Expert insight

Five questions to …. David Stewart

5 August 2019
  • David Stewart

David Stewart, Associate Director, Nursing and Health Policy at the International Council of Nurses (ICN) talks to IFPMA about the importance of nurses in achieving universal health coverage.

Earlier this year, Dr Tedros endorsed 2020 as the Year of Nurses and Midwives. What are your hopes for 2020?

We have been working with Dr Tedros and other senior staff at WHO to raise the profile of nursing and we were extremely pleased that our lobbying to have WHO appoint a Chief Nursing Officer paid off when Elizabeth Iro took up her post in 2017.

Dr Tedros’s endorsement of 2020 as the Year of the Nurse and Midwife is extremely important for nursing across the world and it is gratifying that we have such support at the highest level of WHO. ICN represents the more than 20 million nurses around the world and we believe that they are a force for good that deserves to be recognised as such. 2020 was always going to be a special year for nursing because it is the 200th anniversary of the birth of one of modern nursing’s founders, Florence Nightingale, but now celebrations will be on a truly global scale.

He made a surprise visit to ICN Congress in Singapore on June 30, showing the strength of his commitment to nursing. He addressed the 5,000 nurses there, saying that nurses and midwives are an essential part of the WHO’s vision ‘to go from healthcare to health’.

He said nurses and midwives are a force to be reckoned with that should not be ignored. He said: ‘You have a huge contribution and impact and that’s why for any country to recognize nurses and midwives as key members of the health workforce that can help to realise the dream of any country in terms of better quality of scale is something that really you don’t need to debate. That’s why I’m here. You are a force to reckon with and a force that can help in realising UHC and the honour is mine. I am so pleased to be here.’

Dr Tedros also highlighted the crucial role ICN plays on the world stage: ‘ICN is a very important partner for WHO on a range of issues, including universal health care, quality of care, noncommunicable diseases, antimicrobial resistance and more.”

For us, 2020 is part of the work we started in 2018. We set up, in cooperation with the World Health Organisation (WHO), the Nursing Now campaign, which aims to improve global health by raising the status and profile of nursing. So far, the campaign has been adopted in more than 80 countries and received the very welcome patronage of the Duchess of Cambridge, Kate Middleton.

Our hope now is that having 2020 as the Year of the Nurse and Midwife will boost our efforts to enhance the profession’s visibility within the policy dialogue and the discussions around the Sustainable Development Goals (SDGs). Strong and sustainable health systems require well-educated nurses, yet their contribution to patients’ health and safety has long been undervalued.

We have a number of events and activities planned, not just around the commemoration of Ms Nightingale’s birthdate, but all year long. We want to change the consciousness and narrative around nursing so that it is finally recognised for what it is, a vital link in the health of the global population and the most rewarding job on earth.

What makes nurses so crucial in achieving SDG 3, and first and foremost universal health coverage?

As Dr Tedros has said and we have always said, nurses are essential for a well-functioning primary health care system: they make up nearly half of the world’s healthcare workforce and they perform a number of unique roles while also acting as a bridge between patients and the healthcare system. They are often the first healthcare staff to interact with patients, and sometimes the only health professional a patient will ever see. They provide care, support and treatment for the sick, the injured and the dying, and support their families and communities. They detect illnesses, administer medicines, assist in surgeries, treat patients beyond the initial diagnosis, provide mental support and perform any number of other key roles. Hence, nurses are intrinsically linked to a country’s ability to address health priorities.

Nurses are at the heart of the world’s current health priorities, from fighting non-communicable and infectious diseases via tackling the rise of antimicrobial resistance, to addressing health emergencies and stemming pandemics. So, for the goal of Universal Health Coverage (UHC) by 2030 to remain tangible, countries need to invest heavily in the nursing profession now and into the future.

I think it is important to also recognise that nursing’s contribution goes well beyond SDG3. For all of the SDGs to be achieved, nursing must be mobilised and empowered. For International Nurses Day in 2017, we wrote a publication entitled Nurses’ Role in Achieving the Sustainable Development Goals. In this publication we demonstrated nursing contribution to the SDGs and provide case studies showing the amazing work that nurses around the world are doing to improve access to health care, to educate populations, to address poverty, nutrition, clean energy, inequality, sustainability, innovation, justice and every other goal in the SDGs. Nurses are the primary providers of healthcare services around the world and are pivotal in the achievement of the SDGs.

