Before the pandemic hit, the World Health Organization had chosen 2020 as the International Year of the Nurse and Midwife. Instead of attending symposia and celebrations, however, most nurses faced the most brutal months of their careers. In large countries and small, nurses offered hands-on care in the face of a new virus, attending to the health of their patients even when it meant risking their own safety and that of their families.

Elizabeth Iro, who was named the first chief nursing officer of the WHO in 2017, is making sure that the importance of nurses is amplified, not overshadowed, by the encounter with COVID-19. Iro served for more than 25 years as a nurse and midwife in the Cook Islands before becoming that country’s secretary of health. At the WHO, she immediately began working with a team on producing a State of the World’s Nursing Report, published last year, which lays out how the profession is changing and what must be done to support nurses in the years ahead.

Q: How did you find yourself taking on a series of leadership roles?
A: I’ve always kept my focus on my work, which is to look after people. That mission is a common thread among all nurses, I think. And like most nurses, I found myself running into certain frustrations. I started to look for ways to make a better argument, to advocate more convincingly for the people under my care.

That led me to read up on civil law and produce a few research papers, and then I did a master’s degree in health science and also an MBA. All of that allowed me to see other sides of the problem. It also showed me how issues affecting nurses could be elevated by approaching ministers and other people in power with sound, evidence-based arguments.

Q: Can you elaborate on those “certain frustrations”?
A: One thing was not having enough staff. Nurses were being let go with no one coming in to replace them, yet we were expected to continue delivering the same care. But at the forefront of the response you come to understand how exhaustion becomes the norm, how absenteeism rises because of exhaustion and how work then doubles and quality drops.

This is also something we talk about in the context of the WHO’s Year of the Nurse—that the world needs another 9 million nurses over the next 10 years if we’re going to achieve adequate universal health coverage. Nurses are now responsible for so much and yet remain stretched thin.

Q: How have the responsibilities of nurses changed?
A: There has been a huge shift over the past 25 years. Nursing has evolved into a profession with rigorous academic requirements. There has been a proliferation of accreditations, and of course in many countries now, nurses have become autonomous and specialist practitioners.

Current global health crises have also shaped what we do. Noncommunicable diseases—I’m thinking particularly of obesity—are a primary challenge around the world. Nurses have been the ones responding to the lifestyle and health maintenance needs of patients with obesity in a major way. It is the same with other conditions.

With all of these changes, the profession is able to make a profound impact, especially in settings where health workers are limited. Nurses are often, de facto, primary caregivers. We know that if nurses are allowed to work to the full scope of their licenses, the benefits are enormous.

Q: What has the COVID-19 crisis meant for nurses?
A: The pandemic has exposed issues we have been trying to address. One is the shortage of nurses that I mentioned. We’ve seen nurses who have been overworked, overburdened and burnt out. We’ve seen them be stigmatized because of their work and hands-on proximity to the sick. We’ve seen them on the receiving end of shortages in equipment that jeopardize their health. These aren’t new issues, but the pandemic brought them into sharp focus.

Going forward it is important that governments respond not just with applause and saying thank you. What’s needed is for them to look seriously into the investment in health care workers. And one of the best ways is to incorporate nurses into decision-making. Health care systems around the world can be strengthened by having a nursing and midwifery perspective in their planning and in their policies.