Intended for healthcare professionals

Analysis The Future of Nursing

How to reposition the nursing profession for a post-covid age

BMJ 2021; 373 doi: (Published 14 June 2021) Cite this as: BMJ 2021;373:n1105

Read our collection on the Future of Nursing

  1. Howard Catton, chief executive1,
  2. Elizabeth Iro, chief nursing officer2
  1. 1International Council of Nurses, Geneva, Switzerland
  2. 2World Health Organization, Geneva, Switzerland
  1. Correspondence to: H Catton catton{at}

The pandemic has laid bare the need to invest in nursing for global health and economic security. Howard Catton and Elizabeth Iro outline how the profession must transform to maximize its effect on patient care and outcomes

The effectiveness of healthcare is inextricably linked to the state of the nursing profession. The second report of the Independent Panel for Pandemic Preparedness and Response said, “The world was not prepared, and must do better,” arguing that “the covid-19 pandemic must be a catalyst for fundamental and systemic change in preparedness for future such events, from the local community right through to the highest international levels.”1

Frailties in healthcare systems, exposed by the covid-19 pandemic, reinforce the urgent need for all governments to invest heavily in nursing to bring about such fundamental change.23

In crisis situations, seizing opportunities to reflect, learn, and grow is critical. Countries have an opportunity to address the weaknesses that have been revealed in their healthcare systems and to ensure healthcare is available to everyone. The nursing profession must plan its next steps carefully to respond to the challenges the world now faces. The current context, and increased understanding of the state of nursing in the world, provides lessons that prompt consideration of nursing’s role and the form the profession should take in the future.

But these considerations must be viewed within a wider global context that includes gender equity45 and climate change6 as drivers of a new public health policy debate. And to reach universal health coverage by 2030 nurses must radically reframe their relationship with digital technology.7

A bold vision of the profession can stimulate investment for the fundamentally changed healthcare services needed in the decades after the pandemic. Strengthening nurse education and leadership and including a nursing voice in all decisions about the future of health systems and policies, will be essential if we are to create more equitable services and better outcomes for patients and their communities.8

Year of the nurse, year of the pandemic

The 72nd World Health Assembly designated 2020 as the international year of the nurse and the midwife.9 In April 2020 the World Health Organization, in partnership with the International Council of Nurses, (ICN), and the global Nursing Now campaign published The State of the World’s Nursing 2020. This report detailed the dimensions of the global nursing workforce and provided evidence based policy options to strengthen nursing education, jobs, and leadership.10

Activities were planned worldwide throughout 2020 to raise the profile of the nursing and midwifery professions, showing their important contributions to population health, achieving universal health coverage, and society. However, many were put on hold as nurses responded to the covid-19 pandemic. It was hoped that the advocacy for the nursing role, coupled with a compelling case for investment in nursing, would encourage a new generation into the profession11 and mobilise strategic partners and financiers around the world812 to address the chronic nursing shortages that can limit service delivery and undermine patient care.10 It is also clear that investment is needed to support nurses who are struggling to cope mentally and physically with the consequences of the pandemic and exhausted from the demands of working under extreme pressure over a prolonged period.31314

Despite disruption of planned activities because of the pandemic, 2020 raised the profile of nurses and nursing work around the world. The global media focused on overcrowded hospitals, inadequate protective equipment for the workforce, and desperate personal stories of dedication and compassion—and the world clapped in support. The past year has taught us that applause is not enough. It is essential and urgent to invest in and protect all those who safeguard our health and security. The year 2021 is fittingly designated the year of health and care workers with the campaign slogan, “Invest. Protect. Together.”15

Nurses in top level leadership

The pandemic has exposed the public to the realities of nursing: nurses’ advanced clinical skills, the complexity of their work, and their commitment to patient care. The public has also seen nursing’s frailties: too few nurses with the right skills and in the right place, insufficient plans to deal with a pandemic, and in many countries a lack of nursing leadership at government level to provide much needed direction.8101617

