...it is essential that nurses are able to effectively influence change at local, organisational, systems, national, regional, and international levels. The International Council of Nurses (ICN) believes that nurses are key to improving access to quality and cost-effective care and to enhancing the health of populations. To this end it is essential that nurses are able to effectively influence change at local, organisational, systems, national, regional, and international levels. This is true for every country, whether the country is an industrialised or a developing nation. Every year ICN encourages its members to celebrate International Nurses Day and produces resource kits that include evidence-based materials, press ready messages, and short videos to share with nurses and the general public (ICN, 2011).

In 1999, ICN launched a global vision for the 21^st Century (ICN, 2010a). The vision declared, in part, that “our mission is to lead our societies to better health” (p. 1). If nurses are to realize this vision, nurses must do more than care for patients and conduct research. They need also to be actively involved in shaping health policy. In this article I will begin by highlighting how nurses can advocate for the nursing profession by coordinating nursing actions to develop both public and healthcare-service policies. These actions include maintaining solidarity within the profession and developing strong leadership. Then I will provide examples, drawn from real-life experiences, that illustrate how nurses in El Salvador, Rwanda, Paraguay, Papua New Guinea, and Iran have coordinated actions in their own countries to advocate for public and/or healthcare service policies. I will conclude by noting that all nurses must do their part and use a wide range of opportunities creatively, and with clarity of intent, to improve the profession and the lives of the millions of people who depend upon us.

Although space does not permit a full theoretical exploration of these examples, at the heart of each example can be seen the embodiment of the change equation in action. This equation involves creating a situation where dissatisfaction with the status quo, coupled with a vision for the future and tangible first steps, can overcome the resistance that is embodied in both individuals and the system to a given change (Beckhard & Harris, 1987).

Coordinating Nursing Actions

Nurses' associations can serve as a key vehicle for influencing policy, both nationally and globally...the majority of initial improvement(s) in the profession can be traced to the organised commitment of individuals working under the auspices of nursing associations. Nurses provide essential services and are knowledgeable about client needs. They interact closely with healthcare consumers, including patients, families, and/or populations, in a wide variety of settings. This gives nurses a broad appreciation of health needs, an understanding of how factors in the environment affect the health of clients and their families, and insight into how people respond to different strategies and services. Nurses help to interpret people’s needs and expectations for healthcare. Nurses also understand the needs and expectations of society’s vulnerable groups. The nursing community in every country has gathered valuable knowledge regarding healthcare needs. Hence nurses are well positioned to provide advice regarding accessibility to services and to understand relationships between health and social patterns.

Nurses also have qualities and skills gained as part of their nursing practice that are valuable in other contexts, such as policy development. Furthermore, because nurses, as health professionals, constantly work with the cost-quality constraints of health service delivery, they are in an excellent position to offer advice on policies aimed at cost-effectiveness in healthcare.

Nurses' associations can serve as a key vehicle for influencing policy, both nationally and globally. In my work as the Chief Executive Officer (CEO) of ICN I have noticed that the majority of initial improvement(s) in the profession can be traced to the organised commitment of individuals working under the auspices of nursing associations. ICN itself works to shape health policy at the global level. It publishes, disseminates, and regularly updates a series of position statements covering many aspects of professional practice, regulation, and socio-economic welfare – all available in English, French, and Spanish (ICN, 2010b). The ICN advocates for policies that contribute to the health of populations, sustainable development, and the security and just treatment of nurses and healthcare professionals. Working with national associations in each country, ICN can amplify these effects and realise change.

...policy development has traditionally been nursing’s area of slowest advancement...All too often nursing’s role has been to implement policies and programmes, rather than to participate in and bring the nursing perspective. Unfortunately the area of policy development has traditionally been nursing’s area of slowest advancement (WHO, 2011). All too often nursing’s role has been to implement policies and programmes, rather than to participate in and bring the nursing perspective, experience, knowledge, and skills to policy formulation and healthcare planning.

The question remains as to how nurses who are knowledgeable and skilled health professionals, who advocate for and make healthcare decisions, can become involved with shaping health policy. How can nurses be more effective in assuring that everyone, everywhere, has access to services that are sensitive to patient needs, provide a full range of integrated care, conform to professional ethical and practice standards, and reflect the right to confidentiality, information, and informed consent? I will discuss below how nurses can coordinate their actions so as to advocate for the nursing profession by maintaining solidarity within the profession and developing strong leadership.

Maintaining Solidarity Within the Profession

The single most important factor in influencing health sector policy is solidarity within the profession...the aim is to reach agreement on key issues and maintain that stance in public. The single most important factor in influencing health sector policy is solidarity within the profession. Strong, well-organised nursing associations are a powerful vehicle for influencing and achieving nursing's goals. Unity within the profession is essential to ensure that nursing's voice is heard. Nurse leaders need to work through their national nursing associations. They need to bring all perspectives to the policy debate; determine what the specific goal or purpose is to be; and after often-robust debate, agree and maintain that approach and position in public.

