Advocating for global health locally: Swedish Red Cross nurses as nursing activists for COVID-19 vaccination

Abstract

The COVID-19 vaccination has created turbulence in many communities. The dilemma has been particularly alive among health professionals such as nurses. As lecturers at the Swedish Red Cross University, whose academic profile is global nursing and global health, we promote the importance of the nursing profession as advocates for the COVID-19 vaccination. The main objective of this commentary is to reflect on the Red Cross Red Crescent (RCRC) fundamental tenet based on its principles in relation to nursing commitment beyond traditional responsibilities in times of pandemic when urgency, reactivity, and pedagogical health education become a priority. The notion of ‘globality’ and the contextualization and modernization of nursing responsibilities are associated with these professional reflections. We conclude that activism and advocacy, on issues crucial to planetary health and the advancement of social justice globally, are the responsibility of nurses. Furthermore, the liability of RCRC nurses is accentuated by the seven principles and the significance of humanity within the global perspective.

COVID-19 vaccination dilemma

Variations on the expression ‘My freedom ends when the freedom of others begins’, coined by John Stuart Mill in his work On Liberty, ¹ have been used by the promoters of the COVID-19 vaccination in reply to the anti-vax movement. This movement is highly heterogeneous. Politically, the far right and far left congregate to contest vaccination. ² Although the anti-vax movement became stronger at the end of the 1990s on the political left, a significant far-right political crusade lately joined the anti-vax movement, declaring, amid various convoluted issues, a sense of mistrust of ‘Big Pharma’ and disbelief in governments as their key motives for vaccine rejection. ³ Demographically, the profile of people avoiding the vaccine recommendation is also varied and complex to identify. However, several studies have attempted to define these groups and the reasons for their hesitancy and even avoidance of the vaccine.^4,5 Several millions of people turned down the COVID-19 vaccination. An anti-vax attitude was more probable among individuals less exposed to COVID-19, aged 49 years and younger, less compliant with public constraints, untrusting scientists, less informed on traditional media, and more worried about the vaccines’ side effects. The reasons for refusing vaccination are multiple and it would be a strategic public health error to consider the motivations of anti-vax individuals as alike. ⁶

Pro-vaccine messages, often spread on social media, aim to increase the awareness of the population on the imperativeness to get vaccinated. These words raise many questions about social fairness and the responsibility of the Red Cross Red Crescent (RCRC) nurses. They also carry a combined double accountability associated with the core components of the nursing profession ⁷ as well as the fundamental principles of the RCRC movement fundamental principles. ⁸ Nurses have the obligation to promote health, prevent illness, restore health, and alleviate suffering. Respect for human rights is vital in nursing including liberties in life, cultural rights, being treated with esteem, and with dignity. ⁷ The RCRC movement's seven fundamental principles – humanity, impartiality, neutrality, independence, voluntary service, unity, and universality – summarize the central characteristics of the movement. ⁸

Working as lecturers and scholars at the Swedish Red Cross University (SRCU), we are systematically pulled into debates by family members, neighbors, and other acquaintances about our opinions regarding the COVID-19 vaccination campaign. People from all corners of society, including healthcare professionals, with diverse socioeconomic backgrounds, life experiences, and scientific expertise are eager to discuss the efficiency and risk as well as hesitancy regarding the vaccine. Disapproval towards the vaccine might have varied reasons, such as a lack of trust in local authorities and healthcare system in general, but misinformation through media also negatively impacts uptake of the vaccination. ⁹ Conflicting and overwhelming amounts of information as well as ‘echo chambers’ on the internet and in the media might also have contributed to exacerbate feelings of obliviousness, fear, and confusion by many, independent of their underlying opinions about the vaccination.^10,11 The comments vary greatly on the spectrum of opinions, such as ‘I do not want the RNA vaccination to modify my DNA… we do not know enough about it’, ‘I am just waiting to see if it is really needed’, or, for the more trusting, ‘We are so lucky that this vaccine was developed so quickly…’ When listening to these statements, we sometimes wonder how we, as health workers, should react to them. This brings us to the issue of freedom of information and speech. Many claim that in a democratic society it is essential to grant citizens with free access to information, and freedom to articulate opinions on government decisions, to not only limit governmental actions, but also to establish a trustful milieu in which public health strategies can be operative. ¹² Furthermore, autonomy is one of the central concepts in nursing that implies that patients can make their own decisions. This implies that nurses must ensure that patients have been given all required information to make that decision. It would be unethical for nurses to influence the patient's choice.^13,14 However, as the individual's right to make its own medical decision is paramount, the critical need of safeguarding the health of the global community remains. Individual and public health are intrinsically related as personal decisions impact the group. Nurses, as promoters of social justice, undoubtedly encounter this predicament in the context of vaccination during a pandemic.

