It is both a great pleasure and a great honour to be with you today, in the company of my distinguished colleagues, Beverly Malone and Mary Foley. And to be visiting this part of your vast country for the first time. I come from a very small European country, and it has always been very exciting to visit the United States, with all its possibilities. I have been here many times and still the words "I am going to America" are something special for me; a European born at a time when a trip to America was by boat, and took, at best, 10 days. I think the fact that I visit new places each time I come, also helps create this special feeling. One of my most memorable visits was to attend the meeting of the International Council of Nurses, held in Los Angeles in 1981. Now twenty years later, in June 2001, my country will have the pleasure of hosting the ICN Congress in Copenhagen. I look forward to seeing many of you there, where you can share your experience, knowledge, and enthusiasm with nurses from all parts of the world.
Copenhagen, Denmark's capital, is a tiny one in comparison with your cities. As we compete with the rest of the world, we have chosen to make the smallness an asset; and to present Copenhagen as the capital with the human face. It is well known that Danes enjoy meeting people and learning from others, and are strong promoters of courtesy, respect and helpfulness.
Danish nurses have learned a lot from American nurses, and have adapted many of your ideas to fit the Danish culture. During the past thirty years, I have worked with many outstanding American nurses, and always look forward to the opportunity to meet new colleagues, to learn more about American nursing, and to tell you about ICN and nursing internationally.
As President of the International Council of Nurses, I have the privilege of representing the nurses of the world. Today ICN includes member associations from 122 countries, with more associations anxious to join our international family. The 122 groups vary in size, and are quite different politically, culturally and socially. However, they agree on key common values and goals for nurses and nursing. Within ICN the member organisations work together on three strategic goals:
1. to bring nursing together world-wide;
2. to advance nursing and nurses wellbeing; and
3. to influence health policy.
Care and Caring
One thing that almost every country has in common is that nurses provide the majority of health services. The World Health Organization's Director General, Gro Harlem Brundtland, has stated publicly that nurses are the backbone of the health care systems. There are more than eleven million of us around the world, including more than two and a half million in the United States alone. Every hour of every day, we are there for people of all ages, all over the world. We educate mothers, immunise infants, screen children in schools, counsel adolescents about healthy lifestyles, encourage adults to exercise and eat well, improve the quality of life for the elderly, and comfort the dying. We work in hospitals, schools, prisons, clinics and in makeshift tents in refugee camps. We are there in times of peace and in times of conflict and war. We are everywhere because we care.
The theme for your conference, "Nurses keeping the care in health care", is an important message to nurses and others in these turbulent times. I have been reflecting on your theme - about what caring means today, what it needs to be, and about the circumstances of caring.
What Caring Means Today
Florence Nightingale was quite clear about it. She saw nursing as helping people to live. She looked upon the patient as a member of a family and a community, and she emphasised personalised patient care, and the importance of the nurse's integrity. She considered love, duty, and kindness as heroic virtues, and perceived the nurse as a heroine in daily practise. She also stressed the importance of nurses having broad interest and involvement in society's problems, and in their efforts to fight against social and health evils. Nightingale's wording can seem a little pompous in our time, but the intent is equally relevant today. We merely use more modern words to convey the same message.
For example, Virginia Henderson, considered by many as the modern day Florence Nightingale, saw health care in much the same way. That is, for Henderson, health care was complex, involving patients, families, and communities, as well as health promotion and illness prevention. She cautioned that nursing must change with the times and the circumstances.
Henderson saw nursing as a part of the whole of health care, and the nurse provided for the patient's needs as a substitute for the patient. In her words, "the unique function of the nurse is to assist the individual in performing those activities they would do unaided given the necessary strength, will or knowledge. And to do so in a way that helps the individual gain independence as quickly as possible" (Henderson, 1997)
Today, as a century ago, the cornerstones for our care rest in our values, vision, norms and professional ethics. ICN has been working to ensure these foundations are relevant to our times. In 1999, at ICN's centennial celebrations, nurses of all nations unanimously endorsed a new vision for the 21st century, as well as five global values.
