NCM 120 DECENT WORK EMPLOYMENT
AND TRANSCULTURAL NURSING NCM 120
Topics:
 Introduction to Global Health
o Lack of Human Resources for Health
Globally
o Task Shifting
o Traditional Medicine
o Global Health Disparities
 Millennium Development Goals
 Key Concepts in Global Health and
International Nursing
o Partnership
o Sustainability
o Availability, Accessibility and
Acceptability
 The Global Public Health Sector
 The Nurse in Global Public Health
 Preparing for a Career in International
Nursing and Global Public Health
 Other Nursing Roles Internationally
INTRODUCTION TO GLOBAL HEALTH
• Global health is the constellation of
challenges to and opportunities for health
and well-being that transcend national
borders; have broad socioeconomic and
political impact; and are best addressed by
coordinated, multinational efforts (Holtz,
2013)
• The state of global health results from
historical processes and contemporary
international relations and is felt at the
individual and community levels through the
lens of local culture. Regardless of where
nurses work, global health issues will have
an impact on their work to some degree.
This was particularly evident during the
2014 Ebola outbreak, where nurses in many
countries faced varying degrees of personal
and institutional readiness for a disease that
had once been largely confined to one
region of the world.
• Lack of Human Resources for Health
Globally
– Trained health care providers are in
high demand all over the world. The
countries with the most critical
shortages of health care professionals
are found in Central and South
America, sub-Saharan Africa, and
South and Southeast Asia (Taylor,
Hwenda, Larsen, & Daulaire, 2011).
Three major processes contribute to
the shortage of health care workers,
including nurses: insufficient
supply, inadequate distribution,
and migration (Kasper &
Bajunirwe, 2012).
– Programs aimed at increasing the
number and capacity of nursing
education programs, especially in
underserved areas, attempt to address
the problem of insufficient supply.
– In order to address the problem of
distribution, providers spend a
certain period working in
underserved areas, some countries
require that trained before they can
move to larger cities; other health
care systems assign nurses,
physicians, and other health care
workers to specific posts based on
need.
– The problem of migration of health
care workers, especially nurses and
physicians, to higher-income
countries, however, is considerably
more complicated; this problem is
colloquially known as “brain drain.”
• Although there is broad agreement that this
movement of professionals has a net
negative impact on health care at the local
level in sending countries, there is some
debate as to whether it is positive or
negative on the global scale.
• It is reasonable for individuals to choose
to live and work in a place where their skills
are recognized with higher income, and they
are able to have a higher quality of life. For
the countries that are the most frequent
targets of health care worker migration, the
influx of skilled workers provides some
relief for national health care provider
shortages. Migrants’ countries of origin
benefit when expatriate health care workers
send back part of their earnings to support
family members who remain in the sending
country.
• The term expatriate refers to a person who
is temporarily or permanently residing in a
country other than that of his or her
citizenship. The remittances sent by
expatriates or migrants are frequently used
for spending on consumer goods and
construction, which results in an increase in
tax revenue for the sending country. In
theory, this would then increase the amount
of money available for government
investment in health and education, among
other benefits
• In response to this human resource crisis, the
WHO worked with bilateral and multilateral
development partners, governments, and
private sector and professional organizations
 to form the Global Health Workforce
Alliance in 2006.
– These strategies include task
shifting, improving workforce skill
mix, accreditation of community
and midlevel health care workers,
and improved work environments
to increase worker retention
(Taylor et al., 2011). Other
organizations have also established
internal regulations and codes of
conduct regarding recruitment of
local health care workers (Kasper &
Bajunirwe, 2012).
TASK SHIFTING
• Task shifting, a process wherein tasks
usually considered part of the scope of work
of one cadre are shifted to the scope of
another cadre to mitigate human resource
shortages and problems with access and
availability of services. Cometto, Tulenko,
Muula, and Krech (2013, p. 2) define this
process as “diversifying the skills mix to
harness the potential of nonphysician
clinicians and community health workers.”
• Task shifting became critically important
during the response to the HIV epidemic in
the 1990s and early 2000s. Nonphysician
cadres, primarily nurses, were trained to
manage and monitor the complex medical
needs of HIV positive patients,
demonstrating outcomes that were nearly as
good as those of physicians while increasing
availability and improving access.
