Towards the Concept of Global Health Nursing

Nuruddeen Adubakar Abamu^*
*Correspondence: Nuruddeen Adubakar Abamu, Department of Nursing, Ahmadu Bello University, Zaria, Nigeria, Email:

Introduction

Global Health Nursing (GHN) is an area of study, research and practice in nursing that places a priority on improving health care of the people and achieving equity in health for all people worldwide. It also seeks to understand how diseases and illnesses are managed by the nurses in many countries and how effective nursing care can be rendered to the clients across borders in meeting the health challenges of people in the world globally. With increasing globalization, emerging diseases, shifting health concern and growing health inequities among and within countries, all nurses around the world need skills to address complex global health challenges [1].

Furthermore, GHN reflects an important evolution in thinking about health issues around the world and how nursing can impact on the global health challenges. It tends to provide knowledge on how nurses can meet up of those threats in care of patients and also shows how to influence policy in the care of clients/ patients, family and the community at large. Moreover, GHN describes health related nursing work; seeks to address different issues and concerns of nursing across borders; and identifies and analyzes why nursing care in can transcend national borders class, race, ethnicity and culture. In this paper, the author seeks to: Explain the meaning and concept of global health nursing; explore and highlight the effects/relationship between globalization and population health; give the general overview of global health and nurses role in the promotion of the health and wellbeing of the people globally; and, explain the need for global health nursing and global health nursing activities.

Research questions

i. What is global health nursing and its concept?

ii. Do nurses have influence in achieving and maintaining a good health and health equity globally? And how research and innovation in global health nursing can improve nursing practice?

iii. What role should nurses play in international and global health and How can nurse impact policy related to global health issues?

iv. How does nursing fit into a globalized world and how do I become a global health nurse?

Methodology

This review assesses available evidences, both published and unpublished, on issues relating to the global health nursing and the nurses role in global health. The review is qualitative based and commentary.

Discussion

Who is a global health nurse?

A global nurse is a generalist practitioner with expertise in the areas such as public health, epidemiology and research, who culturally sensitive, collaborative and knows that condition like heart diseases, cancer obesity; diabetes and infections have no borders. A global nurse knows that what happens in one part of the world affects the populations, also understand burden of disease and his/her role on the aspect. A global health nurses will need to embrace change and be an important part of its advancement while ensuring their fully participation in providing solutions for the identified problems for a sustainable future [2].

Purpose of global health nursing

Global health nursing aims to provide nurses and students an opportunity to be aware of different cultural practices and how this affects the health of the population when connecting this to the socio-political, economic and environmental aspects of the population health. Health care professionals are interlinked and interdependent globally and having similar problems and challenges [3]. Global health nursing has a major role in providing solutions to some of these shared global health challenges. This also gives the nurses information and knowledge about the burden of diseases and how to provide and effective nursing care for them. Moreover, global health nursing is also aimed at mobilizing partnerships and resources to facilitate nurses’ contribution, creating and information resource center and promoting policies that strengthen the role of nurses in global health, emphasizing on health equity and programming.

Looking at international and global health as it relates to clinical health problems giving much attention to the identified health issues e.g. poor health, diseases and pathology, without focusing on the origin, causes and predisposing factors of the issues (e.g. economic, social and political elements). Focusing on the origins of international and global health issues requires an analysis of the political economy of health and an understanding of the structural issues which underpin health and social issues.

How can all nurses (who are excellent clinical practitioners) expand their role to become human rights advocates, political activists, engaged citizens and critical artists for global issues? Acquiring these roles requires nurses to have a sound understanding of globalization and the political economy of health, as well as a solid knowledge base in human rights and global health diplomacy [4].

Principles of global health and its impact on nursing

Principles provides rules and guidance on global health issues, they also help in making health policy. According to the US government global health principles, monitoring and evaluation resources guide 2014, there are seven core principles to guide how their government engages in global health. These core principles are derived from the principles outlined in the Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008). The women, girls and gender equality principles aims to address gender related inequalities, inequities and disparities that disproportionately compromise the health of women and girls and in turn affects families and communities.

