Transforming nursing and midwifery towards health equity in Romania

Introduction
Nurses and midwives are the largest workforce in the healthcare profession. They work at the intersection of health, education and communities, and have increasingly diverse and autonomous responsibilities. In recent years, the nurse and midwifery professions have undertaken a dynamic transformation, focused on: 

• recognition of professional identity 
• expanding their role through leadership, research and innovation
• implementation of evidence-based practices (EBP).

This blog presents the key global opportunities for nursing and midwifery transformation towards evidence-based delivery of equitable, safe and quality healthcare in international and national contexts.

Background
In the last two decades in Europe, there has been a broad movement to support and develop the nursing and midwifery professions, which has been endorsed by international and national organisations. In addition, the COVID-19 pandemic brought to the fore the critical importance of health and the major contribution these professionals make in achieving health equity. More than ever, health professionals’ roles as patient advocates and champions of change are being recognised.

Patient advocacy involves providing individualised care in accordance with the patient's culture, values and preferences, while ensuring the patient has freedom to make the best, informed decisions. Champions of change are passionate about improving the quality of healthcare for everyone, especially by encouraging their peers towards innovation and the adoption of best practices in the workplace. However, assuming these roles requires adequate support from nursing and midwifery organisations.  

Until recently, the aim of The Order of Nurses, Midwives and Medical Assistants in Romania Bucharest Branch (OAMGMAMR Bucharest Branch) to further develop the profession seemed out of reach. Limited access to evidence around good practices, lack of cultural appetite for research and innovation, resistance to change, a distorted public image and lack of academic programs for nurses and midwives are only some of the reasons why professional development for this sector was challenging. 

However, the socio-political framework created by international organisations; collaboration with international research organisations, such as JBI; and the perseverance of the national professional organisation helped the nursing and midwifery profession grow.

International organisations supporting the transformation of nursing and midwifery
Since the late 1990s, the World Health Organization (WHO) has been promoting the recognition of nurses and midwives as essential members of multidisciplinary teams due to their:

• importance in the public health challenges approach and in providing safe, high quality, effective and efficient health care services 
• effective contribution to health systems.

The WHO developed Health 2020: a European policy framework and strategy for the 21st century with the main aim of improving the health and well-being of the population and decreasing health inequalities by 2030. 

In this sense, the WHO and the International Council of Nurses (ICN) designated 2020 as the International Year of Nurses. The theme for 2020 was ‘Nurses: a voice to lead – nursing the world to health’, which highlighted how nurses are central to addressing a wide range of health challenges, including health inequity.

The Future of Nursing 2020-2030 Report highlights the unique capacity nurses and midwives have in approaching the social determinants of health, including accessible, quality and equitable healthcare for the entire population. However, to lead and instigate change for health equity, nurses should have:

• a strong professional education
• supportive work environments
• autonomy
• participation in healthcare decision-making at the local, government and international levels.

Currently, the WHO strongly supports nurses and midwives’ professional development through advanced practices. 

Another international organisation that supports the transformation of nursing and midwifery is JBI. JBI is an important international research organisation that, for almost three decades, has supported the transformation of nursing and midwifery by developing and delivering evidence-based information, software, education and training to improve healthcare practices and patient outcomes.

The main aim of JBI is to provide the best available evidence to policymakers and health professionals (including nurses and midwives) to inform clinical decision-making at the point of care, globally. To do this, JBI has established a global network, the JBI Collaboration, to support academic organisations, hospitals and health systems to integrate context-specific, evidence-based healthcare practices using a theoretical model. 

National organisations supporting the transformation of nursing and midwifery
By their nature, professional organisations for nurses and midwives aim to support them in their ongoing professional development and ensure they have the necessary and appropriate skill mix to provide equitable, safe and quality healthcare. 

The OAMGMAMR Bucharest Branch is a national organisation, established in 2008. In addition to administrative responsibilities, the OAMGMAMR Bucharest Branch encourages nurses and midwives to incorporate equity and evidence in their healthcare decision-making. Its support is essential because most nurses and midwives in the country (over 25,000) are registered in this branch, and it has the political capacity to expand good practices at the national level.

