A voice for nurses worldwide

© iStock/Juanmonino In addition to issues of anxiety, stress, and burnout people have experienced post-traumatic stress and what we call moral injury whereby nurses educated to deliver care to a certain standard felt compromised every day.

HEQ spoke to Howard Catton, CEO of the International Council of Nurses (ICN) about the unprecedented impact of the COVID-19 pandemic on the nursing workforce and why global strategic efforts are needed to encourage equal career opportunities and promote sustainable investment in the profession.

The COVID-19 pandemic threw the many challenges affecting global healthcare systems into sharp relief. Like many other healthcare professions on the frontline, the nursing workforce faced unprecedented issues including staffing shortages, limited access to vital resources and emotional and physical burnout. In a telling report released by the International Council of Nurses earlier this year, it was estimated that if a mere additional 4% of the global nursing workforce were to leave their job due to the pandemic, the increased outflow of nurses would be more than one million, increasing the global shortage to an estimated seven million.

To understand more about the impact of international mobility and changing patterns of nurse supply, as well as what can be done to encourage greater workforce retention and sustainability, HEQ spoke with ICN’s CEO, Howard Catton.

What is the role of the ICN within the wider care landscape?

There are nearly 28 million nurses around the world who make up almost 60% of the healthcare workforce, the largest health professional group. Our role as ICN is to be and represent the voice of the nursing profession and provide nursing expertise and perspective to support the development of global health policies, in collaboration with the World Health Organization (WHO). The ICN was established back in 1899 and was the first health professional organisation to formally have recognition and a formal status with the WHO.

Our membership comprises national nursing associations, of which we have 130 from all across the world. National nursing associations are organisations run by nurses to support the advancement of the nursing profession, but their roles can be slightly different in each country. Some have more of a professional focus, others may have trade unions or may be the recognised trade union for nurses in their country, some have regulatory responsibilities, and some are a mix. The most common are those associations that provide professional advice, guidance, and standards and concurrently, deal with workforce employment and trade union issues.

Part of our remit includes collaborating with the WHO to outline strategic directions for nursing, as shown in the inaugural State of the World’s Nursing report in 2020. We have collaborated very closely on issues like patient safety, NCDs and primary healthcare. Similarly, we work with other international organisations including the International Labour Organization (ILO), Institute of Medicine (IOM), as well as those organisations based here in Geneva including the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF).

Looking at the recently published Sustain and Retain in 2022 and Beyond report, can you highlight some of the ways in which the COVID-19 pandemic has impacted the nursing workforce on an individual level but also across the system as a whole?

With the onset of the pandemic, we refocused a large area of our work on supporting nurses and the nursing response. Over the last two years, we have run a commentary and reported on this topic and there are regular briefings that you can find on our website. One of the standout findings from the State of the World’s Nursing report, which was collated before the pandemic and published in 2020, was that the world was six million nurses short. Essentially, we are 20% down in terms of the number of nurses versus health needs.

It is true the world was not fully prepared for the pandemic and nursing is a standout example of the lack of sustained investment in the profession. The key issues that we saw during the pandemic were around lack of vital resources including PPE, we monitored this closely and saw this translate as nurses being exposed to higher viral loads and higher infection rates. Unfortunately, this resulted in many deaths, and we ran a regular commentary on this which was important in terms of raising awareness about the ultimate price that people were paying and where we could have done better in terms of protecting people. There was a whole set of issues around the physical demands that were impacting individual nurses but then very quickly we started to pick up on ways that people’s mental wellbeing was being impacted, too.

When we first started talking about and reporting on the mental health pressures, based on the information we were receiving from our associations, the picture was hugely concerning. The evidence points to mass traumatisation of the global nursing workforce. People said to me at the time that it sounded a bit strong, but we have seen other organisations increasingly recognise the significance of the mental health impact. It is complex because in addition to issues of anxiety, stress, and burnout people have experienced post-traumatic stress and what we call ‘moral injury’ whereby nurses educated to deliver care to a certain standard felt compromised every day simply because there was not sufficient equipment, nor enough staff etc. There have also been issues around misinformation during the pandemic and abuse towards staff as a result.

The Sustain and Retain in 2022 and Beyond report amalgamates all the evidence and data to demonstrate the extent that COVID has affected the nursing workforce. We know from other work we have done that there are approximately five million nurses due to retire over the next few years, who will need to be replaced, and we think that the COVID effect could take out another 10%. We work closely with the other professions but speak on behalf of nursing, and many of these issues are affecting other areas of the healthcare workforce, too. Essentially, this is a global healthcare crisis. We have had a year of the nurse globally and a year of healthcare workers, but a more sustained effort is needed in terms of investment and policy approaches.

One of the report’s co-authors, Dr Franklin A. Shaffer said reliance on the international nursing supply to meet individual countries’ workforce needs will only serve to widen inequalities in access to healthcare globally. How can such a scenario be avoided and how can policymakers work together to improve longer-term nurse workforce sustainability?

