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Annals of Nursing and PracticeCentralResearch ArticleEnhancing the Role ofCommunity Health Nursing forUniversal Health Coverage:A Survey of the Practice ofCommunity Health Nursing in13 Countries*Corresponding authorAnnette Mwansa Nkowane, Department of HealthWorkforce, World Health Organization, Geneva,Switzerland, Email:Submitted: 06 November 2015Accepted: 19 December 2015Published: 06 January 2016ISSN: 2379-9501Copyright 2016 Nkowane et al.Keywords Community health nursing training Deployment and practice Universal health coverageAnnette Mwansa Nkowane1*, Jane Khayesi2, PrakinSuchaxaya3,Margaret Loma Phiri4, SilvinaMalvárez5 and Onyema Ajuebor11Department of Health workforce Department, World Health Organization, SwitzerlandUniversity of Lausanne, Switzerland3Department of Gender, Equity and Human Rights, World Health Organization SouthEast Asia Regional Office, India4University of Malawi Kamuzu College of Nursing, World Health OrganizationCollaborating Centre for Nursing and Midwifery Development, Malawi5School of Public Health, National University of Cordoba, Argentina2AbstractThis study examined the existing education and scope of practice for communityhealth nursing (CHN) and identified factors enhancing the practice. A cross-sectionalstudy among government nursing leaders, regulatory bodies, nursing traininginstitutions, nursing associations and community health nurses (CHNs) was conducted in13 countries facing human resources for health crisis. Only 12 countries are reported inthis paper due to insufficient data in one participating country. Surveyed countries hadfunctional frameworks for nursing workforce education, management regulation andservice delivery. Seventy percent of CHNs had formal post-basic training. Majorityperformed diverse roles at health facilities of which 40% performed tasks theywere not trained for. Only 15% had received inter-professional education. Surveyedcountries had incentives including retention packages. Although CHNs can contribute touniversal health coverage, the enhancement of their skills in order to effectively makethis contribution requires commitment from policy-makers and leaders in the form ofinvesting in the development of the profession.INTRODUCTIONAlthough the shift of health care from hospitals tocommunities directly affects community health nursing (CHN),community health nurses (CHNs) continue to provide necessaryinterventions outside hospitals [1]. The critical shortage ofhuman resources for health compromises the effectiveness ofhealth systems to deliver adequate and appropriate services topopulations [2]. For nursing, a health system solution is requiredto resolve the problems of inadequate nursing services andinadequate use of nursing human resources [3]. In the late 1970sand in 2008, the international community made a commitmentto primary health care (PHC) that emphasized equity, communityparticipation, health promotion, inter-sectoral approaches,appropriate technology, effectiveness, and accessibility [4].Community health nursing is defined as “a field of nursing thatcombines the skills of nursing, public health and some phasesof social assistance and functions as part of the total publichealth program for the promotion of health, improvement ofthe conditions in the social and environment, rehabilitation ofillness and disability [5].” This definition is consistent with otherdefinitions with respect to the utilization of nursing skills for thepurpose of health promotion [6-8].Beyond the Millennium Development Goals (MDGs),emphasis is being placed on universal health coverage (UHC),Cite this article: Nkowane AM, Khayesi J, Suchaxaya P, Phiri ML, Malvárez S, et al. (2016) Enhancing the Role of Community Health Nursing for UniversalHealth Coverage: A Survey of the Practice of Community Health Nursing in 13 Countries. Ann Nurs Pract 3(1): 1042.
