International Council of Nurses

Globalisation, patient safety, nursing leadership and climate change were among the myriad topics debated at the congress.

By NZNO president Grant Brookes

“I just want to say up front, we absolutely have deliberately put this topic on the agenda. For some, it’s a very controversial subject. There are people who may have extreme and differing views.

“It’s an issue which has become political over recent months as well, but there’s no doubt it is impacting on nurses, nursing practice and the work of our associations.”

With these words, ICN nursing and health policy director Howard Catton introduced the panel debate, Globalisation: Its impact on nurses and their associations, at the congress.

When I met Catton before speaking on the panel, he explained that under the leadership of president Judith Shamian and new chief executive Frances Hughes, ICN had been pushing for greater relevance by engaging with the major global challenges of today.

Alongside presentations on nursing leadership, nursing education and specific areas of practice, the congress elevated climate change, gender equality and sustainable development to headline this year’s agenda.

‘Care, compassion and advocacy’

The congress was opened by the former United States (US) deputy secretary of health in the Obama administration, Mary Wakefield, a nurse.

She called on nurses to lead the implementation of the United Nations’ sustainable development goals. Quoting former World Health Organization director-general Margaret Chan, she said we must tackle the root cause of ill health – inequality – and respond to the refugee crisis. “The core of our profession is care, compassion and advocacy for strangers,” Wakefield said.

World-leading researcher into clinical outcomes and nursing workloads Linda Aiken presented the latest evidence that safe staffing saves lives. Welsh chief nursing officer Jean White followed with a presentation on the Nurse Staffing Levels (Wales) Act 2016.

Last year, Wales became the first country in Europe to pass legislation requiring the use of safe staffing tools in hospital inpatient wards.

The tools, now under development, have similarities to the care capacity demand management methodology, currently stalled in the implementation phase in many New Zealand district health boards. From 2018, the Welsh law says staffing levels must reflect patient acuity and the professional judgement of the nurse in charge.

Professor Barbara Sattler of the University of San Francisco began her presentation on climate by quoting from The Lancet: “Climate change is the biggest global health threat of the 21st century. The impacts will be felt all around the world – and not just in some distant future but in our lifetimes and those of our children.”

“We cannot have healthy people on a sick planet”, Sattler said. As well as encouraging activism for transition to low-carbon economies, she gave examples of nurse leadership in creating “climate-smart health care”.

These included ending the use of coal-fired hospital boilers in South Africa, solar-powered cold chains, “meatless Monday” food services and procurement policies for medicines and clinical supplies which favour low-carbon production.

In addition to my presentation on the impact of globalisation, the other NZNO speakers were kaiwhakahaere Kerri Nuku and professional nursing adviser Anne Brinkman.

Nuku spoke on NZNO’s role in the recent gains for advanced nursing practice in this country, including medicines management and nurse prescribing, while Brinkman’s presentation was titled Nurses leading in tomorrow’s globalised world.

Also from New Zealand, Otago University senior lecturer Daryle Deering and Heather Casey of the College of Mental Health Nurses Te Ao Mâramatanga spoke in a plenary session, on mental health and primary care.

Past president of the World Medical Association Michael Marmot, who is a global expert on the social determinants of health and author of The Health Gap, closed the congress.

He quoted Martin Luther King, that “unarmed truth and unconditional love will have the final word”, in support of his two key messages for a world of “post-truth politics”– evidence-based policy, in a spirit of social justice.

With 8200 registrations, 88 sessions in a range of languages, 1900 posters and an unknown number of side meetings, any congress participant would have seen just a subjective snapshot. This was mine. •

Related coverage:

‘Boosting Pacific representation at ICN’

‘In the footsteps of nursing heroines’

 

EIGHTY YEARS ago this month, another group of New Zealand nurses was arriving in Barcelona – part of New Zealand’s Spanish Medical Aid Committee.