This year, revisions have just been completed on the ICN Code of Ethics for Nurses, and the language has been updated to reflect today's terminology. The Code begins with the underlying assumption that the need for nursing is universal, and with the belief that, inherent in nursing, is respect for human rights - including the right to life, to dignity, and to be treated with respect.
Underpinning the Code, as well as all the work ICN does, are the five values discussed in 1997 in Vancouver, and in 1999 in London. These have been accepted by the world's nurses, together with a vision for nursing in the 21st century. The values are: Achievement; Partnership; Flexibility; Inclusiveness; and Visionary Leadership.
The values are purposefully broad so that they can serve the individual, the profession, and the associations as we work to advance health care, nursing, and our own well being in this century. The values, together with the other basic tools, give the profession and the world a message about caring and about working together. They show we are open to co-operation and collaboration with other professions and groups, and they demand knowledge and skill from the members of our profession.
We believe the vision, values, norms, knowledge and our ethics provide a sound basis on which to meet the challenges and shape our future. And, most importantly for me, they shape our humanistic approach; our caring.
Circumstances Affecting Caring
You know we are in a very tough situation in this country and elsewhere. We enter nursing because we want to help people, and we study and carry out research so that we will be able to give the very best care. We work within our associations to develop standards and to lobby for quality care. We go to work each day with the full intention of giving the best care we can. Also, the public has great faith in us.
Too often these days, however, we go home frustrated because we cannot achieve to the full extent of our capabilities. We did not give our best to everyone. Why? The answers are the same everywhere. We did the best we could under the circumstances.
Colleagues in some parts of Africa will tell you they do their best in delivering new-borns, using plastic shopping bags to protect themselves - or the baby - from HIV. But shopping bags are slippery, and so are new-borns.
Colleagues in Central and Eastern Europe go home feeling they did the best they could without drugs, sterile needles, and little other basic equipment with which to give care. Friends in some parts of the Caribbean will say they did their best, given there was only one nurse for 50 patients.
Here, you could say the same - you did your best under the circumstances. You know you could have done more, but were too short-staffed. You could only attend to essentials, yet you knew patients and families needed teaching, comfort, or discharge planning.
Sometimes, when I am visiting public hospitals, particularly in developing countries, I marvel at the commitment of nurses. Despite the lack of supplies and staff; despite the workload and the crumbling conditions, and despite the fact they may not have been paid recently, nurses are there for the patients and their families. You see it and you feel it. And I feel great pride and great frustration.
I feel the same pride and frustration when nurses stand up for their rights and the rights of patients - and get less than they deserve. Even when the public is so supportive.
I think the most incredible and least recognised thing is, that despite all hardship, we are there; our caring is evident to patients and to families. We are a bit like the rabbit in your battery commercial a few years ago - we keep going, and going, and going.
Someone said that nursing is a career measured in moments. We each have wonderful moments that sustain us, lighten up a tense situation, and bond us to patients, the profession and each other. For example, one testimonial from Texas involves a child with asthma. The mother writes: "If it wasn't for the school nurse, A.J. would have been hospitalised on many more occasions over the last two or three years." A thirteen year old writes: "I have leukaemia. It's not fun having leukaemia. People like my nurse make my life easier, even if they have to do things to me I don't like. They hold my hand and wipe my face when I cry. Nurses mean something good to me."
And, finally, a Swedish patient with a new pacemaker writes: "My nurse has a presence and exercises an authority that brings her respect and trust. And, at the same time, she appears to care and wonders how I feel. When I leave her she tells me to call at anytime if something doesn't feel right. If she can't take my call directly, she will get back to me as soon as she can. I am convinced she will stand by her word, even though my recent experience tells me I should not always trust the health care system."