Nkowane et al. (2016)Email:Centralwhich encompasses the principles of equity and social justice,based on the “Health for All” movement and the Alma AtaDeclaration on Primary Health Care [9]. Universal health coverageensures that all people have access to promotive, preventive,curative and rehabilitative health services, of sufficient qualityto be effective, while also ensuring people do not suffer financialhardship when paying for services [10]. Sufficient numbers ofproperly trained, well supported and motivated and accessiblehuman resources for health are key to the delivery of UHC. CHNservices are therefore pivotal to achieving UHC. Communityhealth nurses (CHNs) perform diverse roles in countries Such asIreland and China for example [11-12]. Studies have shown thatCHNs perform an important role of health promotion among theelderly and young people at home and schools thus empoweringthem to achieve their full potential [13-19]. Such roles have led toa positive perception of nursing services by young people, pupils,families and educators [18,20,21].In the context of this background, the World HealthOrganization (WHO) conducted a multi-country study on CHNbetween 2010 and 2012 with the goal of determining the existingeducation and scope of practice of CHNs in countries experiencinga critical shortage of human resources for health].MATERIALS AND METHODSStudy design, setting and participantsThe data used in this paper were collected as part of a crosssectional study by WHO. Respondents were selected from 13countries facing human resources for health crisis, three fromAfrica (Malawi, Senegal and Uganda), the Americas (Belize,Guyana, Trinidad and Tobago), South East Asia (Bangladesh,Bhutan, India, Indonesia and Nepal) and Western Pacific (SolomonIsland). Countries were considered eligible for selection if theywere classified as facing human resources for health crisis (asdefined by the World Health Report 2006). Ethical approval wassecured through the WHO Research Ethics Review Committee(ERC). Informed consent was obtained and participation wasvoluntary. The completion of the survey instrument by the nurseswas made anonymous to protect their privacy. All bodies involvedin the regulation and provision of policy directives for the nursingprofession e.g. Directorates of Nursing in ministries of health MoHand Nursing Councils were asked to participate. Professionalnursing or midwifery associations (or other associations thatrepresent the nursing profession) were also asked to participatein the study. Academic institutions were asked to participate ifthey had been providing training for at least five years. All nursesproviding services at primary health care facilities at district(or equivalent) level were eligible to participate. The procedurefor selecting participants was to randomly select six primaryhealth care centres (two urban, two peri-urban, two rural) infive districts per country. The framework for participation ofCHNs assumed that at each health facility, there will be five tosix nurses. The overall sample size for nurses participating wasabout 36 nurses per country. Government Chief Nursing andMidwifery Officers GCNMOs) responded to the questionnaireson behalf of their respective ministries of health (MoH). Heads ofinstitutions responded to the survey on educational preparationof nurses and CHNs. Registrars or their deputies were responsiblefor responding to the questionnaire on regulation of CHN. ForAnn Nurs Pract 3(1): 1042 (2016)the nursing associations, the Presidents/leaders were asked torespond to the questionnaire. Respondents eventually comprisedrepresentatives of 13 country nursing directorates, 10 nursingregulatory bodies, 44 training institutions, 11 nurses associationsand 432 practicing CHNs.Data collection procedure, study variables and analysisThe survey questionnaires were developed with clearinstructions for self-administration and sent electronically tothe participants who printed them out on site or filled themelectronically before reverting. Five different questionnaireswere used to gather information on national strategies for thepractice of nursing and the nursing profession, educationalpreparation of nurses, regulation of community health nursing,community health nursing practice and advocacy for communityhealth nursing practice. Data was entered onto STATA Infofollowed by quantitative and qualitative analyses.RESULTSNational strategies for the practice of nursing and thenursing professionThe Nursing Directorates in the 13 countries were all directlyunder the MoH. All directorates performed management, policyformulation, advisory and leadership functions. They provided apolicy and governance environment for education, managementand service delivery. All countries had a national HumanResources for Health (HRH) strategy that included a nursingstrategy except Bangladesh, Bhutan, Malawi, Nepal and Ugandawhere nursing was not a part of the national HRH strategy. TheseHRH strategies were implemented between 2003 and 2010.Furthermore, nine of the 13 countries