A Fireside Chat: Curiosity, Courage, and Ethics – A Story of Women’s Leadership in Global Health

This week, Women in Global Health’s Program Associate, Juliet Fleischl and co-lead of the Year of the Nurse and Midwife working group, Natania Abebe sat down to discuss questions on leadership in global health by nurses. This conversation tackles the unique challenges that women have faced and continue to face in the field of nursing.

Nurses and midwives are the backbone of healthcare delivery and primary health care systems. Despite accounting for over 50% of the health workforce in many countries, they also account for over 50% of the shortage in the global health workforce by 2030. For the first time in history, the world will unite in celebration of the benefits that nursing and midwifery bring to healthcare. 2020 is the International Year of the Nurse and Midwife. By strengthening nursing and midwifery, the sustainable development goals will also be strengthened, including gender equity (SDG5) and contributing to economic development (SDG8).

Juliet Fleischl trained as a nurse with a background in health human resource development and management, and development of career training for health workers. Prior to retirement from WHO in October 2018, Juliet was the WHO Representative for Lao People’s Democratic Republic.

Natania Abebe is a registered nurse and filmmaker. She is currently pursuing a double master’s degree in nursing and public health at the University of British Columbia.

Question: What are some barriers to nurses becoming leaders? (Apply power lens)

Juliet: There are barriers to nurses becoming leaders both within the profession and the broader health context. Within the profession, the senior level roles of nurses have changed over time and opportunities for leadership have reduced. The role of Chief Nursing Scientist in the World Health Organization was abolished for many years and subsequently the role of Chief Nurse at the country level became less visible. The vision of the Dr. Tedros, to reinstate this role, needs to be applauded and I look forward to a time where women in nursing are firmly seated as all senior health management tables with a strong voice.

Natania: Building on what you said, I have experienced and witnessed external and internal barriers to nursing leadership first-hand. First and foremost, the external barriers include the lack of opportunities and the devaluation of nurses. Nurses still have to address power imbalances that are the result of hegemonic structures. As a predominantly female profession, we have to overcome negative stereotypes associated with “woman’s work” while simultaneously competing for limited employment at senior levels. However, beyond the external barriers that affect nursing leadership, internal barriers exist within the profession as well. Nurse leaders, for the most part, continue to be white, straight and cisgender. Racial and ethnic minorities in nursing continue to be underrepresented at the leadership level. Therefore, we need to examine oppressive forces that exist even within nursing.

Juliet: Building on that, I think there is also the problem of women emulating male leaders, and not being true to themselves. Leadership to me is about being authentic and resilient. We all want colleagues who are authentic, who we can relate to and feel like we know them. I also think that being resilient is important as well. Part of being resilient is being able to bounce back from problems and to choose the areas you want to progress in and areas you are not going to make leeway on. Additionally, a belief in oneself is important and that’s helped me do more than anything else: believing in myself and having a “can-do” attitude.

“Nurses still have to address power imbalances that are the result of hegemonic structures”

Question: What value did your nursing training and experience add to your leadership skills?

Natania: Nursing is not for the faint of heart and I attribute my sense of leadership from this profession. From my journey starting in undergrad to where I am now in grad school, I had to learn how to advocate for myself and for my patients. Being a leader means you are accountable, passionate, confident, able to problem-solve and have integrity. To be a good nurse, you have to possess all of these attributes. This could look like taking charge and speaking up for medically complex patients to being confident in your assessments to compassionately discussing sensitive issues with patients. When your work is focused on people’s lives, you have to develop a sense of knowing how to stand on your own because people depend on you.

Juliet: It adds enormously to your ability to lead and to your ability to keep the focus on where it really needs to be. For example, what as health professionals do we need to do to ensure the systems are in place, so that children get immunized? What as health professional do we need to do so that the information gets everywhere? We really need to focus on getting the basic structures right to get the end result of improved health for the family. I had the wonderful opportunity to be in-charge in the Solomon Islands, although it was a difficult place to be, I felt I didn’t need to prove anything anymore. With an evidence base but some intuition as well, I could work out how things might move forward in the best way.

Question: What advice would you give another nurse looking to enter the global health field?

Juliet: Sometimes there are barriers in organizations, and it is unfortunate that age is used as a form of discrimination in an international organization. It should not be a barrier if the organization is looking for competence and talent. If young people don’t get recognised in one environment, I would encourage them, if need be, to step back and look at a range of experiences in other environments too.

Natania: I can resonate with that. As a junior nurse, I know how self-doubt can sometimes prevent young nurses from using their voice and trying new things. I think if you want to work in global health, like Juliet said, give it a shot! Global health experience was not something that was provided during my undergraduate degree. I pursued opportunities outside of school to gain more experience. Some suggestions I have is try volunteering with an organization first to see if it is a right fit for you or reach out to old professors to see if they know of any opportunities. Right now, being in graduate school has helped me a lot because I get to make different networks within public health as well as broaden my knowledge.

Juliet: When I was approached for an overseas posting in Papua New Guinea to work on behalf of some nursing colleagues at first, I said no but by the end of the day I had changed my mind. A decision that I have never regretted. So, go for it! Take the risks (not necessarily the risky situations though), stay open to new possibilities and say yes to all opportunities. It is important to keep on laughing, to not be too hard on yourself and to not be limited by what society believes you should be.

Question: How can we advocate for ourselves as women and nurses to be leaders? How do we change the narrative?

