Giving Nurses a Voice On the World Stage - Dr. Michelle Acorn, Chief Nurse at the International Council of Nurses

Michael Carrese: Hi everybody, I'm Michael Carrese and today I'm delighted to welcome Dr. Michelle Acorn to Raise the Line who will help us take a global look at current trends and challenges in nursing from her perspective as Chief Nurse at the International Council of Nurses. Dr. Acorn has over thirty years of experience as a clinician, educator, and leader across multiple healthcare sectors, and is registered dually as a primary healthcare and adult nurse practitioner. She also holds an international certification as a global nurse consultant, was inducted as an inaugural fellow of the Canadian Academy of Nursing, and is a fellow of the American Academy of Nursing. Her scholarship has been included in textbooks, peer-reviewed articles, evidence-informed toolkits, and quality improvement initiatives, and we're very happy to have you on the show today. Thanks for coming.

Dr. Michelle Acorn: Oh, thank you so much for the opportunity to connect with you today, Michael. I'm coming to you from Lindsay, Ontario just recently returning from our headquarters in Geneva, Switzerland and I would also like to respectfully acknowledge that we're situated on Mississauga lands and traditional territory covered by the Williams Treaties. I'm grateful for the opportunity to live and work here and thank the generations of people who took good care of this land and strengthened our communities.

Michael Carrese: Well, that's beautiful. Thank you for sharing that. Because our audience tends to include a lot of younger folks, medical students, nursing students and early career professionals, we like to start by finding out more about our guests' own career journeys and what first got them interested in healthcare, and in your case, nursing.

Dr. Michelle Acorn: Sure. I was destined to be a nurse from birth. My mother named me after a nurse who made a significant impact on her life. Of interest, my daughter is a Registered Practical Nurse and is also working full-time and doing the registered nurse bridging program. I could be a contender of the poster nurse for continuing professional development across my career trajectory. My thirst to maximize my competence and confidence, my compassion and collaboration are unquenchable. After becoming an experienced emergency registered nurse, it was a natural evolution to become a nurse practitioner and maximize my expertise to improve access to advanced primary healthcare specifically -- the usual health promotion, disease prevention, and chronic disease management regardless of the sectors or settings. 

I really wanted to work to the top of my scope as well as enjoy both autonomy and interprofessional collaboration as a clinician providing direct care. I created roles in the emergency department as a nurse practitioner, and then as a hospitalist in geriatrics. And you might be interested to know, Michael, and our listeners, that we innovated the very first nurse practitioner-led model of care as the most responsible provider from admission to discharge in terms of meeting population and organizational leads. I also evolved into a nurse practitioner because I really wanted to encapsulate and leverage my non-clinical dimensions and advanced practice that appealed to me, like building team capacity, advancing quality improvement, competency-based evidence, informed education, and best practices and leadership opportunities. 

You may know I'm diploma-to-post-doctorate prepared, and the more you learn, the more you realize you need to learn to improve quality care, systems capacity, equity and catapult our profession for influence, impact and value. Lastly, I completed my Doctorate of Nursing Practice and Doctor of Nurse Practitioner. It was a family health nurse practitioner program, and my rationale was to continue to build my knowledge base, widen my network and mentorship opportunities and embed myself in diverse opportunities that weren't available to me in one place for one employment, or one organization. The DNP really enabled me to enhance my credibility and legitimacy from the bedside to the boardroom to the classroom, both locally and globally.

Michael Carrese: You know, on that last point, can you give me an example of that? Because DNP for a lot of folks, is seen as a newer credential, even though it's been around for a long time. So, what did you sense about how you were perceived after getting that degree in terms of it adding credibility?

Dr. Michelle Acorn: Well, it's interesting because the title "doctor" is not protected. It's not owned by one profession, but it does give you opportunities. For example, for scholarship opportunities if you want to become faculty. When you think about advancing the strategic directions for nursing and midwifery from a leadership perspective to get on the global stage -- to lead high-functioning executive leadership positions -- that is really important in terms of doctoral-level preparation. But what is more important, and why I did the DNP specifically is, I remain a clinician. I identify as a clinician still while doing leadership. So, it makes me relevant too and credible and relatable as well.

Michael Carrese: And that's an interesting balance. We were talking before we started recording about the travel that you do and this global perspective you have, but you're still grounded in practice, it sounds like.

Dr. Michelle Acorn: I do right now. I formerly was a government chief nursing officer, and I worked at hospital base for almost thirty years. Then I went into long-term care and retirement homes, Michael, and now I'm actually back into the community. I look after populations that are intersecting with the law and those that are exploited in terms of youth, such as human trafficking. I really believe in health equity, and that populations need our care and our expertise. I personally need that to keep my balance and keep connected, as well.

