Welcome to Episode #10 of Contain This, brought to you by the Indo-Pacific Centre for Health Security and hosted by Adam Craig.
On the episode we have Elizabeth Iro - Chief Nursing Officer, World Health Organisation and Michele Rumsey - Director, World Health Organisation Collaborating Centre for Nursing, Midwifery & Health Development at University of Technology Sydney.
Elizabeth, a Cook Islander, is the Chief Nurse at the World Health Organisation in Geneva. Prior to joining the WHO, she served as the Secretary of Health in the Cook Islands and before that was the country’s Chief Nurse. In these roles she spearheaded health system reform with a focus on planning and workforce development. Nursing is in Elizabeth’s blood. In this episode she speaks passionately about the role nurses from around the globe are playing, under increasingly stressful conditions, to ensure health systems continue to function and health security for all is achieved.
Michele, also started her career in nursing. She took this experience to the global stage and now as an academic, advises on international health care and policy in the areas of human resources for health, health system strengthening, capacity development, stakeholder participation and regulation. Michele is the Director of the WHO Collaborating Centre for Nursing, Midwifery and Health Development based at UTS. The Centre is the only one of its kind in the South Pacific. Under Michele’s leadership the Centre has carried out 50 projects in 25 countries. She was awarded the UTS Human Rights Award in 2014 for her work in the South Pacific.
This episode celebrates 2020, The International Year of Nurses and Midwives. Elizabeth and Michele reflect on what this year means to the nursing profession, they talk about the challenges of being a nurse during a pandemic and propose actions that ought to be taken to address issues as broad as chronic work force shortages, achieving universal health coverage, gender inequity and the impacts of power imbalances in nursing and health care more broadly.
For more information on the State of the World’s Nursing Report, click on the link below
For more information on a WHO Report related to the nursing workforce recommended by the guests, please click on the link below:
For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.
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Contain This Team
Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.
The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.
Welcome to Episode #10 of Contain This, brought to you by the Indo-Pacific Centre for Health Security and hosted by Adam Craig.
Adam Craig 2:00
Elizabeth Iro, Michelle Rumsey. Welcome to Contain This.
Michele Rumsey 2:04
It's good to be online.
Elizabeth Iro 2:06
Very good to have this opportunity to talk. Thank you.
Adam Craig 2:09
You guys have known each other for a long time. Can you tell me about where you first met?
Michele Rumsey 2:14
We've known each other a very long time. It's been a wonderful, glorious relationship. And I've just seen Elizabeth continue to climb the career ladder all the way to the top of WHO and we quietly call her the Global Chief Nurse which I'm sure she worries about. We all love the fact that my colleague from the South Pacific is sitting at the top of WHO keeping us all in order.
Elizabeth Iro 2:42
I think from my side. It's been a great association. And the friendship has grown out of this association with Michelle. You know, we met when they first established the collaborating centre and so my engagement grew. And it's been great to get her support along the way in terms of, actually not just nursing, but a whole variety of issues and support that she's provided to me and to my nursing colleagues in the Pacific and also especially in the Cook Islands. So it's just a lovely journey we've had.
Adam Craig 1:23
It’s wonderful to have a Pacific Islander in such a position. This year the World Health Assembly has designated 2023 the International Year of Nurses and Midwives, and has released a report: the State of the World’s Nursing? Elizabeth, can you explain what the International Year of Nursing and Midwives mean and what does the report find?
Elizabeth Iro 1:39
I think first of all, it's been a year as a designated year by the World Health Assembly, which is recognizing the contribution that nurses and midwives make to health and well-being of the population that they look after. It is the global population that they contribute to better health outcomes.
At the same time, 2020 is the year in commemoration of the 200th anniversary of the birth of Florence Nightingale, who many consider to be the founder of modern nursing. So it's a very, very significant designation, that kind of also offered opportunity for a lot of nurses and midwives and leaders to really leverage that opportunity to address the nursing and midwifery shortage as well as the health workforce shortage.
