Exploration of priority actions for strengthening the role of nurses in achieving universal health coverage

ABSTRACT Objective: to explore priority actions for strengthening the role of Advanced Practice Nurses (APNs) towards the achievement of Universal Health Converge (UHC) as perceived by health key informants in Jordan. Methods: an exploratory qualitative design, using a semi-structured survey, was utilized. A purposive sample of seventeen key informants from various nursing and health care sectors was recruited for the purpose of the study. Content analysis utilizing the five-stage framework approach was used for data analysis. Results: the findings revealed that policy and regulation, nursing education, research, and workforce were identified as the main elements that influence the role of APNs in contributing to the achievement of UHC. Priority actions were identified by the participants for the main four elements. Conclusion: study findings confirm the need to strengthen the role of APNs to achieve UHC through a major transformation in nursing education, practice, research, leadership, and regulatory system. Nurses should unite to come up with solid nursing competencies related to APNs, PHC, UHC, leadership and policy making to strengthen their position as main actors in influencing the health care system and evidence creation.


Introduction
The dynamic nature of the health care sector, Health Coverage (UHC) as one of the major targets of the global health goal (1) .The global health goal of the SDG aims to ensure healthy lives and promote wellbeing for all. The global health goal has eight targets, including the UHC (1)(2) .
UHC promotes healthier lives for all ages, and this will not be attained unless there is a true investment in health care systems and the health workforce.
Evidence suggests investments in health systems are key components to improved health outcomes (2)(3) .
UHC does not only remove the accessibility and quality barriers to health care, but the financial barriers as well to everyone including the poor. In 2010, the World Health Report emphasized the disastrous outcome of health care cost in which the out-of-pocket spending had pulled down around 100 million worldwide below the poverty line (3) . Evidence suggests that effective provision of affordable, acceptable, high-quality health care services leads to the improvement of a population's health, especially for vulnerable individuals and communities (4) . The causal analyses from 153 nations revealed that broader health coverage provided better access to necessary health care services and improved the health of the population, with considerable gains to the impoverished (5) .
In an attempt to accelerate progress towards the global health agenda including UHC, a global strategy on human resources for health has been developed by the WHO (6) . Access to essential, quality health care services depends mainly on the key determinant of the supply of health labor, which is the education and training of health care workers. The nursing profession has shown a strong interest in UHC.UHC has clearly articulated the vision of the 2016-2020 Strategic Directions for Nursing and Midwifery (SDNM) "to ensure that the nursing and midwifery workforce contributes to UHC and the Sustainable Development Agenda, by ensuring equitable access to skilled and motivated nursing and midwifery workforces within performing and responsive health systems" (7) .
According to the World Health Organization