Michael Carrese: Yeah, that's critically important work. So, for folks who are not familiar, tell us about ICN and then your specific role there.

Dr. Michelle Acorn: Sure, thanks. So ICN is the International Council of Nurses. We're a non-government organization, and we are actually twenty-eight million nurses strong around the world, if you can believe it. Think about that number, twenty-eight million nurses. This is a powerhouse of knowledge. I mentioned I transitioned into this role, previously as a government chief nursing officer for three years, and I do bring greetings on behalf of our ICN Board staff, and our more than 130 national nursing associations.

We're a federation of nursing associations across the world in high, middle, and low-income countries. The associations could be regulators, they could be labor unions, for example, as well. I wish to also think with a deeper appreciation of twenty-eight million nurses around the world for their dedication, service, knowledge, expertise, care, compassion, and leadership.

I think it's important to realize we pivoted across communities and populations during the waves of COVID to respond, stabilize and rebuild the fit-for-purpose and more humane quality experience, and that's what ICN does. If you think about that, we are really about nursing health policy at the center of everything we do. We ensure that nurses have a voice in developing and implementing health policy, fundamentally, to ensure that we meet the real needs of patients, families, and communities around the world. 

Strategic priorities include leadership, membership, empowerment, and what that looks like from a regulation stance, and education stance. Socioeconomic welfare is critical as well. ICN does many things over many, many places. We have all kinds of resources and educational tools as well, but we really are the global voice of twenty-eight million nurses. So, it is important to connect, engage, be informed, and more importantly, disseminate knowledge and opportunities. Forums like this give nurses a voice on the world stage, so kudos to you as well.

Michael Carrese: So, on having your voice at the table, how do you go about doing that? This is a topic that we also discussed with a previous guest -- Dr. Elizabeth Iro, the chief nursing officer at the World Health Organization -- and she believes, as you just said, that it's critical to have nurses at the table when responses to public health crises are being developed and in every other aspect of healthcare policy. How do you do that?

Dr. Michelle Acorn: It makes me reflect, and I know probably many of the listeners as well. I think we need to be honest and have crucial conversations when the emotions are high, but the stakes are higher, and that's actually the safety and protection of our public and our profession. There were pockets of enabling and empowering nursing opportunities worldwide, but it was made evident that nurses require better access to top-level policymaking, according to our national nursing associations, in an intentional effort by design and governance specifically. 

The pandemic raised the profile of nurses massively. The nursing profession remains the most trusted profession and that has not been just because of COVID. This is long-standing. During the pandemic we were on the frontlines working to educate, resource, research, prevent, treat and care for patients with compassion, care, resilience, creativity and leadership skills. Many of them, tragically, have lost their lives, faced violence and abuse and they continue sometimes to work without the adequate protection and without decent pay. We must be their voice. They've also been separated from their loved ones as well. 

We need to really reset our health system and our societies to address these inequalities between different groups in the communities -- men, women, young, old, rich, poor, healthy and unhealthy, different abilities, minorities, majorities -- as well as the nursing profession. Over time, investments in healthcare brought forth dividends, but it should be seen as an investment for our future rather than a current cost. If societies seriously look at the social determinants of health -- including poverty, education, employment -- we can actually make this more equal and fair. The fundamental thing that the pandemic revealed, specifically, is that many of our health services are not fit for purpose and we really need a drastic reset. It's why we need our global voices, policies, practices and possibilities. How are we ever going to deliver on the United Nations Sustainable Development Goals, Michael? 

Nurses are catalysts. They can positively transform and advance global health. They can build strong healthcare systems and understand the need for investment and protection. ICN closely works with our NNAs and partner organizations to amplify the voice of nurses specifically. Even recently at the World Health Assembly, ICN had a delegation and a high profile intervening in order to raise the nursing voice and nursing presence. As we know, they play a vital role in the health of the nations. We have to make sure our voices are heard on the world stage. We know that whenever nurses are listened to in policymaking arenas, health outcomes improved. As a global voice of nurses, ICN continues to listen to nurses and put their views forward advancing the single global health agenda.

Michael Carrese: You mentioned the UN, and you were at the General Assembly meeting in New York in September. What was your agenda there, and what were your takeaways from the meeting?