Globalization has brought major cognitive, temporal, and spatial changes on how we perceive the world. ¹⁵ More specifically regarding temporality, the pandemic has raised the issue of preparedness at all levels of society, which involves the concepts of time and therefore urgency, implying how fast we need to adapt. Reactivity is directly linked to the actions within this fast-paced adaptation. In line with this, pedagogical health education in the context of the nursing education at the SRCU relates to the education provided to future nurses and their training. It also encompasses an in-depth understanding of global health needs and the ability to comprehend the necessity for flexibility and adaptability in nursing actions within fast-changing and multiple health needs as was experienced during the pandemic. Consequently, teaching about ‘complex humanitarian emergency’ should no longer be considered a nursing specialty but a necessary and fundamental knowledge for all undergraduate students to act in their future profession at both the local and global levels as advocates for vulnerable populations. Therefore, the main aim of the present study was to reflect on the RCRC movement's fundamental tenet based on its principles in relation to nursing commitment beyond traditional responsibilities in times of pandemic when urgency, reactivity, and pedagogical health education become a priority.

Nurses promoting public and global health as activists

Donovan and Warriner (2017) of the Royal College of Nursing clearly summarize the relation between nursing and public health. They state that ‘nursing should be at the heart of minimizing the impact of illness, promoting health, and helping people to function at home, work, and leisure. Improving public health should be seen as part of all nursing and midwifery roles’. They specify further that ‘Public health is everyone's responsibility and should be a fundamental part of all nursing roles’ and ‘Nursing skills are rightly valued as being able to provide meaningful public health interventions across all health and social care settings as part of holistic patient-centered care’. ¹⁶ The integration of global health in nursing curricula has already been taking place under several decades as the concept of global health is developing with an increasing acknowledgement that global economic, environmental, social, cultural, and political issues impact the health of populations worldwide. Nursing faculties are confronted with the need to prepare future nurses to deliver care and highlight ethical discussions in an increasingly globalized environment.^17–20

Many people wonder if it is acceptable that some individuals risk the health and life of millions based on their own beliefs? Is it ethical and moral not to follow health recommendations, based on individual opinions when global health is jeopardized? This is a pertinent question that needs a careful approach, reasoning and understanding. In the context of a pandemic, nurses have a global public health responsibility in educating people that pathogens do not know borders and that we, all together, as citizens, have a global interdependent responsibility. In line with their professional knowledge, nurses contribute to decrease health disparities and mitigate health inequities globally. ²¹ They play a key role as activists in unifying populations in health when confronted with social injustices worldwide. Nurses’ professional commitment to the local village is crucial, as they must use their ability to impact positively on people's decisions and reactions regarding their health. For activism to be significant within the profession, nurses are obligated to discuss and support each other on crucial issues pertaining to planetary health. In the local community, nurses might lead well-informed dialogues about the benefit of vaccination and act pedagogically and trustfully to follow a democratic path.

Enabling trust by nurses is related to communication, openness, competency, practicality, interest, concern, confidence, and shared control. By being good listeners in caring situations, nurses create a dialogical process. They become accessible and act in a safe, holistic manner as the patient's advocate, establishing faith, hope, and meaning. However, the population may be less prone to be open to professional solutions if nurses are not engaged in a dynamic of trust. ²² Thereto, cooperation and dialogue at the individual level are of most importance to protect public health. No dichotomy exists between individuals and population in this context. A population is made up of individuals, and subjective personal experiences are affected by feelings and a perception of trust. Such core features prompt a sense of being taken care of, having the opportunity to ask questions, relying on the ‘Other’, experiencing safety, and overcoming challenges. Today, democratic privileges must be secured and interlinked with human and cultural rights, an individual’s right to choose, impartiality, and neutrality as clearly stated in nursing ethics and the RCRC movement’s fundamental principles, respectively.^7,8 Thus, nursing responsibilities lay on protecting population health as well as individuals.

The Nordic approach to globality

In the Nordic countries, nursing has been traditionally characterized by caring phenomena, social responsibility, and citizenship as well as promotion of humanity for all. However, awareness about the importance of health issues having global implications needs to play a more significant key role in Nordic higher education. It urgently needs to be reinforced, especially in professional education pertaining to health such as nursing. Besides that, there is a need to raise the issue of the global nursing workforce. In Sweden, and in higher education, it is a strength to have a large and competent student body comprising multiple ethnicities. It has the potential to enrich the educational arena with universal experiences, both at the professional and personal levels. This worldwide human resource should be integrated more systematically for academic benefit. As a concrete example, during the COVID-19 crisis, the Swedish public strategy failed with its public health campaign to communicate information in a culturally literate manner to ethnic minorities. It resulted in a significant excess in mortality compared to the overall population. ²³ For example, a better integration of the knowledge of all nurses, nursing students, and health workers through advocacy and activism towards minorities could have reduced the high COVID-19 mortality in this population.

