I wish to start this first editorial article for 2021 by paying a small tribute to my wonderful nurse colleagues who have written the editorial articles for Metas de Enfermería throughout 2020, declared the International Year of the Nurse and the Midwife by the WHO, also forming part in the initiative to support the Nursing Now campaign. I would like to share some notes from their excellent contributions, but I recommend reading them carefully (all these articles are free to access, both in Spanish and in English) (1)), because they are undoubtedly enlightening and should determine our road map for the future of nursing.

Adela Zabalegui, as a representative of European Nurses for the Nursing Now campaign, started in the December 2019-January 2020 issue by emphasizing that “Nursing occupies a central position in the entire Health System”, but that “even though nurses represent half of the healthcare staff throughout the world, and provide the majority of professional care, they are often underestimated, and their area of action becomes limited”. In February, Annette Kennedy, the president of the International Council of Nurses, followed by saying that “nurses must speak about what they do, and amend the wrong idea that doctors are the only ones able to save lives”. Florentino Pérez Raya, president of the Spanish General Council of Nursing, stated in the March issue that the healthcare required by our society can only be provided by making the most of the potential of “the only expert profession in care: Nursing”. A intersectoral bet targeted to improve the conditions for training and performance of the Nursing profession in interprofessional teams was pointed out by Lorena Chaparro-Díaz from Colombia (as a representative of the Upsilon Nu Chapter of Sigma Theta Tau International, Honor Society of Nursing) in the April issue. Isabel Amélia Costa Mendes et al. (Nursing Now Work Group from Brazil) told us that “Nursing represents “the lungs” of Primary Care” in the May issue, highlighting that Nursing is essential for universal access to healthcare. In June, Silvia Helena de Bortoli Cassiani et al. (Regional Adviser for Nursing and Health Technicians. Pan American Health Organization) emphasized that nurses “form a valuable professional group in order to overcome the existing inequalities in health” but that “without the investment required in education and labour market, it will be very difficult for countries to reach the Sustainable Development Goals and Universal Health Coverage”.

“During this period, the population has the opportunity to acknowledge the role of nurses in different settings (…) new challenges (the pandemic) open new opportunities”, wrote Elisabete Borges (High School of Nursing, Oporto, Portugal) in our July-August issue. Doris Grinspun (Chief Executive Officer of the Registered Nurses’ Association of Ontario (RNAO)) told us in September: “Don’t call us “heroines”! What we expect is that nurses can be represented in all the decision-making settings (…) Nightingale would demand us to extend our influence on the politic and social setting”. In October, Lisa Bayliss-Pratt, director of the Nightingale Challenge program, presented this challenge as a wonderful opportunity to improve staff recruitment, retention and training, as well as the access to a community for creating networks to share ideas and learning. Sevilay Senol Çelik, president of the Turkish Association of Nursing professionals, told us in the penultimate editorial article of 2020 that those responsible for decision making should not allow nurses who fight against COVID-19 to be alone, damaged, tired, professionally burned out and without hope.

We closed 2020 with Barbara Stilwell, the executive director of the Nursing Now Global Campaign, who left us some deep and extremely important reflections: “The voices of women are not listened to, and as the majority of Nursing professionals are women, the voice of Nursing is not listened to”, “The world will never look at nurses in the same way again. This terrible pandemic has shown all of us that nursing care is essential, offering as usual sophisticated clinical skills, applied with empathy and, maybe the most important thing at this moment, consolation at times of physical and mental pain”.

During the COVID-19 pandemic, the health system and its professionals, which are a key and essential factor, have played an exceptional role, and probably more particularly in countries like ours, where we believed it to be “very good”. Many alarms have been turned on to warn us that “it was not as good” as we thought, revealing deep shortcomings and precarious situations, caused among other factors by the weakening of the public health and Primary Care structure during the last decades.
But it is important to highlight the lack of nursing professionals, with a ratio well below the mean by the OECD (5.9 per 1,000 inhabitants vs. 8.8 (2); according to the WHO, 5.9 million nursing professionals are needed throughout the world (3)). This precarious situation entails serious consequences, and it will continue like this if no solution is found, because nurses have demonstrated that they are essential professionals in hospitals, and particularly at the Intensive Care Units, handling the respiratory support that has become so indispensable. However, their work is also very important in the community setting, because nurses are responsible for conducting vaccination, diagnostic tests (PCR, rapid antigen tests, etc.); they carry out close contacts tracing, particularly among people living together, they are in charge of health education for an adequate quarantine and isolation, and they have provided emotional support in all settings and scenarios, for patients and relatives faced with fear, panic, suffering, despair and death. I am absolutely sure that without nurse action during 2020, many of the persons who have survived COVID-19 would not had been able to, and that many more people would have become infected. However, I also believe that all these achievements have not been quite visible, and that there has been lack of presence and leadership to highlight the importance and give due recognition to the contribution of nurses during the pandemic.

We cannot forget that, as a social health inequality, COVID-19 is triggered and made worse by other social determinants of health, besides the health system we have already mentioned, which lead to an increase in vulnerability (4). We have seen this disease having a higher impact on poorer people, living in more disadvantaged settings, in overcrowded conditions that prevent adequate isolations and quarantines; also, on those who hold essential jobs which require their physical presence and therefore need to travel by public transport, where safety measures are often not guaranteed; many of these persons are immigrant, and there is also a high proportion of women (5).

Faced with this overall situation, we have witnessed a systematic exercise of blaming, discrimination and stigmatization, attributing the higher burden to individual behaviours: “they are not doing things well”; without noticing that in order to control and eliminate this devastating pandemic, besides having a public health system with universal coverage, contemplating all life stages and targeted to promotion, prevention, healing, rehabilitation and reinsertion, the solution consists in addressing the structural social determinants of health, that is to say, developing intersectoral policies based on social equity and justice.

Well then, within this high-complexity scenario, we nurses must act, of course, by offering our excellence care to persons, families and community; but we must also open our eyes, expand our roles, widen our scope, and that is why I vindicate public health nurses and epidemiologist nurses, areas where we can be experts and leaders in order to face this pandemic and its deep social health inequalities.