Our future is global: nursing leadership and global health*

Global health matters to every nurse everywhere. In this article we outline why. We highlight some important health issues confronting the world today; explore how these issues are being tackled; and consider the implications for nursing. We describe how nurses are making a difference in the challenging contexts, range and complexity of nursing work round the globe, and we conclude with a call to action. Nurses can influence, and become, policy-makers and politicians, and explain to them why the Sustainable Development Goals cannot be reached without strengthening nursing. In this International Year of the Nurse and Midwife, the window of opportunity is open, but it will not stay open for long. Nurses and midwives globally and locally must be ready to jump through it. We ask you to join hands, and join us.


Introduction
As health professionals committed to our local community and country, it is tempting to look no further than our own backyard, where there is always so much about which we care deeply. Yet this solely local focus is not only ostrich-like, but also dangerous: global health is inseparable from local and national health concerns. Infectious diseases, for example, do not recognise borders, and a mingling of germs and genes results in communicable diseases with the potential for rapid global spread. Compare the speed with which the coronavirus and COVID-19 infections spread worldwide, to the four years it took the medieval plague to cross Europe.
The concept of "global health" did not really exist even 20 years ago. Now it embraces a complex concept that engages with all countries and indeed with the health of the planet itself (1) . A growing number of governments and organizations are adopting it as a key policy theme. In thinking about nursing today and tomorrow, we must all look beyond our backyards, and understand how what happens in distant places affects the health and health care of our communities, our loved ones, and ourselves -just as what happens in our backyard affects people we will never meet.
COVID-19 has surely heightened awareness of this.
"Think globally, act locally!", as the environmental slogan says.
Thinking globally is not an academic exercise but a way of seeing that enriches perspectives, increases knowledge, and makes nurses more motivated and effective as leaders, practitioners, managers, teachers, researchers, policy-makers and activists. It helps us to understand how our work contributes to outcomes not only in health sectors, but also in policy, education, economic relations, and environmental activism.
Nurses have a professional obligation to understand the world in its broader context and base decision-making on an expanded understanding of ourselves, our patients, and our circumstances. "It begins with understanding the policies and politics of globalization, the growing interdependence of the world's people, [which] means that national policy and action are increasingly shaped by international forces along with other aspects of our lives" (2) . We increasingly rely on the same groups of workers and technologies and face the same environmental and epidemiological threats. Moreover, the policies that most affect health are not always health policies (3) . Other policies have enormous impact on health determinants and solutions, so cross-sectoral collaboration on global health is critical.

The wealth of a nation is its people -and their health
We live in challenging times, for the health of the planet, nations and communities. The challenges have major implications for nursing as a global profession of some 23 million, from halting pandemics to reducing mother and child deaths, tackling and mitigating the effects of climate change, and caring for older people.
Inequalities between groups of people, and within and between countries and regions, are key to understanding these challenges.
There is a mass of evidence of the interaction between health and wealth at all levels, whether individual, family, community or country. Nurses know that their patients' ways of life and the conditions in which they live and work strongly influence their health and longevity. This challenges us to complement biomedical models of health care with social models, and focus much more on prevention and public health.
Since the 1990s there has been a growing understanding of the interaction between health and poverty, and the need for cooperation and collaboration on a global scale to combat its consequences for health and for economies. This has stimulated many organizations to play a larger role in global health.
Eradicating poverty in all its forms and dimensions is the greatest global challenge, says the United Nations:

Global health politics and policy
Many nurses make naive assumptions about health and healthcare and do not view these issues through a sociopolitical lens (6) . Yet we need to understand some history and politics if we want to be leaders of change, rather than its servants.

Policy, politics and nursing
Policy and politics determines not only the health of populations but also nursing itself -past, present and future. It profoundly shapes the practice and workplaces of nurses at local, regional, national and international levels. Nurses who wish to influence and lead policy, rather than be bystanders, should understand not only the content related to a health issue, but also the policy process, the context, and the stakeholders and their interests (8) .
The largest proportion of the health workforce globally by a large margin, nurses are often the only health care provider available. We are key to ensuring that all people and communities receive the health services they need without financial hardship. Nurses occupy a special position as the interface between the health system and the community; we see, hear and know, as end users of health policies, how policy affects people and their communities. You might think that knowledge would be welcomed with open arms by policy-makers, yet it has been very difficult for nurses at all levels to make an impact on policy, for a variety of reasons (3) . While nurses are acknowledged as key policy implementers -the pairs of hands, they are rarely central to health and social policy developmentat the top table (6) . Nurses engaged in high-level global health work apply their nursing lens to issues that others may not notice. They bring information from the field to high-level meetings, explain the complexities of implementing programmes, and interpret the science or recommendations from these meetings back to the field in a way that may be translated into action.
Australian nurse Amanda McClelland, for example, was the senior officer in the emergency health unit of the International Federation of Red Cross and Red Crescent Societies. "I added a social mobilisation and community aspect to global strategy discussions", she said (9) . "How am I going to explain this to the volunteers and how will they explain it to the community? That's great, but the community would never accept it. That's great, but we won't be able to implement the programme in that way. We're going to need to consider weather/culture/religious factors when rolling this out." Nurses worldwide have become increasingly knowledgeable, skilled and well educated, like McClelland, but this has not been matched with a significant growth in their influence and status. The reinventing itself as a champion of nursing and midwifery, the chief nurse and head nurses in the six WHO regional offices used to have much larger teams and budgets. All have declined in scope and influence, attributable partly to cuts in WHO budgets, but also to long-standing reluctance to recognise the value of the nursing contribution. less assertive" (10) .