This principle guides nurses in addressing women’s health issues in the country and in the world at large. The government gives priority to women and girls comprising adolescent and teenage girls in the planning, implementation and evaluation of health and initiation programs and policies. Leffers, et’al 2014 assert that global health nursing principles could provide the following amongst others [5].

• Assisting in scaling up global health programs through development of and nurturing inter professional health care team.

• Expanding the nurses role in developed countries and into many areas of the globe, nurses are in extreme need of mentoring and networking with their colleagues within and across borders (globally).

• Strengthening health policy development education and teaching to increase future nursing competency in policy making issues on health and illness.

• Providing the nurses with competency in concept of community health to support global health work that transcends borders.

• Creating partnerships with patients is a core nursing competency and a key component of patient-centered health which can be harnessed to uplift patient power in policy making.

Overall, nurses must take advantage of opportunities to fill the gaps and needs of the fragmented health care system around the world not only in their own countries alone.

Why global health nursing?

There are several reasons why Global Health Nursing (GHN) is considered an emerging driving force for change. Global health core concepts include the improvement of health, achieving health equity in health for all people worldwide with emphasis on the transitional health issues and health determinants and solutions; involves many disciplines within and beyond health sciences and also promotes interdisciplinary collaboration [6]. These core concepts of global health provide a clear view of why nurses are needed in global health as they help in promotion and improvement of health and because they represent the largest group of healthcare workers globally with almost 34 million nurses (WHO, 2007). This is because nurses already have these concepts engrained in both training and service. Global health nursing goes beyond the intervention to care for a patient with a particular health problem. Moreover, health is interconnected to the political, economic and social context. Therefore, this explain the need for multi-professional and multisectorial approach to achieve the goal of global health by improving the health for all people by reducing preventable diseases, disabilities, placing a priority on improving the health and achieving the equity in the health of populations globally also reducing mortality/death.

For instance, Sultan and Khan in Upvall and Leffers (2013) cited the need to use a more collaborative approach by medical, nursing and public health professionals to effectively eradicate poliomyelitis in Pakistan and Afghanistan rather than working individually [7]. Despite ongoing campaigns to eradicate it, efforts to control poliomyelitis may be more successful if both medical, nursing and public health professionals used more collaborative approach to address this health challenge rather than working alone. According to WHO nursing and midwifery progress report 2008-2012 (2013), member states have long acknowledged the essential contributions of nurses and midwifes in improving the health outcomes of individuals, families and communities globally.

World health assembly resolution WHA62.12 on Primary Health Care (PHC, 2013) emphasizes Health for all improvement, including health system strengthening; thus, recognizing nurses around the world as frontline services providers engaged in the effort to renew PHC, based on the core values of “equity, solidarity, social justice, universal access to efficient and affordable services, multi-sectorial action, decentralization and community participation” [8]. Lastly, there is now an evolution on the role expansion and involvement of nurses around the world in addressing emerging global health issues such as mal-distribution of health workers, health inequity preparedness and triple burden of diseases to name a few [9]. Recently, several organizations have started to do some initiatives and projects to raise the voice of nurses and empowering them in the context of global health. For instance, the International Council of Nurses (2017) recently launched during the International Nurses’ Day the theme entitled: “Nurses: A Voice to Lead, Achieving the Sustainable Development Goals (SDGs)”.

This along with a resource and website aimed to spread the awareness and empower the profession in contributing to achieve the 17 SGDs. Similarly, in the UK, an All-Party Parliamentary Group on Global Health co-chaired by Lord Nigel Crisp (2017) launched a 3-year global campaign called Nursing Now! which aimed to help promote nurses’ influence, the valuable impact of the profession around the world, a way to empower women and establish the effect of “Nursing-in-all” Policies. This received positive feedback and support from major healthcare stakeholders such as WHO through Director-General Dr. Tedros Adhanom, ICN and others.

If nurses are to expand their contributions to the care of patients around the world and in helping to meet the goal of global health is enormous and this clearly explains the need for global health nursing or why global health nursing. GHN helps combine the knowledge, skills and attitude with general health and nursing-specific context around the societal, political, economic, cultural and environmental aspects of the situation to effectively manage and address key health issues across borders and geographical regions. This in effect will further increase health outcomes and overall cost-effectiveness of health services. If nurses will expand their knowledge in field of global health it would provide a greater outcome in the provision of care to the patient and in their various communities around the world. As such it is recommended that every nurse around the world must have knowledge of global health for better practice and quality care to patients and in meeting the world health challenges.

