Theme: Nurses: A force for change: Improving health systems’ resilience

“Resilience: the capacity to recover from difficulties”
(Oxford English Dictionaries)
Wherever you are in the world it is very likely you will find that health and meeting health needs is a significant focus of public debate and concern. Indeed, it feels like health is always in the news. This may stem from a number of reasons, some predictable and others less so. For example, in many parts of the world, there are increasing health challenges related to the ageing population; a rise in chronic diseases and other long term conditions; growing citizen expectations for more and better health services; and technological progress, which continue to put an expectation of growth in funding for health services. Health systems in countries around the world are being challenged to respond by considering new ways of working and new models of care for their citizens.
The unanticipated impact of the global financial crisis on health systems continues to have implications for public finances. Equally challenging has been the evidence of the vulnerability of global health systems. The 2014 Ebola disease outbreak in West Africa showed that global action to protect health is essential; infections are able to cross borders and travel to all corners of the globe just as people can. Natural disasters and conflict do not respect country boundaries either and require responses from across the world.
This global connectedness can be a difficult concept to consider without becoming rapidly overwhelmed by its complexity. The uncertainty and sense of powerlessness it produces is all too understandable. Where do we start? How can we make a difference? It is easy to feel very small. Yet the impact of globalisation continues to grow and affect our daily lives. We are all intimately connected and, as one of the largest workforces in the world, nurses have to work together to understand and ensure that globalisation is a positive force for good.
Definition of globalisation: a process of increasing global connections, interdependence and integration, especially in the economic arena, but also affecting cultural, social political, ecological and technological aspects of life.”
(Tuschudin and Davis 2008, p.4)

As documented in the Millennium Development Goals Report (UN 2015), the world saw substantive progress in achieving the Millennium Development Goals (WHO 2015a), saving millions of lives and improving conditions for many more. However, the report also acknowledges “uneven achievements”, “shortfalls in many areas” and incomplete work. The disease specific approaches of the MDGs left many countries with fragmentation in care and weak service delivery systems. As a result, many of the countries that received development aid did not build health systems that can provide necessary essential services to all people in need.
As previously mentioned, the Ebola virus disease outbreak in western Africa clearly showed that without a health system capable of responding rapidly and effectively, an epidemic can spread rapidly across borders and cause tremendous problems (WHO 2014)( When hit by the outbreak, the most affected countries had a fragile health system with insufficient numbers of health care workers (WHO 2015b). As a result, the response was not timely; existing health services were disrupted and many health care workers who cared for affected people died (WHO 2015c), further threatening the health of the populations (David et al. 2015) In fact, a May 2015 preliminary report by WHO (2015c) on health workers infected with Ebola, stated that of the 815 health care workers who had been infected by the Ebola virus since the onset of the epidemic, more than 50% were nurses and nurse aides. Two thirds of the health workers who were infected had died.
This outbreak raised many questions: How can you rapidly respond to a lack of health care workers due to illness or even death? How can you rapidly skill up a nurse workforce to deliver care in very different settings? How do you rapidly get access to the right equipment? How do you communicate to the public in an effective way? There is a clear need for health systems that can respond to such shocks in a timely and effectively manner while continuing to provide necessary health services.
“The resilience of a health system is its capacity to respond, adapt, and strengthen when exposed to a shock, such as a disease outbreak, natural disaster, or conflict.”
Campbell et al (2014)
The complexity of this work includes pace of response needed, availability of resources in the right place at the right time and damaged infrastructure and a depleted health care workforce. Therefore, we need to be prepared before the next emergency comes, having in place emergency provisions, people that can be deployed with the right competencies and plans to divert resources.
In the busy life of most practising nurses, thinking about how we can support and strengthen the health system we work in is not a common activity. Yet the need to develop our thinking, planning and profile in this important area is all too evident. We are a vital force for the changes that the system needs.

Responding to new challenges
The nurse workforce has a long history of responding to the changing needs of society. We have developed our practice to tackle public health challenges and to ensure the provision of high quality care. Throughout the 20th century and into the 21st century, significant gains have been made in increasing life expectancy and reducing many of the risk factors associated with child and maternal mortality. Nurses have made significant contributions to improving child survival and their impact is well documented (Awoonor-Williams et al 2013). Major progress has been made in increasing access to clean water; improving sanitation; reducing malaria, tuberculosis, and polio; and decreasing the spread of HIV (Marmot et al 2012). Nurses have been at the forefront of many of these gains (ICN 2013) but we would all acknowledge that more can be done. On top of known health problems, we face emerging global threats such as antimicrobial resistance, new pandemics, emerging infections, natural disasters, global climate change, armed conflicts and migrants. What might this mean for us?
There is much evidence of nurses’ responsiveness and the important role we play in contributing to population health which has been increasingly acknowledged by governments and recognised by the World Health Organization (WHO 2003, 2015d). Indeed, the nursing workforce is increasingly well- educated and able to connect with citizens, communities, policy makers and each other. However, the need to adapt and change more quickly is evident and the challenges set out in the next 15 years will require a new generation of innovation and leadership. As nurses gain a higher profile in the development of local, national and international responses, we need to have confident well-informed leaders who understand their role in developing a workforce to meet new challenges.
Investing in the health workforce to strengthen health systems. The increase in demand on our health systems has been associated with an increased expectation of funding and it is now apparent that there is a strong link between the economic and the general health of a population. However, expecting and receiving a bigger share of public finances at times of economic crisis are two different things; the ability to constantly find more funding is a real challenge at all levels, from individuals to governments. In some cases, as governments seek short-term savings, we have seen real reductions in health expenditure (Karaniklos 2013) leading to both short- and long-term consequences. If not borne by governments, the cost of health care to individuals can lead to increased poverty. A WHO and World Bank Group report (2015) shows that 400 million people do not have access to essential health services and 6% of people in low- and middle-income countries are tipped or pushed further into extreme poverty because of personal health spending. However, as health has a value in itself, as well as being a precondition for economic progress, improvements in health and economic conditions are mutually reinforcing.
The Lancet Commission report “Global Health 2035: a world converging within a generation” (Jamison et al 2013) makes a strong economic case for greater prioritization of health by economic ministers, stating “The returns on investing in health are impressive. Reductions in mortality account for about 11% of recent economic growth in low and middle income countries as measured in their national income accounts.” (Jamison et al. 2013, p.1898).

The report describes the possibility of a “grand convergence” in health, which is achievable within our lifetime. It presents a detailed analysis that shows that with enhanced investments to scale up health technologies and improve delivery systems it will be possible to reduce child and maternal mortality rates as well as mortality rates from infectious diseases to low levels universally. In most low-income and middle-income countries these rates would fall to those presently seen in the best-performing middle-income countries. As Jamison et al. (2013) write, “Achievement of convergence would prevent about 10 million deaths in 2035 across low-income and lower-middle-income countries…” (p.1898)
Additionally, the report notes that employment in the health sector can strengthen local economies. The health care workforce is significant and employs a lot of women. Well-educated nurses are, therefore, good for the economic health of a country.
New Goals: From MDGs to SDGs
There is now a global recognition that whatever the nature of the challenges, staying focused on ensuring healthy lives and promoting well-being for all at all ages is essential to sustainable development. The need for strong and resilient health systems, able to respond to rapid change, is at the heart of the United Nations Sustainable Development Goals (SDGs).
The 17 SDGs (see Box 1) and 169 targets were adopted by Member States of the United Nations General Assembly in September 2015 (UNGA resolution 70/1). Building on the MDGs, the SDGs are relevant to all countries and cover the economic, environmental and social pillars of sustainable development with a strong focus on equity addressing the root causes of poverty. They are all interlinked underlining the fact that sustainable development in any country requires many parts of the system to work together.

