Approaches to improving the contribution of the nursing and midwifery workforce to increasing universal access to primary health care for vulnerable populations: a systematic review

A framework was developed to conceptualize the various elements under investigation and the relationships between them (see Fig. 1). This framework is based upon the approach outlined in a discussion paper prepared for the 2014 WHO Global Forum for Government Chief Nursing and Midwifery Officers [22]. The framework helps to describe the link between nursing and midwifery leadership and governance, workforce strengthening interventions, nursing and midwifery practice and universal access and health equity. The link between leadership and governance on action and intervention is drawn from evidence of the impact of leadership upon patient outcomes [23] and acknowledges the importance of leadership at the management level [24] and the practice level in service delivery [25, 26]. Nursing and midwifery workforce areas are based upon human resources for health (HRH) performance fields that can describe both interventions and indicators to support and assess HRH performance [27].

The analysis of 11 papers identified policies at the national and state level that had impacted upon the increased supply and coverage of nursing and midwifery staff and scope of practice. Two papers describe the Indonesian and Kenyan government’s efforts to increase the numbers of midwives and nurses through scaling up education and training and deployment to underserved areas, particularly poor rural communities. In Indonesia, the presence of village midwives led to significant increases in women’s acceptance of iron tablets and use of antenatal care during the first trimester of pregnancy [41]. In Kenya, the Emergency Hiring Plan (EHP) increased the number of nurses in remotes areas by 37% and enabled the number of functioning public health facilities to increase by 29% [43]. Two papers from Rwanda [47, 48] describe the Ministry of Health’s collaboration with international donors to develop models of task shifting, or the delegation of specific HIV/AIDS tasks in a context of chronic workforce shortages, to optimize nurse performance to deliver care to adults and children with HIV/AIDS. The government’s commitment also included the provision of additional nursing staff supported by laboratory staff and ongoing laboratory services, training and antiretroviral procurement [48].

Other policy and regulation efforts to expand nurses’ scope of practice to better deliver care to vulnerable populations are described in two papers with respect to nurse practitioners (NPs) and advance nurse practitioners (ANPs). Leipert et al. [63] refer to the Canadian Nurses Association and Government-supported initiative to better integrate NPs into health care while a study by Oliver and others demonstrates that American States with legislation allowing full practice of nurse practitioners have lower hospitalization rates among Medicare-Medicaid beneficiaries and improved health outcomes in their communities [68]. Research by Sears et al. also found that the implementation of the Washington State workers’ compensation system, which involved the expansion of the NP scope of practice to increase access to health care for injured workers in rural areas, resulted in increased NP participation and a 16-percentage-point improvement in timely accident report filing by NPs particularly in rural areas [70].

Government support for the introduction and expansion of nurse-led clinics through policy and funding investment was reported in a New Zealand study whose examination of consultations over an 18-month period demonstrated a significant (>30%) reduction in child eczema severity, fewer child hospitalisations and a 50% reduction in family antibiotic use among Maori/Pacific Island and other low socio-economic groups [69]. A review of patient records at one of the first urban academic-nurse-managed clinics in America reported a range of interventions delivered to 334 urban Native Americans [67]. This nurse-led care, according to a previous study of this service, was valued by Native Americans particularly the advocacy that nurses provided on behalf of clients and the continuity of care [75].

Other papers provide examples of nursing leadership in practice. Leadership was reported to underpin successful collaboration between police and nurses in a local government region in Scotland that allowed nurses to focus on the delivery of quality care for prisoners [75]. “Strong leadership” from the Public Health Nurse Facilitator was regarded as critical to the functionality of the community health team in England to provide mainly nursing care to deprived areas [60].

Descriptions of the roles of nurses and midwives featured in the reviewed papers, followed by issues of staffing supply, distribution and skills mix; workload; supervision; performance management; and remuneration, financial incentives and staffing costs. A wide range of primary health care nursing and midwifery roles was described in the papers that contributed to improved outcomes for vulnerable populations. These included taking patient histories, screening of new patients, the surveillance of physical signs and symptoms, conducting diagnostic tests and screening for side effects, cleaning wounds, infection control, prescribing and provision of medication, assessment of social issues, education and counselling of patients, establishing contracts with patients to manage health issues, completing and submitting official forms and reports, referral and community health promotion and advocacy. Nurses and midwives worked in clinics and provided outreach services and home visiting. NP roles were described as autonomous [63] and licensed as independent health care providers whose roles were similar to those of primary care physicians [70] and who consulted with doctors as needed [63]. However, one study noted that where NPs required a doctor’s signature to process compensation for injured workers, delays in health care and accident report filing were observed, particularly for rural or underserved populations [70].

