Commentary

Politics of nursing leadership: reflecting
on the 29th Congress of the International
Council of Nurses and on nursing
organizations' political role more broadly

COLLECTIVE OF AUTHORS*

The International Council of Nurses (ICN) recently held their 29th Congress in Montreal, Canada, July 1-5, 2023. It was the first in-person congress to be held by the ICN since 2019 and it was co-hosted by the Canadian Nurses Association. About 6000 nurses, nursing students and researchers from 126 countries participated in the 5-day event.

ICN purports to "represent nursing worldwide, advance the nursing profession, promote the wellbeing of nurses, and advocate for health in all policies. Our vision is that the global community recognizes, supports, and invests in nurses and nursing to lead and deliver health for all." The congress, a biannual international event, represents an

important opportunity to network and meet fellow nurses
from around the world. And yet, the congress did not rise
to their aspirational vision. With this editorial, we wish to
provide a critical perspective on the event, emphasizing what
it revealed about the global politics of nursing leadership. An
open and transparent discussion on political issues that affect
nurses and people who require nursing care is imperative. We
are thankful some of us were able to speak to colleagues in the
leadership of the ICN and CNA about our concerns. However,
we believe this discussion needs to be brought to, and involve,
a broader nursing audience, as these issues are not limited to
this particular congress or ICN itself. Furthermore, we hope to
reach nurses and nursing students who may not have felt able
or safe to question or critique aspects of the congress or any
other nursing event.

A major observation was the noticeable disconnect between
the formal professional leadership of nursing organizations,
and the participants at the congress, many of them also
leaders within grassroots and social justice organizations. This
disconnect was particularly visible in the lack of nursing voices
from Indigenous and Black communities, despite healthcare, and in particular nursing care, having been identified as key spaces that have harmed people from these communities. Opening events were filled with spectacle and pageantry. For example, Indigenous dancers were featured as entertainment during the opening ceremonies, but Indigenous nurse leaders did not participate in the opening remarks or welcome participants on their land. It was clear that cultural displays were of significant relevance but the sole focus on culture does very little to challenge the hegemony and Eurocentrism upon which our countries are built, causing harm and moral distress to a number of delegates. Many land acknowledgements were uttered by conference organizers and speakers, yet these fall flat without further calls for responsibility and accountability from organizations regarding their participation in contemporary colonial systems. Land acknowledgements are performative if not contextualized and turned into a call to action towards redress and Indigenous sovereignty (1-2). Space must be consistently made for Indigenous nursing voices leading the work on the decolonization of nursing to ensure that decolonization and anti-racist efforts undertaken by non-Indigenous nursing groups do not amount to performative allyship or perpetuate underrepresentation, tokenism, epistemic inequities, and violence (3).

Underrepresentation, exclusion and epistemic violence occurred however through the sidelining of discussions on anti-racism work within nursing, which created tension and harm for nurse attendees doing decolonial and anti-racist work. Of more than 100 sessions, only two explicitly addressed racism within nursing and the healthcare workforce: a symposium and a concurrent session (4), with a few more being relegated to e-poster presentations. The symposium, which consisted of pre-prepared questions to leaders of the American Nurses Association and the Canadian Nurses Association asked by a white woman, was fit in the program at an inconvenient and disadvantageous time (7h15 in the morning), in one of the smallest rooms of the venue. Most participants had to listen to the panel from an overflow room. This was not the first session that faced overflow issues, with people at the door guarding against further admittance to a room some attendees had specifically traveled great distances to enter. Despite the importance of this topic, the symposium lasted only one hour, leaving many questions and concerns unaddressed. Many participants left frustrated, hurt, even traumatized (5). Ultimately, the symposium conveyed a sense of self-congratulation even as it failed to really address the difficult question of racism within nursing.

Many of the volunteers were nurses from Africa or of African

descent, who had paid thousands of dollars to attend and worked many hours unpaid (6), as the conference began around 7 am, and sessions wrapped up at 8:30 pm. There did not seem to be concerns regarding the disparity between the whiteness of organizers and most attendees, and the blackness of these guests who provided crucial support to the congress through their unpaid labour.