Although nurses take on leadership at all levels, globally nursing is least represented at the highest level in governments and ministries of health.8 During the pandemic it has been normal to see chief medical officers speaking alongside government ministers but rare to see chief nursing officers doing the same. The State of the World’s Nursing 2020 indicated that only 70% of countries have a government chief nursing officer position8; an ICN assessment found even fewer countries had a position with appropriate authority.18

For health to be a central tenet of all policy making, nursing leaders must take their seats at tables in every arena where health systems and health policy decisions are directed and driven. Senior nurses have roles as enablers of health not just in health ministries, but in organizations and institutions tackling matters that affect health, including education, the environment, and the economy. For government and industry leaders to recognize the value of nursing input across multiple sectors, nurses at all levels must continue to engage in informed dialogue and debate on a range of global challenges.

WHO Global Strategic Directions for Nursing and Midwifery (2021-2025) will be presented for consideration at the 74th World Health Assembly in May 2021. It includes policy options to tackle current challenges and strengthen nursing leadership.19 Implementation would create stronger and resilient health systems better prepared for future adversities.

Global shortage of nurses

The State of the World’s Nursing 2020 presented data from 191 countries. In 2018 there were almost 28 million nursing personnel; more than 19 million were classified as “professional nurses.”8 Nine out of 10 nurses globally are female, and one in six countries have fewer young nurses than nurses expected to retire within the next 10 years.8

These 28 million nurses translate to a global nurse density of 36.9 per 10 000 population. This figure masks vast disparities in the distribution of nurses around the world. For example, there are 10 times more nurses per 10 000 population in the Americas than in the African region (83.4 v 8.7/10 000). In short, some of the poorest countries in the world have the fewest nurses.8

The report highlighted a current global shortage of six million nursing jobs.8 A further 4.7 million nurses will be needed to replace those expected to retire over the next decade.8 Other analyses have identified a “covid-19 effect,” related to the mass traumatisation of the global nursing workforce,1619 which could result in up to 10% of nurses (2-3 million) leaving their jobs once the pandemic work is done.20 In effect, much of the current nursing workforce could need to be replaced in the next decade, a gap that requires urgent action.

Up to 255 million people have lost their jobs during the pandemic,21 creating a pool of potential candidates to become the new nurses we need. ICN has called on governments to make available dedicated additional “health education and retraining opportunity” funding to support education providers to increase capacity and to support people who have lost jobs to move into the health and care workforce.22

Nurse migration

The inequitable state of the global supply of nurses and migration has left many countries with too few nurses.16 Almost 90% of the six million shortfalls in nursing occurs in low and middle income countries. About one in eight, or 3.7 million, nurses are working in countries that are not where they were born or trained.8 In high income countries, foreign born or foreign trained nursing staff comprise 15% of the nursing workforce, compared with less than 2% in lower income countries, many of which can ill afford to lose nurses.

ICN’s migration report16 underscored the importance of having data on international mobility and migration by nurses and advocated for transparency in terms of each country’s reliance on international nurses. The WHO global code of practice on the international recruitment of health personnel is widely recognized as the universal ethical framework that links the international recruitment of health workers and the strengthening of health systems.23

In addition to full implementation of the code24 ICN advocates that countries employing nurses from abroad follow ethical recruitment principles; ensure working conditions are compatible with individual nurses’ qualifications, skills, and experience; and provide family friendly contracts that allow nurses the freedom to return home or bring their families with them.

Nurse leaders should position themselves in government ministries, to lead changes that build in education and recruitment to foster greater self-sufficiency by making nursing a more desirable and valued career choice.

Valuing nursing

Nurses are valued especially for “being there” for the patient and their loved ones during life’s most challenging moments.25 This has continued throughout the pandemic, with nurses often standing in for loved ones while patients died, providing comfort and compassion in their last moments.2627

Traditionally, this kind of care and compassion is associated with love,25 an aspect of nursing that is important to people, particularly when they are struggling to deal with complex, long term, and terminal illnesses.28 Compassion is a key aspect of healing29 and can affect the delivery of quality health outcomes.29 Nursing with compassion places people at the centre of care,30 but nursing is much more than this: it is both an art and a science, requiring intelligence, skill, knowledge, and, most importantly, high quality education.