There is no guarantee that all nursing associations, or indeed all nursing leaders, will be in agreement on every issue. Yet the aim is to reach agreement on key issues and maintain that stance in public. Although specific issues can be dealt with on a case-by-case basis, agreement on key directions is essential if nursing is to have real influence in the policy arena.

ICN provides its members with the platform and the means to achieve common goals through collaborative action, working together for the benefit of society, the advancement of the profession, and the development of its members. The strength of nursing numbers; strategic and economic contributions; and ability to collaborate with the public, health professionals, families, and communities for whom nurses provide care all add power to the vision.

Developing Strong Leadership

On every continent, in every nation, and in every community, people need to understand that strong nursing leadership is critical... ICN is only as strong as the leaders in the associations that make up the federation. It is therefore essential that nursing leaders develop the ability to give direction and empower those who make up the profession. A range of tools are available to this end that can be downloaded from organisations such as the Western Pacific Office of the World Health Organisation (WHO) (2005) and The World Bank (2011a, 2011b).

The financial challenges currently experienced by many countries have resulted in the recognition that strong and effective leadership is imperative. On every continent, in every nation, and in every community, people need to understand that strong nursing leadership is critical if the ICN vision - to lead societies to better health – is to become a reality. That is why so much of the work at at ICN is focused on developing nurse leaders.

...ICN uses a very basic description of the concept of leadership, seeing leadership as: a relationship, a process of getting things done through people; as something to be shared and celebrated. Today leadership requires us to bridge the ‘divides’ of race, class, gender, culture, language, and nation. Because none of these divides is simple to tackle, ICN uses a very basic description of the concept of leadership, seeing leadership as: a relationship, a process of getting things done through people; as something to be shared and celebrated. Extensive international research, conducted over a period of two decades, has consistently underlined that nurse leaders need to be competent, inspiring, and honest. Increasingly the profession also expects them to be forward looking and to have ‘vision.’

Indeed vision is central to leadership. It is all very well to say that as a nurse one wants to change things for the better. But meaningful change grows from a targeted vision and the development of a strategy to get there. Leaders need the ability to create this clear view out of chaos, change, or rigid conformity to the status quo.

...meaningful change grows from a targeted vision and the development of a strategy to get there. Leadership is one of ICN’s five core values, along with Inclusiveness, Flexibility, Partnership, and Achievement. Nurse leaders have historically had a significant impact on societies nationally, regionally, and internationally. Our predecessors, such as Nightingale and Bedford-Fenwick, recognised the potential value of nurses working globally. Indeed, Bedford-Fenwick and her peers, working in unison to improve health and raise standards of nursing care, established the International Council of Nurses. Over the years ICN’s leaders have understood that if nurses from all nations join together and work toward common goals, they can create political and social change. (Bush et al., 2001).

ICN has three programmes aimed at building the capacity for such leadership in societies around the world. These programmes include the Leadership in Negotiation Programme, the Global Nursing Leadership Institute, and the Leadership for Change Programme.

The Leadership in Negotiation Programme (ICN, 2010c) equips nurses with the skills necessary to achieve safer working environments and fair levels of remuneration as valued members of the society. Over the past 20 years nearly 30 countries have been involved in this programme.

The Global Nursing Leadership Institute (GNLI) (ICN, 2010d), established in 2009, offers senior and strategic leadership development at the executive level for nurses from countries across regions of the world. The programme draws on the expertise of international faculty, allowing participants to review and enhance their national and global leadership skills and behaviours within a collaborative and stimulating learning culture. At the very highest levels of nursing leadership it is often difficult to find a confidante, i.e., a person who can empathise with one’s position and offer a sounding board for one’s ideas. Based on an action-learning approach, participants work in teams to develop and share an in-depth understanding of the challenges that are being faced, the commonalities, the successes, and the failures. In so doing participants get new insights, build alliances, and formulate new and innovative solutions.

The third programme is the long established Leadership for Change (LFC) Programme (ICN, 2010e). This programme aims to develop strong leadership skills that enable nurses to be more effective at their national level. Following an initial ICN programme at the national level, further LFC programmes are delivered by certified LFC Trainers, including some 400 trainers working across all world regions, helping many countries to sustain and continue their nurse leadership development. Established in the late 1990s, the programme has developed some 2,500 nurses around the world. Additional trainers continue to introduce the programme for interested nurses. In this way ICN is helping to develop the capacity of nurse leaders so that they become more effective leaders within their societies. The next section will illustrate leadership activities demonstrated in five different countries.

