ICN

Nursing and Health Policy Perspectives

Nursing leadership and health policy: everybody’s business

Jane Salvage RGN, BA, MSc, HonLLD, HonDSc,

HonDUniv, FQNI
Independent Consultant and Programme Director, ICN
Global Nursing Leadership Institute, Geneva, Switzerland.
E-mail: janesalvage@me.com

Jill White AM, RN, RM, MEd PhD MHPol

Nursing Now Global Campaign Board Member (Western
Pacific Region)
former Global Nursing Leadership Institute Co-facilitator,
and Professor Emerita, University of Sydney
E-mail: jill.white@sydney.edu.au

Jill White (left) and Jane Salvage in Geneva

Abstract
We all know great leadership when we see it. Outstanding nurse leaders, guided by a moral compass, simultaneously see the big
picture and the consequences at micro level. While policy and politics determine health and nursing practice, most nurses just
want to get on with their day job. They carry out decisions made by others but have little say in them, and weak influence or
status, although they are increasingly knowledgeable and skilled. In settings where policy decisions are made - parliaments, gov-
ernments, and boardrooms - nurse leaders are often neither heard nor heeded. This is starting to change. The global Nursing
Now campaign is working with the International Council of Nurses, and the World Health Organization, to create and
strengthen strategic nursing leadership, as modelled by the International Council of Nurses’ Global Nursing Leadership Institute.
A new window of opportunity is opening, with the bicentennial of Florence Nightingale’s birth in 2020. Now is the moment!

Keywords: Health Policy, Nursing, Nursing Leadership, Policy, Politics, Strategic Leadership

‘Leader’ and ‘leadership’ are among the most overused
words in nursing. We say them so often and in such diverse
circumstances as to make them at best muddy, and at worst
meaningless – as in the mantra ‘Every nurse is a leader’. The
thousands of definitions of leadership are often conflicting,
obscure or highly complex, but we keep on using the words,
just as Florence Nightingale said she used the word nursing
‘for want of a better’.
Yet, we all know great leadership when we see it (White
2019). A striking recent example is the leadership shown by
Jacinda Ardern, prime minister of New Zealand, after the
mosque attacks in Christchurch that killed 50 people. The
world watched, in awe of her ability to lead a nation, indeed
a world. Wearing a hijab, she listened, apologized, and
showed compassion and respect. She spoke eloquently of the
policy changes needed, but did not rush to declarations or
grandstanding. She announced unequivocally to the New
Zealand Parliament that gun policy would change, and out-
lined processes and a timeline. Refusing to give the perpetra-
tor notoriety, she did not say his name and never will.