Regional Office for the Eastern Mediterranean Region
(WHO EMRO), one of the main key elements of strengthening health care systems is health workforce planning, production, training and retention which requires the development of well-articulated, wellprepared, and well-managed health care workforce with the appropriate skills mix to meet the needs of their countries (8) .There are a number of challenges facing medical and nursing education in the WHO EMRO, including increased investment on tertiary care, on the expense of prevention and health promotion, as well as the concentrated training and preparation of students within the hospital walls with less exposure to community and primary health care (PHC) settings (9) . Similar problems were reported by the summary report on the regional nursing forum regarding the future of nursing and midwifery in the EMRO, which identified education as one of the main challenges for nursing and midwifery in addition to workforce, practice and service development, regulation, governance, and information systems (10) .
Jordan has one of the most modern health care infrastructures in the Middle East, and it has been ranked the first in the region for medical tourism (11) .
Despite the improvement of the health indicators in Jordan, the rates of chronic illnesses are increasing. The mortality rates from Non Communicable Disease (NCD) in Jordan was 727 per 100,000 population in 2008 compared to 573 per 100,000 population of the global NCD mortality rate in the same year (11) . In addition, the economic growth remains a challenge which has been hindered by global economic depression; the unstable political status in the region; the influx of refugees throughout the last 15 years, which has made great pressure on the education and health sectors especially; the scarcity of natural resources and high stock of external debt.
Unfortunately, the health care sector has invested heavily in curative and tertiary care at the expense of the primary health care, despite the fact that Jordan has a widespread network of PHC centers. The amount of spending on PHC and prevention services from the size of public sector spending is far behind the share of the secondary health care services which amount to more than 72%, compared to 16.4% for PHC and prevention services (11) . UHC is one of the main goals of www.eerp.usp.br/rlae 3 Al Maaitah R, AbuAlRub R.
the National Strategy for the Health Sector in Jordan (2015-2019) and it faces different challenges (11) . In addition, challenges of the health workforce do exist in Jordan and influence the efficiency and effectiveness of service delivery, especially with regards to the PHC sector and UHC (11)(12)(13) .
In Jordan, the baccalaureate degree in nursing is offered by 15 university programs in addition to 13 master degree programs in 6 universities and one national doctorate program (12) . Associate degrees in nursing and midwifery are offered by 26 universities and 4 colleges, following the termination of the diploma nursing programs in 2002 (12)(13) . While the previous reform in nursing education in Jordan has enhanced the status of the nursing profession, further improvement of the sector is required so as not to jeopardize the long-term quality of nurse graduates (12)(13) . Still more striking is the incongruence between the traditional nursing education system, with the contemporary challenges facing the health care sector, including the changing health needs of the population. Hence, the gap among nursing education, the practice sector, and patients' needs is widening. In addition, the absence of regulations to improve the advanced nursing role as well as the lack of clarity nursing role and job descriptions have marked the nursing profession with lack of autonomy and decision-making power (10,(12)(13) .
According to the International Council of Nurses (ICN), Advanced Practice Nurse (APN)/ a Nurse Practitioner is defined as "a registered nurse who has acquired the expert knowledge base, complex decisionmaking skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master's degree is recommended for entry level" (14) .
Many countries of the EMRO are still struggling to introduce the role of APNs, and Jordan is no exception (10) . Laws in Jordan are behind in the area of advanced practice nursing, regardless of the high number of nurse specialists graduates. One of the main barriers is the dominance of the medical profession; in addition to the lack of awareness of policy makers, and health professionals about the importance of APNs in promoting the population's health, and achieving the country's health agenda (10,(12)(13) . Given the global shortage of the health workforce, most countries are searching for solutions to improve their health care systems. One solution is to utilize APNs to provide PHC autonomously and independently, through the performance of assessments and diagnoses, ordering diagnostic and laboratory tests, as well as prescribing medications and offering treatments. In addition, APNs could monitor patients' adherence to medical plans, and offer both counseling and education for noncommunicable disease prevention (15) .
A meta-analysis of 11 trials and 23 observational studies revealed patients were more satisfied by services provided by nurse practitioners, than those provided by physicians. In addition, the results asserted there were no detected differences in patient health status, or the number of prescriptions and/or consultations (16) .
Another systematic review of 37 studies, over a span of 18 years (1990-2008), on all types of APNs, revealed a significant amount of evidence to support equality on measures of the following outcomes, when comparing nurse practitioners and physicians: mortality, functional status, patient satisfaction, blood pressure control, selfreported patient perception of health, patient glucose control, and utilization rates of emergency department/ urgent care (17) .The abovementioned comprehensive systematic reviews asserted the significant role of APNs, in regards to outcomes of patients and clients, which will contribute to the global health agenda, including UHC.
There continues to be a shortage of literature on the roles of APNs in improving the outcomes of health care including UHC. There is also a lack in research reflecting the views of nurse leaders, key health informants, and policy makers for strengthening the role of APNs to achieve UHC. Therefore, the purpose of this study was to investigate priority actions for strengthening the role of APNs towards the achievement of UHC, as perceived by key health informants in Jordan. The results of this study will inform health policy decisions and nurse leaders regarding main issues that demands priority actions to set the stage for advancing nurses' roles and scope of practice, thereby contributing to the national health agenda, including the UHC.

Design
This exploratory, qualitative study uses a semi-

Data Analysis
Content analysis utilizing the five stage 'framework approach' (18) was used for data analysis. The five stages of the framework included familiarization, identification of thematic framework, indexing of the transcripts, abstraction, and synthesis. The stages were applied as follows: 1. the researchers looked at the data and identified key elements and repeated themes; 2. the identified thematic framework was based on survey questions, purpose of the study, and themes that appeared during the familiarization stage; 3. the index or the identified themes were applied to all data; 4. data were charted to appropriate themes; and summaries of views were formed; 5. the researchers examined the summaries and looked for associations between themes to help explain the results.