Public confidence in our care and caring is high. A recent poll in the United Kingdom found that 96% of patients were satisfied with nurses' performance. In Australia, nurses are the most trusted professionals, with a public approval rating of 89%. This is true in many countries around the world.
How To Keep The Care And Caring
How do we help nurses to keep the care, and the caring, in health care? Automatically, we say "We must utilise their skills wisely, compensate them fairly, and solve workplace issues." This recipe is important and we need to follow through on it. But we need to do this and more.
We need enough human and other resources. We need to ensure there are enough qualified nurses, and a sufficient pool of students in the wings. And, given the speed of innovation and change, we need to be sure there is access to continuing education in order to maintain competency.
We must also ensure that high technology does not replace human touch. We must document the quality and cost of nursing care so that we can prove what nursing contributes to positive health outcomes. We must work with our governments and policy makers; first, to establish policy that permits nurses to work to their full potential; and second, to establish the right balance in the supply and demand of nurses and other health care professionals.
In the time available I want to expand on five points in particular: that is, on the impact and importance of technology, information and evidence, human resource planning, innovations in practice, and advocacy.
Nothing is revolutionising our world more than technology. In the not too distant future nanotechnology promises to make building materials, household products, and health care supplies available at a cost all countries can afford. This means we should be able to reverse the current situation where we concentrate 80% of our health care resources on the 20% of us living in developed countries.
Today, in the United States and other developed countries, we can communicate with patients, providers, and each other whether in remote parts of the country, or across the city. Telecommunications is bringing new options to other parts of the world as well. Nearly half of our 122 national associations now have access to email. And, on our visits to Central and South America, Africa, and Central and Eastern Europe, we increasingly find that nurses are using the web for new information. Also, we see that more sophisticated equipment is available to care for patients in some developing countries.
Wherever we go, we find nurses are at the technology forefront, using the advances available to them. I have great faith in technology, and particularly in our ability to use it eventually to deliver affordable services to the poorest of the poor. But, while technology is making health care more accessible and more affordable, such advances also come with risks. We cannot allow technical leaps forward to add distance between patients and nurses. If we do, it will in fact become a step backward. No software program or automated system can replace human assessment skills. Nor can it be as effective as human touch. We must be vigilant in keeping the care in health care. To do so, nurses must respond to the increasing need for information and evidence-based care, especially with health care restructuring and the emphasis on cost-effectiveness. We must investigate, observe, evaluate and record our work, and the contributions we make to the health of individuals, families and communities.
Nursing Information and Evidence-based Care
The need to document the quality and cost of nursing care throughout the world led ICN to begin work on the International Classification of Nursing Practice, or ICNP7. By providing a universal language, ICNP7 allows us to:
1. Describe, measure and compare what nurses do.
2. Compare nursing data across specialities, populations, settings, geographic areas and time.
3. Document the outcomes of nursing interventions.
This data can be integrated into multidisciplinary health information systems and used for decision-making.
The Alpha version of the ICNP7, has been translated into 16 languages, and has received tremendous interest and feedback from nurses around the world. The Beta version was launched a year ago, and in January this year Dr. Amy Coenen, of Marquette University in Milwaukee, became the first Programme Director. In this role, she manages ICN's continuing efforts to develop international standards in health care terminology.
ICN is deeply committed to increasing the knowledge base of nursing and improving nursing education. As an example, in March this year, we re-introduced the International Nursing Review, as a peer reviewed journal, co-published with Blackwell Science. We are delighted to have Dr. Vivien DeBack, another Wisconsin nurse, serving as the editor of our journal. We both hope you will use the INR as a forum for documenting your practice, and communicating your ideas, experience and research with your colleagues in all parts of the world.
Human Resource Planning
If nurses are to keep the care in health care, the world needs more, not fewer nurses. The supply and demand for nurses, indeed for all health care professionals, is a subject of great interest for ICN. You know there is a critical shortage of nurses in many parts of the world, including North America. There is also a troubling shortage of other professionals, including physiotherapists, occupational therapists, clinical pharmacists, speech therapists, and the list goes on. The exception seems to be physicians, who often are in surplus.
