“The year is 2020 and it’s a year none of us will forget due to the Covid-19 pandemic,” said Sarah Barnes, Women and Gender Advisor and Project Director of the Maternal Health Initiative at the Wilson Center at a recent webcasted Wilson Center event. “The year 2020, as designated by the World Health Organization, is also the Year of the Nurse and the Midwife and was meant to be a year of celebration and much due recognition of these two incredible professions.” This month, the first ever State of the World’s Nursing report was published by the World Health Organization (WHO), International Council of Nurses, and Nursing Now.

Globally, there are some 28 million nurses and 2 million midwives. Together, these two professions make up 59 percent of the global health workforce, said Barnes. Nurses are the largest group of healthcare workers in the world. Based on data from 191 countries that participated in the State of the World’s Nursing report, 90 percent of nurses are women. Nurses also provide 80 percent of primary health care worldwide. “There should be no question right now that investing in nursing saves lives and saves livelihoods,” said Leslie Mancuso, President and CEO of Jhpiego.

“It’s hard to fathom that until now there’s never been a global snapshot available of the world’s largest occupation of health workers and one that is predominantly women,” said Jennifer Breads, Gender Technical Advisor at Jhpiego. What is even more notable is the data countries were not able to collect, including data on entry-level salaries, investments in education, and the gender wage gap. Because, as the report found, nursing is overwhelmingly female-dominated, “these omissions are inherently gendered” and undervalue women’s contributions to global health, said Breads.

Another key element of the report is the intersection of gender with other issues impacting nursing, like migration. One in eight nurses work in places where they were neither born nor trained, said Mancuso. Nurses often experience disparities in working conditions based on their identity, as nurses who are migrants and ethnic minorities face a higher risk of experiencing work-related injuries and discrimination than nurses from the majority or who are native to the country, said Rosemary Morgan, Assistant Scientist at Johns Hopkins Bloomberg School of Public Health and School of Nursing.

Gender and Leadership Gap

In Africa, women make up 76 percent of nurses, but in other regions they constitute up to 95 percent of the nursing field. The gender inequality in the global composition of nurses has allowed the nursing profession to follow stereotypes, said Emily Katarikawe, Uganda Country Director of Jhpiego. In low- and middle-income countries, nursing is considered a second choice for those who did not make it to their preferred profession. Even in the developed world, the low rates of men joining the field reflect how the nursing profession is viewed worldwide. Occupations like nursing that are overrepresented by women are often undervalued, said Morgan. While the report provides worldwide sex-disaggregated data, we still do not have global data to show the gender wage gap in nursing. However, the evidence available shows that nursing has a larger average pay gap between men and women than other professions, said Michelle McIsaac, Economist at WHO and Co-chair of the Global Health Workforce Network Gender Equity Hub. This gap reflects the nursing field, which is often segregated, with men in higher-paying leadership positions and women in lower-paying roles.

Nurses make up nearly 60 percent of the health workforce, but hold less than 10 percent of leadership roles in the healthcare system, said Katarikawe. While women who are nurses bump into a “glass ceiling” that prevents them from moving up into broad managerial and leadership positions, men who enter nursing enjoy a “glass escalator” to nursing leadership positions, said Morgan. Sustainable investment in nursing must include investment in nursing leadership positions. “We want to see nurses coming to the forefront and having a seat at the table in all of the decisions we see across the sector,” said McIsaac.

A recent study conducted by Nursing Now found that nurses do not feel comfortable going into meetings and speaking about their expertise, especially when others in the room are men, said Barbara Stilwell, Executive Director of the Nursing Now campaign. Nurses need to find a voice to be confident in sharing data with policymakers, politicians, and budget holders and in pursuing higher level leadership roles in public health, such as Chief Nurse or Director of Public Health positions. While these roles have historically required a medical degree, they only truly require knowledge of public health, which nurses have, said Stilwell. 

Working Conditions and Violence

Because of the dominance of women in nursing, you would expect a working environment conducive to the needs of women, said Morgan. However, nurses report difficult working conditions and inadequate protection from violence. Research found that in professions like nursing, where women are the majority, there is a greater burden of discrimination, said Morgan. The State of the World’s Nursing report shows that only 37 percent of countries have measures in place to prevent attacks on health workers, and only 30 percent have measures to protect workers from physical and sexual attacks. However, 36 percent of nurses report not being respected by higher ups, and 25 percent of nurses report experiencing sexual harassment. Gender issues also intersect with other “social stratifiers” like race, said Morgan. In the United States, white women may experience an easier path than black women into nursing and advancing in their careers.

Issues of workplace conditions have become more pressing in light of the Covid-19 pandemic. In the United States, among 9,000 healthcare providers who tested positive for Covid-19, 73 percent were women, said Barnes. While in the general population, mortality from the virus is higher among men, female health workers are twice as likely to be infected than their male counterparts, said Morgan, because female health workers are more likely to be in caregiving roles where they are exposed to a higher viral load. What’s more, health workers do not have sufficient protection. Female healthcare providers have reported failing their fit testing for personal protective equipment largely because this equipment is designed with the male body as the norm or standard, said Morgan.

It is not enough to just create jobs, said McIsaac. Nurses need to have opportunities that are good and satisfying jobs with good working conditions. They must be fairly compensated, and protected from infection, violence, and harassment.

Investment and Global Movement

The global shortage of 6 million nurses highlights the need for investment in education and training. Sustainable investment in nursing has three domains: education, job creation, and leadership, said McIsaac. The State of the World’s Nursing report highlighted that governments need to invest in accelerating nursing education through students, faculty, and infrastructure, said Mancuso. Governments also need to create more jobs for nurses. It is not enough to simply increase the number of trained nurses. Positions these nurses can fill will be needed to offset the shortages, especially in low- and middle-income countries. The cost of increasing the number of trained nurses by 8 percent every year has an estimated cost of $10 per capita to address the global shortage. This cost should be seen as an investment in improving and expanding the health workforce to improve public health, said McIsaac.

The increased investment also needs to come with investments in girls’ education, said McIsaac. Girls who want to enter nursing should be given opportunities to be able to meet the necessary requirements to enter the field. As it stands, we only spend 25 percent of our educational investment on 59 percent of the health workforce, said Howard Catton, CEO of the International Council of Nurses.

These investments are crucially needed, especially now during the Covid-19 pandemic. While the celebration of nurses and midwives in 2020 has not gone as planned, it’s clear that there’s been a global surge of appreciation, recognition, and even awe for the role of nurses, said Barnes. The State of the World’s Nursing report is a step forward in starting the progress towards real change. “We’re all hoping that this immediate response to the way that nurses have battled Covid-19 will continue and manifest itself into real changes and improvements for nurses and the nursing profession as a whole,” said Barnes.