Confirmation by the World Health Assembly at its 72nd meeting in May 2019 that 2020 would be designated the International Year of the Nurse and the Midwife was greeted with widespread excitement by nurses and midwives across the world and planning began for a year of celebrations. That 2020 was also the bicentenary of the birth of Florence Nightingale gave nurses and midwives an added reason to celebrate. The Commonwealth Nurses and Midwives Federation (CNMF) planned its own celebrations at the 5th Commonwealth Nurses and Midwives conference, scheduled for 6-7 March 2020, with the title ‘Celebrate: nurses and midwives, breaking down barriers, leaving no-one behind’. When the first cases of COVID-19 were reported in December 2019, the CNMF felt no significant alarm about the impact on our conference. However when the World Health Organization (WHO) declared a Public Health Emergency of International Concern on 30 January 2020, each day brought further stress. The conference went ahead, however, in an atmosphere of joy and excitement and was a great success.
The declaration of a pandemic by WHO on 11 March 2020 and the subsequent rapid spread of COVID-19 across the world poignantly changed all plans for celebrating the International Year of the Nurse and the Midwife. Instead, nurses and midwives found themselves on the frontline of the struggle against COVID-19, many becoming infected and too many themselves dying of the disease. As we approach International Nurses Day 2021, members of the CNMF elected Board have taken the time to reflect on the past 18 months and the way the world has changed for themselves and their colleagues. The CNMF Board represents all regions of the Commonwealth. Since the pandemic was declared, the CNMF has had extensive contact from and consultation with its members, which has informed the following comments.
From fear to courage
The rapid spread of COVID-19, having no cure readily available, and watching people fighting for their lives and all too many losing that fight, was quite terrifying. Nurses were not only concerned for their own health, but also for the health and lives of their families and friends. An increasing number of infections in many countries stretched their health workforce to unsustainable limits. The overwhelming number of people needing care and the frustration of not being able to provide optimal care took an enormous physical, emotional and mental toll on all health and ancillary support workers. For most, responding to COVID-19 was the biggest challenge they and their healthcare systems had faced in their lifetime
Nurses were suddenly launched into the spotlight as front-liners: we experienced fear, and bereavement with the deaths of colleagues and loved ones. We became patients, we became burnt-out, we experienced moral, physical and psychological distress: but we emerged resilient.
Nurses spoke of complete exhaustion at their end of their shifts because of heavy workloads; having to pick up extra shifts and work overtime to meet the need; feeling numb from the daily unfolding tragedies; feeling powerless to provide quality care to all who needed it; struggling with a lack of resources; and wondering when or if the number of infections and deaths would start to ease. The impact of colleagues becoming infected with COVID-19 was especially hard, particularly if death was the final outcome. And over 12 months later, the number of cases and deaths globally from COVID-19 continues to rise, although not as rapidly as in the early days of the pandemic (according to WHO weekly epidemiological updates).
How have nurses and other health workers responded? The health and ancillary support workforce across the world has been at the centre of care delivery and their input has been heroic. Leaders and new patterns of work emerged. Scarce clinical resources had to be carefully managed in a way not previously experienced. The limitations of existing buildings were quickly recognised and there was rapid redesign of the workplace in response to the highly infectious environment: masks, personal protective equipment (PPE), hot and cold areas, and social distancing were quickly introduced. Volunteer training and development occurred at a rapid pace to provide support to the paid workforce. Flexible regulation allowed retired health workers and students to enter the workforce to support their colleagues. And nurses did what they have always done in a crisis: they turned up for work, they kept going, and they came back the next day, and the one after, and all the days after that, to courageously provide the very best nursing care they could in the circumstances.
From anger to determination
For many years nurses, nursing associations, global leaders, WHO, and the International Council of Nurses (ICN) have been warning governments of the risk of years of reduced funding and investment in the health workforce, across all professions and ancillary support staff. The first ever State of the World's Nursing report, jointly sponsored by WHO, ICN and Nursing Now, confirmed that warning (WHO et al, 2020). The report estimated the global nursing workforce at 27.9 million, of which 19.3 million are professional nurses. Nursing was confirmed as the largest occupational group in the health sector, accounting for approximately 59% of the health professions. The estimated global shortage of nurses in 2018 was 5.9 million with an estimated 5.3 million (89%) of that shortage concentrated in low and lower-middle income countries. It presented ‘a compelling case for considerable—yet feasible—investment in nursing education, jobs and leadership in order to strengthen the nursing workforce’ (WHO et al, 2020: viii). It outlined 10 policy options for governments, concluding that most countries could accomplish the policy actions within their own resources.