Natania: One thing I’ve noticed about women and nurses is how our narrative has been erased and written by people who are not us. One way I have tried to challenge this is through storytelling and making films. I believe that “evidence informed art pieces” can shift people’s perceptions of what it means to be a nurse and woman. For example, my short film, Just a Nurse, premiered at Lucas Film studios in California after winning the Take 5 Campaign. The purpose of the video was to address the Sustainable Development Goals of Gender Equality and Health Care Leadership. I think it’s important that we tell our stories and tell them well. Advocacy work comes in many forms and it’s important to use our creativity to disrupt the narrative.

Juliet: My perception is that in female leadership, there is more “quiet time.” Women are quieter in their conversations. In contrast, men seem to feel like they need to fill the gap and make a strong mark when they come into a position. Women in leadership can go one of two ways. They can either try and be a “female male” in a male world or bring their “femaleness” into their work and bring others along and nurture them. I’ve read about this idea of keeping the ladder down and allowing women to climb up, which is a nice image. The idea is as you move up the ladder, you kick the ladder down behind you and allow women to climb up and be alongside you. Fortunately, I had a progressive upbringing in New Zealand, and there were a lot of women before me that brought me up alongside them, and I try to practice that in my own career.

“The idea is as you move up the ladder, you kick the ladder down behind you and allow women to climb up and be alongside you.”

Question: How can we encourage our fellow nurses as mentors, sponsors and role models to be gender transformative?

Juliet: I think we just have to keep having these conversations and keep having them not just with our friends and colleagues but with communities that we visit. It really is about talking to people, promoting equality, recognising the battles that we can take on, and the ones to leave for another day. It’s also about confronting some of the attitudes as well. Not holding onto attitudes and taking them on later but confronting them when you see them happening. It is important to say “no,” especially women saying no when they see something that they feel is not right. It doesn’t make you popular at times, but I think it’s worthwhile saying it. If we can live in an authentic way, if we’re true to ourselves and ethically correct, we are going to be OK.

Natania: Nurses account for the largest part of the health workforce yet we are underrepresented in health leadership. I think outside of the nursing profession it is important to create opportunity and training for young nurse leaders by noticing who you promote and who you choose to mentor. Despite being a female-dominated profession, white male nurses still have a greater advantage in terms of pay and opportunity. Therefore, taking an intersectional approach to mentorship is extremely important. Second, within the profession itself, there is a saying that “nurses eat their young.” It’s a phrase that talks about how older nurses “bully” younger nurses. I think this cultural paradigm needs to shift and should be recognized as oppressed group behaviour. Nursing is a profession where the more experience you have, the more respect you earn. I believe there is some truth to this sentiment. But I also believe that there are a lot of young nurses out there who can help move the profession forward as well. Nurses need to also learn how to uplift one another!

Question: What structural change would have the greatest impact in supporting women nurses into leadership roles?

Natania: I think the biggest structural change that would help women nurses into leadership roles is helping people understand what nurses actually do. Many people have misinformed ideas about nursing work and how to make conclusions about how our work relates to womanhood. I believe that people would take us more seriously if they really understood the breadth of our work as well as the intellectual rigor needed to be a nurse. In order for people to be receptive of nurses as leaders, they first must have an accurate understanding of what it is we do. If not, nurses who do make it to the top will have a hard time being effective leaders because there would be resistance or a need to convince others of our abilities. Other professions do not need to “prove” themselves when they branch out to other areas within health care leadership such as policy work, research or administration despite maybe lacking specific training in these areas in their formal training. I think nurses should also be treated the same way.

Juliet: It starts with health. We need to be ethical and think globally, but act locally, eliminating all forms of inequality and discrimination in health. We also need to look at the things that influence health leadership, like where the power structures are and how to influence those. We need to focus on governance and decentralisation, because every country in the world seems to decentralise but then services don’t get delivered because the lower levels aren’t taught how to do it.

“Many people do not enter this profession because of preconceived notions of what a nurse does as this profession continues to hold the image of a ‘woman’s job’ or a job for ‘hardworking immigrants’.”

Question: What is one change you would like to see in the field of nursing in your lifetime?

Natania: The one thing I’d like to see change is addressing gender inequality in this profession. I believe that the gendered nature of this profession does put the public’s health at risk and should be treated as a public health issue. Many people do not enter this profession because of preconceived notions of what a nurse does as this profession continues to hold the image of a “woman’s job” or a job for “hardworking immigrants”. For those who do enter the profession, many contemplate leaving because of the lack of respect and working conditions we must endure. I believe that all of these issues are interrelated. Because nursing is perceived as “less rigorous” and is for “caring women”, austere policies are often implemented at our expense. And often, policy makers make decisions without really understanding the repercussions it has on nurses or justifying their decisions based on ideas of what our work entails. There is a world-wide shortage of nurses and I believe that if we address this issue of gender inequality, we can change global health care. Nurses are fundamental to health care transformation!

Juliet: We need to change the way we do supervision and monitoring and change our approach to communities and act as role models. Engagement needs to be ongoing; it can’t just be a one-off thing. We all have difference experiences that we bring to the table and we can’t expect everyone to act with the same knowledge or experience, we need to share that to effect change. Here’s an example from when I was working in Papua New Guinea. There was a senior nurse for the country, she travelled a lot and about six months into working together, she said to me, “I don’t need to go overseas anymore, I need to send the ones below me to get the experience.” That’s a sign that we’ve made it. It’s a mindset change, really. We need the senior policy makers to do some things, but we also need to get to a point where we are comfortable saying “no, I don’t need to do that, the next person down the line should learn this,” and leave a legacy.

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