had a clear strategy forCHN practice.Twelve of the 13 countries re-affirmed governmentcommitment to PHC, with funds allocated to expanding andstrengthening existing services. Community health nursing wasa recognized specialty in all surveyed countries requiring nursingor midwifery training and a recognized post-basic training inCHN. In Bhutan, Malawi, Nepal and Bangladesh, CHN was offeredat the basic (and post-basic for Malawi) education level. Withthe exception of Bangladesh, India, Nepal and Uganda, the othereight countries had mechanisms for monitoring and evaluatingthe nursing and midwifery workforce.To retain personnel, 12 countries offered incentives, especiallyto CHNs operating in “hardship areas”. Such incentives includedbetter living standards, hardship allowance, travel allowances,vacation allowance, higher salary, free accommodation orhousing allowance and support for further studies or professionaldevelopment. Policy makers stated that the CHN practice couldbe enhanced by improving the quality of education, using servicebased training, strengthening training institutions and increasingaccess to programs in maternal and child health, tuberculosis,HIV, mental health and chronic diseases.Educational preparation of nurses and communityhealth nursesA total of 44 institutions in 11 countries involved in the2/8
Nkowane et al. (2016)Email:Centraleducation and training of nurses completed this questionnaire.Twenty-nine were public institutions, five were private for-profit,another five were private not-for-profit and the remaining fivewere unclassified. These institutions offered various programssuch as Bachelor’s Degree in Nursing, Master’s Degree in Nursingand Diploma in Nursing (Table 1). All the institutions offeredshort courses, in-service training in clinical areas, managementand administration. Thirty-four institutions offered trainingin CHN. The program levels varied from certificate, diploma/bachelor, basic level and post-basic level (advanced diploma,graduate certificate and master’s degrees level). The duration ofthe training varied from 2-week courses, 5-month courses up to4-year courses.Eleven regulatory bodies completed this questionnaire. Inaddition to regulatory functions, most of these bodies performededucational functions, set directives on the formulation ofeducational syllabuses, conducted research and had advocacyroles. All bodies were involved in the accreditation of educationalinstitutions. With the exception of Belize, Bhutan and Guyana, theother regulatory bodies had reviewed the syllabuses of nursingand midwifery since 2004.Seven countries had varied statutory requirements for licenserenewal such as renewal every five years and after a fulfilmentof 50 hours of continuing education (Bhutan) and biannualrenewal with a requirement for nurses to meet criteria of 60hours of minimum contact with patients (Belize). The scope ofpractice was reported to be broad and beyond that of registerednurses. The expanded functions that were regulated includedcommunity assessment and diagnosis, health promotion anddisease prevention, home visits and nursing care at home, andeducation of other health workers.Community health nursing practiceFour hundred and thirty two resident CHNs in practice from12 countries completed this questionnaire. More CHNs in theAmericas and South-East Asia (42%) worked at health centrescompared to only 17% in Africa (Table 2). Majority of respondents(60%) had worked for more than five years. Most CHNs (65%)stated that their place of work was more than 4 kilometresfrom the nearest urban centre. The majority stated that CHNwas a recognized professional specialization, and had receivedformal training in CHN, and had a supervised practicum as partof training by tutors, clinical officers and field staff. However,only 15% of the CHNs had received inter-professional education(Table 2). Sixty percent of CHNs worked on multidisciplinaryteams, comprising mainly health-care professionals. A significantproportion (41%) performed tasks they were not trained forand only 13% received incentives. The incentives includedprofessional and personal development, hardship allowancesand transport allowances.The nurses’ perceptions of working conditions varied. InAfrica and South-East Asia, most CHNs viewed their workingconditions as poor, lacking resources, under-staffed, unsafe andlacking room for improvement. In the Americas, respondentsindicated that facilities were well equipped but needed anupgrade (Table 2). Most CHNs recommended an increase inallowances and the provision of other incentives. For careerprogression, pursuit of higher education was identified as a goalthat most would like to achieve in the decade. Community healthnurses also desired study scholarships and upgrading (Table 3).Advocacy and support for community health nursesEleven nurses’ associations from 10 countries completedthis questionnaire. All the associations promoted professionalinterests of nurses such as developing and maintaining standardsof nursing education and