The group was led by René Shadbolt, head sister of Auckland Hospital’s casualty ward (and the aunt of Invercargill Mayor Tim Shadbolt and author Maurice Shadbolt, and later the Matron of Rawene Hospital), accompanied by Isobel Dodds, a staff nurse from Wellington Hospital and Millicent Sharples a nurse aide from Levin (see photo above).

Shadbolt, Dodds and Sharples were among 40,000 international volunteers who travelled to Spain between 1936 and 1939. They were responding to a humanitarian crisis and a threat to democracy. In mid-1936, a Fascist army backed by Adolf Hitler had risen up to overthrow Spain’s elected socialist government.

Joining others in Spain The trio joined other New Zealanders already working there. There was surgeon Doug Jolly, who had worked as a resident doctor in Dunedin and Wellington Hospital, and Auckland nurse Una Wilson. Dorothy Morris, a Christchurch nurse, had deployed to Spain with the British Universities Ambulance Unit at the start of 1937 and was based in a Quaker-run children’s hospital south of Barcelona.

Their stories are told in two recent books, Kiwi Compañeros – New Zealand and the Spanish Civil War and Petals and Bullets – Dorothy Morris, New Zealand Nurse in the Spanish Civil War, which was reviewed in the August 2015 issue of Kai Tiaki Nursing New Zealand.

I spent the afternoon before the opening of the ICN’s CNR contemplating these nurses’ time in Catalonia, the semi-autonomous province around Barcelona.

At the Museum of Catalan History, I met an historian and we talked over Kiwi Compañeros. He knew of some of the people mentioned in the book, but could shed no more light on our nurses.

In the museum’s exhibition hall, I watched the newsreel footage of Hitler’s air force perfecting its aerial bombardment of civilian areas – the same techniques which, three years later, would be used on London during the Blitz. I thought of the injured and traumatised children who were evacuated from Barcelona and into Dorothy Morris’ care.

History tells us that in 1939 Hitler triumphed, as other countries (apart from Mexico and the Soviet Union) refused the appeals for help from the Spanish government.

As the danger of far-right extremism grows once more, our Kiwi nurses deserve to be remembered.

While walking the same Barcelona streets they described in their letters home, I reflected on their courage and commitment. If allied governments had shown the same spirit during 1936-39 as our nursing heroines, they might have checked the rise of fascism in Europe, and its incomparable horror could have been prevented. •

Report by NZNO president Grant Brookes

Related coverage:

‘Facing up to global challenges’

‘Boosting Pacific representation at ICN’

 

I’M WRITING these words during a break from packing. Tomorrow, I board a plane for Barcelona, Spain, where I will join kaiwhakahaere Kerri Nuku and chief executive Memo Musa, as part of NZNO’s delegation to the International Council of Nurses’ (ICN) biennial conference.

For the next 10 days, our job is to speak up for New Zealand nursing at a time of global change. ICN represents millions of nurses in 130 countries and brings the nursing voice to the world stage.

The first three days in Barcelona are taken up with the Council of National Representatives (CNR), where National Nursing Associations (NNAs) including NZNO will vote on proposals to reshape ICN.

ICN is governed by a board of representatives elected from seven areas. In our area, the Asia-Pacific region, the smaller countries of the Pacific have struggled to get our Pacific nursing voice heard at the top table.

In Barcelona, we’re voting on a proposal to redraw the boundaries so ICN areas match those of the World Health Organization. This would place New Zealand in a new Western Pacific region and strengthen the Pacific nursing voice.

We are also proud to support our kaiwhakahaere’s bid to bring a Pacific voice to the table. At CNR, Kerri is standing for election to the ICN board.

After CNR comes the ICN Congress – the largest international event for nurses. There we’ll be joined by other NZNO members and staff, as we take New Zealand perspectives on nursing to the world.

Kerri is presenting examples of how we have contributed to policy and legislative change to improve advanced nursing practice, eg medicines management and nurse prescribing.

I am taking part in a panel discussion on how globalisation is impacting on nursing internationally, and how NNAs and ICN should respond.

