Perspectives: Now is the time to raise our voices

If we are to achieve the United Nation’s target of realising universal health coverage (UHC), the greatest challenge will be meeting the health needs of the world’s rural and isolated population (approximately 48%). The majority (85%) of the world’s poorest live in rural areas (Alkire et al., 2014; Food and Agriculture Organization of the United Nations, 2018). Yet access to healthcare is limited by a lack of resources and a major shortage of healthcare workers (63% of the world’s nursing workforce work in urban areas (International Labour Organisation, 2015)).

It is our understanding that the future of rural healthcare will be in the development of dynamic teams of professionals working together and bringing their different skills and knowledge to meet the needs of their patients and communities. The World Health Organization (WHO) in the Declaration of Astana emphasised the importance of primary healthcare in achieving universal healthcare coverage and the aspirations of health-related Sustainable Development Goals (SDGs) (United Nations, 2020a). The declaration describes the primary care workforce as being multi-professional and multidisciplinary.

So how can we ensure that, as nurses, we can address the joint WHO and International Council of Nurses ‘Nursing Now’ global campaign to empower nurses to tackle health challenges and help achieve universal healthcare coverage (The Burdett Trust for Nursing, 2020; World Health Organization, 2020). The WHO designated 2020 as the International Year of the Nurse and the Midwife, particularly to address global health inequalities and the need for UHC, as nurses and midwives constitute over 50% of the health workforce. Nurses hold significant roles, presence and respect in their communities and can be powerful influencers in rural settings through direct acute and primary healthcare delivery. However, we cannot achieve UHC on our own and need to develop our leadership role and voice in collaboration within multidisciplinary teams of the future.

To move this agenda forward from both a nursing and a rural health perspective we ran two ‘thought leadership workshops’ at the 16th WONCA World Rural Health Conference in Albuquerque in October 2019. The workshop target audience was rural doctors, nurses and midwives, academics and policy makers. The ‘thought leadership workshops’ were conducted as focus group discussions to explore and gain a deeper, meaningful understanding of what rural doctors and policy-makers could do to develop and strengthen the role and voice of nursing and midwifery leaders in the rural sector across the globe. Participants were asked to come to the workshop to discuss their ideas, successful personal initiatives and experiences. We were keen to collect as many examples as possible of successful strategies to promote engagement between nurses and midwives and other health professionals in order to strengthen and promote the nursing voice and their role in rural communities. Participants explored how rural nurses could be included in key decision-making, advocacy and leadership to plan future strategies that focus on achieving UHC. We used thought leadership techniques of discussion and reflection to address the following key issues raised by the participants.

Evidence for a leadership role

Delegates agreed that a nursing contribution to leadership in rural healthcare is crucial if nurses are to have an optimal impact on UHC. To achieve this, delegates agreed that rural nurses should have an equal voice to their medical and allied health professional colleagues in decision-making at all levels, including clinical work, local teams, board level and within government ministries. There was an acknowledgement that some rural nurses may need additional professional development to be confident to lead at these levels, and that professional governance should support nurses to work to the full scope of their ability. The recognition of nurses as legitimate leaders was seen to stem from good partnership working.

Contributions and challenges

We elicited a general consensus among the participants that rural nurses made a valuable and unique contribution to universal healthcare. Participants talked of the accessibility of rural nurses: they tend to live in their communities and are more equally distributed across the community than other healthcare practitioners. Their presence in the community is especially valuable as they are likely to share a common culture and hold the same values as the people they serve, making rural nurses authentic ambassadors of healthcare services.

Workshop delegates also acknowledged some of the challenges for rural nursing. There was concern about the heavy demands and high expectations placed on rural nurses as often they are the only healthcare professional in a rural area. In some countries there has been a move towards the centralisation of key services and, consequently, rural nurses feel deskilled. Due to the isolation and the poor remuneration for rural nurses, it is often not seen as an attractive career choice. This, coupled with a focus on acute nursing in pre-registration education programmes, means that newly qualified nurses do not choose to work in rural settings and thus succession planning is a challenge. As a consequence, some participants suggested that rural nurses leave their positions because of their difficult professional lives, and hence there were concerns about increased vacancies in rural nursing. Although these challenges were a concern for delegates, the consensus was that they are not insurmountable, as illustrated through the ensuing themes.

Partnership and equity in participation

Delegates submitted a number of opinions on how successful and equitable partnership working could be achieved. The focus here was on shared learning and shared governance to facilitate professional understanding and respect. This, it was suggested, could lead to competency-based working rather than professional role demarcation so that communities received the best services from their rural healthcare team.