Since 2010, OAMGMAMR Bucharest Branch has been part of the JBI Collaboration, hosting a research centre (the Romanian Centre for Nursing Research: A JBI Centre of Excellence) focused on implementing evidence-based practices. It is the only professional organisation in the world that hosts these types of centres. Because the JBI Romanian Centre does not belong to an academic institution, there were some challenges due to the lack of infrastructure and the lack of experience in research and innovation. Over time, the core staff of the JBI Romanian Centre have learned from their JBI mentors how to manage these challenges and continuously grow in order to support evidence-based practice in Romania. 

Institutions, such as quality inspection authorities, help healthcare organisations improve quality and patient safety across the continuum of care through their knowledge, expertise and rigorous standards. The National Authority of Quality Management in Health (ANMCS) is a public organisation established in 2010 that introduced the quality standards in Romania for the first time. It is the local engine for increasing the interest and involvement of nurses and midwives in research and innovation activities.

Clinical partnership
Engaging with clinical partners is core to the JBI Mission of seeing evidence-based healthcare globally improving policy and practice through the local and context-specific activities of the JBI Collaboration. Clinical partnerships can encourage and support efforts by nursing and midwife staff/organisations towards better health equity. In this context, the JBI Romanian Centre has developed clinical partnerships with three university hospitals in Bucharest. The purpose of clinical partnerships is to close translational gaps, which frequently occur across the evidence-based cycle, through increased knowledge, awareness and use of JBI resources for best practice and improved care, for everyone.

Within this formal collaboration, Centre staff provide training and continuous support to the hospital teams. Additionally, the clinical partners organise various events, such as workshops, working groups, brief sessions, lunchtime seminars, dissemination of results and monitoring activities.

After more than a decade of intense work, we can say that the clinical partnership impact is very positive. Some key achievements include:

• nurses and midwives being aware of their roles as patient advocates and champions of change for better healthcare, for everyone
• developing a champions of change group in each partner hospital
• identification and involvement of opinion leaders in healthcare innovation, diffusion and dissemination
• increasing the interest of nurses and midwives in professional development, research and innovation
• strengthening health care teams, and increasing professional satisfaction and patient satisfaction
• improving communication and leadership skills
• advancing the safety of the work environment
• improving knowledge related to evidence-based implementation practices
• publication of evidence implementation reports in the peer-reviewed journal, JBI Evidence Implementation.

Conclusion
In Romania, the socio-political and cultural context favours nursing and midwifery professional development to assume more complex, autonomous and expert roles, so necessary to fulfil the health equity global objectives. This recognition of their contribution leads to higher personal and professional engagement, satisfaction and motivation. Globally, evidence-based practice is the standard recognised by healthcare providers and supported by international and national organisations, including professional organisations and quality inspection authorities. The nurses and midwives' strategic position within the healthcare system indicates the importance of engaging them as change champions and patient advocates in evidence-based, clinical decision-making so that every patient receives better care.

Key take-home messages

• The socio-political and cultural context is essential for the transformation process of nursing and midwifery; adequate socio-political support can be an engine of change.
• To perform their complex role, nurses and midwives need strengthened professional education, supportive work environments, autonomy and engagement in health decision-making at local, government and international levels. 
• Academic education, involvement in projects to implement evidence-based practices, and participation in various working groups within research studies are just a few activities that prepare nurses and midwives for their roles. The supportive environment of the professional organisation and their workplace contributes significantly to their professional development and increases their self-esteem.
• The JBI Collaboration is an international network supporting research and innovation in health care.
• JBI clinical partnerships, as formal collaborative tools between clinical settings, professional organisations and academic settings, have essential benefits for everyone involved: healthcare teams, patients, communities and organisations (including hospitals, universities and JBI).
• Nurses and midwives have an essential role in managing change in practice, and they are best placed to drive change as patient advocates, clinical leaders and champions. With the right mentorship, evidence and a supportive team, they can lead and drive change in achieving equity in health objectives.
   

Authors
Doina Carmen Mazilu, Mariana Zazu
Romanian Centre for Nursing Research: JBI Centre of Excellence

Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.