Globalisation’s impact is being felt in seven main areas: workforce mobility, immigration and recruitment practices, technology and telehealth, population displacement and climate change, workforce development and regulation, trade and investment agreements and in the influence of ICN and member NNAs.

Grow local workforce

New Zealand has the highest dependence on migrant health professionals of any OECD country. NZNO supports the right to freedom of movement, and supports IQNs having secure work visas and supportive work environments. At the same time, we must reduce our dependence on migrant nurses by growing our locally educated nursing workforce, with a supported entry-to-practice place for every new graduate.

Technology and telehealth transcend borders and are increasingly impacting on nurses and models of care. Our position statement contains pointers on how NNAs might respond.

NZNO recognises that climate change and population displacement due to conflict and natural disasters are putting pressure on health systems in many parts of the world, including the South Pacific. Nurses should lead the global transition away from carbon-based economies and contribute to plans to mitigate the impact of climate change on health.

The influence of NNAs and other health sector organisations has been key to halting harmful trade and investment agreements like the Trans-Pacific Partnership Agreement (TPPA). Recent attempts to revive the TPPA and other challenges of globalisation show why international collaboration by nurses at forums like ICN is so important. •

 

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References
1) New Zealand Nurses Organisation (NZNO). (2017). Internationally Qualified Nurses: immigration and other issues (discussion document). Wellington: Author.
2) NZNO. (2016). Position Statement: Nursing, technology and telehealth. Wellington: Author.
3) NZNO. (2016) Position Statement: Climate Change. Wellington: Author.

Yesterday I represented NZNO​ at the ICN Congress​ in Barcelona, in a panel debate on “Globalisation: Its Impact on Nurses and our Associations”. I spoke alongside nurses from Malawi, Denmark, Rwanda and Canada.

Dealing with the impact of globalisation requires international coordination, as it’s too big for any one country to tackle on its own. Opening remarks by Howard Catton, Director of Nursing & Health Policy at ICN​, take up the first seven minutes and are also well worth a watch.

Unfortunately, the video did not capture the Canadian speaker, or the wide-ranging questions and discussion from the conference floor. My speech notes are posted below.

Globalisation: Its Impact on Nurses and our Associations

ICN Congress Panel Debate,  29 May 2017

Kia ora, greetings. I am Grant Brookes, Co-president of the New Zealand Nurses Organisation.

I would like to thank Howard Catton and ICN for inviting to participate in this panel discussion on Globalisation. I would also like to greet my fellow panelists: Dorothy, Vibeke, Barbara and Andre.

Our organisation is a professional association and union which represents 48,000 nurses, midwives, students, kaimahi hauora and health workers on professional and employment related matters. NZNO is affiliated to ICN, the South Pacific Nurses Forum, Global Nurses United and the New Zealand Council of Trade Unions. NZNO embraces biculturalism, the partnership between the indigenous Māori peoples and the more recent settlers of European and other ancestries who have arrived in the last two centuries.
In the words of the whakataukī, or ancient Māori proverb, we all in the canoe together.

 

 

Our association believes that globalisation will be felt by nurses and NNAs in seven main areas.

1. Workforce mobility
2. Immigration/migration/ recruitment practices
3. Technology/telehealth
4. Population displacement and climate change
5. Workforce development and regulation
6. Trade and investment agreements such as the Trans-Pacific Partnership Agreement
7. Influence of ICN and member NNAs

 

Regarding workforce mobility:

• Health workforce shortages globally are predicted to continue
• Workforce mobility is set to continue
• Reliance in some countries on internationally qualified nurses (or IQNs) is likely to continue

 

If allowed to persist, health workforce shortages will increase inequities in access to healthcare, causing preventable illness, disability and death, and threatening public health, economic growth and development. These key points were highlighted by the High-Level Commission on Health Employment and Economic Growth in 2016.

For our association, our publication on Internationally Qualified Nurses and Immigration released this year notes that: “New Zealand has the highest dependence on migrant health professionals of any OECD country (Zurn & Dumont, 2008), and… very low retention of health professionals (Hawthorne, 2012; Ministry of Health, 2016a). [There is a] high percentage of churn among IQNs, both leaving the country and leaving the sector they were recruited for (Walker & Clendon, 2015).”