Attracting and keeping good people in the health care system has always been a challenge. Today women (and most nurses are still women) have many more career choices, certainly far more than when I chose a career. In addition, the nursing workforce in many countries is "greying", for example, the average age of nurses in Canada, the US and the UK is 43 years.
Supply and demand. ICN sees the problems of supply and demand of nurses everywhere. Recently a friend told us about the high infant morbidity and mortality rates in Laos. Because the statistics were much worse than in neighbouring nations and similar countries, an expert was hired to review the situation. He quickly concluded that mortality rates would never improve until the country had enough educated nursing professionals.
In far too many countries, there are not enough nurses to ensure quality care. Just recently a Caribbean nurse asked ICN for help because there is only one nurse for every 30 to 50 patients in the hospital where she works. Worries about the quality of health care sent New York nurses to their state capital this Spring, to remind legislators that nursing care is the key factor in patient safety.
Although we hear more about shortages, situations differ from country to country. There may be a real shortage, a pseudo-shortage, a surplus, or things might be basically in balance. In some countries, there are not enough qualified nurses. In others, nurses can't find work. In still others, the shortage is an artificial one. There are enough trained nurses, but they don't want to work under the existing conditions.
A pseudo shortage also exists when there is "under-filling" of positions. That is, a specialty area may be underfilled when there are nurses working in the area that lack the required specialised training. I believe the current shortage in some parts of North America is a pseudo shortage, but there is a serious crisis brewing.
What shall we do about it? We must do our part to help ensure an adequate, well-trained workforce now and in the future. We must urge governments to reclaim their responsibility for human resource planning, and consider nurses with as much care as other national investments. Valued and valuable resources require thoughtful, continuing attention, and nursing remains the number one resource in every nation's health care system.
Governments need to monitor the number of nurses entering the market, estimate future demand, educate and re-educate nurses, match the workforce competencies and population needs, and carry out ongoing evaluation to determine the effectiveness of their planning methods.
In addition to encouraging planning, the nursing profession must serve as the standard setter, advocate, advisor and watchdog to ensure an adequate, well-trained workforce, with the required competencies to do the work, and ability to respond to new opportunities. Nearly everywhere in the world nurses are capable of working at a higher level of skill and independence than the country's tradition, politics and bureaucracy permit.
Recruitment and retention. Balancing supply and demand cannot ignore the issue of fair compensation and a work environment that facilitates effective practice. Over the past 25 years there has been considerable nursing research in the area of retention, the most famous being the Magnet Hospital study conducted by the American Academy of Nursing in the early 1980s. The study found that hospitals with certain characteristics had well-motivated staff, low turnover rates, and quality outcomes (Task Force on Nursing Practice in Hospitals, 1983). Key characteristics of magnet hospitals are:
1. a flattened hierarchy, thus facilitating communication;
2. decentralised decision making with decisions made closest to where the work is done;
3. self governance as the norm for nursing;
4. flexible scheduling ;
5. autonomy for nurses; that is, nurses and/or the nursing unit have the ability to make nursing decisions;
6. nurses' input to policies and resources is sought and valued;
7. strong support for continuing education.
Magnet hospitals have participatory management with good two-way communication. Management is visible and accessible, and there are strong, qualified leaders and an explicit philosophy of patient care. Finally, the environment supports practice and has appropriate resources.
The work with magnet hospitals is now the focus of an international study involving facilities in Canada, the US, England and Germany, with researchers studying the relationships among organisation, staffing and patient outcomes.
Together with technology, information, evidence, and planning, innovations in care
delivery help us keep the care in health care. For ICN, an example of this is family-centred care. Wherever nurses work, our focus is on the family, its health, and its ability to grow, care for itself, and contribute to the community. That is why ICN is so excited about the Family Nurse as a way to more fully utilise the potential of nurses to meet growing health care needs.