The pandemic has highlighted the need for countries to increase investments in the health workforce, including nursing. The economic and social value placed on what nurses do is deeply rooted in gender norms, including pervasive gender segregation of the nursing profession.5 The challenges surrounding workforce planning during the covid-19 pandemic have highlighted an urgent need for fair pay,31 decent and safe working conditions, and gender equity in health leadership opportunities.832 These types of expenditures should be considered integral to national health security.33

As the demand for health services and nursing care continues to grow, having the right number of nurses with the right skills in every country in the world is an equity and health security imperative. Strategies to retain nurses and midwives, especially in rural, remote, and other underserved areas, are critical.34

Delivering and leading services

Nurses’ clinical skills span a wide spectrum of health service delivery, including public health, health promotion, community care (tackling the social determinants of health), primary healthcare, hospital care, infection prevention and control, antimicrobial resistance, mental healthcare, emergency care, and care in humanitarian and disaster settings.8 Nurses not only care for the sick, they promote health and wellbeing. In some parts of the world nurses are often the first, and sometimes only, healthcare workers that people have access to. After patients have had medical interventions, often using high-tech equipment in hospitals, nurses’ clinical competency is crucial because every member of the healthcare team is equally responsible and must provide an equally high level of care.35

In many countries, nursing professionals have the main responsibility for immunisation programmes, and in some countries they are entirely responsible. With the covid-19 pandemic, nurses are participating in what will be the biggest immunisation event in history, with billions of doses administered in diverse locations worldwide. Many challenges are becoming evident, including supply chains, distribution problems, training, health education of the general public, availability of facilities and equipment for immunisation, the number of available vaccinators, misinformation, mistrust, and vaccine hesitancy.36 Coordinating valued and trusted nurse professionals to deliver on this task will move us closer to ending the acute phase of this pandemic.

At the clinical level, advanced nurse practitioners worldwide provide quality, cost effective care close to people’s homes,8 and these sorts of services can help to reshape the healthcare of the future.37 Advanced nurse practitioners create a huge opportunity to develop and grow strong health systems. They have a leading role to play in the prevention and containment of diseases, as well as in providing first contact and long term care, while benefiting vulnerable groups that other healthcare professionals may not reach.

However, some countries have regulatory restrictions that prohibit the potential expansion of the advanced nurse practitioner role. The ICN published its advanced nurse practitioner guidelines37 to support country-led approaches for advanced nursing practice that is safe, efficient, effective, and cost effective. Leadership by advanced practice nurses can help ensure nurses work to their full potential by designing and implementing nurse-led services.

Universal health coverage and inequalities

Achieving universal health coverage will require nurses to be involved in effective planning of primary healthcare services and strategic management of healthcare delivery.38 Much of the mortality burden for covid-19 has been borne by people with existing vulnerabilities, especially preventable comorbidities, and often within communities already at high risk of communicable and non-communicable diseases.3940 Tackling these inequalities falls firmly within the scope of nursing, and nurses need to be enabled, through high quality education, safe and supportive workplaces, effective leadership, and collaboration in multidisciplinary teams to fulfil this element of their practice.

Optimizing the contributions of nurses to universal health coverage through evidence based policy approaches is a clear priority for countries around the world.

Key recommendations

  • Nurses should be leaders in the design of healthcare systems, not just in delivery of care

  • Health should be considered in every government policy, with senior nurses present at the top of all health system organizations and government departments

  • Governments should lead implementation of globally endorsed strategies as appropriate for their health workforce and nursing professions

  • Countries should adopt long term workforce plans, striving for self-sufficiency in the supply of their health workforces, including nurses

  • Investment in nursing jobs, education, leadership, and service delivery should be viewed as an investment in every citizen’s safety, security, and peace


  • .Competing interests:. We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decisions to publish. The series, including open access fees, is funded by WISH.

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