We know from rigorous evidence that nurses can exert an incredible impact on the everyday lives of people and their health. Nurses can also contribute in much wider spheres of influence by applying their knowledge and skills to address broader issues affecting population health across communities, nations and globally. Despite the prevalence of so many vexing health and social issues, nurses often fail to think globally, or even regionally, when they are lobbying for change. And while much political influence is local, some issues are simply too complex to rely on local influence alone. Importantly in all this, we must acknowledge the ways these complex health issues are shaped by economic and political agendas and not necessarily by healthcare agendas. As such, the nursing community has to act globally and locally, both within and outside of the nursing arena. This paper explores early thinking about an evolving model of spheres – or "bubbles" – of policy influence in which nurses can and must operate to more effectively impact key global health and healthcare challenges.
As the President of the International Council of Nurses (ICN), I have the honour of serving for four years (2013–2017) and during that time, I have chosen a watchword – impact. Nurses have an incredible impact on the everyday lives of people and their health. Nurses can also contribute in much wider spheres of influence by applying their knowledge and skills to address broader issues that affect population health across communities, nations and globally. Nurses can and should:
- Impact the quality of nursing care and patient safety – without risking their own lives and safety, and without compromising their family life;
- Impact global health through nursing knowledge, voice, experience and participation both at policy decision-making tables and at the point of care;
- Impact the social determinants of health by removing barriers and increasing access to quality healthcare; and
- Impact the level of knowledge and skills we use to bring about better health and better nursing.
Global Health Issues
The wealth of our nations depends on the health of our populations, and the health of our populations depends on nursing. As one important determinant of health, the provision of high-quality healthcare services is a significant global issue. The top global healthcare issues today include:
- Access to healthcare services (universal health coverage)
- Non-communicable disease
- Emerging and re-emerging infectious diseases, such as Ebola, tuberculosis and upper-respiratory diseases
- Healthcare financing
- System design – integration, complex adaptive systems and people-centred healthcare system
- Natural and man-made disasters
A key question is where nursing is situated in addressing these global healthcare issues, what contributions are we making and what contributions could/should we be making?
At a global level, ICN is the global voice of nursing. A federation of more than 130 national nurses associations representing the more than 16 million nurses worldwide. The 2014-2018 strategic plan for ICN has four themes:
- Global voice
- Strategic leadership
- Policy impact
From this plan, ICN has identified a series of strategic priorities aligned with the current global healthcare issues, including:
- Improving access to healthcare services;
- Managing and preventing non-communicable disease;
- Fighting infectious diseases;
- Economic, cost, clinical and social returns on investments;
- Complex adaptive system integration: including primary healthcare and rural-urban healthcare;
- People-centred healthcare systems; and
- Advocacy, particularly for poverty and women's issues.
Women and girls are particularly vulnerable in many parts of the world where extreme poverty and lack of access to education and basic health services contribute to early marriage and childbearing, and are associated with high rates of morbidity and mortality. In some places, violence against women continues to be an additional burden on health and welfare that impacts the well-being of children. As a profession dominated by women, nursing can play a key role in advocating for girls' education and access to reproductive healthcare and basic infant care.
Nurses and Global Health
Despite the prevalence of so many of these vexing health and social issues, nurses often fail to think globally, or even regionally, when they are lobbying for change. And while much political influence is local, some issues are simply too complex to rely on local influence alone. It is one of the reasons for collective action by nurses. Importantly in all this, we must acknowledge the ways these complex health issues are shaped by economic and political agendas and not necessarily by healthcare agendas. As such, the nursing community has to act globally and locally, both within and outside of the nursing arena.
What kinds of measures are being taken to ensure nurses remain current with their education?
The practicum experiences of nurse students have to broaden to the other bubbles. Nurses have been too locked into the nursing bubble. We've done that well, but we need to move beyond it.
Like other health professions, professional nursing organizations, when well-supported and involving engaged members, can link with other like-minded organizations to expand reach and influence. For example, ICN's ever-increasing networks and connections to people reinforce the importance of strong linkages with national, regional and international nursing and non-nursing organizations. Building positive relationships internationally helps position ICN, nurses and nursing for now and the future. Our work with the specialized agencies of the United Nations system, including the World Health Organization and the International Labour Organization, and also with the World Bank, is important for nurses everywhere. In addition, we work closely with a range of international non-governmental organizations (see www.icn.ch/about-icn/about-icn/).
While many of us agree that nursing is essential to resolving the global health issues mentioned above, the reality is that far too often nursing is not at the table for these very important discussions. Ask yourself, should nursing be at the table when solutions to universal health coverage are being discussed? Which profession is the one that has the most extensive experience and knowledge of the care challenges for populations outside of urban settings? The answer is simple: nursing. Imagine the discussion on non-communicable diseases and how to manage the burden of illness both from the economic and cost perspective without nursing knowledge, experience and care. The reality is that I can take each one of the global agendas and face the troubling reality that nursing is rarely at the right tables, and as a result the world population loses out. I have seen the positive impact of nursing on public policy decisions too often to accept any of those tables excluding nursing.
