Nursing now and always: evidence for the implementation of the Nursing Now campaign*

Objective: to identify the guiding axes of the documents that grounded the Nursing Now campaign and relate the recommendations of these documents to the campaign goals. Method: documentary research, based on the analysis of the documents that promoted the Nursing Now campaign. The data were collected between March and April 2020, using a form structured into: background, scope, challenges and potentials of health/nursing professionals and recommendations for the future. Results: the challenges and the need for investments in the health and nursing workforce to achieve the Sustainable Development Goals were evidenced. The report of the High Level Commission on health Employment and Economic Growth presents important recommendations, also introduced in the Triple Impact Report and in the Strategic Directions for Nursing and Midwifery, converging to the goals of the Nursing Now campaign, stimulating a profile of nurses with technical, political and leadership skills, engaged in health policy-making, and the effectiveness of their practice is clear to the entire society. Conclusion: knowledge about the dynamics of the factors that converged to the development of the Nursing Now campaign may be a condition for achieving its goals. This reality reveals evidence that global health will not be ensured without strengthening Nursing first.


Introduction
In 2020, Nursing, with approximately 27.9 million professionals, represents 59% of all health professionals worldwide, constituting the majority group in the health area (1) . Contradictorily, despite this numerical relevance, the estimated global shortage of nurses is about nine million by 2030 (2) .
It should be highlighted that, for the sake of standardization, the term nurses is used in this article to designate all members of the nursing team, in accordance with the documents of the World Health Organization (WHO) analyzed in this study. The use of the term Nursing, in turn, designates both the profession and the academic discipline.
As a historical milestone, it is important, initially, to highlight WHO's 72 nd World Health Assembly, which recognized 2020 as the International Year of Nurses and Midwives, not only to honor the 200 th anniversary of the birth of Florence Nightingale, but to reaffirm and grant visibility to the daily contribution of Nursing to the health and well-being of people (3) . Therefore, WHO underlines that nurses are fundamental to achieving the goal of leaving no one behind, in a global context of seeking to implement the Sustainable Development Goals (SDG) by 2030. Among the strategies to achieve the SDG, universal health coverage and access, so that everyone is entitled to health services (2)(3)(4) , requires not only the strengthening and qualification of nursing education, as investments for the continuation of these workers in professional practice.
Thus, the vital contribution of Nursing to the achievement of global and Brazilian goals related to the priorities on the global health agenda is recognized, including universal access, mental health and noncommunicable diseases, emergency preparedness and response and patient safety, always focusing on peoplecentered care (1,5) .
Despite its representativeness and the acknowledged relevance of its work, however, Nursing is still invisible and undervalued in many aspects, especially in health policy-making. Hence, in addition to the recognition and valuation of its numerical importance, it is essential to value high-quality Nursing for leadership, policy and decision-making, participation in decision-making processes, and action ranging from planning to care provided to specific population groups, including the fight against pandemics (5)(6)(7)(8) , as occurs in the context of COVID-19.
In this perspective, it is imperative to invest in the qualification of nurses to prepare them to cope with other health advocates (9) .
The global campaign was based on evidence from key documents that demonstrate the relevance of Nursing to global health: Report of the High-Level

Commission on Health Employment and Economic
Growth-working for Health and Growth (10) , Triple Impact Report (11) and Global Strategic Directions for Nursing and Midwifery (2016-2020) (12) .
In this context, it is worth noting that the goals of the Nursing Now campaign, to be met between  Nursing Officer as part of their most qualified teams in health management and policies. Therefore, greater investments in the training of nurses with political and "policy" skills is fundamental (7) .
In this context, the Nursing Now campaign also seeks to demonstrate the individual and collective

Method
Descriptive and documentary research (14) , based on  Figure 1 illustrates the organization and analysis of the research. Rev. Latino-Am. Enfermagem 2020;28:e3388.