Indigenous and nurses of colour were not the only ones underrepresented, shortchanged, or excluded. Considerations of 2SLGBTQ+ persons and their needs were few, especially with consideration of trans folks (7). This was particularly painful in the context of a US Supreme Court ruling, issued just a day prior to the congress, upholding the exercise of discrimination in the name of religious liberty (8). This ruling effectively sanctions discrimination against 2SLGBTQ+ people, further eroding the civil and human rights of queer and trans people in a time of surging anti-queer and anti-trans sentiment (9-10). There was no mention on any of the panels of this particular ruling, of ongoing anti-trans media representation in Canada, the United States and the United Kingdom, of the way nurses' care to trans persons can be legally prohibited (11), or of the increasingly hostile sociopolitical and healthcare environments that harm 2SLGBTQ+ persons.

There were no sessions dedicated to transgender and gender diverse nursing care. Instead, papers on unified themes were scattered through other sessions with tenuous relevance to the other papers. Much like papers on Indigenous health, individual papers on transgender and gender diverse care were distributed in conflicting sessions with unrelated content. Content on gender equity did not address the serious issues in policy and legislation cited above nor others that were brought up in the question period, such as nursing roles and supports in working with 2SLGBTQ+ refugees and migrants. Content included some very basic terminology using dated resources, several references to American drag culture, and no acknowledgement of the concrete legislative, policy, work, or health systems barriers that trans, nonbinary, and gender and sexual orientation minorities face—including within nursing itself and within the congress itself (for example, during a talk about trans youth, two audience members were heard regendering any pronouns the presenter mentioned about their study participants). As with presentations on Indigenous health, antiracism, and decolonization, the question and discussion periods relevant to 2SLGBTQ+ care were far too short to allow for reckoning and substantial engagement with these complex issues.

In contrast, the congress afforded a wide-open space showcasing how corporate think engulfs nursing in the
neoliberal rationalities and managerial logic that is contributing to the ongoing commodification of nursing practice and “services.” This was apparent in the exhibition space, but it also spilled into the congress programming. For example, one of the panel discussions was about the economic value of nursing in healthcare “markets,” urging nursing leaders to quantify practice and promote strategies that reduce “wasteful care” so nursing can become more visible in economic and fiscal calculations. Instead of interrogating the economic logic of nursing, the discussion prioritized the quantification of productive economic value, which functions to supress the values in relational caring and “being with” patients. This approach devalues important emotional and affective dimensions of nursing care, which become invisible and irrelevant in the discourse of profitability. From this sort of “lean” perspective, care that cannot be quantified and counted is assumed to be time wasted—a waste that should be eliminated. It also carries the risk that nurses are considered too “expensive” a resource with no particular value added and are thus deemed “seamlessly” replaceable with less costly personnel or robotics. Rather than giving nurses space to confront such widespread neoliberal ideologies and managerial rationalities that threaten the profession and its social mandate, the congress was a missed opportunity to engage nurses from around the globe in critical dialogue that collectively envisions health and social systems not predicated on reductionism, commodification, exploitation, and exclusion.

Interestingly, one the central themes of the congress was leadership. Fourteen sessions were explicitly dedicated to nursing leadership and many more alluded to it. However, leadership continues to be discussed in ways that reinforce the current state of affairs, failing to problematize how leadership and management can perpetuate critical problems in nursing, especially harmful policy orientations. This fixation with leadership, often symbolized by high level managerial positions within healthcare organizations, underscores a key problem: the disconnect between the harshest lessons learned these past few years (including in the wake of the COVID-19 pandemic) and the focus of highly visible nursing events, such as this congress.

Part of this disconnect stems from the pandemic constituting a historically significant breaking point. Throughout each wave, thousands of nurses worldwide asked their surprisingly discreet professional bodies to speak out as nurses faced both a deadly virus and equally lethal pandemic mismanagement. Yet, few organizations meaningfully answered that call, leaving nurses to fend for themselves. Despite world and health leaders' seemingly increased respect for the nursing

workforce, nurses' rights and wellbeing have continued to plummet worldwide, with devastating effects. This 29th edition of the congress conveyed a sense of 'business as usual', yet there is nothing usual, nothing normal about the times we face as nurses. A profound fracture has occurred that has worsened the health outcomes of populations, communities, and nurses themselves, with the most deleterious effects disproportionately impacting persons of colour, persons with disabilities, women, gender diverse persons and persons who live in poverty. Nurses continually speak out and act against these realities, against inequities, against unsafe care practices and against dangerous work conditions—and they often pay a high price for doing so. During the pandemic in particular, their continuous efforts and advocacy to expose wrongful pandemic management decisions helped catalyze public discussions about nurses' and healthcare professionals' role in defending the public interest and became a significant driver of the development of whistleblower protection legislation worldwide (12-14). Alongside these nurse leaders on the ground, nursing organizations should have been a highly visible and vocal public contributor to these social debates but their engagement with such critical issues has been minimal, inconsistent, or nonexistent (at the time of writing, the term "whistleblowing" does not appear on the website of the ICN or the Canadian Nurses Association, for instance).