Examples of Advocating For Health-Related Policies

It is important that nurses not become complacent...Societies and opinions change, and nurses need to keep focused on issues that matter. The examples below illustrate the importance of nursing leadership in attaining healthy societies. ICN always has a strong delegation at the annual World Health Assembly held each May in Geneva, Switzerland. At this Assembly nursing’s voice is heard as positions and interventions are delivered in open forums. Nursing’s voice shapes the seeds of the policies that will subsequently be developed and implemented in various countries. Early intervention is essential. Getting the direction right from the outset means that a nation’s nursing work force can truly contribute to the development of a nation’s health and social policies at an international level. It is important that nurses not become complacent about their leadership positions. Societies and opinions change, and nurses need to keep focused on issues that matter.

Leadership and advocacy happen when nursing leaders use different approaches and focus on real issues for society... As nurses we also have a burden of responsibility – we must constantly seek to earn and sustain leadership roles in society through striving for the best and highest standards of care, through using influence to increase access to care, and by being courageous in the face of threats to the quality and safety of that care. This requires us to display strong leadership and advocacy in the interests of society. Leadership and advocacy happen when nursing leaders use different approaches and focus on real issues for society using the various strategies presented below, including addressing emergent needs, coordinating action, using the power of communication, employing planned leverage, and celebrating success.

Addressing Emergent Needs: El Salvador

Although making great strides in the provision of health services to its people, El Salvador still faces many problems. Distressed by the number of patients with Dengue fever one nurse was seeing in a remote and rural clinic, she decided to take things into her own hands and develop a plan for change. She knew that she would need to obtain the support of her local manager, a doctor. She decided to gather evidence as described by WHO (2007a) and to create a plan (WHO, 2007b).

This nurse did not have any public health training; yet she did not let this lack of training stop her. Instead she went to the books and the Internet and learned ... This nurse did not have any public health training; yet she did not let this lack of training stop her. Instead she went to the books and the Internet and learned that by creating a geographic map of cases (Kirschenbaum & Russ, 2002) she could identify the location and magnitude of the problem. She was also able, by looking at the records, to identify that the problem was getting worse. After she presented this information, along with a suggestion that the clinic should develop targeted health information sessions for the most affected local groups, progress in fighting Dengue fever was dramatic. The local people themselves are currently helping in the fight against this major problem; and this nurse, who is now part of the local management team, is helping to develop programmes in other clinics for similar problems.

Coordinating Action: Rwanda

When people hear mention of Rwanda, they often think about the terrible genocide that this population experienced. Although this genocide has not been forgotten, the political leadership of the country has been able to use this experience to move forward. Rwanda has one of the highest percentages of women in government in any country in the world, specifically 48.8% of those in the national parliament are women (Powley, 2005). Women have been empowered to be a major force in the regeneration of the country. It is therefore not surprising that nurses have taken advantage of this opportunity.

Rwanda’s Chief Nurse, along with the president of the national nursing association, recognized that there was a need to introduce professional regulation. Although introducing new legislation can be difficult and time consuming, the Rwandan nurses were not deterred. Instead they worked together to identify what they wanted to happen and to gather support for their proposals using their extensive networks. They also invited ICN to lobby the government on their behalf. Because they were not content with the length of time it was taking to develop appropriate legislation, they persuaded local nurses that until the legislation was passed they should operate as if the legislation was in place. In effect they created a ‘shadow’ and voluntary regulatory council. This legislation focused on making improvements to the quality of nurse education and professional standards of practice; it was synchronized with the government’s vision to improve health services. The legislation has now been passed. A Council, based on this voluntary commitment to a vision created by innovative leaders, has been created. The Council has now completed setting educational and practice standards and is able to improve the quality of nursing practice.

Using the Power of Communication: Papua New Guinea

Papua New Guinea is a country with a variety of health challenges. One challenge relates to the high rate of HIV and AIDS in remote and rural areas and the lack of people coming forward for testing. Some of the nurses in Papua New Guinea, to fulfill requirements of their Leadership For Change Action-Learning Project, decided to tackle this problem. These nurses identified key local stakeholders, including youth and women’s groups and community leaders in 14 villages, among whom they would work to increase awareness about HIV/AIDS. They used short-wave radio services; community-based, outdoor, remote broadcasting systems; and local newspapers to deliver information about health needs and available health services. The nurses offered remote clinics in each village and conducted workshops on HIV and AIDS. They also taught the local people about other primary healthcare topics, such as diabetes, hypertension, prenatal care, and immunisation. Following one of the workshops, 365 people came to the health centre for HIV testing. Anyone who tested positive was referred to the hospital for counseling and treatment.

These nurses not only tapped into their knowledge of the population needs, they also utilised technologies that were commonly available. In so doing they made a difference. Because the nation’s Ministry of Health is a partner in the Leadership For Change Programme, they were able to quickly build upon this initial programme to develop a national approach for increasing public engagement with HIV testing, thus establishing a win, win, win situation – wins for the government, the citizens, and the nursing profession.