Global health nursing threats

With the advent of globalization and modern technologies, nursing role is becoming more diverse and less traditional. Due to globalization, nurses’ role in the health care industry has become enormous and sometime very challenging. Nurse’s responsibilities are now more than caring for the sick individual, families and communities but rather also thinking of all ways to improve the total health of humanity/populations globally. The WHO raises the alarm for the global shortage of nurses and doctors, approximately 4.3 million nurses and doctors. However, this shortage is worsened by the imbalance between the availability of health care practitioners and the global burden of diseases. It also states that the sub-Saharan Africa has the lowest density of nurses and doctors and therefore having the highest burden of diseases in the world. The 2010 WHO Code of Practice on International Recruitment of Health Personnel highlighted these problems which are all said to be worsened by migration.

Example: infectious diseases like pulmonary tuberculosis. Most nursing education does not prepare health threats in the community or around the world. Nurses role in preparing for the threats from new diseases and lack of preparedness to responds to pandemics of potentially catastrophic proportions. However, no matter how we live and where we live, our wellbeing indirectly depends on how health issues are managed around the world. Global Health Nurses need to be aware of this because of the following which contribute to the change in the health of the peoples globally.

i. Travel and migration: Most frequent health problems associated with travel and migration include accidental injuries, malnutrition poor personal hygiene and vulnerable individuals, especially children are prone to respiratory infections and gastrointestinal illnesses because of poor living conditions, suboptimal hygiene and food and sleep deprivation during travel and migration.

Travel and migration can also provide a means of transferring communicable diseases from one country to another.

An undetected infectious disease can easily spreads across border if necessary actions were not taken. This has been a challenge usually in developing countries where proper screening of the immigrant were not done appropriately before entering into a country.

i. Globalization of trade: Although globalization of trade is certainly good for the economy, but it leads to a globalization of health risk. Globalization of trade, marketing and investment has important implication for global health, both negative and positive.

The WHO has estimated that by the year 2020, non-communicable diseases, such as cancers, diabetes, obesity and cardio vascular diseases will cause about two-thirds of the global disease burden, up from 40% at present (WHO, 2013) [10].

This rapid increase again illustrates the globalized risk for condition that are mainly caused by diet and lifestyle conditions for examples; cheaper fuel prices on environmental and human health even less in developed countries that have coexistence under nutrition this can all be attributed to globalization and trade.

i. In adequate public health infrastructure: Essential health services can only be provided effectively when there is a good or standard public health infrastructure in order to carry out its core functions with uniform effectiveness to the members of the populations in any country.

However, when the infrastructures of the systems are weak, inconsistent, or deficient, the system’s ability to function is at stake such as poor or lack of primary health care infrastructures in the communities where they need them.

i. Urbanization: Urbanization affects human health in several ways, from dietary patterns to the physical environment although it allows more accessibility to health services but in the other hand it creates a considerable health hazards which includes inadequate water and sanitation, limited or no waste disposal and poor air quality due to overcrowding.

Global health nursing activities in the developed and developing countries

Global health nursing activities deals with the roles of nurses whose main focus is on the promotion of health, health safety, prevention of diseases and injury, population health assessment, health surveillance as well as management response and emergency preparedness. It also converges health and illness experiences of individuals, family and communities to global health nursing promotion practices.

There are various differences between developed and developing countries in terms of global health activities. In developed countries like Japan, major changes are taking place. For one, the Japanese Community health nurse includes significant development in employment, education and roles of global health nursing. Demographic and economic factors have prompted the Japanese government to focus on health service delivery on community-based care particularly for the growing elderly population. Community health nurses are redacting their roles and are assuming important function in planning, implementing and evaluating community health program for the elderly.