Dr. Michelle Acorn: My agenda and my experience were two different things. Being in New York and navigating that and understanding what tables you need to be at was very helpful for me from a navigational lens. When you attend side events, for example, what’s the purpose? Is it relationship-building? Is it contacting and connecting with people, for example, to drive investments from the World Bank, from the World Health Organization? It’s about who has the voice and who you can partner with, as well.  It really is further evidence of nurses at the top tables influencing global health policy, and if we're going to raise our global nursing profile, we need to really spread and immerse and scale that up with the World Health Organization and the UN as well. 

We raised awareness to health disparities, specifically with minority populations, Michael, if you think about optimizing and understanding informed healthcare between patients and providers, using communication strategies and supports and resources can really reduce language barriers and improve safety. Our health systems need resources to provide patient and people-centered and culturally appropriate care to the diverse populations that we serve. Healthcare systems need to monitor our health disparities with minority groups and recognize trends in the disparities head-on. We also call for nurses and other health professionals to reflect on the ethical recruitment and retention of minorities into our profession, and advancing more minority nurses into leadership positions as well for diversity and inclusion. We need to walk the talk. We need a diverse and inclusive health workforce to address the health inequities of our diverse patient populations and our diverse nursing profession, I would add.

Michael Carrese: While we're on that topic of health disparities and diversity, talk about some initiatives that ICN is pursuing, or what you're seeing happening around the world that you think is working.

Dr. Michelle Acorn: Yes. Great question and observation. The pandemic continues to expose the real vulnerabilities in our health system, Michael. We need to really respond to these emergencies and continue to respond to people's needs throughout life. I think we know the vulnerable populations affected during this period and the barriers to healthcare have the potential to deepen the health inequities as well. 

ICN's vision for the future includes health systems that are sustainable, equitable, ethically based, and fit for a new future. We know the pandemic has increased inequalities and made us realize that the optimum levels of health can't be achieved without addressing other social issues such as housing, education, employment, climate and nutrition. When we work to eliminate the inequalities with race, gender, ethnicity and religion, for example, we lead better societies. We can reduce conflict and violence and everybody can live more peaceful and fulfilling lives. 

Gender inequalities in healthcare are a significant thing that we need to tackle such as biases and data gaps, access to care as part of our vision for future, and an effective way to improve our society. We talked about achieving the SDGs by 2030. We need a more holistic preventative model as well. We should think about systems refocusing as a major role in creating health. We need to think about the systems and sectors and government and public working together to address these determinants and build on the conditions so that people can be healthy throughout their lives. If you think about it, nursing leadership will help to build sustainable climate-resistant health systems for the future and reduce our health disparities. There’s the value-add not just as clinicians, but as leaders as well, and partners in our care.  

Michael Carrese: I'm wondering where you're encouraged? Are you optimistic in any of these areas that you're talking about -- all of which are very important – that progress is being made, or do you feel like you're really in the middle of a long slog and it's hard to see if you're moving forward?

Dr. Michelle Acorn: I think we’re living through the next pandemic. We've talked about COVID-19, being the pandemic, but the pandemic right now is the health workforce shortage, and let's be realistic about that. I really believe we need to have those important conversations. I've made it my mantra as a leader to not leave the profession right now, because we need people right now to continue on this journey together. 

I am encouraged. There's some significant dedication, such as the strategic directions for nursing and midwifery with all state members signing on to this for investing in leadership and education. But we need to hold everybody to task and we need to continue to work together in collective leadership to ensure that we have the energy, we are actually mentally and physically fit to continue to practice and address some of our trauma and resources that are very limited. Emergencies usually are short-lived. We're a couple of years into this. We were already at a health workforce shortage and many have been deployed or are working in different situations. So, I don't want to paint a rosy picture. Although I'm a positive person, I think we need to be realistic, and we are doing great things and nurses never, never have abandoned. They are always here for people. But we're asking for help. We have cried out for help. We have given evidence of the help that’s needed and if we don't do this collectively to drive true investments in education, leadership, service delivery, jobs, and recognition by design to involve nurses to be the voice and inform on this, I think we're missing a huge opportunity for whatever the new norm will be in the future.

Michael Carrese: Very well put. So, speaking of education, we're a teaching company as you know and we love to fill knowledge gaps. One of our favorite questions for guests is, is there a topic, a knowledge gap, a myth, or something you really wish people could understand -- particularly thinking of that med student audience and early career audience. If you were to say "Hey, Osmosis, it'd be great to have a video or a course on that topic," what would it be?