1End poverty in all its forms everywhere
2End hunger, achieve food security and improved nutrition and promote sustainable agriculture
3Ensure healthy lives and promote well-being for all at all ages
4Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
5Achieve gender equality and empower all women and girls
6Ensure availability and sustainable management of water and sanitation for all
7Ensure access to affordable, reliable, sustainable and modern energy for all
8Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all
9Build resilient infrastructure, promote inclusive and sustainable industrialization and foster
10Reduce inequality within and among countries
11Make cities and human settlements inclusive, safe, resilient and sustainable
12Ensure sustainable consumption and production patterns
13Take urgent action to combat climate change and its impacts (acknowledging that the United Nations Framework Convention on Climate Change is the primary international, intergovernmental forum for negotiating the global response to climate change)
14Conserve and sustainably use the oceans, seas and marine resources for sustainable development
15Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
16Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels
17Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development

The third goal, which is the most specific to health and well-being, has 13 targets (3.1-3.9) and enablers (3.a-3.d). (see Box 2)
Box 2. The 13 health targets in Sustainable Development Goal 3 – Ensure healthy lives and promote well-being for all at all ages
3.1By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births
3.2By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births
3.3By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases
3.4By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being
3.5Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
3.8Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
3.9By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and
air, water and soil pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least-developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

It is expected that this will be associated with a range of activities and action plans throughout health systems. While most activities will be focused on Goal 3, many of the other goals will also require action from the nursing workforce and nurse policy makers have a lead role to play in this.
One of the targets (3.8) is Universal Health Coverage (UHC), which has received much attention as a key enabler to sustainable development.
Universal Health Coverage (UHC)
The goal of UHC is to ensure that all people can use the promotive, preventive, curative, rehabilitative and palliative health services that are of sufficient quality, while at the same time ensuring that the use of these services does not cause financial hardship to the consumers (WHO 2013).
The recent report “Tracking universal health coverage: First global monitoring report” (WHO & World Bank Group 2015) shows that we are a long way from its achievement. The report, which is the first of its kind to measure health service coverage and financial protection to assess countries’ progress towards UHC, looked at global access to essential health services in 2013 including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis
"The world's most disadvantaged people are missing out on even the most basic services …A commitment to equity is at the heart of universal health coverage. Health policies and programmes should focus on providing quality health services for the poorest people, women and children, people living in rural areas and those from minority groups".
Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation, WHO (WHO & World
Bank 2015)
treatment, and access to clean water and sanitation. As previously mentioned, the report found that at least 400 million people lacked access to at least one of these services, and that many people were being tipped or pushed further into extreme poverty because they had to pay for health services out of their own pockets.
WHO and the World Bank Group (2015) recommend that countries pursuing UHC should aim to achieve a minimum of 80% population coverage of essential health services and that everyone everywhere should be protected from catastrophic and impoverishing health payments.

Nurses play a central role in achieving UHC and there are numerous examples of nurses expanding access to essential health services (ICN 2011, 2015a). Some of ICN’s initiatives to expand access include the ICN’s Wellness Centres for Health Care Workers (see health-care-workers/) and the ICN TB/MDR TB project ( icn-tb-mdr-tb-project.html).
New Expectations of the Workforce
Sustainable Development Goal 3, Ensuring healthy lives and promoting the well-being for all, at all ages, is essential to the achievement of the other SDGs. UHC means not only reaching everyone in need, but also delivering quality health care services that are people-centred. This requires a well-performing health system with a sufficient number of well-trained motivated health workers. It is projected that there will be a shortfall of 10.1 million skilled health professionals (nurses, midwives and physicians,) by 2030 (GHWA 2015). Many of those countries which struggled to achieve the MDGs face shortages and misdistribution of health workforce (ICN 2014). Scarcity of qualified health personnel, including nurses, is highlighted as one of the biggest obstacles to achieving health system effectiveness (Buchan and Aiken 2008). Workforce investment remains low and it is still the case that future projections demonstrate that low income countries will face a widening gap between the supply and the demand for health workers (Tangcharoensathien et al 2015). There is a growing expectation that rich and poor countries alike build national self-sufficiency to manage their in-country supply and demand for human resources for health through appropriate health human resources planning (ICN 2014).
In this regard, the WHO has developed the Global Strategy on Human Resources for Health (HRH): Workforce 2030 which is expected to be submitted to the World Health Assembly (WHA) in May 2016 for adoption.

Vision: Accelerate progress towards universal health coverage and the UN Sustainable Development Goals by ensuring universal access to health workers
Overall goal: To improve health and socioeconomic development outcomes by ensuring universal availability, accessibility, acceptability and quality of the health workforce through adequate investments and the implementation of effective policies at national, regional and global levels
•Promote the right to health
•Provide integrated, people-centred health services
•Foster empowered and engaged communities
•Uphold the personal, employment and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of
•discrimination, coercion and violence
•Eliminate gender-based violence, discrimination and harassment
•Promote international collaboration and solidarity, in alignment with national priorities
•Ensure ethical recruitment practices in conformity with the provisions of the WHO Global Code of Practice on the International Recruitment of Health Personnel
•Mobilize and sustain political and financial commitment and foster inclusiveness and collaboration across sectors and constituencies
•Promote innovation and the use of evidence
1.To optimize performance, quality and impact of the health workforce through evidence-informed policies on human resources for health, contributing to healthy lives and well-being, effective universal health coverage, resilience and health security at all levels.
2.To align investment in human resources for health with the current and future needs of the population taking account of labour market dynamics, to enable maximum improvements in health outcomes, employment creation and economic growth.
3.To build the capacity of institutions at sub-national, national and international levels for effective leadership and governance of actions on human resources for health.
4.To strengthen data on human resources for health, for monitoring of and ensuring accountability for the implementation of both national strategies and the Global Strategy.

ICN has long recognised the importance of better planning with regards to the nurse workforce (ICN 2014) and has supported the development of this strategy. Once adopted by the WHA, there will be an expectation of local action, and there is a value to National Nurse Associations (NNAs) in starting to work towards these objectives and targets now.
Why should nurses engage in health system strengthening?
We can all acknowledge that the world has never possessed such a wide range of interventions and technologies for curing disease and increasing life expectancy. Yet the gaps in health outcomes continue to widen (Crisp & Chen 2014). The positive impact of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way and on an adequate scale.
The role of public health in building and strengthening health systems and increasing their resilience is clearly a priority for all nurses. Investing in health promotion and illness and disease prevention can have a positive impact by potentially relieving demands made on the health system by those in ill health as well as contributing economically to society through healthy and productive citizens.(Jamison et al
2013). As Tangcharoensathien et al (2015) state in their article on UHC and the SDGs. “Primary health care, which the majority of poor can access, acts as a major hub in translating UHC intentions into practice.”
All of the policy recommendations detailed in the SDGs and the HRH proposal make clear that action on the social determinants of health should be a core part of health professionals’ business, as it improves clinical outcomes, and saves money and time in the longer term. But, most persuasively, taking action to reduce health inequalities is a matter of social justice.
What is social justice?
“Social justice means the fair distribution of resources and responsibilities among the members of a population with a focus on the relative position of one social group in relationship to others in society as well on the root causes of disparities and what can be done to eliminate them (CNA 2009).
When social justice is applied to health and health care, the term “resources” means more than access to health services. It also includes access to others features such as housing, sanitation, transport, work and education. Collectively, these are referred to as the social determinants of health. Taking action for social justice means action to reduce differences and promote equal access. As most nurses on a daily basis see examples of inequity, it is evident that nurses have a significant role to play in contributing

