








key: cord-335737-eq6pibjy
authors: Wilson, Rhonda L.; Carryer, Jennifer; Dewing, Jan; Rosado, Silvia; Gildberg, Frederik; Hutton, Alison; Johnson, Amanda; Kaunonen, Marja; Sheridan, Nicolette
title: The state of the nursing profession in the International Year of the Nurse and Midwife 2020 during COVID‐19: A Nursing Standpoint
date: 2020-07-24
journal: Nurs Philos
DOI: 10.1111/nup.12314
sha: 
doc_id: 335737
cord_uid: eq6pibjy

nan

The International Year of the Nurse and Midwife has not quite played out as we might have imagined. A year of celebrations was anticipated. A much-needed injection of morale boost among the worlds' nursing population. But then, our celebrations were cut short at dawn, as COVID-19, probably the worst pandemic since the H1N1 influenza in 1918 better known as the Spanish flu, arrived. As a profession, we rallied in response, equipped with our socially constructed caring professionalism and scientific expertise. The faces of many exhausted nurses treating and caring for the sickest people populated our social and traditional media screens. And then, the insidious creep of patient, nurse, and medical professionals' deaths around the world 'followed; with the removal of our usual "norms," uncertainty became the hallmark of our immediate future. On the one hand, this circumstance has amplified the public perception of nurses' professional relevance to humanity, and on the other hand, COVID-19 has effectively rained on our party-the celebrations for the International Year of the Nurse and Midwife postponed (not that they had really reached the public). Nevertheless, there is time to pause and reflect on the state of nursing in the world in 2020, to ask ourselves how we will successfully propel our discipline forward in and beyond these adverse times, and to consider how we might mitigate our propensity to miss opportunities for taking our profession forward. How will we be ready to capture the public mood of goodwill when the celebratory international year comes around again?

We suggest that a feminist standpoint theoretical lens may help us to understand our epistemological advantage to position our profession progressively for the future (Ashton & McKenna, 2020) .

There are over 20 million nurses in the world, and typically 90% of the nursing workforce are women (Boniol, McIsaac, Xu, Wuliji, & Diallo, 2019) . Nurses are caring science professionals, and they are a valuable contribution to world health representing the largest disciplinary proportion (59%) of the health professions sector. Despite the extremely large workforce population, nurses continue to be under-represented in global healthcare policy and governance which is dominated by the smaller workforce sector of medicine.

The default medical hierarchical and patriarchal dominance of global health decision-making persists, with the caring sciences relegated to lesser significance, funding, and influence, despite scientific scholarly and practice capacity to participate on equal footings (Grace & Zumstein-Shaha, 2020) .

Caring has traditionally been regarded as the work of women, carrying with it the societal expectations of caring for children and young people, older adults, and people with disabilities (Hartsock, 1983) . The lower societal hierarchical order associated with caring work continues to perpetuate the social oppression of carers who have traditionally been unpaid or underpaid, attributed to low socioeconomic status and associated political powerlessness (Hartsock, 1983) . However, this form of gendered social oppression has enabled the caring profession to develop radical new epistemologies, which, on reflection, enables a theoretical standpoint of epistemological advantage (Ashton & McKenna, 2020) . We see things in a way that others cannot, and will not, and it influences our perspectives and our capacity to describe phenomena insightfully; it is just not always what the dominant and powerful around us want to hear, or respond too.

In the case of nurses, this means our unique experiences, located within a socially oppressed context, have enabled us to develop different perspectives and formulate specific knowledge (Ashton & McKenna, 2020) . From a philosophical perspective, we have an epistemological advantage that uniquely enables us to understand complex human conditions of disadvantage, distress, and inequity from a scientific theoretical standpoint; to create unique evidence to solve human health problems; and to foster health-forming beliefs within society (Harding, 1991) . This may be what we believe of ourselves; however, when the press and public invoke the angel discourse (as we have seen), they compound the reference to women's work and add a religious overlay, reinforcing the saintly narrative with the element of self-sacrificial service to others. Thus, the "sacred" work is deemed reasonably remunerated with honour, rather than finance or social privilege, belatedly bestowed in a heavenly afterlife as though it is some type of superannuation or pension for service rendered. As an artefact of the caring paradigm and a legacy of historical female subservience, nursing too often continues to be overlooked in the bias of a hegemonic masculinist and biomedical view of the scientific health and political world (Carryer, 2019) . Our epistemological advantage also dismissed outright by society's belief in supernatural recognition instead. The perpetuation of a power and influence gap between nursing and medicine persists. This is a powerful historical impediment for a nursing profession that is increasingly highly scientific and academic in practice and central to the need to increase the focus on preventative primary health care.

Modelling has described a current shortfall of 5.9 million nurses throughout the world, with shortages in high-, middle-and lowincome countries and with worse outcomes for low-income coun- Nursing leadership is frequently not esteemed in the academic or political sectors, where powerful medical paradigms dominate, again, operating from a socially oppressed standpoint where nursing knowledge is situated beneath a dominant medical discourse and standpoint, oblivious to the social privilege associated with the elevated position it holds. It is apparent that a more welcoming, inclusive, respectful, and engaging environment within the wider academy is necessary if the world is to recruit, retain, and promote nursing leadership and academic excellence to facilitate the necessary growth of the nursing workforce. This is essential to mitigate the massive and increasing shortfall in work health standards that are pressing and looming and to grow the power and authority of primary healthcare nurses and nurse practitioners. The recent COVID-19 pandemic experiences have been illustrative of the global need and reliance on high-quality, highly sophisticated nursing care to underpin best practice and safe treatment throughout the most dire health crisis circumstances the world has seen in living memory (Jackson et al., 2020) . Simply put, we need more nurses in the world, and to add more, we need more nursing faculty to lead the education and research of nursing scientific knowledge, with more power, influence, and leverage. Yet, we are trapped in a deficit discourse that is resistant to change. "More" is required of us, with a "less" narrative to navigate.

