As described above, communication within the nursing profession and between nurses and other health professionals and the general public is essential not only to disseminate research findings but also to encour-age debate on current conditions and innovations in the delivery of nurs-ing care. Two of the most effective ways of spreadnurs-ing information and
new ideas on nursing and midwifery are professional journals and mes-sages broadcast on audiovisual media.
As previously described, many European countries have one or more professional nursing journals and in some countries, such as the United Kingdom, the amount of written information is overwhelming.
Sometimes nursing education programmes are broadcast on television or radio, and all countries have television and radio programmes or items on health or health care issues. In all the CCEE except Albania, at least one specific nursing or midwifery journal is published. Although nursing journals from other countries are sometimes available, there is no widespread or systematic exchange of written information. Nursing education programmes and health messages are not widely broadcast on television and radio, mainly because of the high costs.
The NIS differ widely in the use of television, radio and written pub-lications to inform nurses of developments. Countries such as Estonia, Latvia and Uzbekistan have monthly nursing journals, and Kyrgyzstan launched a new journal for health workers in 1993. In Kazakstan, the WHO collaborating centre for primary health care and nursing is re-sponsible for a page on health care in the new journal Ave vitae, first published in January 1994. Nurses are fully involved in this venture.
The centre distributes as much material as possible, but lacks resources such as paper. The Republic of Moldova has no nursing journal, but the Romanian Nurses Association sends copies of its own journal to the Re-public Council of Nurses. No nursing journals are known in Lithuania, Tajikistan and Turkmenistan. Many countries are aware of the value of journals but lack money for paper or printing, as well as editorial and publishing skills. Audiovisual media are used to broadcast health mes-sages and discuss nursing issues in only a few countries. In Belarus, for example, daily health promotion radio programmes and twice -weekly
broadcasts on television are reported. The Russian Federation and
Ukraine use television broadcasts to communicate with health workers and the public, while nurses in Moscow have a regular phone -in radio programme that attracts considerable public interest.QUALITY ASSURANCE
WHO regional target 31 (18) calls for "structures and processes in all Member States to ensure continuous improvement in the quality of health care and appropriate development and use of health
technolo-gies". Quality can be defined as the extent to which actual practice
matches the desired outcomes. Nursing has a commitment tointegrat-ing theoretical knowledge and practice. This requires the scrutiny of its own performance; as indicated in the section on research, such scrutiny is a growing and welcome trend everywhere in the Region. Nurses are examining problems that reflect a variety of health needs, and questions important to nursing and other disciplines are being asked about health status, the quality of life and the provision of care. New scientific tech-niques are being used and theoretical understanding is expanding. A wide array of philosophical perspectives from nursing, medicine and the natural and social sciences is being examined, to lay the foundations of nursing science and to guide selection of the most significant questions and the most creative techniques to improve quality. The range of choic-es is now overwhelming. The many factors that influence quality in-clude: developing and maintaining effective information, evaluation and registration systems; effectively managing human resources;
adequate-ly organizing nursing care; ensuring cooperation and coordination among nurses and other health and social care professionals and
providers; and providing sufficient education. Previous sections have looked at these issues separately.In general, the issue of the quality of nursing has gradually gained interest and importance among policy- and decision- makers, the finders and managers of health care, the profession itself and service users. Ris-ing demands and expectations and the high costs of health services are some of the main influences on this trend everywhere in Europe. Health care managers increasingly view the delivery of high -quality nursing services as an important element in improving the performance of the entire system.
One favoured approach to this task is the development and legislative implementation of standards for nursing practice. This is taking place in many European countries, especially in western Europe and the CCEE.
Standards can range from voluntary or obligatory ones determined at the national level by ministries or professional associations, to those set by nurses in a particular hospital department or community team. No mat-ter the type and level of standards, setting them is an important step for-ward, since it can encourage the formulation of patient- centred goals based on a vision of how the ideal service functions. Setting specific standards then enables an assessment of how far they have been achieved and the further problems that need to be overcome, which creates a con-tinuing cycle of achievement, review, and the planning and implementa-tion of innovaimplementa-tions. Of course, as all the preceding informaimplementa-tion indicates, the countries of the European Region vary widely in the quality of nurs-ing, its stages of development, its use of quality assurance methods, and the mix of methods chosen for use in countries, institutions and teams.
