Emory Report

July 10, 2000

 Volume 52, No. 37

First Person

A case for nurses in Europe

Marla Salmon is dean of the Nell Hodgson Woodruff School of Nursing

Over the last decade, the European health picture shifted dramatically. For the first time since the Second World War, the average life expectancy of Europeans is declining. Disparities between advantaged and disadvantaged groups are widening, and premature death and disability are on the upswing. In addition, the costs of health and social services have become unmanageable for many countries. Unless truly dramatic and significant change takes place, these trends will not be reversed.

There are some fundamental shifts already under way in Europe that signal the type and magnitude of change that is needed. Effective health systems reform requires strategic assessment, development and deployment of available human resources. People-health workers-are the centerpiece for development of the public health system, and this raises some obvious questions: Are there existing health workers whose work can serve as a foundation for expanded public health efforts? And are there groups of workers who can be mobilized to staff the public health system and advance overall health reform goals?

Nurses alone constitute the single largest category of health workforce across Europe. They can be found across a variety of settings and in virtually every country. Together with midwives, they offer great opportunity in their numbers. In addition to availability, nursing as a discipline has a unique history and culture that is congruent with what one might desire in a public health workforce. Although the depth of this culture varies across countries, its three themes are consistent: a focus on health, advocacy for the well-being of those in need, and service to society.

Nurses and midwives offer another advantage because of their presence in the community. They do much of their formal and informal work within reach of people where they live, work, learn and play. People look to nurses and midwives for help and advice. This offers a tremendous advantage in developing community health programs.

Culturally appropriate intervention is an important ingredient to effective and equitable services. This requires a workforce that represents the entire spectrum of peoples to be served, and nurses and midwives are found in practically every ethnic and racial group. Actively engaging them in public health will go a long way toward meeting the health needs of all people.

Also, nurses and midwives are a political and social force. Health is fundamentally a political and social phenomenon, and health workers need to understand this if they are to advance public health systems and services. Nurses and midwives have already served as an important source of social activism across Europe, both individually and through their professional organizations. They are a resource to the future of public health.

Finally, nursing and midwifery offer an economic benefit because their practitioners cost less than other key health providers, and they are avenues of economic opportunity for women and other marginalized groups, which has an important secondary affect on their families and communities. Devel-oping and expanding the utilization of nurses and midwives in health systems reform can enhance this effect and benefit society as a whole.

Moving to implementation, consider this proposition: "You can't go anywhere without leaving somewhere." This is one that my mother used to tell me. If we are to actually develop and engage nurses and midwives as public health workers, then we will need to leave some things behind. I want to mention a few of these:

The first is the comfort of routine roles. Taking on new functions will mean that many nurses and midwives will have to disengage from familiar ways of working, and their colleagues will need to support their movement forward. This will require abandonment of stereotypes of what nurses and midwives do and who they are. Stereotypes marginalize individuals and groups, preventing a real understanding of their value and potential.

Nurses, particularly, must become comfortable with leaving the protection of institutions. There is a great deal of certainty and structure associated with working in hospitals and clinics, but rules, routines, hierarchies and prescribed conduct can sometimes foster a certain amount of passivity and compliance. Because public health operates across settings and sectors, its workers must be proactive, self-directed and able to work in many different contexts.

In order to do this, nurses and midwives cannot view themselves simply as hourly workers whose jobs begin and end with someone else's orders. Being successful in a public health context requires a professional attitude toward work-seeing oneself as responsible and accountable for being knowledgeable, skilled and effective. Fostering professionalism is a significant challenge for many countries.

Another thing that needs to be left behind is gender barriers. Nurses and midwives should not experience discrimination because of the predominance of women in their professional ranks, nor should men as they seek to engage in these professions.

Another thing that should be left behind is working in isolation. Nurses and midwives cannot relate only to one another if they are to actively engage in public health. They must expand their network of colleagues to include many others, whether in the workplace or educational setting. It is also essential that they not be isolated in what they know and how they receive new information and ideas. Public health is a discipline that has its own literature, knowledge base and networks. Nurses and midwives need to connect with these.

Let's turn now to where we need to go next. Large-scale development of nurses and midwives as public health workers requires a fundamental paradigm shift. It begins with policymakers understanding and supporting the importance of moving in this direction. It also means, however, that nurses and midwives must advance their own thinking.

To truly develop the nursing and midwifery workforce, the context must change. Policies that frame practice, bodies that foster workforce development and the work settings themselves must be oriented toward better use of nurses and midwives. We will know that necessary change has taken place when we see these key workers engaged at all levels of the health campaign, including serving as health managers and planners, policy makers and even ministers of health.

Moving forward will rely on new models for providing services. Each country has its own sets of experiences and opportunities. However, all the models that we create should be based on the fundamental principles of public health-with nurses and midwives working collaboratively with others in their design, development and evaluation.

This brings me to another future direction: building the evidence and knowledge necessary to truly improving health. We must learn more about the impact of the work of nurses and midwives, carefully assessing existing models of service, developing and evaluating new models and creating a research base that fosters ongoing enhancement of public health. Underlying this is the need for strengthened education and engagement in the academic research enterprise.

All of these future directions depend on partnerships, and effective partnerships signal parity among partners. If nurses and midwives are to be true partners in public health, they must be seen as having high levels of responsibility and accountability for their own practice. Those who have traditionally controlled the work of nurses and midwives must engage in new ways of working as colleagues and collaborators.

Perhaps some of the most significant partnerships relate to policy development. Policy is probably the single most powerful determinant of health. If policy is to be health promoting, the voices of health workers must be heard in the policy process. Nurses and midwives should be engaged both as individuals and in groups. The development of professional organizations aimed at enhancing the overall health of society is an important step in this direction.

Where to go next? The first step is making the commitment to build an effective public health workforce-and utilizing nurses and midwives in this process. The second is engaging in real creativity, abandoning convention for at least a brief time and imagining together what might be possible.

Lastly, real change demands courage-moving from what is known and comfortable to the uncertainty of creating new futures. This is not work for the weak willed or faint of heart. However, it is certainly what all Europeans deserve from their health leaders.


This essay was excerpted from a speech Salmon delivered last month in Munich, Germany, to the Second World Health Organization Ministerial Conference on Nursing and Midwifery in Europe.

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