to strong systems in their daily practice. At the core of promoting health and well-being, a fundamental for all nurses is the notion of social justice (CNA 2009, Sheridan 2011 PJN 2013, ICN 2011).
Every health professional has the potential to act as a powerful advocate for individuals, communities, the health workforce and the general population, since many of the factors that affect health lie outside the health sector, in early years’ experience, education, working life, income and living and environmental conditions health professional may need to use their positions both as experts in health and as trusted respected professional to encourage or instigate change in other areas.
Institute of Health Equity (2013), p.5
The ICN Code of Ethics for Nurses clearly states nurses’ responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations (ICN 2012a). The role of the nurse as an advocate for equity and social justice appears in the guidance of many National Nursing Associations and there are also examples of health professionals working together to have greater influence on policy makers to improve opportunities in this area (Allen et al 2013).
Definition of Nursing
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN 2002)
As Tomblin-Murphy and Rose (2015) note in their summary of relevant literature concerning nursing leadership in strengthening primary health care to support the SDGs and Universal Health Coverage worldwide, nurses are educated with a holistic lens so that all facets of a person’s health and well-being are considered when planning and delivering care. They note that there is an increasing focus on the determinants of health, but stress that the current models of health delivery still tend to focus primarily on the treatment of illness. They stress the importance of primary care in remote communities and/or in low-middle income countries where much of the care delivered at the local level depends upon the expertise of community health workers or nursing assistants. The role that nurses and nursing play in supporting their colleagues in communities through advocacy, mentorship, collaboration and

recognising the important contribution of nursing assistants and community health workers in maintaining local services is key to future development (Dick et al. 2007).
There is recognition that in many health systems, health is defined by an “illness system” with a primary focus on individuals and their diseases (WHO 2007), and this focus has produced a health system that poorly serves the need of a wider society. Do you agree and what can we do to change this?
Research shows that the more divided a society is, the less likely it is to adopt public health policies. How can we work to improve cohesion in the communities we seek to serve?
(McKee and Mackenbach 2013)

Developing a Strong Health System
A deeper look into health systems
Health systems encompass many subsystems, such as human resources, information systems, health finance, and health governance (Box 4.).
Box 4: What is a health system?
A health system consists of all of the organizations, institutions, resources and people whose primary purpose is to improve health. This includes efforts to influence determinants of health as well as more direct health-improvement activities. The health system delivers preventive, promotive, curative and rehabilitative interventions through a combination of public health actions and the pyramid of health care facilities that deliver personal health care – by both State and non-State actors. The actions of the health system should be responsive and financially fair, while treating people respectably. A health system need staff, funds, information, supplies, transport, communications and overall guidance and direction to function.
WHO (2007)
In 2007, the WHO identified strengthening health systems as a global strategic priority. They argued that this priority was “Everybody’s Business” (WHO 2007).
They identified six key building blocks to achieving a strong system which are listed below:
1.Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources.
2.A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).

3.A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.
4.A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
5.A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.
6.Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system-design and
(WHO 2007,
Well-functioning health systems are required in order to deliver quality health care to all people when they need it, where they need it, and at prices they can afford. Strengthening health systems, however, is challenging given their complexity. USAID (n.d.) captured this challenge in its description of health systems strengthening:
“A process that concentrates on ensuring that people and institutions, both public and private, undertake core functions of the health system (governance, financing, service delivery, health workforce, information, and medicines/vaccines/other technologies) in a mutually enhancing way, to improve health outcomes, protect citizens from catastrophic financial loss and impoverishment due to illness, and ensure consumer satisfaction, in an equitable, efficient and sustainable manner.”
All of the subsystems of a health system can be weakened by different types of constraints. For instance, health care may cost too much, causing people to delay seeking care or to forego it altogether. A country’s health budget may not cover all of its population’s health needs. As a result, a country’s health outcomes may suffer.
In most heath systems, expenditure on workforce accounts for approximately 70% of recurrent spending (WHO 2006). However, it is important to remember that a strong health system cannot be achieved without a well-performing health workforce. In other words, the health of the population cannot be achieved without investing in the health workforce. There is growing evidence that, in addition to the economic benefit of keeping people healthy, investments in the health workforce can have positive impacts on socioeconomic development (GHWA 2015). We need to transform the traditional way of viewing the health workforce as a recurrent cost or expenditure to viewing investment in the health workforce as a strategy to achieve health for all and to grow economies by creating qualified jobs in the public sector.

A weak health system cannot be resilient. The next chapter will look at how we can improve resilience of health systems.
Thinking about where you work, do you see the WHO (2007) six building blocks in action? Where do they need strengthening? What can you do and who could help you?
A sustainable health system has three key attributes: affordability, for patients and families, employers and the government; acceptability to key constituents, including patients and health professionals; and adaptability, because health and health care needs are not static.
(Fineberg 2012, p.1020)

What is Health Systems’ Resilience?
“Health system resilience can be defined as the capacity of health actors, institutions and populations to prepare for and effectively respond to crises;: maintain core functions when a crisis hits; and ,informed by lessons learned during the crisis, reorganise if conditions require it.”
Kruk et al (2015) p.1910
What is health system resilience and how can it be improved?
Resilient health systems are essential for the provision of UHC and can provide a prompt response to outbreaks of disease. As Oxfam notes in its account of lessons learnt from the Ebola outbreak (2015), and as supported by evidence from other sources, resilient health systems require long-term investment in six key areas which correspond to the six building blocks of health systems defined by WHO (2007):
1.An adequate number of trained health workers
2.Available medicines
3.Robust health information systems, including surveillance
4.Appropriate infrastructure
5.Sufficient public financing
6.A strong public sector to deliver equitable, quality services

Reflection Point
Critically consider the six points associated with a resilient health system.
How would you “rate” your organisation/system? Are there any actions you could take individually or with colleagues to improve it?
Although much has been done to develop strong health systems it appears that this is not the whole answer; systems, and the individuals within them, also need to be able to cope with change and challenges.
The goal for successful health systems is to be able to adapt, learn and be flexible. These three core concepts are fundamental to building and developing resiliency.

· Flexibility is characterised by an ability in the
Figure 1. The three factors for resilience

organisation to easily modify its processes. These

could relate to factors such as workforce

employment conditions or service delivery models.

· Adaptability is the ability of an organisation to

change or be changed in order to fit or work better

in some situation or for some purpose.

· A learning organisation is an organisation that

facilitates the learning of its members and

continuously transforms itself.

In an article that draws from insights of research into resilience from other fields, Kruk et al (2015) explore health system resilience. They describe resilience as an emergent property of the health system as a whole, which cannot necessarily be addressed by considering the national context alone. They consider health system resilience to be a global public good which needs a collective response from the global community.
Kruk et al (2015) identify five key elements for a resilient health system:
1. Resilient systems are aware: they use information to understand and model risks and responses.