© 2019 International Council of Nurses 147

148 Nursing leadership and health policy: everybody’s business
Ardern crystallized the essence of leadership. Guided by a
consistent moral compass, she simultaneously saw the big
picture and the consequences at the micro or human level.
Outstanding nurses in leadership roles show similar qualities,
but many others struggle to connect the macro and the
micro. This is hardly surprising as nursing is rooted in our
individual practice with our patients and communities.
We ignore the macro level at our peril, however. We
experience daily the influence of policy and politics, in the
funding of our health systems, the health challenges we tackle,
the socio-economic policies that affect the health of the com-
munities in which we live and work, the widening inequalities
within and between countries, and the failure to provide uni-
versal health coverage. The Sustainable Development Goals
remind us that health is interdependent and interconnected:
the policies that most affect health are often not health poli-
cies, so cross-sectoral policy work and collaboration is critical.
Moreover, policy and politics determines nursing itself – past,
present and future. It profoundly shapes the practice and
workplaces of nurses at local, regional, national and global
levels (Salvage & White in press).
Most nurses say they just want to get on with their job, and
not worry about the macro-level concerns of policy and poli-
tics. They make naive assumptions about health and health care
and do not view the issues through a socio-political lens (White
2014). This makes them bystanders, but they are inevitably
end-users of health policies. To shape the present and future of
our profession, nurses must be active rather than passive, and
influence and lead policy. This means understanding not only
the content related to a health issue, but also the policy process,
the context, and the stakeholders and their interests.
Furthermore, nurses have a moral obligation, resonant with
their codes of practice, to shape health and social policy in
ways that advance the interests and health of the public.
‘They have an obligation to speak out and get involved in
one of the most important moral imperatives of our day: pro-
moting the health of families and communities by shaping
health and social policies to end disparities in health and cre-
ate healthy places to live, work, and play’ (Mason 2016).
Neither heard nor heeded
Despite all the talk of leadership in nursing, the reality is dee-
ply worrying. Nurses are the largest group in the global health
workforce, and often the only healthcare providers available.
Worldwide, nurses do wonderful work with brilliant out-
comes. They occupy a special position as the interface
between the health system and the community, and they see,
hear and know how policy and politics affects patients and
communities.
© 2019 International Council of Nurses
They should be feeding that knowledge into policy-making.
You might think that policy-makers would welcome their
inputs with open arms, yet while nurses are acknowledged as
key policy implementers, they are rarely central to health and
social policy development (White 2014). They carry out the
policy decisions made by others, but have little say in those
decisions – mirroring patriarchal doctor–nurse and male–fe-
male relationships.
In recent decades, nurses have become increasingly knowl-
edgeable, skilled and well-educated, but this progress has not
been matched with a significant growth in influence and sta-
tus, and in some respects is going backwards. ‘Weak and, in
some cases, reducing leadership’ is a major challenge facing
nurses globally, according to the influential Triple Impact
report and many others (All-Party Parliamentary Group on
Global Health 2016, pp 17). It is also a major challenge for
health systems globally, not just for nurses, for if the world’s
23 million nurses and midwives are neither heard nor heeded,
how can these systems be truly effective?
This crisis of leadership is evident in individual countries,
and also at global level, where nursing is seriously underrep-
resented in the major global health organizations – many of
which rely on front-line nurses to deliver their programmes,
yet have few or no nurse employees or board members. They
even exclude nurses from applying for positions still reserved
for doctors: a recent call for applications for a World Health
Organization maternal health post in Sierra Leone required
an MD, even without experience in obstetrics and gynaecol-
ogy. There was nothing in the job description that could not
be perfectly well done by a nurse or midwife.
Global nurse-led organizations, comparatively weak and
lacking in influence, are not yet major players. This lack of
strong national and global nursing voices is part and parcel of
structural global inequalities related to gender, wealth, race and
status. These inequalities also underlie the lack of attention paid
Figure 1 ESSENCE of LEADERSHIP
Nursing and Health Policy Perspectives
to voices from low-income countries, indigenous peoples and
other disadvantaged groups, an omission that has a large and
generally unrecognized negative impact on global health.
When nurse leaders do make it into the settings where
decisions are made that have profound effects on health and
health care – for example in parliament, in government, and
in the boardrooms of major organizations – they are often
neither heard nor heeded. The reasons range from gender dis-
crimination and social class to lack of status. Many have little
or no preparation for roles as government nurses, nurse
directors, deans or heads of nursing associations, and do not
know how to influence and shape policy, even within nursing,
and change has not happened fast enough or far enough.
The window of opportunity
Recommendations on nursing that fail to have traction, poli-
cies that ignore or undermine nursing, and nurses’ virtual
absence from policy-making – can this gloomy pattern change