It was also a year to really raise the profile, you know, raise the awareness of nurses and midwives and what they do. It was a really exciting kind of designation announcement. So, of course, you know, within that announcement we had identified we were underway in developing the first ever State of the World's Nursing report. So we haven't actually done any, we had not had any evidence or data on what that looked like. So it was having that report to showcase what it means for nurses globally, and to be launched in the year of the nurse and the midwife. It was for a report to provide the data, the evidence that was needed for nurses and nurse leaders to use within countries to support them in their leveraging for policy changes that they needed to make, within the context. I think that's the purpose of the report really. So we're finding this report is highlighted the roadmap of what countries can do in terms of policy changes, using the data and the evidence that they now have. So I think that's where we are with the Year of the Nurse and the State of the World nursing report.
Adam Craig 6:50
The report finds an extra 6 million nurses are required to achieve universal health coverage by 2030. Why is there such a shortage, particularly in lower and middle income countries? And what strategies are being implemented to close the gap?
Michele Rumsey 6:55
We've been doing a lot of things but also Elizabeth says, we've been lobbying WHO for three years to get these things and the International Year of the nurse and International Year of the midwife. I think nobody can underestimate the value of nurses and midwives in this current climate. I met so many of the amazing celebrations we had arranged, have obviously put on hold. And we're doing a variety of other things. And luckily, because of Elizabeth and our great relationship in the region, we've done quite a lot of different webinars and discussions.
This State of the World's Nursing report is so important for us. We now know that 59% of the world's health workforce are nurses, and in our region, we've actually got 73% of that portion, and in our region, globally, 95% of that health workforce are women and in our region, it's 95%. And also in our region, we have 51 under 35. And that's quite unique because many of our nurses are getting older in other countries, whereas in our region we've got a very young workforce. I think the report clearly says we need more support for leadership, more support for education and more support for job security. And I think having those facts will really help us make those policy changes as Liz says.
Adam Craig 8:30
Absolutely. Leadership, education and job security. It’s what we are all looking for. In your role as the Chief Nursing Officer at the WHO, what are your priorities for the global nursing workforce?
Elizabeth Iro 8:40
Well, I think looking at this global shortage, and why it is. It’s actually 6 million we need by 2030. We have to look at the numbers, the supply, we have to look at the education, what the number of graduates coming out of training within countries and how many are coming out and actually get recruited for a job. So this is it, as Michelle said, it is a complex issue, but I think if you look at the numbers that are actually entering the profession, some of the barriers. For the Pacific it's about the location of where these nursing schools are, because we know they are usually in urban cities so you know immediately for some of our Pacific Island countries this means that a relocation. So we get that that supply kind of breakdown immediately.
Of course there's the big outflow as well you know the push factors come into play as nurses graduate and from schools the opportunities to relocate elsewhere causes this gap within domestic situations. We have to look at what are those reasons behind that? What are the pull factors from an international perspective and we have to look at the availability of thing like I said, better jobs. Better working conditions, better salaries and better resources. Nurses will be pulled to better working conditions. But you also have like I said that if you're graduating in the absence of job opportunities that are in poor working conditions and salary, accelerations and insecurities, you're going to have those factors kind of coming into play as well. So I think when you ask about why there is a shortage, the reasons are not as simple as it may appear. So I think that's my addition to totally support what Michelle was saying.
Adam Craig 11:28
Securing your workforce is always such a challenge and such an important part of a strong health system. Primary Health Care in rural areas is often delivered by community health workers. Can you tell us a little bit about how nurses and community health workers working together to support universal health coverage in rural areas?
Michele Rumsey 12:15
Certainly, I think community health workers, village house workers, traditional birth attendants, it does not matter who you talk about, I think the health sector is a very wide broad church and it's a very huge group of people, civil society have a huge part to play in health. So it's not about groups of health workers. It's how we work together. I think the biggest problem that we've always dealt with is regulation. So regulation is about protecting the people, the public. And nurses and doctors and many health professionals are regulated, and that's the safety net, because it's setting legislation. And I think that's where the gap sometimes comes between unregulated and regulated health workers because that's the dynamic that we need to strengthen across the region. And we need to build those dynamics to make sure that each individual health practitioner, or health individual or village health worker knows what their scope of practice is and their competency is to be able to ensure we know where they fit in that big pipeline of health workers. So it's not about individuals. I think the other problem I know WHO did quite a lot of work on the UHC competencies for community health workers, Liz?
