Task-shifting must recognise the professional role of nurses
Authors: Oladayo Afolabi, Mary Abboah-Offei, Kennedy Nkhoma, Catherine Evans
Journal: The Lancet Global Health (2019)

The Nursing Now campaign and the designation of 2020 as the “Year of the Nurse and Midwife” by WHO highlights the need to acknowledge the competence, increase the influence, and maximise the contribution of nursing to the achievement of universal health coverage. However, poor perceptions and misrepresentation of the professional role of nurses persists. The cluster-randomised controlled trial by Oye Gureje and colleagues (April, 2019)1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar published in The Lancet Global Health, which assessed the effectiveness of task-shifting and stepped care in the management of major depressive disorder at the primary health-care level in Nigeria, and the associated commentary by Bolanle Adeyemi Ola and colleagues,2Ola BA Atilola O Task-shifted interventions for depression delivered by lay primary health-care workers in low-income and middle-income countries.Lancet Glob Health. 2019; 7: e829-e830Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar provide examples of how nurses are misrepresented and the need for the Nursing Now campaign. Ola and colleagues consistently refer to nurses as lay health workers in their commentary, whereas Gureje and colleagues use the terms lay health workers and primary health-care workers to describe nurses, without clarifying whether the terms are interchangeable. Such clarification is important since no consensus definitions have been established for these terms, particularly in a setting such as Nigeria where different staff with variable levels of training work alongside doctors, nurses, and midwives at the primary health-care level.3Mash R Howe A Olayemi O et al.Reflections on family medicine and primary healthcare in sub-Saharan Africa.BMJ Glob Health. 2018; 3e000662Crossref PubMed Scopus (22) Google Scholar, 4Mullan F Frehywot S Non-physician clinicians in 47 sub-Saharan African countries.Lancet. 2007; 370: 2158-2163Summary Full Text Full Text PDF PubMed Scopus (313) Google Scholar This ambiguity raises important questions about the findings of this study and the perception of nurses in Nigeria and Africa in general, with regard to policy. WHO have defined lay health workers as members of the community who have received training to promote or carry out some health-care services but are not healthcare professionals.5Nkonki L Cliff J Sanders D Lay health worker attrition: important but often ignored.Bull World Health Organ. 2011; 89: 919-923Crossref PubMed Scopus (69) Google Scholar, 6Glenton C Colvin CJ Carlsen B et al.Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis.Cochrane Database Syst Rev. 2013; 10CD010414Google Scholar By contrast, the term ‘primary health-care worker’ has been poorly defined in published literature. Primary health-care workers have previously been defined as any staff working within primary health care including physicians, nurses, and other staff.7Adewuya AO Adewumi T Ola B et al.Primary health care workers' knowledge and attitudes towards depression and its management in the MeHPric-P project, Lagos, Nigeria.Gen Hosp Psychiatry. 2017; 47: 1-6Crossref PubMed Scopus (8) Google Scholar The term has also been used interchangeably with ‘community health workers’,8Vasan A Mabey DC Chaudhri S Brown Epstein H-A Lawn SD Support and performance improvement for primary health care workers in low-and middle-income countries: a scoping review of intervention design and methods.Health Policy Plan. 2016; 32: 437-452Google Scholar a term synonymous with ‘lay health workers’.9Medcalf A Nunes J Visualising primary health care: World Health Organization representations of community health workers, 1970–89.Med Hist. 2018; 62: 401-424Crossref PubMed Scopus (10) Google Scholar For this study to influence policy appropriately, the definitions for these ambiguous terms need to be clarified. Registered nurses employed within government and recognised private settings in Nigeria are adequately trained, qualified, licensed, registered, and regulated health-care professionals under the regulatory authority of the Nursing and Midwifery Council of Nigeria. Hence, nurses included in the study by Gureje and colleages1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar should not have been referred to as ‘lay health workers’. Describing nurses as lay health-care workers is inappropriate, condescending, and unacceptable. Additionally, this term does not accurately reflect the challenges faced by frontline nurses who work in Nigerian and African primary health care facilities, which are often understaffed, poorly equipped, and isolated. The views and attitudes held by some physicians in Africa result in policies that constrain the professional practice and development of nurses, which might partly contribute to the poor retention of nurses in the region.10Koblinsky M Matthews Z Hussein J et al.Going to scale with professional skilled care.Lancet. 2006; 368: 1377-1386Summary Full Text Full Text PDF PubMed Scopus (342) Google Scholar The stringency of pre-registration education and regular continuous professional development required to remain licenced as a nurse in Nigeria might have been a confounding factor in the study by Gureje and colleagues.1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Since other non-physician primary health-care workers are not subject to the same continuous regulatory oversight as nurses, it would have been reasonable for the authors to have done a sensitivity analysis comparing the effects of the intervention when delivery was led by trained registered nurses versus other non-physician primary health-care workers. Such an analysis could have strengthened the robustness of the findings, and the health economics and policy implications of this study. The lack of clarity with regard to the professional roles of the individuals delivering the intervention might be an important limitation in the interpretation of their findings for policy.1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Registered nurses represent an important source of knowledge, skill, and competence that is poorly regarded and underutilised. Nurses provide crucial leadership in service delivery and quality patient care where physicians are often absent at the primary health-care level in Africa. The implementation of task-shifting and empowerment of nurses are important policy actions that could meaningfully transform and fill the gap in primary health-care provision in this region and will be crucial for the achievement of the Sustainable Development Goal of universal health coverage. The implementation of task-shifting and empowerment of nurses must be done in a way that acknowledges and values the professional role of nurses. We declare no competing interests. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trialFor patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. Full-Text PDF Open AccessTask-shifted interventions for depression delivered by lay primary health-care workers in low-income and middle-income countriesThe treatment gap for depression is worse in sub-Saharan Africa than in high-income countries.1 In the 2005 World Mental Health survey,2 only about 17% of people with a 12-month history of diagnosable depression in Nigeria had received any treatment. This dire situation is sustained by various factors, including an extreme shortage of specialist mental health professionals, especially in rural areas where the majority of Nigerians live;3 insufficient mental health knowledge and skill among non-specialist physicians superintending over the few community health facilities attended by most people with mental health morbidities;4 and mental health policy that is absent, poorly conceived, or not driven by evidence-based interventions. Full-Text PDF Open AccessTask-shifting must recognise the professional role of nurses – Author's replyWe thank Oladayo Afolabi and colleagues for their comments on our trial.1 Afolabi and colleagues highlight two main points: the use of the term ‘lay health workers’ to describe nurses is incorrect and might be considered disrespectful and derogatory and the ambiguity regarding the definitions used to describe personnel involved in our study might have limited the impact of our findings on policy. 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