practice, developing professional ethicsamong nurses, establishing codes of ethical conduct, identifyingand examining issues relevant to nursing practice and thehealth of the community, advocating for and raising the profileof nursing, and assisting in the development of professionaland leadership skills for nurses. Regarding nurses’ professionaldevelopment, these associations were of the view that the role ofCHNs could be enhanced by upgrading CHN qualifications to postbasic level, providing opportunities to develop advanced practice,ensuring all professional nurses are protected through theNursing Act, providing incentives such as career and professionaldevelopment, scholarships, continuing education, establishingproper job descriptions for all categories of health workers in thecommunity, timely promotions and providing opportunities toparticipate in policy-making at the national level.DISCUSSIONThe 2008 World Health Report on primary health carestipulates that to reduce health inequities, a precondition is tomake services available to all by bridging the gap in the supplyof services [22]. In addition, several other regional goals andTable 1: Nursing and midwifery training programmes offered by institutions in participating countries (n 44 institutions).Programmes OfferedCertificateDiplomaHigher & Post-GraduateDiplomaFellowshipBachelor’s DegreeMaster’s DegreePh.D. or DoctorateAnn Nurs Pract 3(1): 1042 (2016)Programme AreasNumber ofInstitutionsNursing, General nursing practitioner, Community Health, Midwifery, PracticalNursing, Comprehensive Nursing6Midwifery, Community Health Nursing & Family Planning, Public HealthNursing, Neonatal Care9Nursing5Nursing11Family Nursing PracticeNursing, and Nursing & 6.8%3/8
Nkowane et al. (2016)Email:CentralTable 2: Community health nursing practice (survey responses).VariableAFRAMRSEARWPRTOTAL1. Deployment settingN 59N 39N 321N 3432Basic Health UnitChief Surgeon's UnitDistrict Health OfficeHealth CentresHospitalsOther2. Duration in Nursing PracticeLess than 2 years2-5 yearsMore than 5 yearsNo response3. Average distance of workplace to cityUnder 3 kmOver 4 kmNo response4. CHN as a recognized professionRecognizedNot recognizedNo response5. Received Inter-professional trainingYesNoNo response6. Supervision of Practicum during trainingYesNoNo response7. ReceivedInter-professional trainingYesNoNo response8. Work in a multi-disciplinary teamYesNoNo response9. Performed tasks that they are not trained forYesNoNo response10. Receive Incentives for their workYesNoNo viation: AFR: WHO African Region; AMR: WHO Region of the Americas; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific RegionAnn Nurs Pract 3(1): 1042 (2016)4/8
Nkowane et al. (2016)Email:CentralTable 3: The practice of CHN by countries participating in the survey.Bangladesh Belize Bhutan Guyana India Indonesia Malawi Nepal SenegalN 23N 27 N 30N 1N 212N 30N 13 N 36N 5Solomon Trinidad &IslandsTobagoN 3N 10UgandaN 411. Average distance of workplace to cityUnder 3 kmOver 4 kmNo response2091922. CHN as a recognized professionRecognizedNot recognizedNo response22250013. Formal Training in CHNYesNoNo response925180171810220251123262401621111724. Supervision of Practicum during trainingYesNoNo response05. Inter-professional trainingYesNoNo response1572-5 yearsMore than 5 yearsNo response7. Deployment settingBasic health unitChief Surgeon's UnitDistrict HealthOfficeHealth CentresHospitalsOther6YesNo responseYesNo responseNoNo 021211220522010. Receive incentives for their workYes110089. Performed tasks that they are not trained forNo72608. Work in a multi-disciplinary teamNo162116. Duration in Nursing PracticeLess than 2 years0304181Ann Nurs Pract 3(1): 1042 5/8
Nkowane et al. (2016)Email:Centralmandates form a solid foundation for CHN, such as the TorontoCall to Action that provides a framework for enhancing the roleof CHN in the health system [23]. CHN can contribute to reducinghealth inequalities through health promotion, disease prevention,early treatment, follow-up and rehabilitation. This calls for aneffective and efficient PHC system that links communities tohealth care facilities, access to related services, and coordinatescare for those with complex and chronic care needs [24].This study sheds light on important factors to considerin planning for CHN development. The presence of clearframeworks for nursing profession and CHN, high level positionof nursing in government structures and the universal presenceof functional regulatory bodies and associations that oversee thepractice all confirm that CHN practice can effectively contributeto UHC. Regulatory bodies and licensing authorities are essentialin regulating the practice of health professionals. Licensingregulates workers, ensures a sound level of educational training,and facilitates increased wages and higher social status [25].Historically evolving nursing regulations have enabled protectionof the public and improved professional standards and access tocare. There is evidence of some progress in increasing regulationand accreditation