Since its inception, the nursing profession has not been given proper recognition, especially in the developing world. Although nursing has the largest healthcare workforce, its contributions to healthcare systems are not properly acknowledged. There is need to develop a vision for the nursing profession, which must reflect the practice's professional qualification. Every profession in the world is entitled to a degree of autonomy that reflects the level of education and training required to enter that profession. Similarly, nursing should also be allowed to use the full scope of its educational credentials so that it can fully benefit society.
Nurses make up the largest part of Pakistan's healthcare workforce. However, nurses in Pakistan are often undervalued and their contribution to the healthcare system at all levels is underestimated (Chauhan, 2014). If we look at the various roles of nurses around the world, we come to realise that they can run clinics, they can practise as specialists in their subspecialty (such as family medicine, cardiology and maternal and child health) and they have the potential to do much more (O'Rourke, 2013). Unfortunately, in Pakistan's healthcare system, the horizon for nurses has been narrowed and their roles are limited to just administering medications, providing basic hygiene care and obeying doctors' orders.
Doctors in Pakistan's health system are maintaining dominance and the majority of them do not want to share their prescriptive rights with other stakeholders. Our population is dependent on doctors to access health care. Therefore, we need to make many changes if we want to ensure healthcare access for all (World Health Organization (WHO), 2013).
For my part in bringing change to the healthcare system of Pakistan, I have tried to plug this gap by building a vision of the nursing profession (Box 1). I will elaborate the internal and external challenges facing the profession of nursing and strategies to overcome them in Pakistan. I will also reflect on how can we bring about change by involving other stakeholders in my vision.
Health challenges at country level
Pakistan is in the top six countries by population size. According to the 2017 census, the population of Pakistan had increased by 57% in 19 years, to nearly 207.8 million (Pakistan Bureau of Statistics, 2019). There has long been an unmet need for health services (WHO, 2011). The national health vision for Pakistan (Ministry of National Health Services Regulation and Coordination, 2016), stated that the country faced high rates of communicable and non-communicable diseases, resulting in a double burden of disease, which is disproportionately higher among the poor. Pakistan is one of three countries where polio is still endemic (Global Polio Eradication Initiative, 2019) and tuberculosis (TB) is a problem (WHO, 2019). Pakistan is also faced with an increasing prevalence of diabetes in addition to its existing burden of TB (Mukhtar and Butt, 2016). Likewise, hepatitis B and C also contribute to a high death rate, with around 7.4% of the population affected (Farhat et al, 2014).
On the subject of mortality, 42 in every 1000 neonates do not live longer than a month (UNICEF, 2019a). Mortality rates for infants and children below the age of 5 years are 69 per 1000 of the child population (UNICEF, 2019b). Pakistan is facing one of highest prevalence of underweight children in South Asia. Micronutrient deficiencies and low birth-weight babies have been reported for some time and add to the already high levels of mortality (Bhutta et al, 2011). Maternal and child health constitutes half of the total burden of disease in Pakistan. Inappropriate maternal care means that many maternal deaths are due to preventable causes such as sepsis, haemorrhage, and eclampsia (Ministry of National Health Services Regulation and Coordination, 2016).
The majority of our system operates through a vertical healthcare delivery system, which is not sustainable. Low public expenditure on health means the system is based on donations, philanthropic organisations, and the private sector, where quality is not always the priority and basic health needs may be unmet.
Spending on health has been ‘less than 1% of GDP’ for many decades (Ministry of Finance, 2019). The country has very weak primary and secondary healthcare sectors. The majority of the population rely on private clinics and emergency care for basic healthcare needs, where they do not receive optimal care—substandard care in many private clinics in turn increases the number of cases presenting to tertiary care. Besides this, we are facing a shortage of healthcare providers in Pakistan.
Our nurses are not satisfied with their profession due to the lack of respect afforded to it, which ultimately leads to loss of interest in their work and further education. According to the Pakistan Economic Survey 2016–17 (Ministry of Finance, 2017), there were a total of 195 896 doctors and 99 228 nurses—this would represent 1 doctor per 969.8 population and 1 nurse per 2093.9 population, but their numbers might be even less today because many of these health professionals might have migrated to other countries.
Pakistan's growing population (Pakistan Bureau of Statistics, 2019) could have better access to healthcare if healthcare providers other than doctors were also allowed to practise to the full extent of their capabilities so that they can also contribute to bringing about change in the healthcare system of Pakistan. Our health system needs transformation now, as stated by the WHO's Global Health Workforce Alliance:
‘The composition of its health workforce is currently skewed towards physicians, which should be balanced by investing more in other categories of health workers.’
To do this, all healthcare providers including nurses, midwives and doctors, need to be on the same page and all have to do their best to bring about change. Nurses working at an advanced level need accessible advanced education and the support of their regulatory body so that they can practise to the full extent of their scope of practice (Davey et al, 2015).
Challenges within and outside the nursing profession
To spread my vision of a future nursing profession, there are many challenges within and outside this profession. The challenges that I foresee within the profession are greater than those outside.