In addition, there was a recognition that true partnership working extends beyond the healthcare team and should include community partnerships, with shared priorities and mutually agreed strategies to tackle universal health. Of course, to address the range of priorities that a community will identify, rural nurses need to be generalists, and this was highlighted in the workshops.

Importance of generalism in nurse training and practice

As might be expected, there was a lengthy discussion about nurse education and training, and this encompassed both pre- and post-registration education. In some countries nurse registration does not exist and so delegates discussed measures that could be taken to establish programmes leading to registration. Opinions were expressed about the need to ensure that the curriculum is based on generalism, rather than the present tendency to focus on acute nursing. Some participants also asserted that nurse education programmes should be shortened to accelerate the duration by which registrants enter clinical practice. Observations were made about the limited educational opportunities for some young people who therefore are not eligible to pursue nurse education, and this was seen as unfortunate as people who originate from or train in rural settings are more likely to work there after qualification. Therefore, suggestions were made about recognising peoples’ potential to enter nurse education regardless of entry qualifications and paying more attention to rural nursing in the pre-registration curriculum. It was acknowledged that this would require more clinical placements in rural settings and a drive to increase the availability of mentors and preceptors in rural areas. In terms of post-registration, delegates were unanimous in their belief that education should be interdisciplinary, with universal credentialing based on competency rather than professional background. Participants recognised that this interdisciplinary approach will need commitment from other healthcare professions.

Collaboration in reviewing WONCA Rural Health’s mandate

Regardless of their professional background, delegates agreed that the effort to advance rural nursing needs to be embraced by all rural healthcare professionals, and WONCA Rural Health is ideally placed to take a lead in this endeavour. Participants called for a two-pronged approach, firstly by ensuring that WONCA Rural Health encouraged rural doctors to be strong advocates for nursing practitioners within their team; and secondly that WONCA Rural Health embark on a collaborative venture between medical and nursing practitioners to review their current mandate beyond that of the clinical professional role.

Promote full scope of practice

There was a strong belief by delegates that the rural community and their healthcare professionals all benefit from ensuring that nurses’ practice is not restricted through bureaucratic processes, which is a problem that is encountered particularly in developed countries. Rather, rural nurses need to be facilitated and supported to practice within the full scope of their ability, and this falls to nurse leaders, the regulatory bodies, government ministries and other professional organisations and non-governmental organisations such as WONCA Rural Health.

Integrated patient and family-centred team-based care

Participants agreed that WONCA Rural Health has a part to play in promoting a shift in the focus of care, to move from the mainly provider dialogue that currently prevails, to one of flexibility that elicits and meets the needs of the community. Again, multidisciplinarity was seen as the solution here, to draw on the best expertise and skills of individual practitioners regardless of their professional discipline. If this is to be taken seriously, then it was agreed that WONCA Rural Health could act as a catalyst to shift from the rhetoric and establish true multidisciplinary working.

Embed research and data collection

Participants agreed that provision of an evidence base is the most convincing approach to demonstrate at all levels the advantages of highly skilled rural nurses who make an equal contribution to rural healthcare. Gathering and analysing data, they asserted should fall to rural nurses, who may need some research training in order to achieve this successfully. Moreover, delegates agreed that a body of knowledge, based on research excellence, needs to be developed at a global level. Academics and policy developers can undertake such work; however, funding from government ministries will need to be forthcoming to sustain robust research of international relevance.

These eight themes were developed into a conference statement and presented to all conference delegates, where there were over 700 attendees, many present at the final plenary session for endorsement. We were pleased that no dissent was shown. We considered it was a successful step forward because medical practitioners signed up to champion and implement a number of key strategies outlined in the nursing and midwifery statement of Albuquerque (WONCA Rural Health, 2019) in their rural communities. This, we believe, will augment the role and influence of the rural nurse and midwife to lead and achieve UHC for all. The statement was ratified by the WONCA Executive Council.

Is the time now to raise our voices?

The importance of the political voice of nurses and midwives was evident in the discussions in the workshops, and emerged as an important component of leadership. The nature of the work of nurses and midwives requires us to be a voice that can provide advocacy in political arenas. Our abilities to listen, observe, assess and lead situations, either for our patients or colleagues, place nurses in a crucial position (Houskova, 2018). Nurses and midwives provide a supportive and empathetic environment that is safe for many to share confidences and opinions (Choi, 2015). This often puts us at the forefront to represent patients and speak on their behalf; and to provide clear messages to peers, to other professional leaders and most importantly to policy-makers and governments.