The question is, how can the global demand be satisfied adequately, when a major barrier to success for nursing scientific leadership in the academy itself is apparent? For most nursing scholars, the dual nature of developing both clinical practice expertise and scientific practice expertise takes considerably more time to acquire than many other academic fields of knowledge. However, the integration of both fields of knowledge is a powerful representation of adaptability, translational capability, and implementational capacity representative in a nursing workforce. Nursing thus offers the formation of practice-informed evidenced-based knowledge, suited to the real-world delivery of health services delivered with a person-centric impact which extends far beyond the limited and limiting premises of biomedicine. Challenges to nursing faculty development are, however, significant with difficult access to serious research funding and cultures which often fail to value the pastoral care and teaching of students essential to the production of a professional and empathetic workforce.

Nurses have also been described frequently in the public social and traditional media discourse of late as heroes. Our collective commitment to caring for others with empathy in the grip of has been portrayed by the public as superheroes, not in capes-but instead wearing protective clothing. The fantasy of nurses as superheroes, while well meaning, does little to advance our reputation as caring scientists, to be taken seriously in the public health narrative.

Both superheroes and angels do not die, they also do not require training, science, or decent salary, in contrast, nurses do. The narrative we need is one that propels us to leadership in policy and process, and to being actively included in international, national, and local health planning and policy development, and crisis prevention talks with governments and agencies. While we note during COVID-19 that national nursing leaders have occasionally appeared in media conferences alongside their relevant governmental ministers, it is our observation that nursing is under-represented with medical colleagues as more frequent media conference companions for government officials. Too frequently, nurses are wilfully excluded or carelessly omitted from these endeavours. The assumption made by journalists is that the real authority lies with medical spokespeople and that we remain as handmaidens to the central endeavour, even though aspects of care such as infection control are part of our core business. In fairness to journalists, however, they will tell us frequently how very difficult it is to find a nurse who will speak publicly. This must change.

Will our contribution during COVID-19 do anything to change this? All too frequently, nurses themselves are either passively or actively subversive in their behaviours. Horizontal verbal violence, bullying, interprofessional disrespect and discourtesy, and plucking tall poppies are all apparent within the nursing discipline. Care of each other within our ranks still requires much more person-centred and rehabilitative attention. A dominant mainstream of invisibility within the emotionally safe bounds of mediocracy; political whiteness; and stigma towards difference combined within our collective slowness to embrace cultural and (dis)ability diversity within our number continues to undermine our caring profession severely (Fredericks & White, 2018) . Our propensity for "othering" within the nursing profession diminishes our reputation and our capacity to advocate convincingly for those to whom we administer nursing care. It takes courage to reflect on the social construction of our profession, to examine it through critical theoretical lens, and to challenge the behaviours and unconscious biases in our ranks that hinder our progress. We must summon the necessary collective courage.

It is through a longstanding commitment to promote public good that the nursing profession has the right of self-regulation and accepts the responsibility that comes with professional status. Nurses reaffirm their fidelity to nursing's social contract through a commitment not only to the welfare of those for whom they care, but also to the welfare of society through actions that improve health system performance. The nursing profession has a central role to play in the performance of health systems, which are a recognized determinant of population health and equity outcomes. Within our academies, nursing academics need to be kinder, more respectful, empathetic, and inclusive of difference if we are to succeed as a profession of the future, transforming our science and practice of caring within an integrated health system that contributes to equitable public good.

COVID-19 conditions during the early portion of 2020 and the International Year of the Nurse and Midwife have highlighted the need for the nursing scientific academy to transform our discipline and to enhance our scope to meet the needs of a changing world.

Increasingly, we need to be agile, transformative, and amplify the voice, power, and influence of an inclusive and diverse nursing workforce as we work to address the changing needs of the world's population with our core focus on promoting and improving the determinants of health and well-being, recovery, and robustness of people as they encounter challenging circumstances throughout their lives. To do this, we will need to be powerfully kind, influentially ambitious, and entrepreneurial in our problem-solving to ensure our significance in world health impact going forward. Our standpoint for our discipline provides us with a foundation to leverage wider recognition and respect for our collective health and well-being knowledge, at a time when the world cannot do without our important contributions. And in due course, we will celebrate and showcase our disciplinary achievements… at an appropriate time postponed to the future, in lieu of our current collective engagement and priority

Situating feminist epistemology

Gender equity in the health workforce: analysis of 104 countries. Geneva: World Health Organization

Letting go of our past to claim our future

Using bridges made by others as scaffolding and establishing footings for those that follow: Indigenous women in the Academy

Using Ockham's razor to redefine "nursing science

Whose science? Whose knowledge? Thinking from women's lives

Discovering reality: Feminist perspectives on epistemology, metaphysics, methodology, and the philosophy of science

Life in the pandemic: Some reflections on nursing in the context of COVID-19

State of the world's nursing 2020: investing in education, jobs and leadership. (Licence: CC BY-NC-SA 3.0 IGO.)

Sigma organisational fact sheet