International migration and mobility of nurses have been around as far back as one can remember and of course, individuals are free to move and there can be many benefits to this in terms of learning and knowledge sharing. However, what we are seeing now is countries that have not educated enough nurses and who have shortages, looking to international recruitment as a relatively quick fix to address their domestic workforce supply needs. There is a global code to ensure ethical practices in the recruitment of nurses, but the patterns that we are seeing show a strong pull from high-income countries – places like the UK, Germany, Canada, Australia, and the US – who are recruiting nurses from countries that cannot afford to lose them. These countries have a lower ratio of nurses per head of population, the six million shortage detailed in the State of the World’s Nursing report is not spread evenly around the world, low- and middle-income countries (LMICs) account for the majority of that shortage. This has a direct impact on the provision of healthcare services as a result, and in some cases, these services may cease to exist. Equally, it is important to point out that if you are a nurse working in an LMIC and you experience poor working conditions or very little pay, the opportunity of going overseas can of course be very attractive.

Our call to all countries is to invest more in nursing education, aim for greater self-sufficiency and implement more sustainable workforce planning. In our report, we propose the option of a self-sufficiency indicator which would illustrate the percentage of nurses who are educated overseas compared to those educated at home. We need more global attention on this issue, and further data, because if you are going to recruit from another country, how do you offset the potential challenges that ensue as a result and how do you ensure that you are ethically compliant? The global code is important, and we support it, but we are concerned that there is not enough reporting on this issue and would like to see a stronger global structural framework moving forward. 

© iStock/PeopleImages
The relationship between the health of the nursing workforce and the health of the patient is intimately linked.

How far did the WHO’s International Year of the Nurse and Midwife in 2020 support and strengthen the global nursing workforce? Equally, what key message would you like people to take from this year’s International Nurses Day?

Historically, nursing has been somewhat of an invisible profession, so it was incredibly important to recognise those 27-28 million nurses around the world who are making a real contribution and the value that they bring. I do not think the profession has been well understood, and in a way, the pandemic made the case for nursing in a really powerful way and gave people an insight into just how critical this profession is. Part of what we are looking at as part of our International Nurses Day publication is what recovery from the pandemic looks like and how we can build back stronger.

People are worried about increasing waiting times and lists, ageing and NCDs and nursing offers a lot of the solutions to that. Nurses who are working in advanced and specialist roles, particularly with NCDs, who are managing their caseloads, ordering diagnostic tests, managing issues around prescribing etc. will often be the only healthcare practitioner that somebody would ever see in remote or rural areas. While we need to educate more nurses we also need to support and retain the nurses that we already have and consider how we are maximising the potential of the nursing workforce to achieve Universal health coverage (UHC) and the Sustainable Development Goals (SDGs). One of the things we always do with the International Nurses Day is to make policy arguments, but also to bring full case studies. We aim to have a strategy to outline what needs to be done and how strategies can be adopted and implemented in different countries.

The UK recently reported record numbers of applicants for nursing courses and apprenticeships but also showed a continuing gender gap, with women nine times more likely to apply. What can be done to tackle the gendered perceptions of nursing? How can the media support and incentivise people to apply to the profession?

In terms of people being drawn into the profession because of the pandemic, the UK is a good example and I think we have busted some myths as a result which is encouraging. Increased media coverage has enabled more people to see and understand the critical role of nurses; their responsibilities can be technical and complex. Now we need to ensure countries have the faculty and the university capacity to support those who want to pursue a career in nursing but equally, there may be attrition issues for people who think it is one thing but in practice, nursing may not be for them. There are parts of the world where the conversation is very different, where nurses have not had the PPE early on, have been infected and seen colleagues die and ultimately, the pandemic has exposed all of the very worst features and the lack of value and respect for the nursing profession. People are therefore not being drawn in as a result.

Historically, nursing is an overwhelmingly female profession but before we consider how we can attract more men, which we would, of course, welcome, we need to consider and tackle other challenges such as the lack of investment in the profession and lack of recognition of the true value of nursing. There are also problems relating to the lack of nurses in senior leadership positions, a lot of that is embedded in historical discrimination and the undervaluing of the work and what has typically been seen as a woman’s role. The race has also come to the fore as a deeply rooted inequity. We also know that in some health systems where there are not pay equity schemes that pay discrimination exists; men in all health systems are still more likely to be promoted and we need to unpick all the issues relating to that. Lack of flexible working and family support policies often means women who are on a career trajectory have to take significant breaks due to family commitments and do not receive support at work to enable them to come back in a way which would support their career progression. Recruiting more men should not be seen as a quick fix to mask other deep-rooted issues.

There are some countries around the world where there are many more men in nursing, such as Italy, Cyprus and Malta, and countries where women are limited in the jobs they can do. There is an opportunity for men in nursing to talk to others and address the perceptions and preconceived ideas associated with the profession. Again, the pandemic has shown just how courageous nurses and other healthcare workers have to be to undertake this kind of work.

Retention is another key point here, it is so important to hold on to those skilled workers because when 20-30 years of skill and experience walks out the door, it is irreplaceable. We published a report which addressed retention policies and it is not just one policy that will encourage people to stay, of course, pay is important, but respect and recognition of work, feeling that you are valued, that your voice is heard and there are career opportunities, as well as flexibility, are all measures that can make a huge difference. Often the reality or reaction of the health system to a crisis or nursing shortage is to work the people that you currently have harder and harder, we have seen that throughout the pandemic. All health systems really need to be focusing much more on how to support and retain their current nursing workforce.

We hear this time and time again that the relationship between the health of the nursing workforce and the health of the patient is intimately linked and if nurses are stressed and do not feel valued and respected, if their mental health is under pressure, the impact will ultimately be on the quality and safety of patient care.

Howard Catton
International Council of Nurses (ICN)

This article is from issue 21 of Health Europa Quarterly. Click here to get your free subscription today.

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