Results
The information collected in the analysis process, based on the documents (10)(11)(12) that grounded and motivated the Nursing Now campaign, have been detailed below.
In Figure

Scope of health professionals' work
The Commission qualified the launch of its report as a unique opportunity to advance in the political commitment to achieve the SDG * , particularly SDG 1 (poverty elimination), 3 (health and welfare), 4 (quality education), 5 (gender equality) and 8 (decent work and economic growth), through investments in the local and global health workforce.
Potential of health professionals' work Acknowledgement of the health sector as a key economic sector and employment generator. Between 2000 and 2014, employment in health and social work grew by 48%, while jobs in the industry and agriculture dropped. The demand for health services is expected to grow, creating millions of new jobs. Economic development depends on healthy populations. Around a quarter of growth in low and middle-income countries between 2000 and 2011 resulted from improvements in health; the estimated return on investments in health is 9 to 1; one extra year in life expectancy raises GDP per capita by about 4%. In countries with a high fertility rate, bringing down the child mortality rate can positively influence family planning decisions, contributing to a faster demographic transition, associated with economic benefits called demographic dividends. Investments in health systems have multiplier effects that strengthen inclusive economic growth, also through decent jobs. Strategic investments in health systems are fundamental, including in the health workforce and in the promotion of economic growth, via cohesion and social protection, innovation and health security.

Challenges for health professionals' work
The population is growing and the world faces a decrease in the number of health workers. The lack of skilled workers constrains job creation in the sector. Investments in health education/training are needed to promote more inclusive economic growth.

Recommendations
1. Job creation -stimulate investments in creating decent jobs in the health sector, especially for women and young people, with the necessary skills, in the right numbers and places. The Commission calls for urgent actions to develop job market policies to foster the demand for a sustainable health workforce. Government policies need to address systemic issues that result in recurring losses in the health job market. 2. Gender equality rights -maximize women's economic participation, institutionalizing their leadership and addressing gender biases and inequalities in education and work. Women are the main care providers, including in humanitarian crises and conflicts. Hence, the health sector is an increasing employer for women and can contribute to gender equality. Gender inequalities, physical and sexual violence and harassment remain important challenges for health workers. 3. Education, training and skills -value high-quality, transformative education and continuing learning so that health workers have skills to face people's health needs and work to their full potential. In that sense, countries can prioritize investments in education, focusing on building locally relevant competencies. Addressing geographical inequities is a priority, and demographic transitions present opportunities to strengthen youth education for health jobs. 4. Health service delivery and organization -Reform health service models concentrated on hospitals and focus on prevention and efficient delivery of high-quality, integrated, community-based and people-centered primary care, paying special attention to vulnerable areas. 5. Technology -explore the power of Information and Communication Technologies (ICT) that strengthen health education, people-centered health services and health information systems. The rapid technological changes are changing the nature of health services and new health professionals emerge with skills to handle the ICT. Digital technologies also provide opportunities to improve people's access to health services and health systems' response to the needs of individuals and communities. 6. Humanitarian crises -ensure investments in key international health regulations, including the skills development of health workers in humanitarian crisis and public health emergency situations, aiming to ensure the protection and security of health workers in different settings. Countries should build the capacity of their health workforce and health systems to detect and respond to public health risks and emergencies. In conflict settings, public health crises exacerbate the difficulties for offering basic care. 7. Financing and fiscal resources -raise adequate national and international funding from public and private sources and consider the funding of health reforms through investments in appropriate skills and decent working conditions. Societal dialogue and political commitment are crucial to drive appropriate macroeconomic reforms and health funding policies. 8. Partnership and cooperation -promote intersectoral collaboration at the national, regional and international levels, through the engagement of civil society, unions and other organizations of health workers and the private sector. Align international cooperation to support investments in the health workforce. 9. International migration -advance the international recognition of health professionals' qualifications to optimize their skills use, increasing the benefits from and reducing the negative effects of health workers' migration, safeguarding migrants' rights. 10. Reliable evidence -undertake robust research on the health markets, using reliable methodologies to strengthen the evidence, reliability of the data and resulting actions.
*SDG = Sustainable development goals  In Figure 5, the recommendations of the documents that were analyzed are directly related with the Nursing Now campaign goals.
Therefore, the data support that each goal of the Nursing Now campaign is based on complementary evidence in the seminal documents analyzed for the overall strengthening of nursing.
Triple Impact: how developing nursing will improve health, promote gender equality and support economic growth Background Report organized by the All-Party Parliamentary Group on Global Health in the United Kingdom. Its starting point was the goal countries signed in 2015, assuming the commitment to guarantee universal health access/coverage, adopting the view that "nobody should be left behind". This report argues that universal health coverage cannot be achieved without strengthening Nursing; it highlights the need to increase the number, as well as the understanding that its contribution is understood, so as to enable nurses to work at their full potential. In that perspective, the report argues that the strengthening of Nursing will have a triple impact: improving health, promoting gender equality and supporting economic growth.