Elizabeth Iro 13:05
I think this was highly promoted in 2016 Health Assembly and through looking at diversity. When you look at the global, WHO global strategy on human resources for health for Workforce 2030 it looks at diversity in health workforce. And of course, last year, we had the launch of the guidelines, the guidance document on community health workers. And the programs and what that actually means for some countries where there is an absolute necessity to recruit to support the health professionals. So I think that's, that's definitely in many countries do have a need for this group to support the health workforce professionals, for sure. And I think you know, you're right. I think it is about, you know, what does that then mean in terms of regulating the health workforce?
I think what we've seen during COVID-19 is some of these being perhaps teased out in some communities where, you know, contact tracers are being recruited. You know, this is an area where this cadre could definitely add value to the overall health systems. COVID-19 is definitely shone a light on health systems as a whole and health workforce. So it's not just about volunteerism, it's about how do you then take that to the next level, and we do have, as Michelle said, some guidance around community health workers.
Adam Craig 15:00
You guys have both worked and advised in human resources for health. I’m interested in your insights into how prepared the Pacific Island nursing workforce is for COVID-19?
Elizabeth Iro 15:17
I mean, I think Michelle will probably get a better handle on the specifics of it. But I think from my perspectives and what I've seen some of the challenges is actually probably very similar, if not more intense, in terms of gradients, perhaps, as how that impacts nurses. It's an unprecedented situation and therefore, you know, many health workers are impacted and communities are impacted. So how do you prepare for that response? And sometimes in an already under resourced health system. So there and also, on top of that, there are some geographical locations of islands and populations. So there are those challenges.
What I found in the Pacific is that they have WHO in Fiji has actually led a team of donors and partners like SPC in Joint Incident Management, where they are taking a very strategic approach to supporting these countries in terms of the resources that's needed. Also in terms of the training that's offered to nurses and to healthcare workers, in terms of the provision of PPE, as well as testing and laboratory support. I think there's a whole lot of these elements that's been very well coordinated within the South Pacific.
So I think you know, there are, there are challenges and nurses are taking the lead, I know from my country, in terms of public health engagement. So there's been a real need to kind of have the information, the advocacy and communication tools to support the education of the general public in terms of, you know, hand hygiene in terms of PPE, distancing, self distancing, physical distancing, all that can come into play. And so I think that, although they haven't had it, not many countries have been maybe have had a case, but they needed to prepare to really mitigate that and I think that's been a really a key element in terms of the processes for addressing COVID-19. So I think there's been some online training programs has been made available I know that the Pacific Commission have been quite also taking some lead in supporting countries, as well as some of the other key partners like DFAT and MFAT have been supporting Pacific Island countries as well.
Adam Craig 17:50
You’re right. It is a really great example of the different agencies coming together to support the different islands as a collective respond to COVID-19. Michele you’ve mentioned a few times that education underpins the development of the nursing workforce. I’m interested in, what policy frameworks exist within which education can be sustained across the Pacific and the Asia-Pacific?
Michele Rumsey 19:22
Well, I guess from our point of view, we just know nurses are crucial. There's no question that that they are early detection, they're there to stop the spread of the disease. And they're really trusted in their communities in making changes. So I think if they're not educated well enough and haven't had the support right from the beginning. We could actually cause more problems in the long term. And I think that's always been our worry in the Pacific is that we have been looking with DFAT and others for a long time to build the educational quality uplifting education across the whole Pacific, because every country has a slightly different flavour of education, slightly different labs, whether it be community health worker, nursing aide. So I think long term, we really want to build education facilities across the Pacific.
And I think the biggest challenge our colleagues have had is so little bit of misinformation, confusion and feeling really quite scared. We know in Samoa in the Spanish Flu, they lost a third, a fifth their population. And so the Pacific Islanders are very, very aware of what could happen very quickly. There are very few critical care wards and things that we're just used to in Australia, New Zealand and globally. They just don't have access to those things.
