EDITORIALS
Prioritizing professional practice models for nurses in low-income countries
Njoki Ng'ang'a*; Mary Woods Byrne
Columbia University School of Nursing, 617 West 168th Street, New York, NY, 10032, United States of America
The persistent crisis facing human resources for health in low-income countries demands innovative solutions to relieve constraints that include severe shortages, an inappropriate skill mix and maldistribution of personnel. The global response to focus on nurses, who form the greatest proportion of the health workforce, is the right step towards easing the urgent shortage of health workers.
In the most affected regions of sub-Saharan Africa and south-east Asia, the responsibilities of nurses have increased in line with expanding health services to meet local, national and global health targets, including the United Nations Millennium Development Goals. Studies evaluating health outcomes where this task-shifting approach is used have shown that nurses can provide high quality care safely, but only with adequate training and proper organizational support.1, 2 Unfortunately, without a comprehensive model for professional nursing practice, nurses cannot reach their potential in transforming health services delivery where it is most needed.
Professional practice models are systems (structures, processes and values) that support giving nurses more control over the delivery of care and their working environment.3 These models encompass five essential building blocks: (i) professional values, (ii) patient care delivery systems, (iii) professional relationships, (iv) management approach, and (v) remuneration. Professional values refer to a nurses' duty to promote and restore the health of individuals, families and communities while upholding fundamental human rights, respect and dignity for all.4 Without a firmly embedded regard for basic human rights, the patient is no longer central to all care-related decisions. A patient care delivery system includes the process of assigning responsibility for patient care; coordinating the nursing unit; delegating clinical decision-making authority; and communicating patient-related information. A clear definition of roles and functions is central to establishing nurses' professional identity. Professional relationships are the inter- and intra-professional exchanges that occur within multidisciplinary health-care teams. Patient care is improved when nurses are granted full status to collaborate on an equal platform with other members of a multidisciplinary team. The management approach includes support for organizational decision-making. Lastly, compensation schemes include tangible remuneration, such as salaries and bonuses, as well as intangible acknowledgement, for example recognition for achievement. Structuring an environment in which nurses derive benefit from both extrinsic factors, such as financial incentives, and intrinsic factors, such as personal gratification from delivering patient care, is essential for sustaining retention and enhancing recruitment, particularly in underserved areas.5, 6
Endorsing a professional practice model requires providing all nurses with autonomy over their own practice and a single standard of education for entry into practice. These traits, along with possession of a robust body of knowledge, recognition as a science, pursuit of education at the highest academic levels, dedication to the service of others and subscription to a code of ethics, constitute the hallmarks of a profession.7 Aspiring towards these qualities enhances nurses' identification with and commitment to the profession.8 There is evidence that there is a significant positive relationship between commitment to nursing as a profession and patient outcomes.9 To date, nurses have failed to universally achieve the characteristics of a profession as enumerated by Flexner a century ago.10, 11 Furthermore, besides uneven attainment of the characteristics of a profession among nurses in the same country, there is even greater variation in their professional status from country to country. Nurses in Europe and North America are much closer to reaching professional status than their counterparts in less-developed countries.11
Nurse leaders in low-income countries must determine the best way for nurses to make an impact on the delivery of health services. Professional practice models should be supported as a strategy to harness the collective capacity of nurses and maximize the full scope of the nursing role. Advancement towards professionalization for nurses in developing countries is crucial to the health of their populations. When nurses don't have supportive mechanisms that encourage them to fulfil their professional obligations, their ability to improve health outcomes is seriously inhibited. According to the Joint Learning Initiative, an independent network of more than 100 experts on global health, "the promise [to sustain advances in health] will be realized only when the global community mobilizes and strengthens the power of the health worker".12 We propose that professional practice models can strengthen the power of nurses to help attain the Millennium Development Goals. 
References
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* Correspondence to Njoki Ng'ang'a (e-mail: nn2254@columbia.edu).