Understanding policy-making
Speaking with one voice and in a language that appeals to policy-makers has not been one of nursing's successes (6) . Nor has the ability to persuade policymakers to take effective action on nursing issues.
Nursing history in many countries and at regional and international levels is strewn with evidence-based policy reviews and reports making excellent recommendations that go largely unheeded. Compounded by structural inequalities related to gender and social class, nurses' attempts to push for reform have not gained enough traction, and change has not happened fast enough or far enough.
Policy leadership is required in the everyday workings of national and local government and health systems. A key nursing competency, it is rarely acknowledged or formally developed; most nurses learn it, if at all, by bitter experience. The need for nurses to develop these competencies has long been highlighted (11) , but not consistently developed across the global nursing community. White advocates "policy leadership and role modelling" by nurse leaders, who need the right professional, political and policy skills to operate effectively in tough arenas. Whether they work in government, management, education, advanced practice, research or development, they need to know how to maximize their distinctive contribution to shaping, influencing and implementing policy decisions (12) . This requires nurses to grasp White's concept of a "new pattern of knowing called socio-political knowing" (6) and, as Salvage has long advocated, to become policy activists who are politically savvy (13) .

The window of opportunity
Reports and recommendations on nursing that fail to have traction, policies that ignore or undermine nursing, and nurses' absence from policymaking -this gloomy pattern is starting to change for the better. More nurses are becoming policy entrepreneurs: leaders who position themselves to influence policy; who bring together problems, policies and politics into a novel amalgam -new policy; and who soften up the system by presenting participants in the network (visible and invisible) with alternative representations of their realities. This leads to the opening of a window of opportunity, as described by Kingdon -the potential for a truly new policy perspective (14) .
That window is opening wider as demand grows worldwide for solutions to acute problems including current and future health worker shortages, and the rising need for expert care of older people, alongside huge public interest in nursing. There is greater global awareness of the importance of investment in health as a public good, and of nurses' massive actual and potential contribution to improving health, creating gender equality and strengthening economies. Meanwhile more nurses are finding the courage to become "silence breakers" and join the worldwide wave of protests against violence, sexual harassment and other abusive behaviour against women (15) .

A new story of nursing
The major shifts necessary to transform nursing will not be effected through a continuing series of shortterm, piecemeal policy initiatives, however good each may be. Deep-rooted, sustainable change will depend on reaching honest, shared understanding of the barriers to change and the structural inequalities and issues that maintain them, and on tackling the root causes and underlying drivers.
These big issues are not solved by tips on how to exploit the status quo, and patience is unlikely to be the answer either. This is the moment for nurses to shift the paradigm, to be taken seriously together and individually, when the old certainties and ways are being shaken to the core. Nursing organizations, as well as trying to gain influence at the top tables, are making alliances with social movements and considering radical alternatives.
All this could lead us to a new story of health and healthcare (3) . Nurses, as leading actors in this story, will be at the heart of sustainable health systems that meet individual and population needs, are fit for the present, and innovative and adaptable for the future.
Rooted in reality, yet reaching for the stars, nurses work to shape sustainable, high quality, effective and affordable services fit for the future, and responsive to the challenges of turbulent times. They focus on where the needs are greatest and where there is most potential to gain health and reduce inequalities. They take their understanding and experience as hands-on practitioners into all their subsequent roles, as clinicians, managers, teachers, researchers, scholars, policy-makers and leaders. At all levels, from ward to board to international organizations, they inspire and lead.
We began by arguing that 'doing global health' means thinking globally and acting locally: adopting a mindset that seeks to understand the structural and political conditions that sustain armed conflict,  (2) ). "Thinking globally and acting locally" is old wisdom, but never more needed of nurses and nursing than now.
We have also argued that the challenges facing the planet and our own communities have major implications for nursing and nurses, and shared our hope that nurses can influence (and become) politicians and policymakers, showing them that the SDGs cannot be reached without strengthening nursing. In this Year of the Nurse and Midwife, the window of opportunity is open, but it will not stay open for long. Nurses and midwives globally and locally must be ready to jump through it. Will you join hands, and join us? Box 1 -How nurses can engage with global health Begin at home -think globally and act locally.
Cultivate a worldview; be sensitive to the cultural aspects of policy and practice.
Commit to learning more about the global health agenda, above all the SDGs. Know where regional and international organizations and your national and local government stand on key international health and nursing matters, and lobby them.
Get involved in global health issues, and team up with like-minded groups and people at home and internationally.
Through your professional association, trade union, workplace or community, help colleagues in and from other countries -and learn from them -as they work to strengthen nursing and health.
Advocate, initiate, and document nursing's role in policy.
Join others in ensuring that national and local structures and roles are in place so that nurses' voices are heard in policy and practice.
Ensure that nursing leaders -and new nursing graduates -know about policy and politics, how to analyze the environment, how to develop strategy, and how to work together.
Undertake and disseminate research to build evidence of nursing effectiveness.
Share your ideas and achievements through discussions, publications, conferences, social media and the Internet.