Our findings suggest that nursing and midwifery leaders are in a position within rural and remote communities to provide political leaders with situational analysis, professional opinion and advice. Often, nurses and midwives advise governments on components of the SDGs such as hygiene, clean water and food as a means of advocating for: (a) no poverty; (b) zero hunger; (c) health and wellbeing; (d) quality education; (e) gender equity; and (f) clean water and sanitation, and so forth (United Nations, 2020: 1). This position is evident in the literature, with authors such as Benton (2012) lauding nursing and midwifery leaders for their ability to represent vulnerable communities of different ethnic origins, gender status and vulnerable groups. According to Houskova (2018) nurses and midwives are well placed to provide a political stance in leadership through advocacy and professional representation.

Our participants in the workshops acknowledged that there is a long way to go in the development of appropriate training for the future provision of healthcare in rural communities, and they identified the need for research into the potential roles, competencies and the skill mix of the future healthcare workforce. One initiative that is making a difference is the development of rural training pathways for healthcare professionals during their professional training. Rural training pathways have proved beneficial for the long-term recruitment and retention to the rural workforce in Australia and Uganda, and have ensured nurses’ leadership skills are acknowledged and used to benefit the community (Kaye et al., 2010; Playford et al., 2020).

Conclusions

The thought leadership workshops highlighted the importance of developing the role of nurses by promoting their leadership role, encouraging practice within their ability, developing shared learning among healthcare professionals and multidisciplinary team working as solutions to achieving UHC. This creates a need to develop the evidence base to be able to inform the best strategies and practices within the local, national and global context. Research is key to the future development of rural practice for the nursing profession, as well as for the multidisciplinary team. This is especially relevant when taking into account the changes in population demographics globally, reduced workforce availability and the use of new technology. It is important that nurses and midwives have the skills and capabilities to evaluate and lead local services, especially if there has been new innovation in service provision. They are in a prime position to determine whether they are addressing the needs of the population that they serve to establish the impact of any change and to lead in the creation and implementation of new initiatives.

Output

The statement of Albuquerque is a landmark statement developed through discussion and consensus between conference delegates, senior nurses and the WONCA Rural Health executive. The statement aims to support, advocate for and promote nurses and midwives worldwide to be collaborative leaders in the process of achieving universal healthcare coverage. Consequently, this statement is seen as the start of a new collaborative initiative to take this agenda forward in order to have a global impact on rural healthcare and rural communities. This WONCA Rural Health initiative will support and create collaborations across disciplines and sectors to address the WHO State of the World’s Nursing Report and Nursing Now (The Burdett Trust for Nursing, 2020; World Health Organization, 2020). It aims ‘to improve health globally by raising the profile and status of rural nurses worldwide, influencing policy-makers and supporting nurses themselves to lead, learn and build a global movement’.

Rural doctors, including family doctors and rural nurses, work in and service rural communities and it is vital that they work together and help their communities have robust and effective health services. WONCA Rural Health is delighted to welcome nurses onto its council and is proud that its advocacy has been subsequently endorsed by WONCA – an organisation working in collaboration with the WHO.

Biography

Joyce Kenkre is Pofessor of Primary Care at the University of South Wales, and Associate Director of PRIME Centre Wales. Joyce is a Council member of WONCA Rural Health.

Shelley Nowlan is an Adjunct Professor in the School of Medicine, Griffith University, and the School of Nursing and Midwifery, University of Queensland, and has over 30 years’ nursing experience in a range of health settings. Shelley has a strong interest in supporting rural and regional communities to ensure nurses and midwives are able to meet the needs of a contemporary healthcare system.

John Wynn-Jones retired from clinical practice in 2016, having been a rural general practitioner on the Welsh borders for 37 years. He is currently part-time Senior Lecturer in Rural and Global Health at Keele Medical School and past chair of the WONCA Rural Working Party. John founded the UK Institute of Rural Health, the Welsh Rural Postgraduate Unit and was instrumental in creating the European Rural and Isolated Practitioner’s Association.

Bruce Chater is a rural general practitioner and the head of the Mayne Academy of Rural and Remote Medicine at the University of Queensland. He is the Chair of WONCA Rural Health and has contributed actively to statements, documents and strategy over the past 25 years.

Fiona Irvine is an Emeritus Professor of the University of Birmingham. During her career, she has held various teaching, research and leadership roles relating to community nursing in England and Wales.