Let us start with the quality of education and training for nurses in Pakistan. Quality is a major concern in nurse education. We need more highly educated and experienced nurse educators and clinical instructors who are fully competent and registered with the Pakistan Nursing Council. At present the system is producing some nurses who are not fully competent, which presents a poor image of nursing in the region.
There are many Pakistani institutions that provide good-quality education for nurses. However, competent nurses find this does not translate to higher pay, nor is their contribution valued by society. As a result, they pursue their career in developed countries, which contributes to the ‘brain drain’ of competent nurses from Pakistan (Chauhan, 2014). If we see the advantages of introducing roles such as advanced practice registered nurse (APRN), nurse practitioner (NP) or community health nurse practitioner (CHNP) in Pakistan then it is clear that the Pakistan Nursing Council should take a stand now.
Other challenges may arise at the level of national policy development. To overcome those challenges, we should have a spokesperson representing the nursing profession at national level, who can reflect on the nursing profession globally to convince the nation of the need for these advanced practice roles. We need to introduce these potential new roles to the public through the media, to make it easier for the public to understand and accept them.
Another challenge is the legislation and licensing of APRNs/NPs/CHNPs as independent practitioners in Pakistan, so that they can contribute to reducing the burden of disease and ensuring health care is improved and more easily accessible to the population.
The Pakistan medical and dental regulator needs to play a greater part as a stakeholder to share the rights of practice with APRNs/NPs CHNPs. This is not impossible, as legislators and regulators need to see that major healthcare systems throughout the world have achieved this goal through utilising the knowledge and skills of nurses to their full extent, and to their full scope of practice (All-Party Parliamentary Group on Global Health, 2016). As the authors of an article on US health care state:
‘Nurses are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team.’
Sharing the vision
When I reflect on and compare the role of the nursing profession in Pakistan with the profession worldwide, I feel disappointed that nurses in Pakistan have been unrecognised and undervalued for so many decades. The facts and figures related to the health status of our population are alarming, and to tackle these our nation needs our role. Pakistan faces many health challenges—many disease are preventable but, due to our weak system, nurses cannot intervene.
There is approximately 1 doctor for every 1000 people in our country (Ministry of Finance, 2017). But if we increase the number of healthcare providers who can be accessed by patients at community level, this would help reduce this access problem. Nurses are at the top of the list of providers who can be used in this capacity. Nurses are the first to interact with patients at all levels of care.
Nurses learn many subjects during their 4–5 years of training that are of no use in our current system. For example, nurses learn the fundamentals of anatomy and physiology, pathology, biochemistry, microbiology, community health, health assessment, pharmacology, developmental and behavioural psychology, paediatric health, adult health, mental health, epidemiology, English, ethics, biostatistics, critical care management and nursing research. They then undertake 1 year of clinical internship.
Unfortunately, despite this education, the role of nurses in our country is not what it should be. In some areas nurses just provide basic hygiene and personal care, in other areas they are used as phlebotomists, while in others they are just expected to obey doctors' orders. If we stopped this and allowed nurses to act as a true profession, that 1000:1 ratio could be halved to 500:1, and it could even go lower within a very short time. We could build a great health system.
We need a strong healthcare system, particularly at a primary level. In this way, cost-effective health care can be provided (Huang, 2015).
Stakeholders: who and why?
Involving the stakeholders in this vision is crucial. In our vision, stakeholders in the healthcare system would include the population of Pakistan, other healthcare providers such as physicians, governmental regulatory bodies, budgeting and financing authorities, and policy makers (Horev, 2005).
Sharing the vision with physicians and motivating them to change the healthcare system in Pakistan is mandatory because we want them to share aspects of their current role. The vision should also be shared with government and regulatory bodies who are responsible for nurses' licensing and accreditation. Hospital administrations and teaching institutions need to be involved in sharing the vision so that nursing careers can be mapped out, with potential for experienced nurses to take on senior positions in hospitals and teaching institutions. Feedback from all stakeholders will be required, including budgeting and financing authorities, so that these positions can be budgeted at country level. The media should be involved to help spread and share this vision of the development of APRN/NP/CHNP roles in Pakistan.
Driving forces and resistance to change
To implement this vision, nurses need to prove themselves through their knowledge and skills. Nurses and other stakeholders must be the champions to achieve this vision. Pakistan faces a lack of access to health care at all levels, a lack of equitable healthcare delivery and a lack of funds at primary level. There is also a lack of healthcare providers, high costs in the private sector, and an increasing burden of disease in the country. These are all driving forces behind the change needed. In addition, we need to ensure our education institutes are of high quality and well regulated.
I would expect some resistance to the changes needed to realise this vision, because resistance is a normal phenomenon in any change process. Government policy-makers, and licensing bodies may resist for reasons including costs. Doctors may resist change because they may fear that their role will be shared by APRNs/NPs/CHNPs and their dominance in health care lost. But the health care system can only be made stronger when a highly qualified, confident nursing profession provides shared care with doctors In that way, we could achieve a shared dream of excellent health care in Pakistan.