Results
The findings revealed the following themes  Another participant elaborated on the role of APNs: The low level of nurses' involvement in the policy and decision-making process was also a main concern voiced by most key informants. Increasing visibility of nurses in policy and decision-making, as well as national boards and committees, will enable nurses to effectively impact the health care system and the role of APNs:  (7,20) . In order to influence and deliver quality health care outcomes, there is a need not only to transform the way in which health care is provided, but also the way in which health care professionals are educated and trained. Evidence suggested a strong correlation between the level of education and the patients' outcomes (21)(22) .
Unfortunately, the education system in Jordan remains very traditional with major gaps, especially in the area of community, prevention, and PHC which are crucial for UHC (11,20) . This was the expected result of the fragmented silo efforts in improving nursing education and weak inter-professional and interdisciplinary collaboration among education, service, research and nursing institutions as well as lack of awareness of many nurse educators and leaders about contemporary health issues related to national and global health agenda. It is imperative that nursing emphasizes the wider health context, including its social determinants, financing, and sustainable development (7)(8)10,23) .
Achievement of UHC in Jordan will place increased pressure on the nursing profession as a whole, and nursing educators and leaders in specific. Planning for an appropriate and well-prepared nursing workforce is becoming a major challenge in Jordan especially in light of the absence of a database for the nursing workforce.

Establishment of a data base for the nursing workforce in
Jordan is essential for improving the nursing workforce's strategies and evidence-based workforce policies.
This will ensure appropriate quantifications for the nursing workforce, demands and supply; appropriate geographical distribution and a balanced allocation of nurses in all health sectors including PHC, as well as better monitoring and alignment of investments in the nursing workforce with future needs and demands of the health systems to achieve the UHC and national health agenda (6)(7) .
Nurses should find the right fit between their role and the demanding new global health agenda to ensure that the global health goal and its targets are achieved.
Such balance requires the preparation of a critical mass of well-prepared nurses as well as the expansion of nursing roles and scope of practice. Therefore, major transformations in nursing education, standards, competencies, as well as an entire revision of the pedagogy and content, is required.
New nursing competencies are needed to ensure a productive nursing workforce and efficient health care system (7,11,19) .To assure achievement of UHC, Building capacity and capabilities of the nurses' educators and faculty is crucial for understanding and implementation of a solid transformed nursing education programs (7) . Likewise, inter-professional education and collaboration are crucial for PHC and maximizing the dialogue about UHC to achieve the health agenda (7) .
Therefore, regulatory, administrative and other barriers that limit health care providers from working together should be eliminated. vision for the quality of nursing workforce we need to prepare for the future to achieve UHC. Interestingly, with the expansion of the SDGS, and the global health agenda, there is a window of opportunity for the nursing profession to start developing nursing residency programs, especially in PHC. This also demands the strengthening of the education, practice, and work environment of the nursing workforce. In addition, strengthening the PHC sector and its workforce to be attractive for nursing students and nursing workforce is crucial for UHC (6) .
Advanced nursing practice in Jordan and the entire region is behind (7,10) . with the belief that there is no need to have other major players, such as nurses, in their "territory". This is a profound misjudgment, especially with the fact that PHC in Jordan is totally disregarded, and devastated by lack of quantity and quality health care providers including physicians (11,13,20) . The challenging goals and targets of the SDGs implied a necessity for establishing a range of policy options to maximize the utilization of all health workforce, including the nursing workforce, who comprised about more than 70% of the health workforce, by investing in their full potential and scope of practice to contribute to the achievement of UHC and sustainable development (6,20) .
Nurse leaders identified the importance of eliminating the regulatory barriers that prevent nurses from practicing to the full extent of their knowledge and training, to achieve the UHC and health agenda.
Advancing and expanding nurses' roles and scopes of practice will not only result in producing and retaining competent nurses to meet population needs and UHC but also in maximizing the economic return on investment (7,10) . The Summary report on the regional nursing forum about the future of nursing and midwifery in the EMRO indicated that "Universal coverage is an opportunity to bridge the gap between access and coverage, coordinate increasingly complex care, fulfill nurses and midwives' potential as primary care givers to the full extent of their education and training, enable the full economic value of contributions across care settings to be realized, and change the reference point from which nursing is understood" (10) .
The We must be aware about the fact that nurses will only be able to influence and enhance the accessibility and training" (25) . It is imperative that nursing leadership is anchored within all mechanisms and sectors of the health care system (7) .Capacity building is highly needed  (7,20,24) .
Nurses as a whole should invest in their collective power to be recognized as evidence producers and They were all keen that Jordan needs to put in place solid policies and regulatory mechanisms that ensure a perfect fit and the relevance of nursing education, practice, research, and leadership skills to population needs that cater not only for current but also for future health needs.
A focus on UHC for the coming years could be a remarkable achievement for nursing education, practice, leadership and research at the national,