Global public goods are defined as those from which nobody should be excluded and the use by one person does not reduce use by others.
Oxfam (2015)
2.Resilient systems are diverse: they are able to address a broad range of challenges due to the variety of resources available, e.g. primary care, capacity in the workforce. (This is more feasible where there is UHC).
3.Resilient systems are self-regulating: they can contain and isolate threats and still deliver core health services and move additional resource if required.
4.Resilient systems are integrated: they generate strong connections to other key partners, communities and agencies.
5.Resilient systems are adaptive; not just in times of crisis but normal times too, e.g. they change to demographic needs, internally displaced people and delivery methods.
This then raises the question of where to invest the limited resources that are available for building resilient health systems. As Oxfam (2015) notes, “While public provision has historically suffered from chronic under-investment and concerns have been raised over the quality of services, the evidence shows that it is still the most effective and equitable model to deliver health for all.” (p.21) It is important to remember that primary health care (PHC) is the preferred and effective means of delivering essential health services at a cost which governments and communities can afford (WHO 2008). A national health care system is more effective when it is based on PHC that provides a range of publicly funded essential, universally accessible and equitable health services to the population. In countries that have achieved near-universal health coverage, health care services are funded through tax revenue systems (WHO 2010a). Financing mechanisms need to allow universal access to care without putting a heavy burden on the poor. This means putting in place a sound financing model that removes barriers to access - such as out-of-pocket payment, distance and travel time to the health facility - and to high quality care. (ICN 2015a, p.9)
As many reports have noted, when the costs of healthcare become a financial burden, poverty increases, especially in the case of women. On the other hand, free public health services not only improve the health of a population but also remove financial burdens and contribute to the reduction of inequality (WHO 2010a). Just as interventions such as basic vaccines for children are a global public good, investment in health resilience should too be viewed as a global public good (Oxfam 2015).
Likewise, control of infectious diseases, such as HIV/AIDS or TB, is considered a global public good (WHO 2016), but we need resilient health systems – systems that are adaptive, aware and integrated – in order to effectively handle infectious disease outbreaks such as the 2014
Ebola virus. Investment in resilient health systems should be seen as a global public good and ‘aid’ as a contribution to mutual benefit for all. Instead of focusing on a particular programme or policy, such as targeting a particular disease or building scheme, donor ‘aid’ to a country would become a contribution to the financing of resilient health systems in that country to benefits its citizens and those outside its border.

Reflection Point
Do you believe that investment in health system resilience is a global public good? Would it change your views about the distribution of “aid” if it was framed this way?
Nurses at the core of resilience
Nurses make a significant contribution to developing and maintaining resilience in health systems. We contribute to service development; supervise and develop other members of the team; work with and advocate for patients, their carers and communities; and collect data and inform the development of evidence.
The importance of nursing at all levels of the health system, including governmental and policy levels, is recognised in health systems strengthening. Ventura et al (2015) reviewed the evolution of WHO’s initiatives for strengthening nursing and midwifery and found clear documentation of the increasing importance of nurses as multidisciplinary health team members and their role in the improvement of health systems. Nurse leaders involved in health systems capacity building bring knowledge of population needs and can ensure that strategies are in line with these needs.
There is also a clear link between the vital role nurses play and the availability of evidence. Nurse leaders should be present at all levels of the health system in order to participate in health systems capacity building that is based on population needs (Ventura et al 2015).
Shamian et al. (2015) list nine areas where nurses can make an essential contribution to discussions on health systems and health workforce strengthening. These areas of impact are explored further below.
Nurses and nursing can:
1. Lead and support interprofessional education (IPE) and interprofessional collaborative practice (IPCP). Interprofessional collaboration is an innovative solution to health systems’ strengthening. IPE prepares health workers for interprofessional collaboration and is an essential precursor to collaborative practice. IPCP creates a strong and flexible health workforce with health professionals sharing best practices in the face of opportunity and challenge. Collaborative practice represents an opportunity for nurses to maximize their skills and practice at their highest capacity (WHO 2010b).

Nurses are encouraged to advocate for IPE to be included in core curricula and as a part of health worker training programmes. In all of the settings in which they work, nurse leaders have an important role in advancing interprofessional collaboration and ensuring that it is supported by appropriate governance, policies, environments and delivery models (Sullivan 2015).
2.Advocate for a paradigm and operational shift in health care that balances illness focused care with population health. Global agendas and plans “require a recognition that we need to be in the business of health and not in the business of illness” (Shamian et al. 2015). As nursing care is focused on people, we understand the need for a balance between illness-focused and population-based health systems. Nurses can advocate for a population health approach in their practice. This approach incorporates community-based wellness strategies and acknowledges the determinants of health of populations (see point 9 below).
3.Identify and champion global and national strategies to address health workforce maldistribution and migration. These strategies should be evidence-based and tailored to the local context. They should aim to address regulation for nursing education, skill mix, working conditions and environments, continuous professional development, and career structures. National nurses associations can cooperate with decision-making bodies, governmental and nongovernmental, to achieve appropriate human resources planning, ethical recruitment strategies, and sound national policies on the immigration and emigration of nurses (ICN 2007).
4.Strengthen and diversify primary health care. Primary health care (PHC) creates resilience, efficiency and equity in health systems. Strengthening PHC requires international, national, educational, institutional, regulatory and individual support. There are many ways in which we can take action to build, support and sustain the nurse’s role in PHC. Examples of nursing contribution include advocating for legislation and policy that allows nurses to practice to their full capacity, participating in PHC research, working to influence educational policies to include PHC concepts and principles as at least basic elements in nursing curriculum, and encouraging communities to lobby for political support for PHC.
5.Ensure a strong nursing voice in all health and social system policy development and planning dialogues. ICN believes that all nurses should contribute to public policy development and planning related to care delivery systems, health care financing, ethics in health care and determinants of health (ICN 2008). As a group, we have a massive potential to build and expand our political capital. However, the key to achieving this potential is found in the ability of the individual nurse to recognise and use her or his own voice. Nurses who are unfamiliar with how to engage in policy making can begin by first gaining knowledge of the policy process.
A number of examples can be found how nurses in different parts of the world have worked to coordinate their actions and advocate for public and health care service polices (Benton 2012).Numerous opportunities exist for involvement in policy at the micro level especially policy development related to nursing workforce needs (Patton et al 2015, p.17).

ICN calls for NNAs to employ a number of strategies to contribute to effective policy development, including monitoring the utilisation of nurses in the workforce; incorporating new models and management strategies; continually marketing a positive image of nursing to key management and policy stakeholders nationally and internationally; disseminating relevant knowledge and research; and, continually developing and maintaining appropriate networks to enable collaborative working relationships with governmental and non-governmental organizations (ICN 2008).
6.Consider the influence of regulation and legislation on the health system and HRH planning issues.
Meeting HRH demands requires a qualified and competent nursing workforce that is able to meet the needs of the population. ICN calls for regulation to be purposeful, transparent, accountable, ultimate, flexible, efficient, representative and proportionate; and for collaboration with stakeholders in order to ensure that nurses have sufficient competencies and are practicing to the full extent of their education and training.
7.Design and improve information infrastructures and data collection to support health system redesign and planning. Information infrastructures can collect information about the size, skill-mix, license type, demographics, distribution and education of the nursing workforce. This nursing workforce data is required to make informed decisions related to health system redesign and planning.
8.Participate in research related to HRH and in health systems research and evaluation in order to create and synthesize the best evidence. Nursing research will play an important role in HRH planning and development and in addressing health system and policy questions required for health systems strengthening. Health systems research builds evidence-based knowledge for use at policy and planning, programme, and operational levels. Evaluation assesses health innovations and outcomes. Within the nursing community, more awareness of the benefits of health systems’ research is needed to highlight the importance of nurses’ participation this area.
9.Consider the influence of complex, ubiquitous social and gender issues such as the determinants of health, and inequality and inequity. HRH research indicates that systemic gender imbalances pose a major challenge for the health workforce (Newman 2014). Women must participate in decision-making and policy-setting and have a lead role in setting the health agenda. Nurse educators and managers are encouraged to promote gender equality in their settings. Anticipating health care workers’ lifecycle needs and recognising that sociocultural factors call for vigilance can assure equality of opportunities and non-discrimination (Newman 2014).

