The Global State of Nursing During COVID – Elizabeth Iro, Chief Nursing Officer at the World Health Organization

Shiv Gaglani: Hi, I'm Shiv Gaglani. It's fair to say that appreciation for frontline healthcare workers increased considerably during the pandemic. That's especially true of nurses who have worked tirelessly to confront the overwhelming challenge presented by COVID-19. That's why we're particularly honored to welcome today's guest, Elizabeth Iro, who's the Chief Nursing Officer for the World Health Organization. 

Before being appointed to that post in 2018, Elizabeth Iro served as the health secretary for the Cook Islands - the first nurse, midwife, or woman to hold that job. For the first 25 years of her career, she was a practicing nurse and midwife, serving in several roles in the Cook Islands and in New Zealand. I'm looking forward to getting her unique perspective on the state of nursing now and in the future, and her assessment of the pandemic response. So, Elizabeth Iro, thanks so much for taking the time to be with us today.

Elizabeth Iro: My pleasure.

Shiv Gaglani: So, I'd like to start by first learning more about you and what got you interested in a career in healthcare, and then specifically nursing and midwifery. 

Elizabeth Iro: Well, as you've mentioned in my bio, I come from the Cook Islands, a little paradise in the Pacific Ocean. It is a self-governing island country in free association with New Zealand. That just basically means I'm a New Zealand citizen. After college, I was deciding what to do. Nursing was an option for me and having received a government scholarship, it opened the opportunity as well. So, I went in. 

I saw it first as an opportunity to travel. I heard stories about how nurses had mobility and were traveling to different countries, which was really exciting for me coming from a small island state. At the same time, knowing that there was some security in a job -- that you could basically work anywhere in the world with this qualification -- I set out to do my nursing training in New Zealand. I was only about 18 years old at the time. I then returned to the Cook Islands and after working for two years, realized some of my own limitations in my skill sets, so I sought to return to New Zealand and I completed my training. 

On completion of my training, I was a sister in the surgical ward in the Cook Islands in the main hospital and I think that's when I realized the motivation for nursing went a little bit deeper than the travel or the job inspiration I had after college. I was kind of determined to focus on making a difference in the lives of the people that I looked after, and the people in the general community as a whole.

There was an emotional connection with the people I cared for. So, for me, seeing and hearing from people about the difference I made to them as patients or to their families because of the care that they received from me I think has been the motivation to remain in this profession. It's what continues to motivate me now, even in this role. At the same time, I did appreciate the respect I also got from my colleagues -- the doctors, other nurses, midwives, the cleaners within the hospital -- and also the administrators. So that was very heartwarming. 

But I have to say that in my experience, there was this gravitation to take on more responsibilities. You go from a clinical to a policy lens in everything that you did, or everything that I did, anyway. There was this kind of need to take on more responsibility, but that meant looking outside of the clinical space as well. As I have migrated to different roles and responsibilities that I've taken, I've felt there are transferable skills that you build and you take along to the next role as you either go sideways in your career, or go up in your career. That's been a key element in the work that I do and what's kept my interest in this field. 

As you mentioned, I played various roles within the Ministry of Health in the Cook Islands prior to actually coming to this role, and I did feel very privileged that I was able to do those things. But this is the thing about this career…this is what nursing allows you to grow into. The potential and the possibilities are really endless. You build the skills, the competency, the knowledge base and really, it's about where is the next opportunity is. I think perhaps that's how I came to this role. Some of us don't always have the opportunity. We may have either the talent or the competencies but not many of us perhaps get that opportunity. So, this is one opportunity that opened up for me, and here I am.

Shiv Gaglani: Yes. Thanks for that bio. It's a pretty amazing career progression. You said you like responsibility. I can't think of a career that requires more responsibility than joining the WHO in the chief nursing officer role a year or two before a global pandemic hits. Can you talk to us a bit about what it's been like working at the WHO and some of the major accomplishments that you're proud of over the past two years or so?

Elizabeth Iro: The timing was perhaps perfect in a sense. There was this real global movement to make nursing visible to everybody...from policymakers, from clinicians, from students. You had the Nursing Now campaign that started in 2018. There was engagement with not just nursing global communities, but health officials globally. 