The Japanese are using a variety of health promotion strategies to initiate change at the local level. In another country, the Community Health Nurses of Canada [CHNC 2011] a volunteering association of community health nurses, contributes in many important ways for improving peoples’ health in the community. They are leaders of change in the society that support health and play a vital role in disease and injury prevention, as well as health promotion. Public health/community nursing practice is guided by the Canadian Nurses Association’s (CAN) code ethics. Nurses in all domains of practice bear the ethical responsibilities identified under each of the seven primary nursing values (Canadian nurses association code of ethics 2017):

• Providing safe, compassionate, competent and ethical care.

• Promoting health and well-being

• Promoting and respecting informed decision-making

• Preserving dignity

• Maintaining privacy and confidentiality

• Promoting justice and being accountable.

• Work with people to enable them to attain their highest level of health.

They fulfill this role by working toward the goal of health for all and by providing access to service. Their activities include: Advocacy; building capacity; building coalitions and networks; care and counseling; care management; communication; community development; consultation; facilitation; health education; health threat response; leadership; outreach; policy development and implementation; referral and follow up; research and evaluation; team building and collaboration and others. Because of the presence of adequate facilities and sufficient equipment (CHN 2011).

The community health team finds it easy in providing health service of the community which in contrast with the developing. In contrast, Global health nurses activities in a developing country like Nigeria, this include health service to individuals, families, and communities which involve promotion of health, alleviation of sickness, maintenance of health and health education. There are several health indicators used in assessing the status of a nation, including health E.g. maternal morbidity and mortality of a nation.

When these indicators are measured in African population, it becomes clear how poorly Africa is doing. A common problem one encounters is the absence reliable data/statistics for doing so. Even though the community health nurses in Nigeria, for example, has the same aim with the Canadian nurses, the former encounters a lot of problems in doing so which include cultural practice, poor infrastructures, over population, and low life expectancy, bad drinking water and lack of advance technology.

Moreover, in developing countries, the global/public health nurses focus on treatment of disease help in prevention of it transmission to unaffected individuals mostly by immunization and health education on how to live a healthy habit and maintenance of good health with the available resources.

Thomas Quinin notes that: global health nursing incorporates multiple disciplines, interdisciplinary approaches to solving the health problems of the world [9].

It is not limited to one field it belongs to all fields of expertise directly or indirectly related to health care and health wellbeing for all people.

New challenges and opportunities for global health nurse

As all health practitioners faces some challenges in one way or the other, Global Health Nurses as part of the health team also faces many challenges such as reforming and designing of effective system of health care delivery.

I. Global technological advancement:

Advancement and complexity in technology in nursing are intended to help nurses to practice easier and has went a long way to reduce or take away nursing errors in the management of patients. Global health nursing also caters the health needs of the population, whether in acute (hospital) or at the community setting. However nurses need to be aware of the new developments in the fields of technology around the globe to standardize their practice.

Technology continues to assist nurses and other health practitioners in developed countries to provide quality care and improve outcomes for the patients. Although information technology does not eliminate the need for professional judgment; but nevertheless, human beings are bound to make mistakes at all course of delivering health care services and the management of patients with different health needs. Ergo, nurses are also prone to make mistakes and those mistakes can however be prevented. Most common mistakes committed by nurses include the following amongst others: Documentations/charting errors, medication errors, iatrogenic infections and others. All these practices are detrimental to the patients and the population at large. However, among all the nursing errors occurring in the treatment of patients on hospitalization or at the course of delivering any health services medication error is the most important as it causes a serious problem to patients undergoing treatment, meanwhile the clinical concern is increasingly in the response to this complex.

Patients in a hospital experiences at least one medication errors (WHO, 2016). Prevention of medication errors has therefore become a high priority worldwide. There is mounting evidence that systems that use information technology are key components of strategies to prevent medication errors globally.

I. Scaling up of a global health nurses capabilities:

In an attempt to achieve health for all and provide health equity globally, I think nurses must be involve in research, community assessment, planning, implementation, management, evaluation, emergency response, health policy, advocacy and legislations.

Nurses must be aware of the health challenges of many countries, such as communicable and non-communicable diseases (double burden of diseases) and how these globally affects people and also beyond the present situation (i.e. other health problems that may be either due to war, violence, accidents and so on - triple burden of diseases).