The Family Nurse is a professional nurse whose work focuses on prevention and care. The nurse is community-based, and is trained to detect early signs of emerging problems; is able to give family members advice that is tailored to their age, life-style and gender; and is able to treat and refer as the situation requires. The nurse is also skilled in community development and is an active member of local community health programs.
ICN believes this is an important primary health care approach for the 21st century. We have made this the subject of our first Virginia Henderson Fellowship and have initiated a project to review and analyse current family models worldwide; and propose core competencies for the Family Nurse. Madrean Schober, an Indiana nurse practitioner, is the ICN Henderson Fellow. She is visiting South Africa, Botswana, Spain, Denmark, Thailand and Korea to conduct interviews and learn more about Family Nurse models in different corners of the world.
The four factors I just highlighted are tremendously important to our care and caring, but equally important is our advocacy. It is by our ongoing vigilance and lobbying that we will keep the care in health care. This means we need more nurses in politics, all nurses comfortable in the advocacy role, and more emphasis on communications and marketing in our organisations.
Successful advocacy, whether for better health services, more opportunities for nurses, or better salaries and working conditions, calls for unity of the nursing voice. I commend you on your capacity in this country, and within the American nursing profession, to put aside your individual differences and come together for common goals.
The advocacy that we must do for patient care is bigger than any one of us, or any one speciality. To lead the world to better health, we need the strength of our numbers. The nursing profession must accommodate all the diversity of opinion and background that exists among nurses today, whether in this convention centre, or globally.
American nurses have become increasingly involved in international nursing issues over the past decade. I commend you for your growing interest in the world of nursing and health outside the boundaries of your nation. I look forward to working with you to address global health and nursing issues.
As I end my remarks you could claim that the picture I paint is a bit bleak; that the work ahead is gloomy; or that it will require new flexibility, new thinking, and more effort. You could also claim that I have not said one humorous word. You are correct on all counts. But I hope you have also sensed that I believe we have made great strides, and that we do and will make a difference in health care.
We have work to do to harness technology; to continue to build the evidence of our value and effectiveness; to ensure there are sufficient, satisfied, and qualified nurses; and to offer innovations and new opportunities for nurses. And we must continue our vigilance and advocacy.
I hope you have sensed from my remarks that I have a deep belief in my profession and in my fellow nurses. I believe nurses do and will continue to keep the care in health care. I believe we do so through the art and science of nursing and through our humanity. Humanity is the watchword I chose for my Presidency of ICN. Without humanity, we provide a cold clinical service. With humanity as our driving force, we retain trust and make the difference in the progress of nursing, nurses and health for the world's population.
I am very excited about nurses and about our future. We have always been, and will continue to be, a global force for good. We are expert professionals and humanitarians, committed to working together and with others, to achieve our goals. We are bound only by the limits of our vision and our collective determination. We will succeed. Why? Because we care. Because we can. And because we ARE the care in health care.
I look forward to seeing many of you next year in Copenhagen. I wish you a very successful conference.
International Council of Nurses
Kirsten Stallknecht is a formidable force in nursing and public life, not only in her native Denmark but throughout Europe and internationally. Beginning her nursing career at age 18, she became president of the Danish Nurses' Organization (DNO) at age 30 and served in that position for 28 years (1968-96). She is currently the 23rd president of the International Council of Nurses (ICN). She also served as president of the Nordic Nurses' Federation (1989-95) and president of the Standing Committee of the Nurses of the European Union (1991-95). Throughout her career Stallknecht has had great influence in bargaining for better work conditions for nurses. At ICN she leads programmes to provide nurses around the word with negotiating skills. She has initiated many programmes and partnerships to assist nursing associations hard hit by war, financial difficulties and catastrophes, and those in poorer countries.
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Henderson, V. (1997). Basic principles of nursing care. Geneva, Switzerland: International Council of Nurses.
Task Force on Nursing Practice in Hospitals, American Academy of Nursing. (1983). Magnet hospitals: Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association.