A global meeting like the ICN congress provides a crucial opportunity to take stock of such events and their brutal lessons, and to rethink how we must change in order to pursue our social mandate. But this can only happen if nursing leaders and organizations see it as a priority. Sadly, this did not seem to be the case here. For example, some of us attempted to tackle this issue through a proposal for a master class on political advocacy and leadership to address the unrest that is harming nursing and driving nurses away from the profession, only to be turned down "due to the limited number of master class slots." Yet seven master class slots were exclusively allotted to a repeat presentation on robotic assisted surgery while three others were allotted to a virtual reality platform. What made these topics so suddenly urgent for our profession that they would be given such disproportionate, privileged exposure? The fact these master classes were led by corporate sponsors provides a bitter, disappointing answer to this question.

Leadership discussions divorced from important sociopolitical questions that nurses and patients must confront everyday are an empty promise. Traditional leadership structures were developed by and for dominant structures, groups, and ideologies in nursing, following the imperialist trajectory laid out since their very beginnings. The politics of these leadership
structures can only evoke transformative practices that actually reproduce new forms of managerialism, new forms of colonization and new forms of abuse (15). This gives way to an inability—or unwillingness—to question and challenge the role of organized, professionalized nursing in contemporary healthcare, economic and policy systems that harm patients, communities, and nurses.

Time and time again, nurses have shown their willingness to step up, be creative and collaborate on new scales to protect patients and care systems more broadly. But nurses need new tools—new ideas, new analyses, new advocacy, new leaders—to confront these troubling times. They also need a more powerful, more consistent presence in public realms. More than position statements occasionally disseminated through websites and social media, nurses need to see their leaders take up more space with more critical ideas in public discussions, social debates, and the media. Further, massive gatherings such as international nursing conferences are opportunities for creating a collective call to action, mobilizing and further deploying nurse advocacy and mutual aid networks, for normalizing political discourse and action, for embodying anti-racist and decolonization work, and for challenging harmful economic ideologies that corrode care systems. Grassroots nursing leaders are emerging around the world in fights for social justice, but these leaders are often not found within professional organizations. We demand accountability and more substantial action from nursing organizations themselves, through a more meaningful engagement with the politics of care and nursing leadership. Nursing activists and leaders on the ground will continue to rise and lead our profession towards greater care equity and social justice. Will nursing organizations keep up?

Références

1.First Nations Health Authority. Territory Acknowledgements. Available from: https://www.fnha.ca/Documents/FNHA-Territory-Acknowledgements-Information-Booklet.pdf

2.Amnesty International. A Meaningful Land Acknowledgement Example. 2017 Sept 1. Available from: https://amnesty.ca/activism-guide/activism-skills-land-and-territory-acknowledgement/

3.Bourque Bearskin, L. Decolonization the what, why and how: A treaties on Indigenous nursing knowledge. Nursing Philosophy. 2023; 24(2), e12430. https://doi.org/10.1111/nup.12430

4.International Council of Nurses. Session list. [Internet] Available from https://icn23.myeventapp.com/

5.TheCBNA. Sadly @ICNurses @canadanurses @TheCBNA received the same feedback in addition to how traumatic this was to experience: https://twitter.com/TheCBNA/status/1676224929061109760 2023 July 4

6.birgitomo. Most Canadian nurses did not opt to volunteer for the #ICN2023 because it's unpaid work: https://twitter.com/birgitomo/status/1676588544511410179?s=46&t=s8VusyTiLa gA9hE3BxP39w 2023 July 5

7.RnCarroll. A final reflection on @ICNurses #ICN2023 #ICNCongress: https://twitter.com/RnCarroll/status/1677383212236939264 2023 July 7

8.Marks. G. US small business owners: discriminate at your own peril. The Guardian 2023 July 9. Available from: https://www.theguardian.com/business/2023/jul/09/us-small-businesses-supreme-court-discrimination