Improving Organizational Resilience
There are many ways in which nurses are well placed to contribute to developing health systems, but for most nurses it is at the individual, health care team and organisational levels that they can have the most impact.
However, as models and pathways of care change, even the term “organisation” can become difficult to describe. Sometimes even the question, “Who do I work for?” may not have an obvious answer.
The ability to be prepared for different challenges is increasingly being viewed as a key outcome for a successful organisation and strategic leadership teams have a key focus on this. Organisational preparedness or resilience is a core competence of a board team (CIPD 2011).
British Standard, BS65000 (2014) defines "organisational resilience" as "ability of an organization to anticipate, prepare for, and respond and adapt to incremental change and sudden disruptions in order to survive and prosper."
Using a structured approach to resilience, consider the following examples that could occur in practice:
·an emergency department anticipating a surge of demand associated with a major accident
·a health facility looking after older adults anticipating a response to a flu outbreak
·an isolated health facility anticipating a scenario where adverse weather reduces communications
·an infection control lapse in a community clinic affecting hundreds of residents
·a paediatric department anticipating an increased child respiratory illness in winter
Looking at these scenarios, it is apparent that there are many parts of the health system that need to work together when faced with challenges in order to prevent a serious breakdown in the ability of the system to deliver appropriate care.
Resilient organisations strive to be prepared for the best, but also for the worst, quickly restoring business capabilities when faced with disruptions. Individuals in resilient organisations are attentive and aware that failure may occur and continuously search for mechanisms to improve the reliability of operations across the whole organisation.

1.What has been the effect of the last major and unexpected change in your organisation? What did you learn about this change? How were these lessons shared?
2.How does your organisation prepare for changes in the health care environment? Does it work with partners to do this?
3.What processes does your organisation have to identify and analyse emerging trends? How effectively are these trends acted upon and are the necessary changes made?
4.What more can you do to contribute to your organisation’s resilience?
Approaches to developing resilience
In a guide developed to help organisations develop resilience, the Chartered Institute of Personnel and Development (CIPD 2011) identifies four areas for consideration in the development of approaches. These are: the characteristics of a person’s job; the culture and operating procedures of an organisation; the characteristics and influence of leaders in the organisation; and external events and the environment within which the organisation operates. CIPD (2011) describes each of these in the following manner:
1.Job design – resilience is dependent on the features of a person’s job role, that is, how demanding the person’s job is, how much control they have in their job, and what type of motivators or rewards (internal and external) are associated with a particular job.
2.Organisational culture and structure – the culture of the organisation and way the organisation adopts work processes and procedures are seen as central to resilience. For example, if an organisation has a bureaucratic structure coupled with a command and control culture, this may be detrimental to the extent to which people within the organisation are able to respond and adapt to challenges.

3.Leadership – emergent leadership (leadership from middle managers) and engaging, supportive leadership styles may heavily influence the ability of employees to be resilient to adverse events.
4.Systemic/external environments – the external environment and social relationships are seen to be key to resilience. If networks of successful relationships are not established, both for employees and for the organisation itself, the organisation may not have the resources to adapt to change effectively and positively. Social and institutional support is seen as key at every level. Also, organisational resilience is seen as dependent on the resilience of stakeholders, competitors and the industry in which it operates.
Team care
Team approach is an important concept for organisational resilience as in today’s complex health care delivery systems, it is impossible for a single professional group to provide a continuum of people- centred care and consultations. Instead, linkages and referrals are needed to achieve coordination and continuity of care. The evidence of the benefits of a team approach is growing and include better health outcomes, improved client and staff satisfaction, and lower cost for health institutions (Mezzich et al 2015), all of which can help organisations to be more resilient.
Work environment
Organisations can support resilience by ensuring a positive practice environment (PPE) that offers a safe and healthy workplace, opportunities for continuing education and professional development, access to necessary equipment and supplies, appropriate workloads and attractive working conditions (WHPA 2008) ). Organisational culture to support effective team work, such as open communication, transparency, support, supervision and mentorship, are other elements of PPEs.
Recruitment and retention can affect health systems’ resilience. Flexible job design is an important element of efforts to recruit and retain skilled employees and to improve the deployment of available nursing skills (ICN 2012b). Benefits to flexible work practices, where nurses have influence or control, include improved health and well-being, improved job satisfaction and organisational commitment and reductions in organisational staffing concerns, such as absenteeism and turnover. Choice is the critical link between flexible work practices and better outcomes and nurses’ involvement in staffing and scheduling decisions can make the difference between success and failure (ICN 2012b).
Approaches to risk management
A significant part of developing flexible, adaptable and learning systems is linked to the ability to identify and manage risk. The adverse health effects from identified risks can be avoided or reduced by the application of a wide range of risk management measures by health and other sectors working together

Risk management is assessment, analysis and management of risks. It is simply recognising which events (hazards) may lead to harm in the future and minimising their likelihood (how often?) and consequence (how bad?).
NHS Direct (2007)
with people who are at risk of these events. This will include actively working with patient and community groups as partners in developing innovative responses.
Much has been written about risk assessment and management and there are many resources available to support learning in this area but in its simplest form, risk assessment seeks to answer four related questions:
·What can go wrong?
·How often?
·How bad is it?
·Is there a need for action?
It is not usually possible to eliminate all risks, but health care staff have a duty to protect patients as far as ‘reasonably practicable’. This means we must avoid any unnecessary risk. It is best to focus on those risks that really matter – those with the potential to cause harm. If the risk assessment process becomes too complicated, it can detract from the real purpose which is taking some action to prevent risks from occurring.
Our understanding of risk and resilience needs to be connected and new research in this field points to how a combined understanding of these elements will help us
develop new insight into health disparities (Panter-Brick 2014). Specifically, researchers have advocated a sophisticated knowledge of risk, a more grounded understanding of resilience, and comprehensive and meaningful measurements of risk and resilience pathways across cultures.
As Panter-Brick (2014) notes “In matters of health, research on risk often trumps research on resilience. However, there is growing momentum to shift attention from risk to resilience in health research and practice”.
Increasingly, evidence supports the strong link between organisational resilience and outcomes. Positive strategies to support the development of organisational resilience can result in significant individual and organisational benefits including improved productivity, improved well-being, and reduced absenteeism and turnover (McAlister and McKinnon 2009).

Reflection Point
What risks can you identify in your organisation? How would you prepare for these risks? One example to consider might be a member of the health care team becoming ill and taking a day off
What areas need to be strengthened to improve resilience of your organisation? How could you address these?

Developing Personal Resilience
Nurses and nursing are subject to growing pressures, including regular reviews and reorganisations, coping with changes to service delivery and models of care, financial pressures, expanding scopes of practice and enhanced expectations of what a nurse workforce should achieve (ICN 2015b, 2015c). Nurses, along with other health care staff, also experience physical and psychological stress caused by long working hours. The experience of increased stress and difficult workplace environments contributes to increased sickness rates and poor staff retention (McAlister and McKinnon 2009). The resultant staff shortages can put additional pressure on the remaining staff. We have looked at what can be done at an organisational level, such as ensuring PPE. This chapter will look at solutions at individual level.
Much has been documented about the stresses of the health care environment, which are real and valid, and the solution to addressing them is the focus of much research. Chronic stress can lead to cognitive impairment and mental-health disorders, taking its toll on emotions, memory functions and the ability to think clearly (Jackson et al 2007). Many approaches to dealing with stress are focused on coping strategies and do not necessarily help an individual to build resilience and to overcome difficulties as they happen or to react to challenges (Sull et al 2015). Also of interest is why some nurses adopt strategies, which are self-protecting, but may reduce their ability to engage with patients and colleagues in a supportive way; others develop positive ways of coping. We all have a responsibility to look after ourselves and develop resilience strategies. If nurses and organisations in health care cannot care for themselves, how can they care for the populations and communities they serve?
The CIPD guide (2011) to developing resilience identifies three approaches that individuals take to develop resilience. The approaches can be clustered according to whether they focus on internal attributes of the person, the social environment, or a combination of the two:
1. Personality/individual characteristics – resilience is internal to the individual and is seen as an innate ability that forms part of their personality. This might include: internal locus of control (control over one’s life), perseverance, emotional management and awareness, optimism, perspective, sense of humour, self-efficacy (belief in own capabilities) and the ability to problem-solve;