There's been a few what we call safety stops in Papua New Guinea and other places where they've just put down tools and said we haven't got PPE. We'd actually like some soap and sanitation that has improved significantly over the last few months, I think we can only just hold really firm and be really thankful that the Pacific understood the risks hugely and shut their borders really early. But now we've got to use this opportunity to build investment in the Pacific. And we've got to really strive forward and make sure they're educated. All our research has shown that many of them have never had any formal continuing professional development. So I think this is the time to really start finding out what we can do to make sure we're prepared because these public health emergencies are going to continue.
Adam Craig 20:30
Elizabeth, you've got some perspective from other parts of the world from your role at WHO. What can the Pacific and the Asian Pacific Region learn from other regions?
Elizabeth Iro 20:35
Well, I think first of all, collaboration I think it's a key and partnerships, you know, whether that's in education or in practice, we can definitely learn from different models of care that are successful in one country that could possibly be adapted within other countries. So I think for me, there is a real need for opportunities to establish these relationships outside of regions. It could be a South-South kind of arrangement, but it could be a totally, high income to low income kind of support system that could kick in place. I think for me, so that's the first suggestion, I would say to look at just what exists and what can be adapted.
But I think if anything, what the Pacific are doing in some areas are actually a lesson that the rest of the world could definitely learn from us. I think some of the models of care that's being provided within I think in some tall now with the, you know, the nurse-led NLC clinics, and how everything that's I think that's a model that was supported by Australia initially. That's really a very efficient way of addressing NLCs. And this is the model that could be replicated and I think it is being replicated in the sense that you'll find advanced nurse practitioners training is using the model that addresses primary health care with allowing them to practice to the full scope of their practice. I think it's been some of the key things. It goes both ways. We definitely have a lot to offer as well to the rest of the world.
Adam Craig 22:40
Here in the Pacific we have lots that others can learn from. We can never underestimate that. Michelle, your centre, the World Health Organization's Collaborating Centre for Nursing, Midwifery and Health Development is the first of its kind in the region. How did it come about? And what sort of work are you doing?
Michele Rumsey 23:30
I think we were really, really lucky. And please can attest to this because it's the first meeting actually happened in the Cook Islands of with Liz, I think, was Chief Nurse at the time, where a group of senior nurses came together and said they wanted to support really. I think they recognized at that time that the Pacific being very isolated, and having lots of similarities but also being unique in their own right in each country. So they came to us and asked us if we'd be a collaborating centre. So I guess that was in 2004. Quite a few years later. And we've been very lucky.
We have been Secretariat for the Pacific Nursing Alliance then, and our terms of reference is quite broad and nursing and midwifery are quite broad programs if you like. There's no point in being very tight. I think even WHO struggled at times. We've got such a broad spectrum but mainly we look at Maternal and Child Health Leadership, human resources for health, and some regulation. And really, that enables us to utilize the wonderful staff we have at UTS and other partners across Australia and New Zealand and work with all our chief nurses on education support and regulation.
Adam Craig 24:30
Sounds like you're really working from the bottom up strengthening those building blocks of a health system through the nursing workforce and looking at integration across the different components of the health system.
Michele Rumsey 24:40
Yeah, we certainly use an integrated approach and everything we do are integrated approaches looking at governance. We've been fighting for many years to make sure there's a Chief Nurse in every country in the Pacific and, and broader than that in the State of the World's Nursing Report said we've got 27 out of 57 countries in the region. So we've got 10 more to go, Liz. We've got to look at education, then we look at associations, because associations are really, really important to make sure that there's continued professional development, for our nursing staff, and they're supported. The associations support the health workforce, and then regulation is really about protecting the public. So for us, it's that big, broad, integrated approach that we always sort of work through doing any programs.
Adam Craig 25:30
Approximately 90% of the nursing workforce are female, yet a few leadership positions are held by women, what can be done to address the gender imbalance and what impact would addressing it have?