Dr. Tedros' appointment of me and his championing of nurses and midwives were critical to the work that I ended up doing. We had the International Year of the Nurse and Midwife in 2020, and then we have the global pandemic in 2020. All of that, somehow, still got the focus on nurses and midwives and what they do. COVID-19 definitely made that possible in terms of really understanding what nurses and midwives contribute to health care globally. 

Also in this time frame, we launched the very first State of the World's Nursing Report. Up to that point, we hadn't had any real data on nurses and where they are, where they were short, and what they were doing. That was one major piece of work with key partners -- with ICN and Nursing Now -- led by WHO. 

I think that these were key things that somehow, despite the pandemic, nurses were able to complete. On top of that, we also had the third State of the World's Midwifery report. All of this in the time of this global pandemic. The challenge was to really engage and work together on this because I think it was really critical that we got the data to actually show what more we could do. That's just been one of the big pieces. At the same time, we were responding to the COVID-19 pandemic and supporting our nurses in all countries. 

Those are perhaps some of the big major events or items that we were able to fulfill in the last couple of years, but there are also some events that we had to postpone and also some that we took to a virtual platform. We held our Global Forum for Government Chief Nursing and Midwifery Officers virtually. It was quite an experience, and we had huge participation in that forum. The State of the World's Nursing Report findings were discussed with government chief nurses and nursing leaders identifying the priorities they want to take forward, really laying down the foundation for WHO to come up with policy options in those areas. As a result of all of those reports that were done, we were able to present those to the World Health Assembly just this May, and had a resolution on strengthening nursing and midwifery endorsed by member states. 

So, we have something really solid to help us go beyond COVID for the next five years. We have some real solid policy options that we can take and support countries to make a difference. At the end of the day, it is about what countries can do, understanding the overwhelming situation they're already in at the moment. So, it's about how far we can actually support them, and that's just a work in progress. 

Shiv Gaglani: Totally, and speaking of supporting countries, you hail from the Cook Islands and you're a New Zealand citizen. Clearly, New Zealand is one of the shining stars in how they've approached the pandemic and there's been a lot of praise for your Prime Minister. What are some of the countries, in your opinion, that are doing the best for their nurses and midwives -- whether it's letting them practice to the full scope of their license, helping address burnout, forming enough new nursing schools and training programs so that the workforce is rejuvenated…are there any specific examples from countries that have done a good job that other countries should consider?

Elizabeth Iro: It's interesting that you say this because this is also something we found in our discussions with our Government Chief Nurses. Some are at different levels in their health systems so it depends on how much they have actually had a say in the planning and the decision-making in their countries. Then we've also got some who are very well matured in their health systems and they were given real direct responsibilities around COVID response and vaccine roll-outs. That's been something we're quite keen to address and share those stories. 

For me, one of the key ones right now is the Government Chief Nurse in Israel who has been a part of the decision-making in their response to COVID-19. She has a key role in that and with the program around the vaccine roll-out.  In Australia, we've had their chief nursing officer who's also been a key and has actually been the face for them for COVID-19 response. She has been anticipating the next surges and assisting her nurses to enable them to move into Intensive Care Unit mode as the situation arose, and we're seeing that. That for me is something really quite important that should be shared. 

In terms of mental health support, we've had cases where basic psychosocial support online is becoming a thing that's been shared. We've had our colleagues from collaborating centers actually making this happen for nurses and healthcare workers. We've really managed to make this a virtual approach to supporting our colleagues globally. That's just been something fantastic that I've seen as a result. It's not just one country. It's actually a collaboration of the nursing and with midwifery community. That's just some of the ones that I can share with you right now.

Shiv Gaglani: Those are wonderful. On that last point about mental health and resilience, obviously, there are systemic improvements that need to be made for the health systems. One of the things I'm most proud of from this podcast is we had Arianna Huffington on a couple of months back and with her organization, Thrive Global, we made a continuing education course on nursing resilience and we've distributed to our audience. I'd love to share that with you after this, at some point.

