The best of times and the worst of times


30th Anniversary Invited Editorial reflecting on Henderson V. (1986) Some observations on health care by health services or health industries. Journal of Advanced Nursing11, 1–2

‘For nursing this is the best of times and the worst of times’, so begins Virginia Henderson's Editorial in JAN 30 years ago, and I use the same words now as they describe nursing in the first decade of the 21st century, three decades later. So, has little changed? Was the legendary Virginia Henderson completely right? Or totally wrong? Has little happened in these 30 years? What about health care? Surely that has improved over this time? We have seen great improvements in many areas of health: we have seen many countries eradicate polio; treatment for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is now available; and new and effective treatments help people with many cancers and also with cardiac disease. However, we also have seen mortality rates rise in many developing countries as the scourge of HIV/AIDS, tuberculosis (TB) and malaria prove so hard to check, and there is a pandemic of chronic illness which is affecting not only the richest countries. Sadly, the end of the 20th century came and we did not see fully realized the goal of ‘Health for All by the Year 2000’ and, 5 years later, WHO has not reached its less ambitious target of ‘3 by 5’ to provide treatment by the end of 2005 to 3 million people with AIDS.

And what about nursing? Nursing today is on the world stage in a new and very exciting way: every health minister talks of nursing in a way that would not have been happening 30 years earlier. Why is this? Not primarily because of our great achievements over these past decades (although there are many), but because of the severe shortage of nurses in so many countries. Nurses are leaving their jobs and often their countries, and few countries in the world now have an adequate nursing workforce. Yet nurses in many countries have seized opportunities to expand their roles, to prescribe, to offer telephone triage, to diagnose and treat. Patients everywhere are seeing better educated nurses in strong and influential roles. In Africa, public health nurses are crucial to the survival of rural communities. Our frustration is great because, within many of our healthcare systems, we too often find ourselves unable to provide the care we believe is needed.

Virginia Henderson believed that nurses must be able to make health prevention a priority in their practice, and she wanted us to bring health education into all schools and especially to give people their own health records. She was, of course, quite right, but more progress has been made with records than with health education. Citizens have access to much more health information, particularly through a more open culture, and I found it exciting to talk to nurses in the countries of the former Soviet Union who are able now to develop patient information systems. One of several exciting projects led by the International Council of Nurses (ICN) has been to provide mobile libraries to be shared among the clinics and rural hospitals of Africa. Now, for a relatively modest cost, nurses working far from a library or the Internet can access the information they need in order to give their patients current information and treatment. Even the poorest countries are seeing the development of patient self-help groups, some of which are very strong. The many changes in the way information is handled have made it easier to give people more information: indeed, it is inevitable. However, this has not automatically given the majority of people more control over their own health or better access to good quality health care.

The Oxford Health Alliance, based in the UK (, has shown that three risk factors – smoking, physical inactivity and poor diet – cause the four diseases that account for 50% of deaths worldwide: namely, diabetes, cardiovascular disease, cancers and respiratory illness. As globalization brings similar patterns of consumption to all countries, chronic diseases are rising fastest among the better-off in poor countries and among the least advantaged in the rich countries. Nurses need to mobilize resources to help people choose healthier lifestyles – and there are many excellent examples of such initiatives. But nurses also need to be able to influence policy decisions in areas outside health care with regard to issues such as healthier school meals, safe play areas in housing estates, cycling tracks and safe water supply. However, to have that level of influence, nurses need to be educated and listened to, and there need to be enough of them.

In those countries where malaria, TB, and most of all AIDS, are devastating the population, nurses are often the only people holding together a community, and nurses' families are often swelled by the addition of orphans. In hospitals, nurses work with too little protection for themselves, and too little medicine or equipment to care for their patients and, when colleagues leave or die, they are often not replaced. Nurses and midwives know how to encourage preventative measures; they know how to encourage testing and treatment; they can encourage the use of malaria nets and treatment for TB. To effect change, nurses again need to be educated and listened to, and there need to be enough of them.

As President of the International Council of Nurses ( for the past 4 years, I have had the opportunity to see nurses at work in some 50 countries across all continents. I thought I would be shocked by the differences I found between nursing in different countries, but I was surprised by the similarities. Of course, the countries varied enormously: some rich, many poor, some ravaged by war, others newly emerging from oppressive regimes, some where famine and disease were everywhere, others where sick people could only be seen in gleaming new hospitals. But in all 50 countries I visited, nurses had the same three basic problems:

  • • Everywhere nurses are relatively poorly paid.

I met nurses paid just a few dollars a month and nurses who were not being paid regularly or at all. I also met nurses who were very well paid by any standards but, even so, paid less than those undertaking low skilled jobs in their own country.

  • • Everywhere nurses feel they are too few to care properly for their patients.

Linda Aiken from the University of Pennsylvania has shown how, in the USA, UK and Germany, higher staffing levels and better educated nurses give better patient outcomes (e.g. Aiken et al. 2002). We need to use that evidence more, and we need similar studies in the poorer countries.

  • • Everywhere nurses want a stronger say in health policy.

Doctors, politicians and administrators still take most of the important decisions in health care, at the local hospital level and at government level. Rarely are nurses able to affect significantly the system in which they care for patients.

Most nurses are women, most women are mothers. The health of any community is proportionate to the education of women. ICN launched in May 2005 a charity ( to provide education for the orphan daughters of nurses who have died. We know that in Africa, girls who go to school marry later and their children will be healthier, but that for a poor family it is usually the girls who are taken from school in order to save money and to look after the family. For just £120 a year we can make a difference not only to one child, but to the future generation. The poor position of nurses in many countries, both rich and poor, is linked to the position of women. There is some optimism, however, with a nurse as health minister in Botswana and South Korea, and many nurses holding political office in countries around the world.

For nursing this is the best of times and the worst of times. How can we shift the balance more positively? We nurses need to work together: it is difficult when resources are insufficient and when so much needs to be done, but we do not have time not to work collaboratively. We need to find allies: most of all among patients, citizens, and patient groups who should be our natural allies. It is essential that nurses listen to patient opinion, especially when it is critical, as informed patients will rightly expect to meet nurses who are both competent and caring. The strength of popular support for nurses is because patients generally do receive the care they need, but that support should not be taken for granted. We also need to collaborate with doctors who see the importance of nurses to their patients and will support our cause.

The International Council of Nurses’ vision is to harness the knowledge and enthusiasm of all nurses to lead our societies towards better health. Working together we can promote healthy lifestyles, healthy workplaces, and healthy communities. And then we will see ‘the best of times’, not just for nurses but for the people of the world.