So the question is why we are relegated to – or worse, accepting of – the role of canary in the coal mine instead of sitting at the head of the table. It might be because over the past few decades, we invested much time and energy in strengthening the nursing profession, nursing knowledge and practice. While focusing and doing a great job on nursing, we have not sufficiently attended to maintaining our voice and influence in the global health context.
As I reflect on the global population health and health systems, I see four bubbles that have led me to discuss and play out what I call the "Bubble Theory." As depicted in Figure 1, this evolving model suggests that health system decisions are made in four spheres or "bubbles":
- The nursing bubble;
- The healthcare bubble;
- The regional/national bubble; and
- The global bubble.
While we are strong within the nursing bubble, we are less engaged within or across the other bubbles. As a result of this lack of engagement, policies, actions and systems transformations do not benefit from the knowledge, experience and contribution that nursing can make to health systems.
We all work hard within our respective bubbles, but we are missing many of the strategic partnerships that could exert the desired impact on health policy, planning and delivery. If we think carefully, each of these bubbles, while perhaps being effective within its sphere of influence, is poorly linked with other spheres of influence that are vital to making sustained changes.
Thoughts on an Emerging Nursing Policy Model
If we circle back to the current global issues and examine how they are being managed across the four bubbles, the gap between the current reality and the optimal reality becomes very clear. Let us examine briefly the agenda of universal health coverage. There are millions of people in all countries – not just in low-to-middle-income countries – who do not have basic access to care and live in extreme poverty. Often their access to health services includes traditional healers and local "wise men/women." In some places, we see the emergence of "community health workers" in multiple forms. The global organizations in the national and global bubbles, including financial organizations, are committed to turning the tide around, reducing extreme poverty and providing access to basic care without financially disadvantaging the population. To achieve that laudable goal, we need to build both economic prosperity and efficient health systems.
Nursing can offer solutions to both. A career trajectory that helps men and women gain proper employment and a potential career track in healthcare, including nursing, is part of a viable economic solution. Coupled with a health system infrastructure that puts nurses at the centre of the hub could help maximize the various groups of workers currently in the field. If nurses with the right knowledge, experience and perspective sit at policy, funding and systems tables, many of their contributions in the third and fourth bubbles could lead to very different decisions from the ones currently in place.
It is vital to acknowledge the rigorous bodies of return-on-investment evidence showing that nurses have:
- Economic impact and value;
- Clinical/care impact and value;
- Cost/benefit impact and value; and
- Social impact and value.
But the public cannot afford to have nurses sit back passively and wait to be acknowledged and recognized for the value we bring to solving some of the world's significant health challenges. As the most educated generation of nurses in history, we need to take the bull by the horns, so to speak, and make sure that we play significant roles and make contributions in each of the four bubbles.
Are we working effectively in the right bubbles? Nurses need to be visible and vocal in the right places. We must be effective partners with other healthcare providers and organizations to address the pressing issues identified earlier in this paper, while also having a lead hand in health human resources planning and in education, regulation and accreditation standards. This means not just being visible, active and credible within these important policy bubbles, but being deeply engaged in work that crosses and links these spheres through networks that include the public, political and policy decision-makers, health professionals and those in other sectors, including, for example, education, housing, employment and social services.
As depicted in Figure 2, all of our work should embed nursing — our business, after all — as the core that links with and reaches out strategically to the broader health system, and from there to regional, national and global nursing policy; health and social systems; economic trends; and political agendas.
Included in ICN's strategic plan is a statement of commitment to prepare the next nursing generation to be comfortable in all of the bubbles, ensure that we use evidence to improve care and strengthen our position, ensure that our voices are heard and encourage nurses to become engaged. We are striving to become stronger leaders and lead our communities, our nations and our populations to better health.
There has never been a time when the voices of nurses are more urgently needed at high levels of policy formation and decision-making than they are now. A nursing perspective can inform numerous foci for health services delivery by offering alternate, less technically complex, but no less impactful and innovative solutions to the many health and social issues facing the world today. It is up to nurses to demonstrate leadership at many levels, and through purposeful, strategic interconnection of all of the "bubbles."
About the Author(s)
Judith Shamian, RN, PhD, LLD (hon), DSci (hon), FAAN, President, International Council of Nurses,, Geneva, Switzerland
For their thoughtful contributions to this paper, Dr. Shamian would like to offer her sincere thanks to Dr. Kathleen MacMillan, Dr. Lianne Jeffs and Michael Villeneuve. Dr. Shamian would also like to acknowledge the work of the International Council of Nurses.
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