The CNMF Board (left to right): Kathleen McCourt (UK) President; Rosemarie Josey (Bahamas) Deputy President; Annie Butler (Australia) Pacific Region; Dimitris Loizou (Cyprus) Europe Region; Bettyann Murray-John (Trinidad and Tobago) Atlantic Region; Abdrafiu Alani Adeniji (Nigeria) West Africa Region; Evelyn Kannan (India) Asia Region; Paul Magesa Mashauri (Tanzania) East, Central and Southern Africa Region
Nurses were rightly angry that their words of warning over the years fell on deaf ears, leaving them, when a crisis arose, to bear the brunt of the burden of response. Although the words of praise and thanks for their response to COVID-19 were welcome, those words will be meaningless unless governments genuinely engage in implementing the policy actions outlined in the State of the World's Nursing report. Scientists are united in their assessment that the current pandemic will not be the last one our world experiences. Nurses are determined that once the pandemic is over, it is time for action.
Nurses spoke strongly of the lack of current and comprehensive training in infection prevention and control (IPC) and in emergency response preparedness (ERP) and the need for annual IPC and ERP competency certification. This was clearly demonstrated in the confusion around the use of PPE and the number of healthcare workers who were infected through an inadvertent breach of IPC protocols. This is an area where governments, healthcare administrators, regulators, nursing and midwifery leaders and educators must make enduring change. We must not face another crisis like this one unprepared.
From uncertainty to hope
For many of us, March 2020 became known as the beginning of sorrow, amid the unknown and uncertainty of the management of COVID-19 and the proclamation of a pandemic by the WHO. Uncertainty was a word frequently used by nurses when talking about COVID-19, and this included:
- How to stay safe from infection
- How long the pandemic would last
- When vaccines might be available
- Whether vaccines would actually stop the pandemic
- Disruption caused by lockdowns
- Concern about what lockdowns were doing to the economy and employment
- Concern about what lockdowns were doing to the education sector—universities and schools
- Effect of the pandemic on providing care for other health conditions, elective surgery, and routine primary health care
- Impact of isolation, restrictions, and anxiety on mental health.
Adding to the uncertainty were vast amounts of information and misinformation, some of the misinformation promulgated by civic leaders, politicians and even world leaders, making it difficult for health professionals and the general population to navigate their way through. Nurses were encouraged only to access information from a reliable source (such as WHO, Johns Hopkins University, the Centers for Disease Prevention and Control in the USA, or the Commonwealth COVID-19 Data Dashboard), and to challenge misinformation and be advocates for information that was research and evidence-based. What made this task more difficult was that even the advice from WHO frequently changed as more research and evidence became available and more was learned about COVID-19 and effective responses.
The development of a range of vaccines brought with it hope that the end of the pandemic was in sight. Nurses have been deeply saddened that the result has been unequal access to vaccines across the world. Leaders and vaccine developers and manufacturers have lost an opportunity to work together to provide equitable distribution of vaccines to all. As has been said many times: no-one is safe until we are all safe.
A source of hope, however, is that nurses report true teamwork and inter-professional collaboration between all the health and ancillary support workforce in their response to COVID-19. Hierarchy disappears as everyone works together to do the best they can for as many patients as possible. Nurses became full partners with physicians and other health professionals to transform the delivery of health care. None of us will forget or want to lose that feeling of true teamwork, pulling together, sharing tasks, and supporting each other.
A vision for the future
The vision of nurses is for a future where countries unite to systematically eliminate inequities in the provision of health and social care services across the world. Where the social determinants of health—adequate housing, clean water and sanitation, good nutrition, a comprehensive education, and a living wage—are comprehensively and compassionately addressed to provide a safe environment in which the global population can live and grow. Urgent action to mitigate the risks of climate change and reduce biodiversity loss is critical to a sustainable future for us all.
It is also important to address digital inequity. Online platforms have the power to transform the way we learn, the way we work, and the way we connect with each other. COVID-19 lockdowns have taught us that. We can see the possibility of real change in the way education is provided, with a mix of online, face-to-face and clinical learning, and, more importantly, in enabling health professionals to be educated together so the experience of true teamwork can be carried forward.
Nurses want to see a post-COVID-19 world where world leaders work together for global peace and prosperity. The lessons learned from the management of the COVID-19 pandemic will influence and empower nurses and midwives across the world to plan strategically, become bolder, visible and vocal as they demand a seat at the table and active involvement in every step taken toward securing a safer world for us all.