2.Environment – resilience is wholly dependent on the experiences that a person has with their environment so factors external to the individual, such as how much social support they receive, will determine how resilient a person is. The individual’s personality is not seen as relevant;
3.Person–environment – resilience is a product of a person’s personality in combination with environmental influences such as family, peers and social environment.
People may react differently to the same challenges. Personal resilience is a combination of personal characteristics and learned skills and, increasingly, there is a view that supporting individuals to develop their resilience is of significant benefit to individuals, patients, and organisations.
Sull et al (2015) make a strong case for organisations to support personal resilience learning interventions within the workplace based on the importance of staff well-being and its impact on patient care. In the UK, the NHS Health and Wellbeing Review (Dept of Health 2009) identified clear links between staff health and well-being and patient safety, patient experience and the effectiveness of patient care. The report recommended that all UK national health organisations should develop a clear strategy and vision for the future.
Figure 2. Robertson Cooper Model of Personal Resilience
Available on: resilience-1
Having feelings of competence, effectiveness in coping with stressful situations and strong self-esteem are inherent to feeling resilient. The frequency with which individuals experience positive and negative emotions is also key

Social Support
Having a clear sense of purpose, clear
Building good relationships with others
values, drive and direction help

and seeking support can help individuals
individuals to pursue and achieve in the

overcome adverse situations, rather than
face of setbacks

trying to cope on their own
Flexibility and adapting to changing situations which are beyond our control are essential to maintaining resilience. Resilient individuals are able to cope well with change and their recovery helps its impact tends to be quicker

Well-being specialists, Robertson Cooper (Figure 2), describe personal resilience as the capacity to maintain well-being and work performance under pressure, including being able to effectively bounce- back from setbacks. They have developed a model which is used to support training and development approaches to strengthen resilience. It is their view that resilience in an individual can be positively developed whatever an individual's starting point.
This view is also supported by research from Jackson et al (2007), who suggest that nurses in particular can reduce their vulnerability to workplace adversity by developing and strengthening their own personal resilience. It is increasingly recommended that resilience training is incorporated into nursing education and that professional support should be encouraged through mentorship programmes.
Resilience, well-being and mental health: a bigger role for nurses
If we develop a better understanding of the relationship between personal resilience and our ability to provide care, then by extension this helps us to extend our skills outwards to support improved personal resilience in the wider population. We know that many of the societal shocks mentioned earlier have immediate impacts on mental health and well-being, including potentially increased risks of suicide and interpersonal violence. Unemployment is one major risk factor for mental health. Globally, major depressive disorders are the second leading cause of years lived with disability. While the major costs to societies relate to lost productivity from work and other economic activity, the human costs are also well documented (McDavid 2013).
A good working environment work is beneficial to physical and mental well-being. Whilst some levels of stress and high demands can be good for health, a poor workplace environment can have an adverse impact (Jackson et al 2007). If we understand this then we can expect employers of health workers to take a leadership role in modelling best practice in the system. Changes in working practices, restructuring and rapid boundary changes can all increase the possibility of psychological stress, fatigue, burnout and depressive disorders. If the health system works actively to limit change, then this might lessen any negative impact.
What are the issues hindering your personal resilience at workplace?
How can you mobilise support at your workplace?

The Way Forward
In the preceding chapters, we have looked at the different ways that nurses can contribute to strengthening health systems and improving resilience. There are many examples where nurses have been drivers of transformational change; they have led significant improvements in the delivery of many services at all levels of the system, from policy to practice. For that reason, our response may naturally tend to be about continuity, to carry on doing as we do now. But now, more than ever, we need to consider our role in the wider system. There are three priority areas associated with new skill sets for new futures, and, for many us, these areas will need to be a focus for development if we wish to accelerate the rate of change and our professional impact. We need to be flexible, adaptable and open to new forms of learning. The three areas are: 1) nurses’ role in relation to the adoption of digital technologies, 2) demonstrating quality and impact, and 3) systems leadership.
1. Adoption of digital technologies
As noted by WHO (2007, 2010b) in their six building blocks for a strong health system, there is a need for well-functioning information systems and nurses must be appropriately resourced in relation to this goal. The connectedness of health care systems and the rapid changes in communication technologies has enabled health care innovations to be developed and shared more rapidly than ever before. Nurses are using technologies to connect to remote primary care facilities to ensure expert advice is accessible to more people. On a daily basis, nurses use technologies to monitor vital signs, deliver medications, and measure outcomes. Being digital requires being open to re-examining our entire way of delivering care and understanding where there are new possibilities.
Adopting new technologies will require nurses to be assertive in their requirements for appropriate technological support. Too often technology is seen as a top-down project and nurses are engaged in the change process too late, leading to slow and inefficient implementations. Instead, we need to be leaders in the system and promote an understanding that technologies can transform pathways of care and improve patient safety and quality. Digital technology affects every aspect of the nursing practice environment in every clinical setting and we need to make sure we have leaders up to the challenge. As Cooper (2013)
“Globally, we spend over USD $4trillion on health care every year, but only a tiny fraction of this goes toward harnessing digital technology to transform services. Of course, it cannot be a solution itself, and if it is not embedded as part of a wider culture of change, its impact will be negligible.”
Wilson and Langford 2015

notes “getting value from technology and information requires training, strategic planning, and an appetite for health data to improve the way we work” (Cooper 2013, p11).
Do you have an appetite for health data? If not, how could you develop one? How could health data improve the way you work?
2. Demonstrating Quality and Impact
A robust information infrastructure (i.e. digital technology) is a precondition to the second priority area. How nurses demonstrate the quality and the impact of their work is key to ensuring the rest of the system understands and values the role nurses play. This will ensure that necessary resources and environments are mobilised to optimise the nursing contributions to improving resilience. Nurses’ work is often invisible to others and the use of technologies at point-of-care may help improve this visibility. However, it is essential that nurses are actively involved in the development of standards for quality and have greater opportunities for influence on policy and system level changes. This will enable a greater impact of nursing expertise around quality and person-centred systems. At all levels of governance and policy making, nursing expertise must be visible and valued as a crucial actor in the delivery of quality care across the health system.
How do you demonstrate the impact of the care you carry out? What are the different tools available to you? Do you use every opportunity to show how nurses make a difference?