A recent report you launched, Investing in the Power of Nurse Leadership, highlights the greatest barriers women face in becoming leaders of the nursing profession, contrasting the fact that 70% of the global health and social care workforce are female with the reality that just 25% of leadership roles are occupied by women. What needs to be done to remove the obstacles and support female leadership roles in nursing?

Just to be clear, this report was developed by Intrahealth, Nursing Now and Johnson & Johnson not by ICN.  However, I believe, in the first place, that the perception of nursing as a ‘soft science’ or ‘women’s work’ needs to change. Similarly, the status of the entire profession needs to transform from being undervalued to being recognised as key to a sustainable, well-functioning healthcare system. If we are to unlock the full potential of both women and men in the healthcare workforce, then gender-based barriers must be broken down. What’s more, policy and regulatory environments need to ensure fully inclusive workplaces and gender discrimination of all kinds at work should be eliminated. By empowering nurses and removing artificial barriers, we will empower all women.

We face the alarming prospect of a large-scale global shortage of nurses within the next decade. This has major implications for efforts to strengthen health systems and deliver UHC. What are the most important implications in your view?

You cannot have health without a health workforce, yet the global shortage of nurses is predicted to hit nine million by 2030. It will be impossible for the world to achieve access to safe, quality and affordable health care without addressing this issue. As mentioned earlier, if this shortage is not resolved, the SDGs will never be achieved.

Nurse staffing levels are normally a low-profile topic within the global health community, yet this is a real concern and a growing issue critical to patient safety. There is strong research evidence that having safe staffing levels saves lives – you only have to look at any of Professor Linda Aiken’s research to see the direct correlation between survival and good health outcomes, and the number of registered nurses on duty.

The implications of poor staffing levels are dire: It can mean that patients are not monitored as carefully as they could be, which means that acute conditions or complications may not be detected. Nurses also prevent medication errors and provide a safe space for treatment and mental support. There is another aspect that’s often overlooked, which is the burden on the care providers themselves. The relationship between care errors and delays, personal pressure, burnout and even suicide are inseparably linked to staffing issues and deserve greater attention both in research and practice.

Through our 130-plus National Nursing Associations we are on the ground, in every region, pointing out these issues. It’s not just increasing demand, driven by population growth and ageing. Recruitment and retention strategies for nurses require greater priority and notable investment by governments. High-quality nursing education and the potential for nurses to advance to leadership positions are also two decisive factors.

Nurses are at the front line in ensuring patients trust the health care they receive. What are the key issues that ICN focuses on in this area?  Are nurses key players in the fight against falsified and poor-quality medicines?

Patients’ safety and patients’ trust go hand in hand. People will only seek healthcare services if they trust healthcare professionals and the healthcare system as a whole.

The growing prevalence of sub-standard and falsified (SF) medicines is one issue that can severely undermine that trust, and ICN intervened on this issue at the 72nd World Health Assembly in May. If SF medicines end up on the market, in hospital pharmacies, the role of nurses in detecting such products and preventing the adverse effect of SF medicines becomes lifesaving. As a partner of the Fight the Fakes campaign, we believe it is incredibly important to increase awareness-raising efforts around the issue of SF medicines on a national, regional and global level. One area where there is a definite need for improvement, particularly in low- and middle-income countries which suffer from the greatest burden of fake medicines, is proper training for nurses on how to detect SF medicines, how to treat patients who were exposed to them, and where best to turn to in reporting them. Even before people are exposed to fake medicines, nurses have a crucial preventative role in educating the public on the dangers of SF medicines and discouraging highly dangerous self-diagnosis and self-medication.

Most patients take some form of medication, and nurses play a vital role in helping them to administer their drugs and monitoring the effects and side effects that occur. Their feedback through reporting systems ensures that adverse effects are quickly recognised and acted on. Nurses form an essential link in the system that puts the correct pharmaceutical products into the hands of the right patients at the right time. It’s a crucial relationship that can only continue where there are sufficient numbers of properly educated nurses, working on the ground in close contact with their patients and other healthcare professionals.


  • David Stewart