Michele Rumsey 25:45
I think that's another thing that's come up really, really clearly in the State of the World's Nursing Report that we need a lot more support for leadership. And we're very lucky that we carried out a leadership program for many years at the Collaborating Centre in line with our regional partners. It was a very small program. But it was supported for many, many years. And that program has seen a marked improvement across the region of our colleagues. We've been able to support many Chief Nurses and out of our program, we actually have two health ministers now. So we're very excited. But DFAT stopped the funding for that. So it's really hard because DFAT do fund a lot of really brilliant things. But I think actually, maintaining the momentum of this work is crucial. How do we maintain these things? How do we maintain this leadership across the Pacific?
It's a bit like I was saying before, if our colleagues are invisible and not fighting locally, for their own needs, because they're so busy and they've got family. It's really, really hard to make sure this leadership is on the table. I'm sure Liz will talk about it more but we often talk about nurses being at the policy table, how can we get more nurses at the policy table? Because if they're not at those policy tables in their ministries, they can't help push this change. And so it's enabling that change. And certainly our leadership program showed a huge impact of confidence of our colleagues around the region, they suddenly understood how to move things forward in a project sense. It wasn't all about nursing. It was about really empowering them as individuals.
Adam Craig 27:30
Elizabeth Iro 27:35
I was just going to just add on to Michelle's comment about the leadership programs that was that was provided through the Collaborating Centre to Pacific Island nurses. And of course, I was privy to some of my colleagues who have attended that and I think to see the trajectory of the growth as a result of some of these leadership programs was just amazing to see where they are today. In terms of within the organization, the leadership roles that are taken within the organization.
I think for me, leadership definitely is the key. The report kind of highlights that as one of the big recommendations. But for me personally, it is about how it cascades, a lot of policy changes can cascade from actually having the right people in the right places at the right time to influence change. And I think this is about understanding not just the nursing agenda, but actually to understand the context of where you work, and the policies and politics that happened within that context.
I think, lessons that we are definitely imparting on a lot of them colleagues across the world in terms of the government chief nurses and midwifery officers, and other nursing leaders within countries. So I think that's really quite critical to understand that, as Michelle said, you know, we've been trying to make the shift for quite some time. And so there's a lot of stuff going on for Nursing and Midwifery right now in terms of the visibility that we're getting from the Year of the Nurse and the Midwife from the Nursing Now campaign, from the COVID-19, even. I think COVID-19 is definitely highlighted the value that nurses and midwives are contributing to healthcare. So I think, you know, from a leadership perspective, we definitely need to have that voice at the decision making table. I think we heard in some countries how just having the nurses in the decision making as part of the preparation of the response to COVID-19 actually had some positive rollout for the country in terms of how they addressed the situation.
So I think we have lessons that we can learn from. So I think it's, we are going to see those changes. And I think the government chief nurses, government chief nurses and officers and leaders of associations. They are aware, and they know where to get help from, as Michelle said, you know, the awareness through the various programs that are being offered is making a difference. And the report says, you know, having that leadership actually makes a difference to the regulatory processes. So, I think that's important that we need now use what we have in the data to influence our politicians.
Adam Craig 30:50
COVID-19 has demonstrated how essential nurses are in combating pandemics and also how difficult their jobs can be. Across the Indo-Pacific region, approximately 12,000 health workers are tested positive for Coronavirus, and almost 200 have died. What drives nurses to talk to work each day given these risks?
Elizabeth Iro 31:10
I think for nurses, it's always been about an art and the science. And I think what you've seen is some of the responses from nurses is because they are passionate about what they do. They want to continue to provide care. They are trained to provide that care.
The key though, is that they need to be protected while they deliver that care. I think there's an element that that I think is important to capture within this conversation. But I think that they continue to because they know they can make a difference. They are trained, they are educated, and they have compassion for what they do. I think that's why they continue to go to work, despite they understand that the risk of catching the infection and actually of death is there. So I think, you know, as employers, they have an obligation to make sure that the nurses are getting the resources they need to do the jobs that they do.
Adam Craig 32:40
Does the compensation nurses receive reflect their contribution?
