Traditionally, the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader. As a result, nurses have automatically been assigned the backseat in decision making in the healthcare industry. This has led to a recurrent gap in expected patient care outcomes across most healthcare systems especially in the developing world despite them forming the largest cadre in any health system. Nurses and midwives make up more than 50 per cent of the health workforce and deliver almost 80 per cent of hands-on care. This is according to reports by Annette Kennedy, president of the International Council of Nurses (ICN).

A good example is the primary healthcare setting that forms the entry point for most patients and, therefore, the most in number. A typical health system, especially in the developing world, has a nurse or midwife as the lead of the primary health facility. When they are posted into the various primary healthcare units, they are expected to carry out both the functions of the caregiver across all services to the community as well as be the administrator and facility manager. Unfortunately, as they go through nursing school, the leadership skills and competencies of how to manage a complex health system are rarely part of the curriculum for the same nurses and midwives posted to these facilities immediately after graduation. Rarely do they receive these necessary skills or competencies as part of professional career development in the already complex health system. With this background coupled with severely restricted resources, poor infrastructure, knowledge deficit on required standards of care and poor problem-solving skills, the patient suffers the most with poor outcomes recorded most of the time with the blame lying on the same nurse or midwife by both the community and the health system leaders.

Year of the nurse

As the world makes another attempt at achieving universal health coverage by 2030 and WHO declaring the year 2020 as the year of the nurse and midwife, it is the perfect time to turn the tables and invest in the nurses and midwives to have a lasting impact and better patient outcomes. After all, it is estimated that the world needs 9 million more nurses and midwives to achieve UHC by 2030. Even though not mentioned, the world needs the nurses to be more empowered in their positions than they are currently for the said UHC to be achieved otherwise the same scenario would replay over and over. For the transformation of the healthcare system to occur, the nurses and midwives must become part of the decision-makers and be full partners alongside the rest of the healthcare professionals and not be viewed sorely as implementers all the time.

For nurses to function in this role as partner and decision-maker, there is a need to focus on a few critical aspects. These are:

1. Leadership skills and competencies:

It is necessary to invest in the nurse to acquire knowledge, skills and competencies in leadership to effectively handle the complex health system through the nursing school curriculum and as part of professional development. Working in teams, collaboration across disciplines, patient advocacy, knowledge on standards of quality and safety improvement, monitoring and evaluation of patient care and overall administrative competencies would be part of the curriculum. This would empower them to take the lead in identifying gaps in patient care, develop improvement plans and making the necessary changes to achieve set goals alongside the rest of the team successfully.

2. Team member in health policy development and validation:

As implementors of most of the policies put in place in the health system, nurses and midwives possess great potential to provide value during health policy development and validation. Non-compliance to set policies and standards is a recurrent challenge in the health system and this is partly because there is poor involvement of the implementors during development and validation leading to little or no buy-in. Being part of the team that develops health policies ensures better chances of buy-in and adherence to the policies, which automatically improves patient outcomes. As such, more nurses and midwives should intentionally be given a chance to serve actively on advisory committees, commissions and health boards where policy decisions are made to advance health systems and, in the process, improve patient care. In addition, they should be empowered with knowledge and skills to effectively handle this role.

3. Innovation opportunity:

As 80 per cent of frontline workers, it is inevitable that nurses will always face challenges at work and as such have the highest opportunity to find creative ways to ensure patient care is not disrupted. This is especially common in severely resource-restricted zones, especially in the developing world with poor infrastructure. In the developed world, the challenges present themselves as a shortage of nursing staff, an influx of patients with complex conditions and unrealistic working hours. It is not unusual to find nurses improvising ways to make their work easier and better in the ever-challenging environment. More often than not, the improvised processes cost very little due to the already complex situation and as such would reduce the burden of health finance in the health system if the production of the innovations was made commercial.  This can be an opportunity for the relevant stakeholders to invest in these creative ways to promote the nurses work and, therefore, offer them a global platform to be viewed as much more than just implementors.

Achieving universal health coverage in 10 years may be an uphill task but it is not impossible. Investing in the nurses and midwives who form the largest cadre of human resources in the health sector is one strategy that will have an impact. At the end of the day, most patients will still access the primary healthcare unit and it is still the nurse/midwife who will care for them or determine the care they will get.

Imagine if each nurse/midwife in the primary healthcare setting of the health system is empowered to identify gaps in the system, plan for improvement, identify innovative ways to solve the gaps in the ever-changing healthcare environment that can be scaled up, use the lessons learnt to influence policy changes and lead the way to sustainable gains, the transformation of the health system would occur seamlessly.

The year of the nurse and midwife 2020 provides a platform for stakeholders to intentionally shift their focus to this priceless resource and strategise on how to maximise the gains that can be achieved in the next 10 years if the investment is made to empower, improve and transform the nurse/midwife.

