Insights from Howard Catton: Part 1 - Addressing global nursing challenges
December 9, 2024
This two-part interview article features an in-depth dialogue with Howard Catton, CEO of the International Council of Nurses, who was in Malaysia from November 19 to 21 to attend the 22nd Asia Workforce Forum (AWFF) and the 18th Alliance of Asian Nurses Associations (AANA) meeting, hosted by the Malaysian Nurses Association (MNA) and the International Council of Nurses (ICN).
Covering 22 critical questions, we explore the pressing issues facing the nursing sector in Malaysia. The article presents a conversational format, showcasing questions followed by Howard's insightful responses. General perspective on nursing challenges Question: How do the challenges faced by Malaysian nurses compare with those faced by nurses in other countries, particularly in low- and middle-income nations? What are the key lessons from other countries that Malaysia can adopt to address nursing challenges effectively? Howard: The challenges that countries face are very similar around the world. We have a global shortage of nurses, estimated to be around six million. There are approximately 28 to 29 million nurses worldwide. This shortage is occurring at the same time as the demand for healthcare is increasing due to aging populations and more people with non-communicable diseases. There’s a growing gap between supply and demand, which is as much an issue in Malaysia as it is in several other countries. This global shortage also means that it is becoming more competitive to hire nurses. After the pandemic, many countries that entered the crisis with too few nurses found that more nurses left than would have under normal circumstances. At the same time, we were trying to respond to the pandemic, and there was a delay in addressing other healthcare needs, all of which added to the demand. Countries that were short of nurses and could afford to began looking overseas to recruit from other nations. From Malaysia and several countries in this region, nurses are attracted to opportunities in other parts of the world, leading to a brain drain. This poses significant risks to the health of the Malaysian population, as there may not be enough nurses to care for them and meet their healthcare needs. This situation is detrimental not only to health but also to the economies of these countries, as a healthy population is essential for economic stability. If people become increasingly ill, it becomes more expensive to treat them compared to addressing health issues early or, ideally, preventing them altogether. The key lesson is for countries to invest more in their nursing workforce to ensure they have enough nurses to meet their own needs and to retain them in the workforce, preventing loss to migration. It is crucial to recognize that spending on nursing should not be viewed merely as a cost or a budget item but as an investment in the country's prosperity and economic well-being. On poor welfare and salary scheme Question: What role does fair compensation play in retaining nurses within the public health system? How can governments balance limited budgets while ensuring fair pay for nurses? What international benchmarks exist for nurse salaries, and how does Malaysia fare in comparison? Howard: Pay is undeniably a critical factor for nurses, just as it is for everyone else. While nursing is often described as a vocation or calling, that alone cannot put food on the table. Many nurses are paid below the average wage in their economies, and they frequently lack opportunities for career advancement and promotion. At the same time, nurses face enormous demands. They give their all every day to provide the best possible care, both physically and emotionally, which can be incredibly draining. They work shifts and weekends, and during the pandemic, many nurses stayed at their workplaces for days on end to care for patients. It’s essential that nurses receive fair and decent pay; otherwise, they may choose to migrate to countries where they can earn significantly more. Fair compensation for nurses is also crucial for ensuring patient safety. However, there are additional factors to consider. In other countries, while pay is fundamental, career progression and flexibility in working hours are also vital. With 90% of nurses being women, many have caregiving responsibilities. Balancing home life and work life is immensely important. Nurses also want their voices to be heard in the workplace. They often liken themselves to air traffic controllers in healthcare, as they can see when things begin to go wrong, such as patient deterioration or systemic failures. Health leaders must listen to nurses to ensure safety and quality care, yet often their voices are not heard at the highest decision-making levels. Many countries lack a chief nursing officer, and while hospitals may have a chief executive, chief financial officer, and medical director, there may be no senior nursing representation. Running healthcare without strong nursing leadership is akin to flying blind. In addition to fair pay, we must address working conditions, leadership, and career and educational opportunities. Countries that successfully recognize, reward, and retain their nursing workforce do so through a combination of strategies rather than a single solution. People often think of nurses in terms of their care and compassion, but when you delve deeper, they describe their roles as simply helping with feeding, cleaning, and washing. The pandemic has significantly shifted public perception of nursing. We witnessed the care and compassion of nurses in intensive care units, managing complex equipment and administering medications. Nurses responsible for patient care must make critical decisions in life-and-death situations while increasingly providing leadership. In conflict zones and disaster situations, nurses demonstrate immense courage, often running toward danger when others turn away. Nursing is not merely about physical care; it involves well-educated professionals making difficult decisions, possessing technical skills related to equipment and medication, and being attuned to patients' mental health and emotional needs. They guide individuals through complex healthcare systems. Given this comprehensive role, should nurses really be compensated at just the average wage of the economy? The average wage may reflect positions in retail, which, while valuable, does not compare to the demands placed on nurses. This discrepancy largely stems from nursing being an overwhelmingly female profession—90%—which has led to perceptions of low value and discrimination. However, this perception is changing. The World Economic Forum has begun to focus on the care economy, recognizing the significant value that caregiving brings to global economic growth. Investing in nursing not only enhances public health but also contributes to economic dividends. A substantial body of evidence—academic, peer-reviewed studies published in medical and health journals—clearly demonstrates the relationship between the number of nurses and patient safety. When there are too few nurses, the rates of infections, falls, medication errors, and failure to identify deteriorating patients all increase, leading to higher mortality rates. On workload and staffing Questions: What are the long-term implications of high patient-to-nurse ratios on health care systems? What strategies have been successfully implemented in other nations to address nursing shortages? Is getting foreign nurses to replace the shortage a good decision? How can technology, such as AI or automation, alleviate some of the burdens placed on nurses? Howard: Politicians have a primary responsibility to ensure the safety and security of their populations. The availability of an adequate number of nurses is a critical aspect of this responsibility. Evidence indicates that insufficient nursing staff can lead to increased harm to individuals and communities. This heightened risk not only has dire consequences for health but also incurs significant costs. Poor healthcare ultimately costs more—not just in treating illness but also in terms of lost productivity and the inability of healthy individuals to contribute to society and the economy. Many countries have recognized this issue and have established clear standards for nurse-to-patient ratios, working hours, and patterns that promote nurses' well-being. When these standards are implemented, sickness rates, absenteeism, and turnover decrease, while job satisfaction increases. This dual benefit enhances both nurse retention and patient safety, making a compelling case for investing in the nursing profession. However, as healthcare needs continue to grow, it is unrealistic to expect that we can simply increase the nursing workforce indefinitely. Therefore, we must explore alternative ways to support nurses. The integration of technology, such as DigiHealth and AI, plays a vital role in complementing the nursing workforce. For example, in China, remote patient monitoring and consultations allow healthcare providers to receive real-time data from patients. This system enables nurses to assess patient stability and intervene promptly if issues arise, such as offering advice or arranging for further tests. Upon arriving at the hospital, patients can access terminals to download their latest test results and documents, significantly reducing the burden on nurses who would otherwise have to re-enter information—a task that frustrates both nurses and patients alike. Technology can also help identify patients at higher risk and assist with medication management to minimize errors. These advancements provide essential support for nurses, ultimately improving patient care. I am not concerned about technology or robots replacing nurses; rather, my concern lies in nurses not fully embracing and controlling these technological advancements. If nurses take ownership of these tools, they can greatly enhance their work and improve healthcare delivery worldwide. On career development and education Question: What is your opinion on raising the minimum qualification for nurse recruitment to a degree level? What role does professional development play in improving job satisfaction among nurses? How can international organizations, like the ICN, support countries in expanding educational opportunities for nurses? How important is transparency in promotion processes to retain nursing talent? Howard: Globally, countries are transitioning to nursing as a graduate-entry profession. Many nations that previously offered nursing education through certificates or diplomas are now requiring a minimum of three to four years of university education. This level of education is essential for nurses to effectively manage the complexities and demands of modern nursing practice, which requires a deep knowledge base, technical expertise, and a diverse skill set. In aged care facilities, the complexity of patient needs is escalating. As populations age, patients often present with multiple health challenges, including chronic diseases, lifestyle-related issues, anxiety, burnout, and complicated family dynamics. Nurses and caregivers must be equipped to address these multifaceted concerns, which underscores the necessity of a degree-level education. Research indicates that both staffing levels and educational qualifications are critical to ensuring high-quality care. When nurses possess higher education, safety indicators improve, care becomes safer, and overall quality of service increases. It is unrealistic to expect that a nurse who graduates at 20, 21, or 22 will remain in the same role throughout their career. In no other industry would it be acceptable for someone to perform the same job from entry-level to retirement. Career progression is a natural expectation for professionals in any field. There is also a pressing need to develop more specialized nursing roles, as there is a global shortage of these positions. Recruitment efforts are increasingly focused not just on filling general nursing roles but on attracting nurses with specialized skills that are crucial for meeting future healthcare needs. When organizations invest in nursing education and career development, nurses feel valued and supported. This leads to greater job satisfaction and increases the likelihood that they will remain with their employers. From the perspectives of patients, nurses, governments, and healthcare systems, investing in nursing education is a win-win situation. Moreover, with 90% of the nursing workforce being women, investing in nursing directly supports gender equality and the status of women in society. The International Council of Nurses (ICN) is recognized by the World Health Organization (WHO) and other international bodies as the voice of global nursing, bringing nursing expertise and experience to the forefront of global policy-making. One of the key ways we achieve this is by developing a comprehensive global nursing strategy. The current strategy was first established in 2020 and will conclude next year, prompting the development of a new strategy. ICN collaborates closely with WHO, which includes a chief nurse and representatives in various regions, to analyze data and evidence regarding the global nursing workforce. This collaboration led to the agreement on the strategy in 2020, where health ministers from around the world affirmed their support during the World Health Assembly in Geneva. However, it remains uncertain whether all countries have effectively implemented this strategy upon returning home. The strategy outlines four key pillars: investing in nursing education—not only for initial training but also for ongoing professional development; promoting decent work and favorable working conditions; fostering leadership and its advancement; and ICN’s own global leadership training programs, which are crucial for the future of nursing. The strategy emphasizes that countries should enhance the advancement of nursing roles, including specialization and advanced practice. For instance, in many countries, nurses are authorized to prescribe medications. This focus by the WHO reflects the recognition that addressing global health challenges—such as aging populations and non-communicable diseases—requires not just medical intervention but also significant nursing involvement. Nurses play a vital role in developing models of care that meet the increasing health demands of the future. They are also essential for improving prevention and public health, which is another key pillar of the strategy. Each country is encouraged to create its own nursing strategy, prompting the question: What specific strategy and action plan do you have in place to align with the global nursing strategy? Furthermore, are you aware of the current nursing workforce numbers and the planning necessary to ensure there are enough nurses to meet patient needs now and in the coming years? These outcomes do not occur by chance; they require careful planning, strategy development, and resource allocation. This diligent work is often lacking, but organizations like the ICN, the Malaysian Nurses Association (MNA), and other national nursing groups can provide the necessary support and guidance to make these goals a reality. |
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