The next slide illustrates our association’s response.
Long-term planning for a sustainable nursing workforce should include a commitment to employment of new nurse graduates. In 2016, only 57 per cent of new graduates from New Zealand education institutes found work through the Advanced Choice of Employment scheme, according to the Ministry of Health.

Meaningful IQN retention strategies could include:

• Accessible and affordable competence assessment programmes
• Security of working visas (for example, freedom from revolving renewals)
• Supportive work environments (including safe clinical environments, equitable remuneration and freedom from xenophobia and racism)

Technology is the fastest growing enabler of health care delivery. Technology transcends borders and thus its impact on nurses, on nursing practice, and on associations is inevitable.

Technology allows for remote care (telehealth) and interdisciplinary clinical support, as well as knowledge transfer. It has been shown to enhance people’s access to health services.

The way in which consumers/patients use technology as an enabler for their own self care will also impact on nursing and influence future models of care.

Technology and telehealth will change the notion of place and presence. Consequently, nursing care may not be provided in the traditional way (face-to-face). It may be provided across national boundaries, which raises regulatory concerns.

To influence direction in New Zealand we have developed a Position statement: Nursing, Technology and Telehealth, published in 2016.

According to the High Level Commission on Health Employment and Economic Growth, the number of political conflicts globally has doubled over the last decade. The number of people displaced due to conflict has increased from 37 million to 60 million, mainly in middle income countries. Between 2008 and 2014, natural disasters displaced 184 million people.

Within conflict zones, healthcare workers and nurses might become deliberate targets.

Nurses and our associations will need to be more prepared, educated and trained to work with displaced populations and refugees, including providing nursing care in conflicts.

Regarding climate change, our association published a position statement in 2016. We have since divested our funds from fossil fuel companies. The communiqué of the 2016 South Pacific Nurses Forum, which we attended, identified population displacement as a result of climate change – along with migration, education and regulation – as key areas for attention. Our members frequently respond to disasters in the Pacific caused by extreme weather events.

The health crises caused by SARs, Ebola virus, MERS, Zika virus and yellow fever demonstrate the interconnectedness of global health and the inescapable impact on nurses and our associations.

To succeed in implementing the agenda for sustainable development through SDGs in poverty reduction, quality education, decent work inclusive economic growth and gender equality, we potentially will see a shift in workforce development away from narrow specialisation to broader and lifelong building of competencies.

Nursing workforce development, education and training will likely have a strong emphasis on early intervention, community based care, primary care, population health, public health promotion. This will be complemented by improvements in advanced nursing practice to improve access to health services.

Likewise, our associations are likely to change their focus to support a broader approach to workforce development but will continue to ensure that this results in decent jobs, working conditions and pay for health workers.

Globalisation requires NNAs to engage more in political commentary.

Some governments respond to globalisation by entering into trade and investment agreements like the Trans-Pacific Partnership Agreement (TPPA). These have a potential negative impact on economic inequality and other determinants of health and illness, on health policy, health funding and access to medicines. Nurses and our NNAs will need to promote inter-sectoral collaboration at local, regional, national, and international levels.

We have an election in New Zealand this year. Our political commentary will be based on our Election year manifesto (2017), which identifies 7 priorities for nursing and public health:

• Sustainable nursing workforce used to its full extent
• Investment in public health
• Primary care approach to improving population health
• Best start for children
• Safe clinical environments
• Fair employment
• Social & health equity in Aotearoa/NZ, Asia-Pacific region & globally

I will conclude by saying globalisation will require multi-level engagement to address the seven areas highlighted in this talk:

1. Workforce mobility
2. Immigration/migration/ recruitment practices
3. Technology/telehealth
4. Population displacement and climate changes
5. Workforce development and regulation
6. Trade and investment agreements such as the Trans-Pacific Partnership Agreement

Nurses and our associations will need to be adept at managing the impact of globalisation.