of advance practice nurses [26,27].Regarding training, the study found that what was consideredas basic CHN training was inadequate when compared to theactual scope of practice in the countries. This may explain whymany nurses were performing tasks they were not trained for.For an enhanced role, nurses who practice CHN should receiveformal recognized post-basic training that would provide criticalskills in planning, management and evaluation of health services.As this study has shown, there are educational institutions thatcan offer this training; the challenge is to incorporate elementsof nursing education associated with significantly better learningoutcomes some of which include – skills (including clinical),communication, advocacy and community mobilization [28,29].Another challenge regarding regulation is coordinatingprivate versus government training in order to maintain thequality of nursing services by eliminating training differences. Astarting point would be a comprehensive review of competencesfor those already in the practice [30,31]. Our study revealed thatmost of the CHNs worked on multi-disciplinary teams. There is,therefore, need for inter-professional education at basic, postbasic levels and in-service training. Nurses have found this highlyrelevant to their job performance and career progression [32].Clinical care is the mainstay of CHN. Priority should begiven to measuring their productivity and developing criticalindictors of care to assist in work force planning and continuousquality improvement in the public health nursing service [33].CHNs contribute significantly to mental health and well-beingof children [34,35] and therefore need proper skills to handlethese health issues, hence, the importance of developing corecompetencies in interactive care [36]. Training based onappropriate competences is feasible for school nurses to providehelpful interventions to families and children [37]. Communityhealth nurses perform multiple and expanded roles. It is crucialthat such role expansion is accompanied by revised and clear jobdescriptions as these are critical and are an important motivatingfactor [38]. Public health nurses/CHNs – are well-placed to shapeAnn Nurs Pract 3(1): 1042 (2016)and influence health service culture through effective clinicalleadership [39].Career associated rewards are vital for CHN jobs tobe attractive. Career progression dependent on advancedknowledge and practice specific to the clinical practice is a strongincentive for nurses to remain in the work [40,41]. This can beapplicable to CHNs and would address the findings that careerprogression in non-acute, community-based and primary carecontexts of practice has limited the attractiveness of employment[42]. Lack of a policy framework for education and career pathsfor nurses needs to be addressed by policy-makers in MoH,educational and regulatory institutions in countries. It has beendocumented that nurses are attracted to work and remain inwork because of opportunities to develop professionally, gainautonomy and participate in decision making while being fairlyrewarded [5]. Priority should therefore be given to fundingof programs for specialist post-basic or in-service training,exchange programs that offer experiences in other practice areassuch as non-communicable diseases, public health and regularinter-professional educational opportunities.Incentives enhance the contribution of health professionalsto improved health outcomes [13,16]. Most countries that haveHRH plans which have been developed in the last 12 years haveincentives in place. The non-uniformity of applying incentivessuch as retention packages reflects failure of implementationof recognized factors that enhance practice. While all types ofincentives were deemed effective, professional and personalsupport remain the most important of them all. Experts supportthe establishment of a international framework to moderatelosses of health workers to minimize the impact on vulnerablepopulations, increase in training of health workers, invest ininfrastructure, training, supervision and support mechanisms,and increase motivation and performance incentives toencourage retention with appropriate living wage embedded instrategic planning [43].It is clear from our study that CHN is sought after and commonlypracticed across countries surveyed. Although the education androles vary, CHN interventions are cost effective. For example astudy that determined the possibility of replacing junior doctors’one-year internships in remote rural areas with nurses concludedthat replacement of junior doctors with properly trained nurseswould be more cost effective in improving health in rural areas[44]. Services provided by community health practitioners(registered nurses with six months special training) are moreeffective than physician services [45] and can improve patients’sense of well-being with no increase to patients’ health care cost[46] Furthermore CHN has been shown to reduce hospitalizationlong stay and home visits [47-49] and CHN and peer counsellorsupport have been shown to increase breastfeeding education inlow-income mothers and has a potential to reduce the total costof health care interventions including cost of support [50].CONCLUSIONThe findings of our study have reaffirmed that CHN contributessignificantly to health services in the community. Although CHNs’educational preparation, practice and roles vary, they are wellplaced to contribute to PHC and improve UHC. Key roles that6/8