Advocacy and activism involve social, economic, and political capital

Advocacy and activism are central concepts describing the SRCU profile area.^17,24 Yet, advocacy, defined as an activity that aims to influence decisions within political, economic, and social institutions, ²⁵ is still inadequately unspoken and not sufficiently conceptualized in nursing. ²⁶ In turn, Florell ²⁷ states that activism diverges from advocacy since it involves the outflow of energy with social, personal, and/or political capital. Nursing activism as a concept expands from social contract with humanity and ethics in relation to social accountability, health inequities, and growth in the nursing profession. ²⁸ Furthermore, the Sustainable Developmental Goals (SDGs) framework supports the holistic philosophy intrinsic to nursing and midwifery ²⁹ and they directly connect the nursing core responsibilities, the RCRC strategies, and profile of the SRCU. Nevertheless, nurses struggle daily to connect the SDGs to their nursing role, asking for an intensified boost in education and research, because they feel detached and disengaged from the goals. ³⁰

Activism is a hazardous term to use in the minds of many and even riskier for people working within some humanitarian organizations such as the RCRC movement. For some, the word activist personifies the ‘good intentions’ of self-centered actions with little understanding for the real needs. The operational activities of the RCRC movement rely significantly on the volunteers’ actions to defend and support the most vulnerable. Despite all of this, the term activism is still reluctantly used in the organization, partly by the misguided fear of going against the seven principles and, more especially, impartiality, neutrality, and independence. The term activism sparsely appears in the documents from the International Federation of Red Cross and Red Crescent Societies (IFRC), International Committee of The Red Cross (ICRC), and national societies but was used, for instance, in a IFRC campaign in 2016 entitled ‘16 Days of Activism Against Gender-Based Violence’. In fact, activism reinforces and amplifies the meaning of these principles as it is the act of working to achieve a change with the full awareness and active understanding of the principles.

Overall, nurses constitute a significant percentage of the medico-social workforce worldwide. A parallel can be drawn between the Ebola Virus Disease (EVD) and COVID-19 in terms of ‘out of the ordinary’ nursing environments, apart from the difference in risk between the viruses. In a previous study exploring the complex psychosocial experience of the IFRC nurses upon their return from deployment at an Ebola treatment centre during the EVD outbreak between 2014 and 2015, it was found that the IFRC nurses sustained their duties with high resiliency in a threatening environment as global nurses, advocates, and activists. ³¹ Although many nurses find their profession to be a civic engagement, they often have difficulties acknowledging the vocational and altruistic motivation of their work. ³² The term ‘vocation’ associated with nursing should not be considered a deprecating term but instead a modernized and contextualized one in relation to a wider impact of nursing globally in times of pandemics and future planetary health challenges. Nurses’ vocational skills during the COVID-19 pandemic have proved to be of vital significance and to promote health, which can be a cardinal driver to tackle both social and health inequities. Indeed, a parallel can be drawn between vocation and activism. These two terms show the potential growth of the nursing profession in a fast-changing world. It might be necessary to develop the definitions of those two terms within a nursing context. Therefore, it is critical for nurses to be aware of the broader ethical and humane impact of their professional accountability and how local activities are part of an interactive global effort. Activism is possibly metamorphosing into an integrating part of the nursing profession and even more so for the professional identity of RCRC nurses.

Urgent reflections are needed for the future nursing profession

After weighing for the various public health priorities in a time of pandemics when urgency, reactivity, and pedagogical health education are needed the most, it is time to reflect, expand, and clarify what professionalism is for the nursing profession beyond traditional responsibilities. We have identified that the notion of ‘globality’ and the contextualization and modernization of nursing responsibilities are associated with these professional reconsiderations.

- The nursing profession has a major role to play in a fast-changing world confronted by global challenges that have health issues in common, impacting vulnerable populations in which nurses have a pivotal role as advocates. In this context, it has become critical for nursing programs, in their pedagogical health education, to educate nursing students in ‘complex humanitarian emergency’, which encompasses fast-acting nursing actions in term of reactivity at the local and global levels, already at the undergraduate level, as the need becomes urgent.

- The importance for the nursing profession to fully understand the meaning of ‘globality’ is imperative. As global public health professionals, nurses need to recognize the linearity and interdependency linking the health of the local community to the planet as well as understand how individuals relate to wider groups.

- Simultaneously, the growing complexity of the nursing profession needs to be redefined and well contextualized while it expands to a global arena. More specifically, during a pandemic there is a necessity to ensure nurses’ accountability empowering them to act to the most of their professional capacity.

In conclusion, a call for nursing activism and advocacy on issues crucial to planetary health and the advancement of social justice globally is vital. More specifically, and with this text, we encourage nurses to advocate actively for the COVID-19 vaccination. The liability of RCRC nurses is accentuated by the seven principles and the significance of humanity within the global perspective.