NR 506 RN as Healthcare Policy Leader Discussion

Yet, we all know great leadership when we see it (White 2019a). A striking recent example is the leadership shown by Jacinda Ardern, prime minister of New Zealand, after the mosque attacks in Christchurch that killed 50 people. The world watched, in awe of her ability to lead a nation, indeed a world. Wearing a hijab, she listened, apologized, and showed compassion and respect. She spoke eloquently of the policy changes needed, but did not rush to declarations or grandstanding. She announced unequivocally to the New Zealand Parliament that gun policy would change, and outlined processes and a timeline. Refusing to give the perpetrator notoriety, she did not say his name and never will. Ardern crystallized the essence of leadership. Guided by a consistent moral compass, she simultaneously saw the big picture and the consequences at the micro or human level. Outstanding nurses in leadership roles show similar qualities, but many others struggle to connect the macro and the micro. This is hardly surprising as nursing is rooted in our individual practice with our patients and communities.

We ignore the macro level at our peril, however. We experience daily the influence of policy and politics, in the funding of our health systems, the health challenges we tackle, the socio-economic policies that affect the health of the communities in which we live and work, the widening inequalities within and between countries, and the failure to provide universal health coverage. The Sustainable Development Goals remind us that health is interdependent and interconnected: the policies that most affect health are often not health policies, so cross-sectoral policy work and collaboration is critical. Moreover, policy and politics determines nursing itself – past, present and future. It profoundly shapes the practice and workplaces of nurses at local, regional, national and global levels (Salvage & White in press).

Most nurses say they just want to get on with their job, and not worry about the macro-level concerns of policy and politics. They make naive assumptions about health and health care and do not view the issues through a socio-political lens (White 2014). This makes them bystanders, but they are inevitably end-users of health policies. To shape the present and future of our profession, nurses must be active rather than passive, and influence and lead policy. This means understanding not only the content related to a health issue, but also the policy process, the context, and the stakeholders and their interests.

Furthermore, nurses have a moral obligation, resonant with their codes of practice, to shape health and social policy in ways that advance the interests and health of the public. ‘They have an obligation to speak out and get involved in one of the most important moral imperatives of our day: promoting the health of families and communities by shaping health and social policies to end disparities in health and create healthy places to live, work, and play’ (Mason 2016).

Neither heard nor heeded

Despite all the talk of leadership in nursing, the reality is deeply worrying. Nurses are the largest group in the global health workforce, and often the only healthcare providers available. Worldwide, nurses do wonderful work with brilliant outcomes. They occupy a special position as the interface between the health system and the community, and they see, hear and know how policy and politics affects patients and communities.

They should be feeding that knowledge into policy-making. You might think that policy-makers would welcome their inputs with open arms, yet while nurses are acknowledged as key policy implementers, they are rarely central to health and social policy development (White 2014). They carry out the policy decisions made by others, but have little say in those decisions – mirroring patriarchal doctor–nurse and male–female relationships.

In recent decades, nurses have become increasingly knowledgeable, skilled and well-educated, but this progress has not been matched with a significant growth in influence and status, and in some respects is going backwards. ‘Weak and, in some cases, reducing leadership’ is a major challenge facing nurses globally, according to the influential Triple Impact report and many others (All-Party Parliamentary Group on Global Health 2016, pp 17). It is also a major challenge for health systems globally, not just for nurses, for if the world’s 23 million nurses and midwives are neither heard nor heeded, how can these systems be truly effective?

This crisis of leadership is evident in individual countries, and also at global level, where nursing is seriously underrepresented in the major global health organizations – many of which rely on front-line nurses to deliver their programmes, yet have few or no nurse employees or board members. They even exclude nurses from applying for positions still reserved for doctors: a recent call for applications for a World Health Organization maternal health post in Sierra Leone required an MD, even without experience in obstetrics and gynaecology. There was nothing in the job description that could not be perfectly well done by a nurse or midwife.

Global nurse-led organizations, comparatively weak and lacking in influence, are not yet major players. This lack of strong national and global nursing voices is part and parcel of structural global inequalities related to gender, wealth, race and status. These inequalities also underlie the lack of attention paid to voices from low-income countries, indigenous peoples and other disadvantaged groups, an omission that has a large and generally unrecognized negative impact on global health.

When nurse leaders do make it into the settings where decisions are made that have profound effects on health and health care – for example in parliament, in government, and in the boardrooms of major organizations – they are often neither heard nor heeded. The reasons range from gender discrimination and social class to lack of status. Many have little or no preparation for roles as government nurses, nurse directors, deans or heads of nursing associations, and do not know how to influence and shape policy, even within nursing, and change has not happened fast enough or far enough.