Gagnon (1994) described how home care service providers like nurses faced many challenges in the United States and globally, ranging from estimating financial implications and calculating potential caseloads which are complex factors in the design of effective health delivery systems. Inadequate hospital assessment, insufficient discharge planning and referral, restrictive or irrelevant policies regarding eligibility, failure to discharge clients from unnecessary home care services; and an inability to find less costly services as client gain independence are other significant variables. Preparing nurses for roles in global health can contribute to saving lives by improving health throughout the world.

I. Women’s health:

As new health trends emerging globally both in care and management of women’s health conditions. Nurses need to develop and improve critical skills in the field of obstetric care and gynecology to improve the standard of rendering effective and sensitive care for women in all ramifications and across the lifespan with emphasis on conditions unique to the woman.

Nurses should also render supportive services, explore more additional knowledge in their fields to improve evidenced based practice and know how women’s health problems are treated globally with scientific evidences.

In improving the quality of care for women, nurses must work with other health professionals like midwifes, gynecologist and obstetricians to achieve a common goal.

A study conducted in Bangladesh has shown that complication during pregnancy and parturition increased the risk of perinatal death fivefold and accounted for 30% of perinatal mortality. This shows the need for the advancement of nursing and midwifery services and global health nursing education all over the world to reduce the global perinatal mortality. Women health nurse is delegated with the following responsibilities in delivering a range of acute to chronic, preventive health care services like:

• Gathering important health history which includes a comprehensive obstetric and gynecologic history with emphasis on gender based differences.

• Directly examining the women obstetric and gynecologic conditions/ needs that include pregnancy, contraception, sexually transmitted infections, infertility, premenopausal menopause, post menopause and other gender specific illnesses.

• Assessment, diagnosing and treating diseases, risk factors peculiar to women.

• Identifying female gender variations in manifestation and progression of health problems and responses to pharmacological agents and other treatments.

• Assessing social and physical environmental health risk/threats that have impact and influence on health and child bearing which includes teratogens etc.

• Finding out if there is any evidence of intimate partner violence, sexual abuse and substance abuse.

• Collaborating with other health care providers for management or referral of high risk pregnancies.

• Women health nurses globally helps in proving management and education for women and men in need of family planning and fertility control.

I. Child health and survival:

It is estimated that 15% of women will develop a potentially life-threatening complication during pregnancy or childbirth. Rather than investing in predicting which women or new-borns will have life-threatening complications, maternal mortality reduction programs should recognize the principle that every pregnant woman and newborn baby is at risk for life-threatening emergencies (WHO, 1996). Nurse’s role here is of enormous importance in providing maternal and child health services to aids in reducing or preventing complications.

I. Advocacy in global health nursing: this has been a challenge especially in developing countries for nurses globally:

According to the Oxford dictionary (1884): An advocate is one who publicly supports, recommend or depends a particular cause or policy. The general role or goal of patient advocate is to protect his rights.

When people are ill they are frequently unable to assert their rights as they would if they were healthy. Nurses need to provide advocacy for their clients globally in building alliances and communicating ideas and best practice. Nurses who function responsibly in advocating for patients benefits in the developing and improving public health policy at many institutions and government levels and sectors help in achieving a better health system for the populations.

I. Health system strengthening and global health nursing:

Health System Strengthening (HSS) in global health using multi-sectorial action, equity based approach is one of the WHO agendas. Good health services are the one which can provide safe, effective, quality and personal and non-personal health interventions to the population in need and where needed (WHO, 2000)

Ultimately Health System Strengthening (HSS) emphasis on helping countries saves live. Proven cost effective intervention and technologies for combating disease are more likely to be effectively delivered and sustained in the presence of high performing health systems. Through HSS, the U.S government seeks to maximize and sustained its longstanding and continuing investments in the health sector, there by adding valve to its own investments and those of other actors including country governments, other donors and private sector.

The following are required to strengthen health system for better health services according to WHO health system framework (World health report (2000):

• A well-functioning health management information system- this provides the health care system with proper dissemination, analysis and the use of timely information on health determinants, health system performance and health status.

• A good health system should provide access to essential medical products, vaccines and technologies of standard and reliable quality for effective delivery of the health care services in the community.

• Good health financing- the system should provide a means of raising funds and financing for health in the ways that ensures the masses can have access to the services they required. Incentives can be given to both health care providers and the users to be efficient and to serve as a motivation for them.