3. Systems Leadership
Much has been written about the nature of leadership and its importance to nursing and health care (Benton 2012). However, as we have described, current nurse leaders are facing an unprecedented number of challenges and changes, both anticipated and unanticipated, that will require them to work in flexible and agile ways.
Traditional models of leadership that are based on a single organisational model, associated with hierarchical organisational structure will simply not be sustainable. Particularly in public sector leadership, there has been a blurring of organisational, professional, and geographical boundaries as services are integrated, pathways of care transformed, resources shared, and staff deployed in very different ways. It has been suggested by researchers in this area (Fillingham and Weir 2014) that “there is a need now for all leaders to shift their centre of gravity from loyalty to their organisation to loyalty to the citizen and wider population” (p.23). This is a shift in emphasis which underlies the importance of shared vision and co-production of solutions.
Fillingham and Weir describe an approach called “systems leadership. This approach can be characterised by two distinct and interrelated attributes: i) collaborative and ii) crossing boundaries – organisational, professional and virtual – thereby extending leaders beyond the usual limits of their responsibilities and authority. The authors describe the attributes of “great” system leadership and suggest that these should be developed more purposefully by individuals, educationalists and organisations (Box 6).
Box 5 - Addressing Emergent Needs: El
Although making great strides in the provision of health services to its people, El Salvador still faces many problems. Distressed by the number of patients with Dengue fever one nurse was seeing in a remote and rural clinic, she decided to take things into her own hands and develop a plan for change. She knew that she would need to obtain the support of her local manager, a doctor. She decided to gather evidence based on WHO recommendations.
This nurse did not have any public health training; yet she did not let this lack of training stop her. Instead she went to the books and the Internet and learned that by creating a geographic map of cases she could identify the location and magnitude of the problem. She was also able, by looking at the records, to identify that the problem was getting worse. After she presented this information, along with a suggestion that the clinic should develop targeted health information sessions for the most affected local groups, progress in fighting Dengue fever was dramatic. The local people themselves are currently helping in the fight against this major problem; and this nurse, who is now part of the local management team, is helping to develop programmes in other clinics for similar problems.
(Benton 2012)

Great systems leadership is often evidenced in leaders through:
·Their personal core values – such as inspiring shared purpose by taking risks to stand up for a shared purpose
·How they perceive – such as evaluating information by gathering data from outside their area of work or applying fresh approaches to improve current thinking
·The way they think and analyse – such as sharing the vision by communicating to create credibility and trust or holding to account by managing and supporting performance
·How they relate to others – such as connecting services by adapting to different standards and approaches outside their organisation
·Their behaviours and actions – such as developing capability by creating systems for succession
·Their personal qualities and way of being – such as influencing for results by developing collaborative agendas and consensus
NHS Leadership Academy (2015)
The above approach to leadership underlines the importance of building alliances and authentic partnerships. These are leaders who understand that sustainable change takes time, commitment and a constancy of vision. This approach requires working across boundaries and through collaborative networks so that resilience of health systems is improved.
What can you do to lead your organisation and health system to be more resilient?

An Action Plan
Having considered the different aspects to strengthening and improving health systems and developing their resilience, it is possible to summarise some key action points and consider planning our response:
Individual Nurses
üMaintain your health and well being
üPrioritise developing your personal resilience and support the development of your co-workers’ resilience
üConsider ways in which you can actively work with patients, carers and communities to improve their understanding of how to improve their abilities to self-care and influence the development of services
üDevelop your skills to demonstrate the positive impact that high quality nursing has on outcomes
üDevelop your health systems thinking by making strong networks across the system
üEnsure PPE for health care staff
üSupport health and well-being of health care staff
üProvide employees with learning opportunities
üEnsure a system of critical incident review is in place
üEstablish place disaster plans
Policy makers
üEstablish and implement legislation to protect health care workers and ensure PPE
üProperly plan and manage the health workforce. Establish a national HRH plan and implement it effectively
üAccelerate the move from a dominant illness-focused system to one that focuses on preventative services and health promotion
üEnsure resilience planning is part of the strategic development of the health system
üEngage nurses at policy level to ensure the optimal use of nurse skills throughout the system
Role of NNAs
üEnsure the development of effective health policy to support nurses to perform at their optimal level and to maximise the nursing contribution
üDevelop nurse leaders to maximise the nursing contribution at all levels of the system

The focus of this tool kit has been on how the nurse workforce can contribute to improving health systems’ resilience. It is clear that we need to work together to build strong health systems that are resilient to cope with future challenges to achieve the ambitious target set out in the SDGs.
Providing quality health care services to all people in need is the ethical and professional responsibility of nurses. As committed, innovative and solution oriented professionals, nurses continue to provide care with resilience and versatility even with little or no resources or organisational support. However, improving health systems’ resilience requires intersectoral efforts by all actors at all levels. Nurses, who deliver the majority of health care services in collaboration with colleagues in both health and non- health sectors, have an important role in this process.
Another reason for nurses to be involved in health sector policy reform is the large impact that these policies tend to have on nurses’ work environments. Through our involvement in decisions for health systems’ strengthening, we can promote positive practice environments which will in turn result in improved health systems’ resilience and health outcomes.
Nurses must play an integral role in leading change. With redesigned health systems and full participation of nurses in policy, we will be better equipped to provide quality care for all, even in times of difficulties.

Position Statement
Health human resources development (HHRD)
ICN Position:
The International Council of Nurses (ICN) judges that health human resources development (HHRD) - planning, management and development - requires an interdisciplinary, inter-sectoral and multi-service approach. This recognises the complementary roles of health service providers, and values the contribution of the different disciplines. Inputs are required from the key stake holders -- consumers, service providers, educators, researchers, employers, managers, governments, funders and health professions’ organisations. Similarly, ICN acknowledges that integrated and comprehensive health human resources information systems and planning models as well as effective human resources management practices are desired outcomes of this consulting process.
Patient need should determine the categories of health personnel and skill pools required to provide care. When new categories of health workers are created or role changes are introduced, the possible consequences on national and local health human resources, career structures, and patient and community outcomes need to be identified and planned for at the outset. These would include financing arrangements and organisational impacts. Planning for this should take account of:
·Health care needs and priorities.
·Available competencies within the health care provider pool, including competencies shared by more that one health care provider group.
·Initial skills set development.
·Skill changes, such as new and advanced roles for nurses.
·Educational implications of making changes to roles and scopes of practice, including provision for life-long learning programmes.
·Appropriate and accessible supervision and mentoring programmes.
·Quality and effectiveness factors, when deciding the scope of practice of nurses and others.
·Equity as a basic value of the health system.
·Consequences for service organisation, management, delivery and financing.
·Work environment and conditions of nurses and other health care personnel.
·Regulatory implications.
Health human resources development (HHRD), page 2
·Impact on responsibilities of those workers already in the health care system.
·Effect on the career pathways for existing health care workers and career structures available for new types of health workers.
For effective participation of nursing in HHRD, the core scope of nursing needs to be identified and fully articulated. This will minimise duplication and overlap between the work of nurses and other health care providers. ICN considers that the nursing profession needs to be a leader of change, continually reappraise the consequences of planned and unplanned health service changes on nursing, nurses and patient outcomes. Continuing evaluation of and research into the contribution of nursing to health care should form an important part of HHRD processes. This should include data from evidence-based practice, informing future decision-making.
National nurses associations (NNAs) and other nursing organisations need to:
·Identify critical issues related to the supply of and demand for nursing personnel, including factors that influence recruitment, retention and motivation.
·Ensure involvement of nurses in policy, decision-making, planning, management and monitoring at all levels of HHRD. Nurses should participate in interdisciplinary reviews of the roles of different types of health workers, research and evaluation studies, and in decision-making with respect to the functions of existing and new categories of health care providers.
·Assist nurses to acquire and improve research skills, to carry out research, and to use research findings as a basis for decision-making in HHRD.
·Engage in public debate on appropriate responses to demand for health services.
·Promote the development of quality practice environments, including opportunities for professional growth and development and fair reward systems as a positive feature of recruitment and retention programmes.
·Acknowledge and reflect the cultural diversity of society in Health Human Resources Development.
·Promote capacity building in the area of health sector human resources management, including nurses working at senior and executive levels.
·Assist in the development of a humane approach to HHRD.
·Offer an inter-disciplinary analysis and develop effective interventions to address health needs.
Nurses need to be aware of and utilise HR services in their workplaces. HHRD policies need to encompass education, regulation and practice factors.
HHRD policies need to focus on self-sustainability, guaranteeing a core of health professionals in adequate numbers and with the right skills, capable of meeting the health needs of the target population.