9.Santhanam, L. Majority of Americans reject anti-trans bills, but support for this restriction is rising. PBS News Hour 2023 Mar 29. Available from: https://www.pbs.org/newshour/politics/majority-of-americans-reject-anti-trans-bills-but-support-for-this-restriction-is-rising

10.Ferreira, L. British media 'your bigotry is killing trans people'. OpenDemocracy 2022 Jan 11. Available from: https://www.opendemocracy.net/en/5050/british-media-your-bigotry-is-killing-trans-people/

11.Beaty, T., Farrington, B. and Schoenbaum, H. Transgender adults in Florida are blindsided that a new law also limits their access to health care. AP 2023 June 4. Available from: https://apnews.com/article/florida-transgender-health-care-adults-e7ae55ee634923e6593a4c0685969b2

12.Visslan. How the pandemic has affected whistleblowing. [Internet] 2022 Apr 13. Available from: https://www.visslan.com/en-blog/how-the-pandemic-has-affected-whistleblowing

13.Brown, A. J. Protection of whistleblowers vital during Covid-19. Transparency International 2020 June 22. Available from: https://www.transparency.org/en/blog/protection-of-whistleblowers-vital-during-covid-19

14.Boycott-Owen, M. Government reviewing whistleblowing rules amid record pandemic sackings. The Telegraph 2021 Mar 22. Available from: https://www.telegraph.co.uk/politics/2021/03/22/government-reviewing-whistleblowing-rules-amid-record-pandemicsackings/

15.Rodriguez, C. O. How academia uses poverty, oppression, and pain for intellectual masturbation. RaceBaitr. [Internet] 2017 Apr 6 Available from: https://racebaitr.com/2017/04/06/how-academia-uses-poverty-oppression/
*List of authors

Natalie Stake-Doucet, RN, PhD

Assistant Professor

Faculty of Nursing

Université de Montréal

Jessica Dillard-Wright, RN, CNM, MA, PhD

Assistant Professor

Elaine Marieb College of Nursing

University of Massachusetts – Amherst

Mohamad Hamze Al-Chami, RN, PhD

Postdoctoral Research Fellow, Centre for Research on Health and Nursing

School of Nursing, Faculty of Health Sciences

University of Ottawa

Wendy Gifford, RN, PhD

Full Professor

Loyer-DaSilva Research Chair in Community and Public Health Nursing

Co-Director, Centre for Research on Health and Nursing

School of Nursing, Faculty of Health Sciences

University of Ottawa

Brandon Blaine Brown, RN, MSN, CNL

Clinical Assistant Professor

University of Vermont – College of Nursing and Health Sciences

Lisa Bourque Bearskin, RN, PhD

Cree Métis Registered Nurse leader from Beaver Lake Cree Nation

Inaugural Canadian Institute of Indigenous Health Research (CIHR)

Indigenous Health Research Chair in Nursing, University of Victoria

Past President of the Canadian Indigenous Nurses Association

Benjamin Carroll, RN, MNSc

Doctoral Student

School of Nursing

Queen's University

Kim English, RN, BScN, MN

Professor

Fleming School of Nursing

Trent University

Josephine Etowa, RM, RN, PhD FWACN, FAAN, FCAN, FCAHS

Professor and OHTN Chair in Black Women's HIV Prevention and Care

School of Nursing, Faculty of Health Sciences

University of Ottawa

Jane Hopkins-Walsh, PhD, PNP-BC, RN

Assoc. Clinical Staff Dept. of Pediatrics

Primary Care Longwood Boston Children's Hospital

Evy A. Nazon, RN, PhD

Associate Professor

Department of Nursing

Université du Québec en Outaouais

Ovie Onagbeboma, RN

President

Canadian Black Nurses Alliance

Ava Onwudegwu, RN, MN

Vice President and Director of Academic Relations

Canadian Black Nurses Alliance

Hanna Ouellette, RN, MN

Doctoral Student

School of Nursing, Faculty of Health Sciences

University of Ottawa

Wendy Peterson, RN, PhD, PNC(C)

Full Professor

School of Nursing, Faculty of Health Sciences

University of Ottawa

Margaret Ellen Rauliuk, RN, MN, FCAN

Doctoral Student in distance education

Athabasca University

Birgit Umaigba, RN, MEd, CCRN

Clinical Instructor

Centennial College