Scope of nursing work
Nurses play different roles, in varying circumstances and contexts, through a unique combination of people-centered competencies and humanitarian values; they provide and manage care, work with families and communities and play a central role in public health, disease and infection control. In diverse contexts, nurses are the primary or sole professionals people see in health care. Part of the community, they share its culture and are alert to social, individual and programmatic vulnerabilities.

Potential of nursing work
Nurses are the largest part of the professional health workforce. Achieving the goal of universal health coverage/access globally depends on these professionals' comprehensive action.
There is important innovation and creativity in nursing care, with great potential not yet used that will ensure that citizens have better access to health care. The increase in the number of nurses and the use of Nursing's full potential will result in a triple impact of improving health, gender equality and economic growth.

Challenges for nursing work
In many contexts, Nursing remains undervalued and its contribution underestimated. These professionals still face problems in the team, poor infrastructure and inappropriate education and training. All of these factors can result in care of inferior quality; in this context, they are frequently unable to fully practice their skills and share their knowledge. They also get few opportunities to develop their leadership, hold leading functions and influence policy making.

Recommendations
1. Strengthen Nursing and make it central to health policies. A high-level global summit on Nursing should be convened, consisting of political and health leaders outside Nursing, to raise awareness of the opportunities and potential of Nursing, create political commitment and a establish a process for supporting development. This should be part of a long-term initiative that embraces all other recommendations.   The document builds on the following guiding principles: ethical action -planning and offering care based on equity, integrity, fairness and respectful practice in the context of human rights; relevance -development of education programs, research, services and systems guided by health needs, evidence and strategic priorities; ownership -adoption of a flexible and strategic approach that ensures effective leadership, management and capacity building, as well as transparency, engagement and involvement mechanisms of all beneficiaries; partnership -joint work on common objectives; quality -adoption of mechanisms and standards based on evidence and best practices, through education and research.

Scope of nursing work
The global disease burden is increasing and gaining complexity, including emerging and re-emerging noncommunicable diseases. Nursing is critical in the delivery of essential health services and thus strengthens the health systems. Acting as individuals, members and coordinators of interprofessional teams, nurses bring people-centered care closer to the communities where it is needed most, improving the health outcomes and service effectiveness. They are active in promoting and maintaining the health and wellbeing of the elderly population. At the same time, they contribute to reductions in newborn, infant and maternal mortality. They are responsible for a wide range of hospital services, ranging from accident and emergency to palliative care. They are core in crisis and post-crisis situations, contributing to risk communication, response planning and multisectoral participation aspects of different programs, providing services ranging from trauma management to mental health.

Potential of nursing work
Nurses and midwives constitute more than 50% of the health workforce. In that scenario, there is demonstrable evidence supporting the contribution of Nursing to the strengthening of health systems through increased patient satisfaction, decreased morbidity and mortality rates, stabilization of financial systems through the reduction of readmissions and length of stay, among other conditions such as hospital-acquired infections, providing an overall contribution to patient wellbeing and safety. The utilization of the nursing workforce is cost-benefit. Nurses are the first responders to complex humanitarian crises and disasters, protecting and advocating for the community; and serve as team coordinators.
Nursing interventions in the treatment of chronic conditions stimulate improved treatment adherence. Studies also show that family planning and maternal and child health interventions can avert a total of 83% of maternal and neonatal deaths.

