Strengthening the voice of nursing in policy-making


Dr Anne Marie Rafferty is Professor of Nursing Policy in the Florence Nightingale Faculty of Nursing and Midwifery at King’s College London (United Kingdom). She was elected President of the Royal College of Nursing for 2019–2021. She is also one of the co-editors of the European Observatory on Health Systems and Policies’ new publication “Strengthening health systems through nursing: Evidence from 14 European countries”. Here, Dr Rafferty shares her personal views on the role of nursing and her thoughts on the new publication.

To what degree has the role of nursing in health system strengthening been recognized to date?

Nursing’s role has received limited recognition to date, though its visibility is beginning to grow through research studies at scale supported by such bodies as the European Union (EU). Evidence is only part of the answer; the historic subordination of nursing to medicine in a number of EU countries remains an issue. The absence of the nursing voice in policy design and delivery is a consequence of this historic trend and something that is being challenged by better-educated nurses insisting on playing a part in decision-making. Reimbursement systems where doctors are reimbursed for specific services that nurses may provide are increasingly being challenged, particularly in the arena of advanced practice nursing. Also, the development of advanced practice roles for nurses means that nurses are a flexible, skilled and versatile asset in the system, capable of filling skills gaps in shortage areas if enabled to operate at their full scope of practice.

How does this study seek to capture the contribution of nursing to health system strengthening?

Each chapter follows a template so readers can compare and contrast a common data set and series of insights and observations. The introduction to the companion thematic volume to this book (to be published soon) provides an overview and synthesis of the trends and dominant themes.

What is the benefit of taking a systematic country case-study approach to understand more about health system strengthening through nursing?

By using a case-study approach, contextual factors, policy choices and variations in inputs and outcomes become self-evident and can be identified across countries. This raises questions which can then become prompts for further analysis, research, policy interventions, engagement and/or professional mobilization.

In editing this volume, what struck you as the main policy challenges confronting nursing in Europe?

What struck me most was the degree to which the policy challenges remain remarkably similar yet vary in intensity across Europe. Nursing reflects broader societal trends and is an important barometer of those trends. For instance, nursing has been hard hit by austerity and the financial crisis in Europe, and this is reflected in the workloads of nurses in Greece, Poland and Spain; England, meanwhile, has among the highest levels of burnout, lowest levels of job satisfaction and most diluted skill mix. Nursing has not been regarded as a policy priority in Europe and, therefore, investment levels in salaries have historically been relatively low to average, touching the mean or falling slightly below the average wage in different countries. Being a female-dominated profession means nursing is subject to gender bias and not necessarily taken seriously as an academic discipline or player in the policy arena.

How are responses/solutions emerging? What are the main ones?

Comparative analysis and benchmarking of salaries are being conducted by representative organizations with peer professions across Europe as the basis for lobbying for better salaries and conditions. Research and a growing evidence base is being used to formulate workforce interventions to improve the practice environment and outcomes for nurses and patients. A growing awareness of the dangers of diluting skill mix and the need to invest in upskilling to and at advanced practice levels is being promoted in a number of countries. There is an increasing emphasis on retaining the current workforce as a key solution to workforce shortages; publicizing the scale of such shortages; and advocating for the return on investment of nurses in terms of length of stay and reduced readmission, complications and missed care. In the literature examined in the study, we see that consensus is building on workforce interventions and policy levers, management of workloads, and enhancement of the skill mix and concentration of better-educated nurses to leverage better outcomes for patients.

In the context of broader skill-mix research and discourse, how is the role of nursing changing and influencing other professions?

Doctors and allied health professionals in the United Kingdom are beginning to explore the issue of safe staffing and what safe might look like. The profile of the campaigning in the United Kingdom seems to have triggered a #MeToo campaign, in a different and positive way.