For more on the WHO Nursing Now campaign see https://www.who.int/hrh/ news/2018/nursing_now_ campaign/en/

Task-shifting must recognise the professional role of nurses
The Nursing Now campaign and the designation of 2020 as the “Year of the Nurse and Midwife” by WHO highlights the need to acknowledge the competence, increase the influence, and maximise the contribution of nursing to the achievement of universal health coverage. However, poor perceptions and misrepresentation of the professional role of nurses persists. The cluster-randomised controlled trial by Oye Gureje and colleagues (April, 2019)1 published in The Lancet Global Health, which assessed the effectiveness of task-shifting and stepped care in the management of major depressive disorder at the primary health-care level in Nigeria, and the associated commentary by Bolanle Adeyemi Ola and colleagues,2 provide examples of how nurses are misrepresented and the need for the Nursing Now campaign.
Ola and colleagues consistently refer to nurses as lay health workers in their commentary, whereas Gureje and colleagues use the terms lay health workers and primary health-care workers to describe nurses, without clarifying whether the terms are interchangeable. Such clarification is important since no consensus definitions have been established for these terms, particularly in a setting such as Nigeria where different staff with variable levels of training work alongside doctors, nurses, and midwives at the primary health-care level.3,4 This ambiguity raises important questions about the findings of this study and the perception of nurses in Nigeria and Africa in general, with regard to policy.
WHO have defined lay health workers as members of the community who have received training to promote or carry out some health-care services but are not healthcare professionals.5,6 By contrast, the term ‘primary health-care worker’ has been poorly defined in published literature. Primary health-care workers have previously been defined as any staff working within primary health care including physicians, nurses, and other staff.7 The term has also been used interchangeably with ‘community health workers’,8 a term synonymous with ‘lay health workers’.9 For this study to influence policy appropriately, the definitions for these ambiguous terms need to be clarified.
Registered nurses employed within government and recognised private settings in Nigeria are adequately trained, qualified, licensed, registered, and regulated health-care professionals under the regulatory authority of the Nursing and Midwifery Council of Nigeria. Hence, nurses included in the study by Gureje and colleages1 should not have been referred to as ‘lay health workers’. Describing nurses as lay health-care workers is inappropriate, condescending, and unacceptable. Additionally, this term does not accurately reflect the challenges faced by frontline nurses who work in Nigerian and African primary health care facilities, which are often understaffed, poorly equipped, and isolated. The views and attitudes held by some physicians in Africa result in policies that constrain the professional practice and development of nurses, which might partly contribute to the poor retention of nurses in the region.10
The stringency of pre-registration education and regular continuous professional development required to remain licenced as a nurse in Nigeria might have been a confounding factor in the study by Gureje and colleagues.1 Since other non-physician primary health-care workers are not subject to the same continuous regulatory oversight as nurses, it would have been reasonable for the authors to have done a sensitivity analysis comparing the effects of the intervention when delivery was led by trained registered nurses versus other non-physician primary health-care workers. Such an analysis could have strengthened the robustness of the findings, and the health economics and policy implications of this study. The lack of clarity with regard to the professional roles of the individuals delivering the intervention might be an important limitation in the interpretation of their findings for policy.1
Registered nurses represent an important source of knowledge, skill, and competence that is poorly regarded and underutilised. Nurses provide crucial leadership in service delivery and quality patient care where physicians are often absent at the primary health-care level in Africa. The implementation of task-shifting and empowerment of nurses are important policy actions that could meaningfully transform and fill the gap in primary health-care provision in this region and will be crucial for the achievement of the Sustainable Development Goal of universal health coverage. The implementation of task-shifting and empowerment of nurses must be done in a way that acknowledges and values the professional role of nurses.
We declare no competing interests.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
*Oladayo Afolabi, Mary Abboah-Offei, Kennedy Nkhoma, Catherine Evans oladayo.afolabi@kcl.ac.uk
Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London SE5 9PJ, UK (OA, MA-O, KN, CE); and Department of Nursing, University of Maiduguri, Maiduguri, Nigeria (OA)
1		Gureje O, Oladeji BD, Montgomery AA, et al. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial. Lancet Glob Health 2019; 7	: e951–60.
2		Ola BA, Atilola O. Task-shifted interventions for depression delivered by lay primary health-care workers in low-income and middle-income countries. Lancet Glob Health 2019; 7: e829–30.
Correspondence
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