Elizabeth Iro 32:45
I think this is a conversation that is actually a pre-COVID conversation, not just a COVID conversation. And that there are differences within countries as to what that compensation is. But I think you will find that I think, where there were conditions and salary are before COVID is very perhaps on the negative side. And so what that is what they have done, though I think what has come out in some of these countries that have been really highly impacted by COVID is the recognition by heads of state, by ministers of health, of the value that nurses actually make during this COVID-19. So, we need them to make those changes to those address those, those statements that are made by heads of states to make sure that they correct those right now, they correct the working conditions and the salary, the remuneration and the hazard compensation now. I think that's going to be the case, not about preparing for the next pandemic, it's about actually getting it right.
Michele Rumsey 34:10
But I think it's about recognition. And I think nurses, if they're recognized they have higher motivation, and higher morale. And that's always been recognized. And it's not always the huge things. If a hospital suddenly charges a nurse for car parking to come to work, the morale of those nurses is terrible. So I think it's about the small and the large recognition, especially during this time that actually enables nurses to think their employer really recognizes them. The thing with PPE and support equipment for COVID-19 that was a huge one. They was saying we're out there doing amazing work and there's not enough equipment, what's going on? So I think it's that it’s always about recognition. And nurses actually wants to nurse.
Adam Craig 35:10
Michele, you articulate so clearly about recognition and how that is a motivating factor for turning up to work and giving it your all. Some of the work I’m doing with nurses in Solomon Islands at the moment around early warning disease surveillance systems and their motivation about participating in those systems is reflecting what you are saying. People are saying they will contribute and are willing to contribute as long as they feel respected.
To finish up the interview, what have been the lessons learned from the COVID-19 experience so far, and how will they frame global health security moving forward?
Elizabeth Iro 35:40
Well, I think for me what COVID-19 has highlighted is the need for investment in health systems, so they can provide the necessary health care and to also address not just the social but the gender and racial inequalities. That's what COVID-19 has highlighted.
I think some of the issues that were gaps pre-COVID has really been being amplified during the COVID. You've had the nursing shortage, violence against nurses and healthcare workers, you had nurses who have been stressed and burnt out because of various reasons shortages of staff and lack of good working conditions. That happened prior to COVID. And COVID has just brought all those elements out.
And then we've seen some of the negative impacts, of course, you know, with the violence of the stigma and discrimination against the nurses and health care workers. We've seen the mental distress, the issues that's impacted a lot of the nurses. So I think those are issues that needs to definitely be factored in our recovery. So I think for me, for us as nurses and midwives it is for us to leverage the situation, if you call it that, to make the gains for policy changes within countries. We really need to do that.
And with the focus on the Year of the Nurse and the Midwife also around being visible and aware and informing our general public about what nurses do and what midwives do. I think it is going to be a critical part of that recovery because it’s not just preparation for the next pandemic but getting it right for normal circumstances. So that’s some of the lessons learnt from COVID-19.
Michele Rumsey 38:30
I think we have learnt so much from this pandemic. I feel quite emotional. We were on a big global meeting with Liz last week. It was 600 nursing and midwifery leaders and I think the most traumatising thing was seeing some of our colleagues in associations, especially in Italy, who were absolutely exhausted and still working so hard to support the nurses in their countries. And yet at the same time the public are so scared themselves that they have been abusive to the very health professionals that support them. So I think in some ways there has been a lot of humanity around the whole pandemic, a lot of confusion about this whole pandemic, a lot of misunderstanding and I think nursing has been at the forefront.
People can never forget that nurses and midwives are there to look after them and you just have to keep remembering that. We have to provide the leadership, the education and the moral support, recognise those nurses and midwives. Of course at the end of the day they want money to be supported and good equipment but actually they just want to be recognised.
Adam Craig 40:00
Nurses are certainly the heroes of the pandemic. Elizabeth Iro, Michele Rumsey, thank you for making time to speak to me.
Michele Rumsey 40:05
Thank you, Adam.
Elizabeth Iro 40:10
Thank you, Adam. It’s been our pleasure.