Health human resources development (HHRD), page 3
The attainment of the highest possible level of health in a country depends, to a substantial degree, on the availability of sufficient appropriately prepared and distributed health personnel, capable of providing quality cost-effective services. The goal of HHRD is to ensure that the right quality, quantity, mix and distribution of health personnel are available to meet health care needs in an environment that supports effective and safe practice. Some of the factors influencing decisions about numbers, types and distribution of health care providers include:
·Advances in health science and technology, altered patterns in the delivery of health care in hospitals and in the community, demographic changes and the emergence of patterns of disease.
·The growing public awareness of the availability of health services, resulting in greater demand for services.
·Increased health care costs, limited resources for health often necessitating a continual review of priorities, and the creation of new categories of health care providers.
·Labour laws, professional regulatory requirements, civil service rules and regulations, human resources and national health and development policies.
·Gender and cultural factors.
·Changing health risks.
·Access to and level of education.
·Culture and health beliefs.
·Access to alternative medicine.
·Intergenerational factors.
·Organisational factors.
·Socio-economic, financial constraints.
·The local, national and global labour market globalization.
Nurses need to engage in the activities and lobbying efforts of their professional associations and unions.

Health human resources development (HHRD), page 4
Adopted in 1999
Reviewed and revised in 2007
Replaces previous ICN Positions: “Support of Nurses”, adopted in 1989 and “Proliferation of New Categories of Health Workers”, adopted in 1981, revised in 1993.
Related ICN Positions:
·Scope of Nursing Practice
·Nursing Regulation
·The Protection of the Title “Nurse”
·Assistive or Support Nursing Personnel
·Socio-economic Welfare of Nurses
·Career Development in Nursing
·Nurse Retention, Transfer and Migration
ICN Publications:
Guidelines on Planning Human Resources for Nursing (1993)
It’s Your Career: Take Charge
Career Planning and Development
The International Council of Nurses is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

Position Statement
Publicly funded accessible health services
ICN Position:
The International Council of Nurses (ICN) and its member national nurses associations (NNAs) advocate for the development of national health care systems that provide a range of publicly funded essential and universally accessible and equitable health services to the population.
People have a right to equitable health services: promotive, preventive, curative, rehabilitative and palliative. ICN believes that these services should be patient- and family-centred, evidence-based and continually improving in quality measured by agreed benchmark standards and indicators.
Where such services are not publicly funded, ICN believes that governments have a responsibility to ensure accessible health services to the population with focus on vulnerable groups especially those from low socioeconomic groups.1
ICN supports efforts by national nurses associations to influence health, social, education and public policy that is based on the health priorities for the nation, equity, accessibility of comprehensive and essential services, efficiency (including productivity), cost-effectiveness, and quality care.
ICN views primary health care as the preferred means of delivering essential health services at a cost that governments and communities can afford.2
Accessible, cost-effective and quality services, appropriate regulatory principles and frameworks, standards and mechanisms, and positive practice environments need to be established and applied equally to both private and public health services.
Nurses and NNAs have a responsibility to advocate for such health services, monitor their effectiveness, and drive health policy development, decision- making and implementation to ensure that all people have access to nursing and quality health services.
ICN supports efforts by NNAs to ensure that government policy for publicly funded and accessible health services does not downgrade the level of nursing education required by the complex demands of these services since evidence shows that registered nurses achieve better care outcomes.3
1Commission on Social Determinants of Health (2008). Closing the gap in a generation: health equity through action the social determinants of health. Final Report of the Commission on Social Determinaints of Health. Geneva: World Health Organization.
2The World Health Report 2008. Primary Health Care Now More than Ever. Geneva: WHO.
3Aiken L, Clarke S, Cheung R, Sloane D & Silber J (2003). Educational levels of hospital nurses
and surgical patient mortality. JAMA, 290, 1617- 1623.

Publicly funded accessible health services, page 2
A healthy nation is a vital national resource. A prime goal of each nation must be to achieve the best health status possible for the population within the resources available.
All people should have access to competent nurses who provide care, supervision and support across the range of settings. Health systems need to scale up nursing capacity and encompass a range of strategies that address workforce planning, education, skill-mix, regulatory frameworks and career pathways to ensure effective, efficient and safe health systems.
ICN and member associations need to maintain effective networks with relevant stakeholders to help ensure resource allocation and availability of services are based on needs and priorities, promote primary health care, and consider quality and costs. This includes advocacy for the resources needed to prepare the nursing workforce for the growing burden of chronic and noncommunicable diseases, injuries, disasters and other health challenges facing nations and populations worldwide.
Adopted in 1995
Reviewed and reaffirmed in 2001
Reviewed and revised in 2012
Related ICN Positions:
ICN Publications:
·Nurses and Primary Health Care
·Health Human Resources Development
The International Council of Nurses is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

Position Statement
Participation of nurses in health services decision making and policy development
ICN Position:
Nurses have an important contribution to make in health services planning and decision-making, and in development of appropriate and effective health policy. They can and should contribute to public policy related to preparation of health workers, care delivery systems, health care financing, ethics in health care and determinants of health.
Nurses must accept their responsibilities in health services policy and decision-making, including their responsibility for relevant professional development.
Professional nursing organisations have a responsibility to promote and advocate the participation of nursing in local, national and international health decision-making and policy development bodies and committees. They also have a responsibility to help ensure nurse leaders have adequate preparation to enable them to fully assume policy-making roles.
Because of their close interaction with patients/clients and their families in all settings, nurses help interpret people’s needs and expectations for health care. They are involved in decision-making at clinical practice level as well as in management. They use the results of research and trials to contribute to decisions on quality, cost-effective health care delivery. They conduct nursing and health research that contributes evidence to policy development. Because nurses are often coordinators of care provided by others, they contribute their knowledge and experience to strategic planning and the efficient utilisation of resources.
To participate and to be effectively utilised in health planning and decision- making, and health and public policy development, nurses must be able to demonstrate their value and convince others of the contribution they can make. This may involve improving and expanding the scope of the preparation of nurses for management and leadership, including their understanding of political and governmental processes. It may also involve increasing their exposure through management and leadership roles and positions in both nursing and other health care services, encouraging nurses to participate in government and political affairs, and improving and marketing the image of nursing.

Participation of nurses in health services decision making and policy development, page 2
The International Council of Nurses (ICN) and its member national nurses associations (NNAs) promote and support all efforts to improve the preparation of nurses for management, leadership and policy development. This preparation should be broad and must include the development of knowledge and skills for influencing change, engaging in the political process, social marketing, forming coalitions, working with the media and other means of exerting influence. It must recognise the complex processes and factors involved in effective decision- making.
Professional nursing organisations need to employ a number of strategies to contribute to effective policy development, including monitoring the utilisation of nurses in the workforce; incorporating new models and management strategies; continually marketing a positive image of nursing to key management and policy stakeholders nationally and internationally; disseminating relevant knowledge and research; and, continually developing and maintaining appropriate networks to enable collaborative working relationships with governmental and non- governmental organizations. For its part, ICN will promote and make available information regarding the contribution of nursing in health decision-making and policy development.
Adopted in 2000
Reviewed and revised in 2008
Related ICN Positions:
ICN Publications:

· Health Policy Toolkit, 2007
The International Council of Nurses is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

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