Role challenges and issues were noted in two studies. Proscribed and narrowly defined nursing roles in two studies presented by Goodman et al. were said to result in nurses limiting their involvement in district nursing efforts which led to nurses feeling ambivalent about their roles [55]. Concerns were raised in a research by Dorney-Smith about role isolation and conflict that nurses may experience while working in a hostel for homeless people which may lead to “burn out”. A number of suggestions were offered to deal with such issues if they occurred, including the presence of management at a weekly handover meeting to provide supervision and support, monthly one-to-one and group supervision and rotations to enable time away from the hostel at the main team office [53].

Many of the studies outlined the role that nurses and midwives played in the delivery of new interventions which involved the addition or specialization of the tasks they performed. This was described as an expanded or extended role using delegation or task shifting. The design and implementation of community-based health promotion, education and advocacy were regarded as expanding the role of Women’s Health Nurses in a paper outlining a programme focused on building resilience and social capital through networks in a disadvantaged community in urban Australia [56]. The addition of the provision of care to injured workers as part of newly introduced compensation legislation was also described as expanding the role of NPs [70]. The roles of two diabetes nurses who set up a weekly diabetes clinic in a rural area of South Africa were seen to have taken on extended nursing roles while diabetes-related tasks were delegated to other nurses who showed interest in the clinic in order to optimize the service [45]. Shifting specific tasks to nurses, in addition to their usual work, to scale up the care of poor rural dwelling Africans with HIV/AIDS, hypertension and diabetes was the focus of research outlined in two papers [44, 47]. Supportive mechanisms were developed to assist these nurses in their role, including the modification of clinical data collection forms, checklists and job aides to guide the process of data collection [47] and clear processes for setting up contracts with patients for disease management [44]. Shifting tasks to nurses through nurse-led clinics was found to have positively impacted upon doctors’ workload [69].

Strategies to optimize nurse’s performance and ensure appropriate workloads through task shifting from nurses to other health workers were described in two papers included in the review. Health support workers were employed in a homeless hostel, and tasks associated with dressings, observations, and medications that would normally have been undertaken by nurses shifted to this cadre so that the caseload for the nurse could be increased to best serve clients [53]. In another study, nurses’ administrative work and data collection were shifted to receptionists, counselling work was shifted to counsellors and community support groups and lab staff took on blood collection [48]. In one study, nurses viewed the establishment of a community health team to enhance services to disadvantaged communities as additional work, particularly in the initial 12-month set-up phase [60]. One nurse in this study said she was concerned that this work was not part of her paid role, highlighting the need for tasks that address the needs of vulnerable groups to be clearly identified and integrated into nurses’ roles and appraised.

In another study, substantial increases in nurses’ workload associated with the fast scaling up of an antiretroviral therapy (ART) programme in Rwanda were introduced alongside a performance-based financing mechanism [48] where nurses were contracted and remunerated according to their performance. In this study, nurse retention was found to be high which contrasts with the approach taken in other research in Rwanda where nurses did not receive salary increases or other incentives for their new role under this task-shifting initiative [47]. Staffing costs can often be the largest component of a health service; however, another study in Africa found that the provision of multiple nurse-led services via a mobile cervical cancer screening programme was an approach to potentially expand access to health care to rural populations without added costs [46]. Non-financial incentives may therefore be just as important when it comes to delivering quality care. Nurse performance in South Africa has been associated with adequate training, mentoring and support [47]. The nurse’s performance in other studies in this review was supported through a range of supervisory and recording mechanisms. Checklists and reporting forms assisted nurses to adhere to guidelines in clinical protocols [46, 61, 65] while nurses were supervised by senior nurses [59] or their work reviewed by primary care physicians [47, 51, 62].

Education and training activities are described by a number of authors to support nurses and midwives to deliver care. In a study involving nurse-led care to prisoners, nurse education was aimed to enhance the nurses’ existing core capabilities and “minimize organizational risk while supporting nurses’ role expansion” [59]. In inner city English general practices, a cascade model was employed to train specialist nurse trainers to train and mentor 23 community-based practitioners to deliver an eczema education programme to disadvantaged families [54]. However, high nurse turnover and the high levels of dermatological expertise required to deliver the sessions confidently led to this model being discontinued and replaced with specialist nurse delivery [54]. In a South African diabetes programme, an English expert nurse was employed for the first 12 months of the project to train and support the newly appointed local diabetes nurse [42, 45]. Nurse training in the start-up phase of a nurse-led service was also noted in other studies [44, 65] along with regular continuing professional education provided by special nurses [62] or doctors [39, 61].