As the High-Level Commission on Health Employment and Economic Growth stated: “No single agency and no single sector can implement the changes required to achieve a fit for purpose health workforce in the context of persistently high unemployment and underemployment in many countries, and amid the major demographic, technological and socioeconomic changes occurring across all countries. Political will, leadership, inter-sectoral action and international partnerships will be critical to success”

Thank you

Do you sometimes feel, when you’re battling to make positive changes in health care, that you’re banging your head against a brick wall? That it’s not even worth trying, because everything is decided higher up? Or that other priorities, like economics, will come first anyway? You’re not alone.

This is why NZNO representatives meet employers and government, to put the nursing agenda on the table. And it’s why NZNO kaiwhakahaere Kerri Nuku, chief executive (CE) Memo Musa and I went all the way to Geneva last month, to attend meetings organised by the International Council of Nurses (ICN) – the first under the new ICN CE, New Zealand nurse Frances Hughes, and new ICN policy consultant (and former RCN secondee to NZNO) Howard Catton.

As Catton told us in one meeting, “Nurses need to be at the table, not just for discussions on nursing policy, but health policy, social policy, housing, education. We need to be where all the social determinants of health are discussed.”

ICN enables this to happen at the highest level, by working with the labyrinth of specialised agencies that make up the United Nations (UN) system – and particularly with the World Health Organization (WHO), the International Labour Organization and the World Bank.

 

Feeding into WHA

The meetings we attended in Geneva were timed to feed into the World Health Assembly (WHA), a biennial gathering of the world’s health ministers and officials taking place under the auspices of the UN, the following week.

For the first two days in Geneva, we met more than 100 leaders of national nursing associations (NNAs) from around the world.

Then we all came together with regulators (including our Nursing Council) and government chief nurses in the Triad meeting, to formulate a nursing response to some of today’s key global issues.

The initial discussions revealed a remarkable level of agreement about the health issues facing the various NNAs, and about the necessary responses. The demands of ageing populations, non-communicable diseases and health workforce shortages have resulted in a worldwide shift towards nurse-led health care in the community.

To continue this shift, we discussed implementing the WHO’s Global Strategy on Human Resources for Health: Workforce 2030. This strategy was adopted unanimously by the WHA meeting which followed, in a resolution that also affirmed “the emerging political consensus on the contribution of health workers to improved health outcomes [and] to economic growth” and the “mounting evidence that investments in health workforce . . . are conducive to economic and social development”.

The New Zealand government delegation to the WHA voted in favour, along with all the other countries, but also spoke about a need to ensure the best return on investments.

Meanwhile, the top-level shift away from thinking about health workers as a “cost” to the economy was also apparent during our ICN discussion of the UN Commission on Health Employment and Economic Growth and on the WHO Strategic Directions for Nursing & Midwifery 2016-2020, which was formally launched at the ICN NNA meeting.

Introducing that document, Catton commented that “there’s a healthy scepticism which says, strategies come and strategies go, and nothing changes”.

So NNA leaders were asked to come up with plans on how we could advocate for, influence and support implementation of these strategies back in our home countries, to ensure changes happen this time. A wide range of approaches was presented, including wielding our industrial power as unions and mobilising for political campaigns.

But there’s always a danger that powerful global institutions like the UN, WHO and the World Bank will drive the agendas of NNAs and ICN, rather than the other way around. The way to avoid this danger is the same at the global level as it is within NZNO: the members must be the ones who set the direction.

So the speech from ICN CE Frances Hughes on her transformation and regional engagement plan to ensure “the sanctity of the NNAs” was very reassuring. “Your role is paramount”, she said. “You are our members. You give strategic direction to the ICN board.”

After this, NZNO took the opportunity to convene an impromptu meeting of NNAs from the Asia-Pacific region, to ensure nurses from our region are heard more clearly within ICN in future.

We didn’t achieve all our NZNO goals in Geneva. In particular, more work will be needed to increase global understanding of indigenous nursing issues.