A significant share of health spending is at best ineffective and at worst, wasteful. One-fifth of health spending could be channelled towards better use.’ Organization for Economic Cooperation and Development (OECD), 2018.

Health Economics is not about money, it concerns the most effective and efficient allocation of scarce resources to meet a specified goal. Our goal in healthcare is the cure or mitigation of disease, but we cannot afford to fix everything so our goal as clinicians and as administrators is also to obtain the maximum cost-benefit from the treatments and strategies we employ for patient care. In this we would also be following Hippocrates’s dictum, primum non nocere, ‘first, do no harm’.

Patient harm is estimated to be the 14th leading cause of global disease burden. This is comparable to the impact of diseases such as tuberculosis, while OECD evidence suggests that 15 per cent of hospital expenditure treats safety failures. The annual cost of common adverse events in England was calculated to be worth the equivalent of the yearly salary of 3,500 hospital nurses.

Patient harm also impacts the broader economy through partial or total incapacitation of workers and productivity losses. This is a difficult figure to calculate but we can be sure that it is significant, and some work has been done on the human capital and an individual’s contribution to Gross Domestic Product (GDP) lost through medical error. A human life is priceless, but in terms of economic contribution to GDP an American study found that whilst US$19.5 billion was the direct cost of treating medical error, a further US$20 billion was lost in productivity, and in long-term disability costs.

A strong economic case at a national level can, therefore, be made for investment in patient safety, as unintended patient harm exerts a burden on society and investing in the prevention of harm can create long term value. ‘Value’ is defined here in classical economic terms, as the net impact or effect in reducing patient harm per dollar invested, expressed mathematically as: Value = Patient Outcome / Cost.

Well-constructed studies from as long ago as 1998 identified medication error (50 per cent) as the most common type of unintended harm. The word unintended is important in this context and serves to distinguish between adverse events and complications. No healthcare intervention is completely devoid of risk. Another key concept is preventability, a medication error is not easy to prevent, but investments in smart pumps, Dose Error Reduction Systems (DERS), automated dispensing cabinets, and barcode medication administration systems have all been shown to make a difference to reduce error rates.

Below we take a very simple example of how health economics can be applied to intravenous infusions given by gravity and via smart pumps with DERS. Whilst we recognise that much of the Gulf Region operates at extremely high levels of integration, well beyond a simple DERS, this is a useful exercise as around 80 per cent of all patients admitted to hospital will have an IV infusion of some sort during their stay. Furthermore, WHO data indicates that two-thirds of all adverse events occur in low-to-middle-income countries, where highly integrated solutions may not attainable.

In Health Economics Cost-Effectiveness Analysis (CEA) we commonly use a comparator to rate the introduced technology against. In this case we have gravity delivery of IV infusions as the comparator to a smart pump with DERS, (we might call this the ‘do-nothing’ option, as it employs no technology in terms of rate/dose control, warning for empty or near empty infusions or pressure limiting / vein protection alarms).

Such comparisons take place through head-to-head studies, randomised controlled trials, or literature reviews. Gravity infusions and smart pumps are such long-established technologies that we can turn to the literature to compare their efficacy and efficiency; efficacy being how well a technology performs under ‘ideal conditions’, and efficiency being how well it performs in the ‘real world’.

A summary of the documented evidence for both technologies in terms of accuracy from the literature is given below:

For the appraisal of the value impact of gravity versus DERS smart pumps, we need to know how many times the procedure is undertaken. An average Adult Day Medicine Unit (DMU) would perform about 150,000 gravity infusions per annum. We cost the resources used by both techniques, and apply costs to some of the complications, if the evidence exists. We have followed the conventions of Health Economics by applying Monetary Units (MU) to all costs in ratios that are common to the healthcare market in our region. The smart pump cost reflects staff training time in new technology, initial capital investment, disposables costs, etc. Classically the capital investment for medical technology should be discounted over time as the initial, one time, the investment gives benefits over its lifecycle but in our model, we have included all costs in a disposables cost (5.5 MU) to make comparison simpler.

Above, we have taken very basic performance figures for the smart pump and DERS, ignored fixed costs such as cannula and dressing replacements, and chosen the very lowest costs for serious IV medication error and extravasation injury from the available literature.

An OECD Cost-Effective Incremental Factor of 5:1 is in-line with expectations of such programmes in terms of investment made and return. Furthermore, extravasation injuries have been estimated to cost up to £45,500 (56,000 MU) per incident in the UK NHS, and medication errors in Europe have been estimated at €6,700 per incident. (7200 MU). Using these numbers (35X56,000) + (840 X7200) would make the Cost-Effective Incremental Factor of the programme 12:1. The OECD has saluted programmes to reduce central line infections with cost-effective incremental factors of 3:1! 

Medication error causes suffering, and for that reason alone we cannot afford to ignore it but given that active medication safety initiatives and technology bring cost-benefits, there are also compelling hard-headed financial reasons for embracing it.