All current initiatives in the NIS to improve the quality of nursing concentrate on establishing the prerequisites: up -to -date legislation and regulatory systems, better education and staff development, better
work-ing conditions and more efficient health services. Except for some
initiatives, mainly in the Baltic states, the NIS have not been able to tackle the introduction of quality assurance methods to nursing practice, although there is some interest in it and an awareness of the need to be-gin as soon as some of the major reforms are under way. This is due partly to the severe economic crisis in most NIS and partly to the lack of information, skills and understanding among policy- makers and health care and nursing leaders. At the local level, few if any leaders of health care teams are familiar with either quality assurance methods or the skills needed to help a team to use them. This in turn is the result of poor basic education and the lack of continuing education, textbooks and journals.Similar conditions and situations exist in some CCEE, such as Al-bania, Bulgaria and Romania. Other countries reveal initiatives and im-provements in many areas. In general, policy- makers, nursing associa-tions, and health care and nursing managers in, for example, the Czech Republic, Hungary, Poland and Slovakia are trying to raise the quality of nursing by paying some attention to improved human resource plan-ning, education, teamwork in PHC, and the rationalization and stan-dardization of nursing skills and practice. Progress is piecemeal and patchy, however, and depends very much on the initiative of inspired in-dividuals rather than the commitment of organizations.
Western Europe shows enormous differences in the stages of develop-ment of quality assurance in nursing and in the use and mix of methods.
Little commitment and few initiatives are reported in some, especially the Mediterranean countries. On the other hand, the commitment of governments and the nursing profession is strong and many innovative projects have been undertaken in a multitude of settings in, for example, the Nordic countries, Israel, the Netherlands and the United Kingdom.
By reforming education, legislation, working conditions and other factors, initiatives aim to improve the context and framework in which nurses prac-tise and the quality of practice itself. Most contemporary European soci-eties value high -quality nursing. The issue of measurement, which lies at the heart of quality assurance, is further discussed in Chapter 8 as a key question facing nursing in the years to come.
One indicator of the depth of interest is the establishment of a Eu-ropean Nursing Quality Network (EUROQUAN). It was launched in 1992 to promote high standards of nursing care through the
dissemina-tion of research findings and the applicadissemina-tion of this knowledge in prac-tice. Sixteen countries have joined, all from western Europe (see Table 4- p.35). In addition, WHO has coordinated networks with similar goals,
including one for midwifery in the early 1990s and a francophone
intercountry network led by the WHO collaborating centre for nursing in Lyon, France, whose aims include exchanging information and de-veloping standards for practice.CONCLUSION
This report on nursing in Europe is an attempt to describe and analyse the context and conditions in which the almost 5 million nurses and midwives in the WHO European Region work. By focusing on some key areas of nursing policy and activity, and comparing countries and subregions, it contributes to a better understanding of the many factors influencing the development and practice of nursing. These factors in-teract with each other and with the traditions and current conditions in society. While this interaction creates different conditions for practice in different countries, the study shows more similarities than differences in
nurses' advantages, problems and choices for development. It also
shows the magnitude and complexity of the challenge that countries face: to raise the standard of nursing in terms of health outcomes and job satisfaction.Despite the difficulties of reorienting nursing towards patient -cen-tred PHC, alongside high -quality nursing in hospitals, achievements have been made throughout the Region. All countries are working hard
to improve the level of nursing education, regulation and practice.
Some, particularly the NIS, are taking the first but essential step: health care planners and nurses are thinking about and discussing possible op-tions for the future. Differences in progress arise from differences in the starting points of countries and in the degree of support from policy -makers. There is by no means a simple east -west divide.
The reform efforts under way in almost all European health care systems provide the nursing profession with new opportunities to prove its cost -effectiveness and its willingness to adopt new responsibilities in both daily practice and the management of nursing services. Nurses should keep on trying to improve the way nursing can be measured in terms of input and outcomes, especially health outcomes. These initia-tives should be reinforced by the growing bulk of evidence -based re-search on the outcomes of nursing practice. Rere-search initiatives will
therefore need a strong focus on evaluating established and innovative ways of delivering nursing services, especially in PHC. Nurses must also continue critically to review and evaluate their daily practice, adapt to changing circumstances and needs, and record the process. Nurses everywhere should be encouraged to read and write more about their work, to improve the visibility of nursing and the recognition of its im-portance. Realizing their potential, however, is not a task that nurses can complete in isolation. Their success will be directly related to how far countries value and support nursing and nurses.
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