Employing Planned Leverage: Paraguay

Paraguay, in Latin America, has faced many challenges. Yet the national nursing association’s leadership is strong. During my recent visit ICN-CEO visit to Paraguay it became clear to me that the Paraguay Nursing Association was going to use my visit to leverage change. Taking a results-focused approach the association sent me emails describing what issues they wanted to address and what national outcomes they wanted to achieve as a result of my visit. The association sought to raise the profile of various issues with government officials, the profession, the media, and key citizens during the various events scheduled as part of the visit.

Upon my arrival in Paraguay the Board of Directors and senior leadership of the nursing association, under the expert guidance of the association president, arranged a series of meetings. For example, my early meeting with the Ministry of Health was immediately followed by press conferences, and later with formal presentations on a range of relevant topics to leaders, frontline staff, and students.

The idea was to use my visit both to highlight the appalling levels of staffing in the country and to secure a stronger and more influential voice in the policy-making process for the nursing profession. We developed clear messages on these two themes, marshalled the evidence, and took advantage of the opportunity to raise awareness of these situations.

The Ministry of Health was fully engaged and attended all the presentations offered to the various audiences. Then, mid-visit, Ministry representatives decided to take advantage of an arranged meeting with nurses to share the government’s ideas regarding future healthcare policy directions. This provided a significant opportunity in which nurses could talk directly to the Minister and senior officials, providing first-hand information on what nurses are doing and could do in the future. We described how nurses in other parts of the world have supported governments in dealing with the same problems that Paraguay was facing and explained how nurses could contribute to meeting the healthcare goals set by the government. Working in partnership, ICN and the nursing association were able to open doors and move forward the agenda to strengthen healthcare in Paraguay.

Celebrating Success: Iran

Having recently returned from a fascinating visit to the Islamic Republic of Iran, my perspective is now very different from the perspective I had of Iran before visiting there. The Iranian Nursing Organisation has made extremely rapid progress since the election of its first Board in 2002. The organisation has taken a broad-based approach to the development of the nursing profession. It has explored opportunities in education, regulation, socio-economic welfare, culture, and wellness to advance the status of its members and the role of nursing.

Utilising the International Nursing Day theme, the Iranian National Nurse’s Day commemorations now attract approximately 5,000 nurses from various parts of the country to celebrate the contribution of the profession and take advantage of the creative and locally sensitive resources that ICN makes available. Events that profile nurses are well attended by ministers of health, government officials, the Iranian President, and senior religious leaders. This approach creates opportunities in which the nursing voice can be heard loudly in the corridors of power. In doing this the organisation fully utilises ICN’s position statements to initiate debate and bring about change. In 2011, the Vice President of the country launched an Ethical Code of Practice based on an ICN document. The impetus for initiating the development of this Code came directly from a discussion and request by the Supreme Leader of the country, Grand Ayatollah Seyyed Ali Hoseyni Khamenei.

Conclusion: Transformation, Solidarity, and Progress

If each nurse would take every opportunity to learn from the experiences of colleagues throughout the world and to initiate and influence policy development, we would have the expertise, strength, and knowledge to lead the world to better health. Additional examples of these activities of nursing associations could be highlighted; but instead of doing so let’s focus on the future. As ICN’s Leadership for Change Programme explains, nurse leaders are transforming agents, effective in bringing about change. These leaders are creative thinkers who consider long-term needs. They develop their members into new leaders. They learn, listen, coach, experiment, and network. In short these leaders lead their societies toward better health.

All nurses must do their part to speak with one voice, develop leadership skills, and advocate for healthy public policy using a wide range of opportunities creatively, but with clarity of intent, to improve the profession, and the lives of the millions of people who depend upon us. If each nurse would take every opportunity to learn from the experiences of colleagues throughout the world and to initiate and influence policy development, we would have the expertise, strength, and knowledge to lead the world to better health. Indeed we have already begun.

Author

David C. Benton, MSc, MPhil, RGN, RMN, FRCN
E-mail: benton@icn.ch

Mr. Benton is the Chief Executive Officer of the International Council of Nurses, a federation of over 130 national nursing associations around the world. He has worked in a wide range of policy position for over 20 years and is both a registered general and mental health nurse. David has undertaken research in a wide range of topics, and is an expert in nurse regulation. He has published over 100 articles and book chapters. Mr. Benton earned his nursing qualifications (RGN and RMN) from the Highland College of Nursing and Midwifery, Inverness Scotland, his BSc from the Robert Gordon University in Aberdeen Scotland, his MSc from the Complutense University, Madrid, Spain, and his MPhil at the University of Abertay; Dundee, Scotland.

© 2012 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2012