Details of physician involvement in nurse training are provided in the studies examining nurse-led ART care in Rwanda [47, 48]. In addition to formal training through the National HIV/AIDS programme that involved physician-observed practicums, three nurses received training by doctors at each PHC facility, as well as ongoing supervision and mentorship, before they were allowed to consult patients independently [47]. An additional nurse also received the training at each PHC facility, in order to ensure replacement of staff in the ART service in case of need.

One study in this review involved the pilot of a module on social inclusion/exclusion with a group of nursing and midwifery university students. The study found that the majority of students surveyed on completion of the module held views that were generally positive and inclusive. However, some respondents held stereotypical views potentially compromising their ability to provide health care to vulnerable groups suggesting that ongoing efforts to build empathy and commitment to addressing equity may be required throughout nursing and midwifery undergraduate education [74].

This review identified significant collaborative efforts between nurses and midwives and other health providers and health care organizations, across the community, education and justice sectors, and with communities and consumers/clients/patients. Despite nurses leading the provision of services to vulnerable groups in many studies, they worked with doctors by reviewing patients together [48, 51, 52, 66] or referring when needed [53, 62, 72]. Papers described nurses also working closely with other nurses [45, 60] and midwives working with child and family health nurses [58]. In addition, nurses worked in teams with allied health professionals including physiotherapists, occupational therapists, social workers, dietitians and speech pathologists and non-professional personal support workers [64, 65], prison pharmacists [66], dieticians [72] and community support workers [45]. Communication between different professional groups was described as difficult in the early stages of the implementation of a community health team but improved over time when professionals became “aware of each other’s public health work, more confident in contacting each other to ask questions, and were beginning to share skills” [60]. Participants in this study reported that interprofessional communication would not have occurred had it not been for the community health team initiative [60].

Collaboration was also found to be central to the ability of nurses and midwives to deliver culturally competent care. In a New Zealand study, nurse communication with families and the acceptability of health care was enhanced through working with interpreter services and grounding their practice in Maori understandings of health [69]. In Australia, the staffing of The Malabar service by midwives who worked alongside Aboriginal Health Education Officers and community health workers helped to ensure community engagement, cultural safety and individualized continuity of care [58]. The importance of collaborating with community health workers to provide appropriate care to pregnant migrant Turkish women is noted in the study by Hesselink and Harting [57] where Dutch midwives and physiotherapists worked with ethnic Turkish community health workers. In addition to increasing the supply of midwives to scale up access in Indonesia, the study by Frankenberg, et al. also described the importance of midwives in developing collaborative relationships with traditional village midwives [41]. These efforts not only aimed to ensure referral to skilled providers but also acknowledged the important cultural role played by traditional birth attendants in supporting women before, during and after birth [41]. In an American study, bicultural/bilingual nurses were employed as part of a diabetes team to provide culturally acceptable care to poor Hispanic patients with type 2 diabetes [72].

The findings of two papers in the review noted the importance of collaboration with the public health sector at the national level and international donors to ensure that efforts to deliver nurse-led HIV/AIDS care are co-ordinated, well supported and contributed to health system strengthening efforts [47, 48]. Collaboration and strategic partnerships with area hospitals, community health centres and public health departments were also described in relation to the operation of a large nurse-managed clinic in America to provide ancillary and specialty health care services to the uninsured [67].

Collaboration and partnerships across sectors were also regarded as a necessary part of care provision. In Germany, The Youth Welfare Services were significant collaboration partners enabling midwives to develop trusting relationships with mothers and provide continuity of care [50]. In other studies, partnership with the voluntary sector [53], police [59] and social workers [73] not only improved the quality of care that vulnerable groups received but also assisted with linking to other services and advocacy efforts. Finally, collaboration with the community is described as a significant component of nursing and midwifery care. This includes nurses undertaking community needs assessments to inform the planning of nurse-managed care to urban Native Americans [67], consultations with community members to inform the development of activities to support networking and social cohesion [56] and working with women [63] and people living with HIV/AIDS who are patients themselves to ensure that all patients received home visits, medications and social support [47].