• Good leadership and governance- good leadership can ensure strategic policy frame work exist within the health system. It helps in building, regulation and moderation the health policy and also ensures accountability in providing health care services.

I. Promoting global health nursing partnership:

This help in expanding the access to health services, partnership can be an integral part of reaching objective since not one donor organization or partner country can address all health needs. Governments strive to work with a variety of different partner to achieve health outcomes more effectively and efficiently.

To see progress sufficiency in global health nursing and to reduce mortality and morbidity to attain health equity global partnership must be advanced and promoted. Developing countries must be able to take and lead own solutions and should be supported by international and local partnerships based on mutual respect and solidarity. The developed states, such as the United States and others should see the possibility of having global employers to the massive scaling up of training, educating and employing health workers in developing countries to help to increase the capacity building of the nation and empower all health sectors and groups/ organizations of their national human resources for health. Not only systematic spreading of good practice should be advocated, high use and utilization of information communication and biomedical technology must be given priority.

Gaps in research utilization plays a huge factor in building health partnerships Intensive research and evaluation of some implemented programs should also be done. Although there has been an enormous international efforts over recent years to address the issues but, however it is not the same as it applied to other countries due to some policies that might affect the implementation of such. Government, non-governmental organizations and other private industries should influence more international partnerships in global health nursing and initiate some programs and also make funding available.

I. Integration of health care:

This principle lays emphasis in the collaboration between health professionals to provide complete treatment to patients and clients and improve overall wellbeing. The term integrated health care often referred to as inter-professional health care according to American physiological association.

The integration and different health activities contained within the health care sector (family planning counseling at an HIV and AIDS facility and immunizations programs at an antenatal care facilities are just a few example and in other sectors (health into water and sanitation, education, food security, agriculture, economic growth, microfinance and democracy and governance) can provide high outcome for health and nurses play important role in the provisions of those services globally this are the nurses vital roles in intra and inter-sectorial approaches to health.

I. Research and innovation:

Research and innovation is a key for growth and development in any country. In an attempt to improve the global health and global health nursing care services of any country around the globe, investment in research in research must be given the highest priority.

Achievement of the US government goals requires innovative translation of investments in health research into real and measurable health outcomes. This principle encourages innovation along the scientific continuum which is reflected in the full range of US government under research [10].

II. Improving monitoring and evaluation in global health nursing:

The effectiveness of any health services can only be assessed through good and intensive evaluation; this provides feedback and helps to identify the progress of the intervention carried out. Monitoring and evaluation should be incorporated throughout the program process, beginning with needs assessment and program planning through routine monitoring of implementation with a robust evaluation agenda

Conclusion

This article argues that there is a need for global health nursing and also explained the concepts of global health, why global health nursing and its impacts in the health promotion worldwide. However the effectiveness of global health nursing practice and education can go along in promoting and enhancement of the health and population worldwide and can be strengthened or build up by providing:

✓ The avenue for increasing global health nursing partnership and capacity building for nurses globally.

✓ Global nurses’ involvement in policy making and in leadership positions and supporting global health nursing research, innovations and integrating globalization with the population health and the triple burden of diseases.

✓ Adequate public health infrastructure to meet up with the global health challenges which would support global health nursing care and practice.

✓ Funding for global health nursing initiatives and education that could yield or promote the reduction of global burden of diseases especially in low and middle income countries.

✓ Awareness on the importance of global health nursing among both practicing nurses and nurses’ academicians.

Recommendation

Global health equity can be accelerated and increase drastically if the profile of nursing and nurses will be raised and enable nurses to be aware of global health issues so as to enable them to work to their full and maximum potential, if countries around the world are to achieve universal health coverage, achieve greater health outcome and wellness.

The following are recommended for further study in global health nursing: (1) how government and other agencies can contribute in raising the profile of nurses and nursing globally. (2) Supporting global health nursing education and employments globally while involving nurses in leadership and policy making. (3) How to strengthen and promote partnership in nursing and in global health and how to develop global strategies to meet the global health nursing needs and concern.

Acknowledgement

None.

Conflict of Interest

None.

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