Regarding global health -- obviously you're in a prime position at the WHO to talk about this -- we're talking just a couple of days after the U.S. said that now they're recommending booster shots, and Israel has been doing this for people over 60. It's caused a bit of a global outcry because somebody at the WHO compared it to giving an extra life jacket to those who already have a life jacket, versus 3.6 billion or more people who have not even gotten their first shot.

We've had people like Dr. Ashish Jha and Chelsea Clinton on who talked a bit about vaccine equity, but you're probably in the best position, given your role at WHO, to weigh in on the debate. What are your thoughts on how best to move forward here?

Elizabeth Iro: Well, I'm not going to differ too much from what you have heard already in terms of WHO's position around vaccine inequity. I see some of my colleagues in other countries, and they’re not even hitting two percent coverage. It's just really quite disheartening because we know that if we don't address this in every country, it's not going to go away. We're keeping to that principle. We want to ensure that globally, in every country, we are being equitable in our approach to support them to address and mitigate the circumstances that we're in at the moment. There are issues around vaccine hesitancy, and we're also interested in the question of whether vaccines should be mandatory for all healthcare workers. These are conversations that I think nurses everywhere are very keen to get in on the debate. And they should.

I feel though, from the WHO perspective, we will continue to encourage everyone to take the basic principles that WHO has been promoting from the beginning of this pandemic around masking, around physical distancing, around good hygiene practices, and of course, vaccination. That is also the message I will continue to encourage my colleagues and everyone to take on board.

Shiv Gaglani: Yes. It's remarkable to see how different countries have different problems based on socioeconomic status, the amount of misinformation, conspiracy theories, political situations, and other things. So, imagine you're speaking to a young Elizabeth Iro about whether to pursue a career in nursing or midwifery...what advice would you give to her, and the millions of other potential nurses and midwives, especially given now that we've had a pandemic? I know some people are diving in because they want to be on the frontlines helping people. Others may be a little concerned about what they're hearing about burnout and other things. We've had tens of thousands of frontline healthcare workers die in the last year and a half because of COVID, as an example. 

Elizabeth Iro: From the outset, I want to say that I'm really proud of the global response from nurses and healthcare workers to this pandemic. They really have stepped into a situation that is high risk -- unprepared and under resourced in some areas -- but they continue to care in the most difficult situation. 

I recognize this has come at a huge personal cost to many in this profession. At the beginning of the pandemic, we saw the excellent response from the general public in regards to how nurses were responding, but it really has tested all of us...tested our profession across the world, as a community, as a family member, and as individuals.

I just really want to say that despite this pandemic, the crisis recently in Afghanistan, in Haiti, the climate change impacts of flood, fire...all of it is so overwhelming. I just want everyone to remember to pause and breathe and focus on things that are around you, and the people around you that matter to you. It can feel really lonely at times, but remember, there are about 28 million of us nurses out there. So, I'd say latch onto good role models that inspire you and be kind to yourself and to each other.

Shiv Gaglani: That's wonderful advice and speaking of role models, absolutely many of the people listening to this will already consider you to be one of those, or if they haven't yet been familiar with you yet, they will now. Is there anything else you would like to share with our audience? We have an audience of millions of current and future health care professionals. I know anything you say, they're very interested to hear. So, anything else I haven't asked you that you'd love to get across to them?

Elizabeth Iro: I'd like to say that one of them is new initiatives that we're taking forward because we've listened to Government Chief Nurses and Government Chief Midwives and they've told us that they want to get connected and remain connected. So, we're building a new initiative…a global community of practice for nurses and midwives. 

We are starting by onboarding Government Chief Nurses and Government Chief Midwives. We anticipate in the new year a rollout to engage and hopefully onboard as many nurses and midwives as possible to get connected and provide some inspirational kind of discussions that will be current. We really just want to listen to them about what they want. I just want to highlight that at this moment, and we will be reaching out and making this a little bit more public and formal in the coming weeks. 

Shiv Gaglani: I'll definitely lookout for that, and if we can be helpful in spreading the word we'd absolutely love to do that, even beyond this podcast. So, Elizabeth Iro, thank you so much for taking the time to be with us today, and more importantly, for the work that you and your colleagues do to raise line and improve global health care capacity. 

Elizabeth Iro: Thank you. Take care, everyone. 

Shiv Gaglani: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.