Dr. Michelle Acorn: I'm actually doing something similar -- not a video -- but I'm writing a paper about it because I think we need to check what our global nursing leadership literacy is. We tend to think of the difference between being local or provincial, or national to global, and how you navigate that space and maximize your influence and impact. For example, I'm writing about what our top global resources are that we're using and why. It actually gives you the competence, the confidence, the evidence to be able to approach anybody and have your elevator speech -- or your latte chat as I say it -- and be able to deliver on what you want and what's most important. 

A lot of times it’s about even navigating the professional space. For example, people want to be involved in ICN as a global voice but you need to be a member of the national nursing association. You also may be part of your provincial association. So, you need to kind of understand about that. 

The other thing I found in my global literacy search is understanding the quads. Most people do not understand the quads. To move policy and have impact you need four things: the regulators who can do regulation and legislation; the educators to get curriculum or continuing professional development afterward; the government -- and specifically a government chief nursing officer -- aligning with NGO chief nursing officers or system chief nursing officers; and then you need your national nursing association and labor. 

If you get everybody in the same room, and on the same common agenda, can you imagine how you could move mountains? We have great evidence of this in Astrakhan and in Africa. We have pockets of great best practices. But nurses need to think about their role as leaders right from the beginning of their career. I know you will focus on providing safe patient care, but we also are all leaders informally, as well and maybe formally. There's a difference between leadership and management. Think about the diversity and opportunity nursing presents. I never dreamed that I would be where I am now. I never even contemplated something like this. You should realize these possibilities are within your reach, or you create them, more importantly. I think that's important as well.

Michael Carrese: We hear that from so many guests in nursing...what an amazing career you can build in ways that you never expected. There are just so many different pathways to take. 

So, as we're wrapping up here, what's your general advice to people starting out in a healthcare career about meeting the challenges of this moment -- as we're still battling through this pandemic -- but just generally approaching their careers in healthcare?

Dr. Michelle Acorn: I think, first of all, thank you for this exciting opportunity and I do not regret it. After almost thirty-five years, this will really set you for life. To be honest with you, you have invested in a wonderful career and I thank you for that. Share your stories and exemplars as you move forward. I think that's really important. Don't underestimate the nursing power of the largest group of health professionals as a trusted collective health force. I think that's important. You cannot control your individual contributions, but how can we really leverage the collection together is very powerful. Nurses are champions to address response, recovery, building back a better system, and sustaining nursing as a rewarding career opportunity, as you evolve from novice to expert, as a clinician, as an educator, as a researcher, as a quality improver -- you can do all those things as well. 

I guess I would issue an action challenge because students like to have little points down that they're going to do and check off in their learning plans. My first one would be get involved in your organizations -- your school councils, your professional organizations -- and don't just join, be actively involved in engaged and understand the difference between local to global. You will think local at first, but start to think about global, which is powerful. For example, we are getting our boosters for COVID. Some countries have not even had access to vaccinations. Put some of these things in context, and the working conditions and industrial actions that are happening around the world. We're looking for fair pay and decent working conditions when some do not even have access to PPE, or water to wash their hands properly. When you really think about different perspectives, I feel it's powerful. 

Secondly, you need to really showcase the meaning and value of our contributions as nurses. Make the invisible work that we do visible and vital with your voices. Don't break it down into task-oriented activities, because our knowledge is vast and we should be able to articulate that in our rationale. Nurses invest in others. We need to invest in our own personal and professional wellness. Bring joy into your practice and a balance between your profession and your work life, and your personal life. As those that know me know, I work really hard, but I also play really hard and we have a good balance as well. So I think that's important. 

Take time to reflect and do self-care, and celebrate your valued contributions and do some career planning along the way. I would also save the date for our International Council of Nurses Congress in Montreal.  It’s July 1-4 2023 and there is actually a student assembly just before the Congress. If you have any opportunity to attend Congress outside of the assembly, I would highly, highly encourage this because you're going to see truly global aspects of models of care, service delivery, mental health investments and true workforce considerations that will really inspire you as well. I hope to see you in person and thank you for your valued contributions. Get a mentor, get a couple of mentors, and then more importantly, pay it forward. Once somebody actually mentors you or takes time, do the same for somebody else. Remember how you wanted to be treated and treat others that way as well.

Michael Carrese: Well, that is so much great food for thought, and I know our listeners are taking notes and taking pointers. We really appreciate you coming on today and sharing all that with us.

Dr. Michelle Acorn: Oh, thank you, Michael. And thank you on behalf of our nursing profession. Thank you for your trust.

Michael Carrese: We've been talking to Dr. Michelle Acorn with ICN. I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to strengthen the healthcare system and engage, as Dr. Acorn said, because we're all in this together.