But we did manage to put pay equity for women onto the global agenda, getting the issue into discussion summaries at the NNA meeting and successfully proposing its inclusion in the official communiqué from the Triad meeting to the WHA. And we strengthened the message sent to the WHA about the need to invest more in nursing and midwifery workforces.

But if NZNO representatives are listened to in international forums like this, it is because of the efforts of NZNO members and staff. Your collective actions, in campaigns like “All the Way for Equal Pay” and the new “Speak Up for Health” campaign for better health funding, are what can elevate these issues all the way up to the international level.

So the next time you feel you’ve run up against a brick wall when you’re trying to make change, please take a deep breath and keep on pushing. •

(First published in Kai Tiaki Nursing New Zealand, June 2016. Reposted with permission).

THE WORLD of nursing got a wee bit smaller in February when New Zealand nurse Frances Hughes took over as chief executive (CE) of the International Council of Nurses (ICN).

NZNO belongs to ICN. Our membership dates back to 1912, when our far-sighted forebears in the New Zealand Trained Nurses Association decided to join.

But it’s taken until 2016 for the organisation that represents millions of nurses in 130 countries and brings the nursing voice to the world stage through such activities as International Nurses Day, to be headed by a New Zealander.

Although Frances is a fellow mental health nurse who trained and practised in my adopted home town of Wellington, I met her for the first time this year.

Next month, I will see her again when I travel with NZNO Kaiwhakahaere Kerri Nuku and CE Memo Musa to the ICN meeting in Geneva. There we will take up the fresh opportunities her appointment presents, to continue our work for New Zealand nurses in the big (and acronym-filled) world of nursing.

In going to Geneva, I aim to carry out the democratic will of NZNO members, who voted at last year’s annual general meeting to expand our global connectedness with fellow nursing unions and professional associations.

Even flying economy, it’s still a lot of money. So why has the NZNO Board decided I should go, and what exactly will I be doing for our hard-working, fee-paying members?

Firstly, I’ll be taking part in a two-day meeting of national nursing associations (NNAs) from around the globe. This will finalise the nursing input into the World Health Assembly (WHA), which takes place in Geneva the following week.

The WHA is the world’s highest health policy-making body. It governs the World Health Organisation (WHO). This year, the WHA will discuss how to implement the new WHO Global Strategy on Human Resources for Health: Workforce 2030. This will set objectives for the next 15 years, which member governments (including New Zealand) should meet. So it’s an important discussion.

Based on an “environmental scan” which NZNO has already submitted, Kerri, Memo and I will talk about why safe staffing must be a top priority when implementing the new workforce strategy.

We also want to make sure that unregulated care and support workers remain a valued part of the nursing team, and aren’t used in place of it.

Support for pay equity agenda

We want to see commitments to pay equity locked in, along with ethical recruitment (especially for migrants), transition programmes for new graduates (like the nurse-entry-to-practice programme) and expanded nursing roles (like nurse prescribers). And we want to uphold the rights and role of indigenous peoples in developing a health workforce and systems that support their health.

The WHA is made up of health ministers, plus invited officials and guests. Without ICN input, which we will help shape, the nursing voice on global workforce issues like these would be largely absent from its deliberations.

The ICN and WHA meetings will also consider how to help countries meet the updated set of Sustainable Development Goals (SDGs). These were adopted by the United Nations last year, replacing the earlier Millennium Development Goals. The SDGs include objectives like reducing inequality and ending poverty, and protecting the ecosystems that our health depends on.

We will also participate in the “Triad” meeting, to take up these issues with nursing regulators and government officials. Nursing Council representatives and Chief Nurse Jane O’Malley will be at that meeting, too.

And finally I will stay on in Geneva for the World Health Professions Regulation Conference. This year, the conference includes topics like “Health professional regulation and trade agreements: Protecting the public vs facilitating commerce” – very relevant, I thought, given our experience with the Trans Pacific Partnership Agreement (TPPA).

So this trip to Geneva is going to be a challenge, as well as an opportunity. I will report back on our achievements for NZNO members, on my return. •