The second sentence of the United States Declaration of Independence lists a number of truths, held by the authors to be ‘self-evident’. The most fundamental of these truths was that ‘all men are created equal’, endowed with a number of inalienable rights. The declaration is generally seen as a statement of human rights, widely quoted and hugely influential.
While declaring truths to be self-evident is a powerful statement of conviction, it is not an approach that invites further enquiry. Nor is it an approach that is likely to engage with those who are not already persuaded of the message and, as can be seen from the fact that the declaration was drafted by Thomas Jefferson, an owner of slaves, and adopted by 13 former colonies who conspicuously did not see fit to extend all these rights to women, declaring something to be self-evident may invite a certain complacency.
In this special issue, we bring together a series of articles linked by a common theme. All address in some way ‘the impact of nursing’. For many in the profession the beneficial impacts of nursing are seen as self-evident. Yet when discussing the potential ‘triple impact’ of nursing in improving (global) health, promoting gender equality and supporting economic growth, UK parliamentarians Crisp and Watkins (2017) clearly imply that this potential is often unrecognised and sometimes unrealised.
In compiling this special issue we do not intend to exhaustively catalogue the impacts of nursing. Nor do we intend to take such impacts for granted. A common theme among the studies here is that they ask questions about whether, and how, nurses are making a difference to the recipients of their services. Sometimes the answers given are equivocal. For example, Jiang et al. (2017) found evidence about the short term benefits of psychological interventions to support self-care in people with heart failure, but were unable to draw conclusions about longer term benefits and were unable to determine optimal forms or formats for intervention. Findings such as these illustrate the importance of studying the impact of nursing services on patients rather than just assuming benefit. In this example, clearly more needs to be known before the best way of providing support to patients can be determined.
Coster et al. (this issue) provide an overview of the research evidence on the impact of nursing, through a review of reviews. The range of services, health conditions and potential impacts considered is huge, but they too illuminate significant areas of uncertainty. However, other reviews do illustrate the emerging evidence base that shows how nurses are playing increasingly significant roles in delivering effective primary care (Norful et al., 2017), prescribing for chronic conditions (Tabesh et al., 2017) and managing the complex care needs of older people (Chavez et al., 2017).
The study by Ball et al. (Ball et al., 2017) focuses on what has long been a core area of nursing practice – general medical and surgical care in hospitals. The association between nurse staffing levels and patient outcomes in these settings have been widely studied – perhaps more so than any other aspect of the configuration of nursing services. Yet while the association between nurse staffing levels and patient outcomes may seem, to some, to have been unequivocally established, doubts have remained as to whether or not the current evidence is sufficient to establish cause, and the utility of the evidence in helping to determine safe staffing levels has been questioned (; Griffiths et al., 2016). Ball et al’s study provides important evidence for the ‘missing link’ between nurse staffing levels and patient outcomes, showing that when staffing levels are low nurses report leaving more necessary care undone and that this ‘missed care’ partially mediates the relationship between nurse staffing levels and mortality rates.
Rather than focusing on broad roles, other studies in this special issue focus on specific nursing services provided to patients in diverse settings and with diverse problems. These articles include studies of decision coaching about immunotherapy for people with Multiple Sclerosis (Rahn et al., 2017), pain management after caesarean section (Schoenwald et al., 2017) and diabetes (Tabesh et al., 2017). In contrast Yang et al. (2017) review evidence that is not about nursing or nurses per se. Rather they aim to provide evidence to help nurses select and deliver effective interventions for people with cognitive impairment.
The authors of these diverse research studies span the globe, from Australasia to Asia, Europe and North America, with some demonstrating research collaborations that also reach across continents. While the studies included in the reviews are even more diverse, this does highlight a major deficit. None of the studies published here are from South America or Africa. While both these continents contain pockets of wealth, they also have large populations living in both relative and absolute poverty. As Crisp and Watkins (2017) make clear, some of the most significant impacts of nursing may occur when access to health care is most challenging. Although a large proportion of health care in Africa and other low to medium income countries is delivered by nurses, the great majority of healthcare research is conducted in the USA and Europe, creating evidence for nursing practice which may not be applicable to countries where nurses are working with limited resources and with very different health problems. (All Party Parliamentary Group on Global Health, 2016). A recent review of nursing research from Africa highlights the lack of nursing research on many of the most pressing public health problems including communicable diseases (Sun and Larson, 2015). The sad fact is that although the International Journal of Nursing Studies does occasionally receive and publish submissions from Africa countries and other underrepresented areas (e.g. Milford et al., 2016, Murphy et al., 2016), and papers dealing with problems facing practitioners in less developed countries are sometimes prepared by teams from other areas, for example Diallo et al.’s recent review on the management of childhood diarrhoea (Diallo et al., 2017), such submissions are rare.
In spite of this, the papers in this special issue do much to demonstrate the global significance and impact of nursing for many individuals, populations and health services. Those who hold this to be a self-evident truth should recognise the value of rigorous research, which challenges easily held assumptions and drives the generation of new knowledge that can improve care and patient outcomes. Those who are sceptical about claims of the significance of nursing might do well to reflect on how easily we could have filled this issue twice over. It was compiled from material that was routinely submitted rather than by a special call for papers. It does illustrate the gaps in our knowledge about the impact of nursing, but such gaps exist across all areas of health professional practice. The role of other professions is often taken as ‘self-evident’ while that of nursing is questioned in many jurisdictions. It is perhaps a tired argument, but one that needs to be revisited time and time again. As Crisp and Watkins argue, reflecting the findings of the UK’s All Party Parliamentary Group on Global Health (2016), more needs to be done to raise the profile of nursing and to ensure that it is central to health policy in every country. We hope that the research published in this issue, and the many other studies showing the impact of nursing that continue to be published here and elsewhere, will go some way to support that endeavour.