Challenges for nursing work
There is continued need to strengthen the quality of nursing education, in response to unhealthy lifestyles, risk factor reduction and provision of different disease and infection-related interventions. Nursing education and practice takes place in an environment of constant technological changes, and its promotion is an important element for the future. Technological advancement can support transformational outcomes of more integrated, high-quality and knowledge and evidence-based approaches. In response to the challenges nursing and midwifery face, the document emphasizes that robust leadership, governance and accountability are essential. Strategic planning based on collecting and monitoring data and country indicators can contribute to effective education and recruitment, as well as to the retention and effective management of the nursing workforce.

Recommendations
1. Ensuring an educated, competent and motivated Nursing workforce within effective and responsive health systems at all levels and in all service settings.
Objectives: to educate, recruit and retain a sufficient number of nurses with appropriate competencies, equipped with the necessary resources and governed by professional regulation. Strategies: to align investments and coordinate plans for the development of nursing in workforce coordination; in continuing education; regulation and in guaranteeing healthy practice environments.

Discussion
The three documents analyzed in this article emphasize the challenge imposed on the international community to invest in the health and Nursing workforce as a condition for achieving different SDG (4) and, specifically, targets for the advancement of global health (10)(11)(12) . Thus, the Report of the High Level

Commission on Health Employment and Economic
Growth (10) presents a global diagnosis of the health workforce conditions. With the participation of an ICN representative in the Commission, this document presents important recommendations that were also introduced in the Triple Impact Report (11)  its socioeconomic value (7) , understanding Nursing not as a cost to institutions, but as an investment (13,15) .
This necessary demonstration implies, however, facing the challenge of opposing arguments that support the thesis of this investment, knowing beforehand that two priorities of health managers are always at the top of the list: cost reduction without changing the quality Rev. Latino-Am. Enfermagem 2020;28:e3388.
of care and improvement of patient outcomes while maintaining reasonable costs (16) . In this negotiation, the assertiveness of nurse leaders' arguments needs to be based on the best evidence on the effectiveness of Nursing work, through evidence deriving from comparative analyses between similar conditions of performance, with and without nurses, proving the added value of this workforce in the health indicators of the patients under their care.
In addition, the defense will be convincing if the nurse leader demonstrates to the health manager the value of Nursing in achieving health outcomes in economic terms. In the same perspective of budget containment, nurses who ensure the patient's safe return of the patient successfully develop the alternative of a shorter hospital stay (17)(18)(19) .
In this perspective, it should be emphasized is attractive to future nurses, avoiding, as early as in the education process, possible drop-out movements (11) .
Thus, the goal is teaching based on evidence of the best and most modern practices for learning (1) , with prepared and sufficient teachers who acknowledge In this sense and strongly articulated to the necessary investment in high-quality education, motivating and mobilizing future nurses, health systems need to be responsive, with the necessary perspective of attractive jobs, not only to welcome young newly qualified nursing workers, but to ensure their permanence and motivation for the practice of the profession. Therefore, jobs and openings need to created that are recognized as decent, with salaries that permit fulfilling nurses' basic needs, whose work organization is also decent, fair, appropriate, and compatible in terms of sufficiency, quality and value of human resources, and materials and equipment essential for their performance (1) .
Despite different possible problems, Nursing practice at the regional, Brazilian and international level may share the competencies of its workers, requiring continuing development, which implies the recognition and valuation of nursing with lifelong experience and the strengthening of clinical leaders, highlighting that good leaders create other leaders (1) . Achieving this objective will only be possible when enhancing funding and fiscal resources,  (20) .
They also focus on the importance of Nursing and its work through interprofessional collaborations, as well as investment in search of scientific evidence that strengthens the development of the Nursing workforce.
For this, "breaking silences" is needed (6) , rupturing walls that sometimes Nursing itself has built in a siege process, conquering other health professionals, politicians, legislators and health leaders as allies for the work of nurses, so that they are allowed to freely use their full potential and competence, not only in a technical, but essentially in a political perspective. Efforts are urgently needed to enhance the prospection of candidates for leadership posts and concern with other determining factors, such as that generation Y nurses consider or reject leadership roles (22) .