for the better? Change is in the air, at long last. The profes-
sion is learning, and moving along the spectrum of political
development, through the four stages from buy-in and self-
interest to where we are now, developing political sophistica-
tion and aiming to lead the way (Cohen et al. 1996). This
slow pace of change is accelerating and a new window of
opportunity is opening, pushed by new ways of thinking and
acting on nursing.
The first-ever Year of the Nurse and Midwife in 2020, with
the first WHO report on The State of the World’s Nursing (it
only took 72 years!), is an exciting prospect. Urged by its
nurse-savvy director-general Dr Tedros Adhanom Ghebreye-
sus, WHO is taking steps to embed nursing and nurses in its
thinking and actions. Meanwhile Nursing Now, launched on
the back of the Triple Impact report, aims to match global
policy action with local campaigns as a social movement. The
campaign works with ICN and WHO to ensure that experi-
enced nurse leaders are available in the right places and right
roles, to help nursing deliver its potential and include the
nursing perspective in policy-making and decision-making. It
advocates creating and strengthening strategic nursing leader-
ship all in countries, and the Nightingale Challenge 2020 will
be launched at ICN Congress in Singapore in June 2019 to
every large employer of nurses to provide leadership and
development training for nurses and midwives.
The development of strategic and policy leadership is
missing from most nursing leadership programmes, with
the rare exception of the ICN Global Nursing Leadership
Institute (GNLI). Now in its tenth year, this innovative
programme has inspired nearly 300 nurse leaders from
round the world to ‘think globally, act locally’ – not as an
© 2019 International Council of Nurses
149
academic exercise but as a way of seeing that enriches per-
spectives, increases knowledge, and makes nurses more
motivated and effective. Seizing nursing opportunities in a
global movement committed to sustainable development,
GNLI focuses on the foundations of policy understanding
and influence. Most top nursing leadership programmes
focus mainly on organizational management. These pro-
grammes are few, although a full mapping is needed.
GNLI, in contrast, helps senior leaders to hone their pro-
fessional, political and policy leadership skills to operate
effectively in tough policy arenas, while maintaining per-
son-centred, humanitarian values.
These top leaders, in many different roles, learn together
how to maximize their contribution to shaping, influencing
and implementing policy. For policy change – to make things
happen – they need to consider not just the content but also
the context, the change process, and the interests and power
of the key actors/stakeholders. This means dropping ‘nurse-
speak’ and the familiar nursing virtue script, addressing them
instead in language that speaks to their priorities.
GNLI scholars work on live projects, underpinned by a
review of their own countries’ health status and policies, and
consider how nursing can make a more effective contribution
through effective evidence-based policy-making that addresses
health needs. Thus, GNLI helps them to join the dots between
what happens in their own organizations, in their own
national scenarios, and globally. All this requires greater
awareness of how nursing contributes to outcomes not only
in health, but also in education, gender equality, poverty
reduction and environmental activism.
The programme evaluation is highly successful. However,
we need not just 300 policy-competent nurse leaders in
10 years, but at least 3000 in the next decade – and a top
cohort for each country. Moreover, all top nurse leaders in
each country should work closely together, but in many
countries these nurses do not collaborate or even know each
other. Some countries lack properly funded and supported
senior nurse posts in government and elsewhere. Collaborat-
ing to produce and implement a national action plan for
nursing as advocated by WHO, within a country’s health
strategy, can engage and motivate thousands of nurses and
other stakeholders. We would like to see more cooperation
and sharing on this globally, and in the six WHO regions
worldwide as well as at national and local levels. The triad
model adopted at global WHO/ICN and European Union
meetings of government nurses, regulators and heads of nurs-
ing associations is an important step in bringing country-level
leadership teams together to learn, share and return home
with new energy and ideas, and much more could be done.
150 Nursing leadership and health policy: everybody’s business
In our vision, nurse leaders are experienced, confident and
effective champions of quality with a powerful voice at all
levels of health and policy systems, recognized and valued by
the public, service users, colleagues and policy-makers. They
are in posts in the right places and right roles, and receive the
support and resources they need to help nurses deliver their
potential. They ensure that the distinctive nursing perspective
is included in policy-making and decision-making.
Achieving this vision requires champions to provide serious
support and serious money, beyond our impoverished nurs-
ing organizations and our usual faithful donors. The 2020
window of opportunity may soon slam shut again (Salvage &
Stilwell 2018). Now is the moment to shift the paradigm, to
be taken seriously, when the old certainties and ways are
being shaken to the core by economic crisis, climate change,
insecurity, a deep desire for stronger social solidarity, and the
rising clamour of women’s voices – and of nursing policy
leaders.
Acknowledgement
We acknowledge the contribution of Diana Mason, Deputy
Programme Director, Global Nursing Leadership Institute,
International Council of Nurses in the development of this
article.
© 2019 International Council of Nurses
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