Nkowane et al. (2016)Email:Centralcan be enhanced for which many CHNs are not fully equippedinclude planning of health activities, management of other healthprofessionals, use of information for planning, coordinationwith other community partners and advocacy for resources foruniversal coverage from the political leadership. CHN practice canlead to improved health outcomes if well developed, regulated,and supported by appropriate policies. Low CHN staffing levelsnegatively impact health care delivery and outcomes. Nurses arethe main professional component of the health care providersin most health systems, and their contribution is recognized asessential to meeting the health needs through the provision ofsafe and effective care. In the management of CHN services, itis vital that the conditions of service are conducive enough toretain CHNs. All nurses, including CHNs, are attracted to workand remain in work because of the opportunities to developprofessionally, gain autonomy and participate in decisionmaking, while being fairly rewarded. CHNs can be catalysts insupporting and supervising community health workers, andmaking a contribution to better health outcomes.ACKNOWLEDGEMENTSAll participating countries for their contribution to the bodyof knowledge and community health nursing. Dr Eric Chan,Formerly, Chief Scientist for Nursing and Midwifery, WHO, is alsoacknowledged for his support in the development of the studyinstrument.Conflict of InterestThe authors alone are responsible for the views expressedin this article and they do not necessarily represent the views,decisions or policies of the institutions with which they areaffiliated.REFERENCES1. Schofield R, Ganann R, Brooks S, McGugan J, Dalla Bona K, Betker C,et al. Community health nursing vision for 2020: shaping the future.West J Nurs Res. 2011; 33: 1047-1068.2. World Health Organization. World Health Report 2006 - Workingtogether for Health. Geneva. 2006.3. Buchan J, Aiken L. Solving nursing shortages: a common priority. J ClinNurs. 2008; 17: 3262-3268.4. World Health Organization. From Alma-Ata to the Year 2000:Reflections at the Midpoint. Geneva: World Health Organization. 1988.5. World Health Organization. The World Health Report 2000. HealthSystems: Improving Performance. Geneva: World Health Organization.2000.6. Hitchcock J, Schubert E, Thomas SA. Community Health Nursing:Caring in Action. Cengage Publ. 2nded, 2002.7. Winslow CE. The Untilled Fields of Public Health. Science. 1920; 51:23-33.8. Mosby’s Dictionary of Medicine, Nursing & Health Professions - 9thEdition, Elsevier Publication, 2013.9. World Health Organization. The World Health Report 2013 - Researchfor Universal Health Coverage. Geneva: World Health Organization,2013.10. World Health Organization. The World Health Report – HealthSystems Financing: The Path to Universal Coverage. Geneva: WorldHealth Organization, 2010.11. Carr-Hill RA, Jenkins-Clarke S. Measurement systems in principle andAnn Nurs Pract 3(1): 1042 (2016)in practice: the example of nursing workload. J Adv Nurs. 1995; 22:221-225.12. Streiner D, Norman G. Health Measurement Scales: A Practical Guideto Their Development and Use, 3edn. Oxford: Oxford University Press,2003.13. Nkowane AM, Boualam L, Haithami S, El Sayed el TA, Mutambo H. Therole of nurses and midwives in polio eradication and measles controlactivities: a survey in Sudan and Zambia. Hum Resour Health. 2009;7: 78.14. Wood S. The contribution of nursing to public health practice in theprevention of depression. Nurs Health Sci. 2008; 10: 241-247.15. World Health Organization. 10 Facts on Ageing and The Life Course.Geneva: World Health Organization, 2011.16. Nyonator F, Abgadza C, Gbeddy D, Nyarku G, Tanya C. Jones, James F.Miller, et al. Community-Based Health Planning and Services (CHPS) inGhana: A multi-Level, Qualitative assessment in Volta Region: Reportof the CHPS M&E Secretariat. Accra: Ghana Health Service, 2002.17. Runciman P, Watson H, McIntosh J, Tolson D. Community nurses’health promotion work with older people. J Adv Nurs. 2006; 55: 46-57.18. Downie R, Tamahill C, Tannahill A. Health Promotion Models andValues. Oxford: Oxford University Press, 1996.19. Barlow J, Davis H, McIntosh E, Jarrett P, Mockford C, Stewart-BrownS. Role of home visiting in improving parenting and health in familiesat risk of abuse and neglect: results
Community health nursing was a recognized specialty in all surveyed countries requiring nursing or midwifery training and a recognized post-basic training in CHN. In Bhutan, Malawi,
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