范畴,护士需要通过高质量的教育、安全和支持性的工作场所、有效的领导以及多学科团队的协作来实现其实践中的这一要素。

通过循证政策方法优化护士对全民健康覆盖的贡献是世界各国的明确优先事项。

主要建议

  • 护士应该是医疗保健系统设计的领导者,而不仅仅是提供护理

  • 每项政府政策都应考虑健康问题,所有卫生系统组织和政府部门都应配备高级护士

  • 政府应牵头实施适合其卫生人力和护理专业的全球认可战略

  • 各国应采取长期劳动力计划,努力实现包括护士在内的卫生人力供应的自给自足

  • 对护理工作、教育、领导力和服务提供的投资应被视为对每个公民的安全、保障与和平的投资


原文链接:

https://www.bmj.com/content/373/bmj.n1105

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关键词:
护士,全球,国家,护理,健康

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