The window of opportunity

Recommendations on nursing that fail to have traction, policies that ignore or undermine nursing, and nurses’ virtual absence from policy-making – can this gloomy pattern change for the better? Change is in the air, at long last. The profession is learning, and moving along the spectrum of political development, through the four stages from buy-in and self-interest to where we are now, developing political sophistication and aiming to lead the way (Cohen et al. 1996). This slow pace of change is accelerating and a new window of opportunity is opening, pushed by new ways of thinking and acting on nursing.

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The first-ever Year of the Nurse and Midwife in 2020, with the first WHO report on The State of the World’s Nursing (it only took 72 years!), is an exciting prospect. Urged by its nurse-savvy director-general Dr Tedros Adhanom Ghebreyesus, WHO is taking steps to embed nursing and nurses in its thinking and actions. Meanwhile Nursing Now, launched on the back of the Triple Impact report, aims to match global policy action with local campaigns as a social movement. The campaign works with ICN and WHO to ensure that experienced nurse leaders are available in the right places and right roles, to help nursing deliver its potential and include the nursing perspective in policy-making and decision-making. It advocates creating and strengthening strategic nursing leadership all in countries, and the Nightingale Challenge 2020 will be launched at ICN Congress in Singapore in June 2019 to every large employer of nurses to provide leadership and development training for nurses and midwives.

The development of strategic and policy leadership is missing from most nursing leadership programmes, with the rare exception of the ICN Global Nursing Leadership Institute (GNLI). Now in its tenth year, this innovative programme has inspired nearly 300 nurse leaders from round the world to ‘think globally, act locally’ – not as an academic exercise but as a way of seeing that enriches perspectives, increases knowledge, and makes nurses more motivated and effective. Seizing nursing opportunities in a global movement committed to sustainable development, GNLI focuses on the foundations of policy understanding and influence. Most top nursing leadership programmes focus mainly on organizational management. These programmes are few, although a full mapping is needed. GNLI, in contrast, helps senior leaders to hone their professional, political and policy leadership skills to operate effectively in tough policy arenas, while maintaining person-centred, humanitarian values.

These top leaders, in many different roles, learn together how to maximize their contribution to shaping, influencing and implementing policy. For policy change – to make things happen – they need to consider not just the content but also the context, the change process, and the interests and power of the key actors/stakeholders. This means dropping ‘nurse-speak’ and the familiar nursing virtue script, addressing them instead in language that speaks to their priorities.

GNLI scholars work on live projects, underpinned by a review of their own countries’ health status and policies, and consider how nursing can make a more effective contribution through effective evidence-based policy-making that addresses health needs. Thus, GNLI helps them to join the dots between what happens in their own organizations, in their own national scenarios, and globally. All this requires greater awareness of how nursing contributes to outcomes not only in health, but also in education, gender equality, poverty reduction and environmental activism.

The programme evaluation is highly successful. However, we need not just 300 policy-competent nurse leaders in 10 years, but at least 3000 in the next decade – and a top cohort for each country. Moreover, all top nurse leaders in each country should work closely together, but in many countries these nurses do not collaborate or even know each other. Some countries lack properly funded and supported senior nurse posts in government and elsewhere. Collaborating to produce and implement a national action plan for nursing as advocated by WHO, within a country’s health strategy, can engage and motivate thousands of nurses and other stakeholders. We would like to see more cooperation and sharing on this globally, and in the six WHO regions worldwide as well as at national and local levels. The triad model adopted at global WHO/ICN and European Union meetings of government nurses, regulators and heads of nursing associations is an important step in bringing country-level leadership teams together to learn, share and return home with new energy and ideas, and much more could be done.

In our vision, nurse leaders are experienced, confident and effective champions of quality with a powerful voice at all levels of health and policy systems, recognized and valued by the public, service users, colleagues and policy-makers. They are in posts in the right places and right roles, and receive the support and resources they need to help nurses deliver their potential. They ensure that the distinctive nursing perspective is included in policy-making and decision-making.

Achieving this vision requires champions to provide serious support and serious money, beyond our impoverished nursing organizations and our usual faithful donors. The 2020 window of opportunity may soon slam shut again (Salvage & Stilwell 2018). Now is the moment to shift the paradigm, to be taken seriously, when the old certainties and ways are being shaken to the core by economic crisis, climate change, insecurity, a deep desire for stronger social solidarity, and the rising clamour of women’s voices – and of nursing policy leaders.