TRADITIONAL MEDICINE
• The WHO defines traditional medicine as
“the sum total of the knowledge, skills, and
practices based on the theories, beliefs, and
experiences indigenous to different
cultures, whether explicable or not, used in
the maintenance of health as well as in the
prevention, diagnosis, improvement or
treatment of physical and mental illness”
(Qi, n.d.). People all over the world continue
to rely on traditional medicine to treat and
prevent illnesses.
• Nurses working in global health will
frequently confront local complementary
and integrative health and traditional
remedies that are new to them, which may
be neutral, helpful, or harmful in nature.
• Both at the level of the individual patient
and at the level of the health system, nurses
must find productive ways to
accommodate, negotiate, or repattern
these practices to promote the health and
well-being of those under their care. Two
types of traditional care providers with
whom a nurse may come into contact are
traditional birth attendants (TBAs) and
shamans or traditional healers.
Global Health Disparities
• There are large disparities in health and
wellbeing at the global level, which result
from complex political and economic
processes. These disparities affect all of us
through their direct and indirect impacts on
issues such as immigration, spread of
infectious disease, national and international
conflict, poverty, and the global economy.
• Differences in health and well-being
between countries are difficult to measure.
The most commonly used gross
measurements of health are morbidity,
which measures illness, and mortality,
which measures death; these measures are
generally used with regard to a specific
disease, such as diabetes.
The Changing Landscape of Global Health
• Over the past 50 years, significant efforts
have been made to improve the well-being
of people living in low-income countries.
These efforts, including maternal and
child health interventions, water and
sanitation improvements, and HIV/AIDS
prevention and treatment, have resulted in
a reduction in morbidity and mortality due
to infectious diseases and childbirth. The
causes of death in countries at the extremes
of national income are still very different,
but as national income increases, causes of
morbidity and mortality begin to
approximate those of industrialized
countries (GBD 2013 Mortality and Causes
of Death Collaborators, 2015).
MILLENIUM DEVELOPMENTAL GOALS
• In 2000, leaders of countries around the
world met at the United Nations to define
and commit to a systematic approach to
reduce extreme poverty. This commitment,
laid out in the United Nations Millennium
Declaration, was organized under eight
goals known as the Millennium
Development Goals (MGDs).
• The eight MDGs have been used by
countries and development institutions
around the world to guide efforts to mitigate
poverty, hunger, and disease (United
Nations, n.d.). Three of the MDGs relate
directly to global health: Goal 4: Reduce
Child Mortality; Goal 5: Improve
Maternal Health; and Goal 6: Combat
HIV/AIDS, Malaria, and Other Diseases.

KEY CONCEPTS IN GLOBAL HEALTH AND

INTERNATIONAL NURSING
• Partnership
– is the idea that development is not a
package delivered by experts but
rather collaboration among peers
with complementary and equally
important expertise.
– Engagement, the first step of
partnership development, is a two-
way (visitor–host) process
characterized by cultural bridging,
collaboration, capacity building, and
mutual goal setting.
– Cultural bridging relies upon the
visiting nurse’s openness to the
experience of the host country and
host partners, and involves cross-
cultural communication, mutual
respect, and mutual learning.
– Collaboration requires the
development of teamwork based on
the needs of the host partners,
respect for the constraints faced by
host partners, and the resources
available to the visiting nurse and the
host partners.
– Capacity building refers to
contributions made by the visiting
nurse to improving the education,
institutions, or leadership of the host
community and partners, which
empowers them to take leadership of
the project and facilitates
sustainability.
 – Mutual goal setting allows the
visiting nurse and host partners the
opportunity to tie together their
mutual interests, diverse resources,
and diverse capacity toward a
shared desired outcome that guides
their work together. The result of this
process is partnership (Leffers &
Mitchell, 2011).
• Sustainability
– is the idea that interventions should
be easily maintained by the target
community or country after outside
support has ended.
– The concept of sustainability means
that once a project is completed, its
results can be maintained by the
community or government without
further outside input. In other words,
the system has been changed in a
way that provides lasting improved
outcomes rather than short-term
gains that can only be maintained by
continued outside investment and
intervention.
• Availability, Accessibility and
Acceptability
– Availability, the presence of a
product or service in a community;
accessibility, the ease of obtaining a
product or service; and
acceptability, the degree to which
the product or service is culturally
and social appropriate, also have an
impact on the success of global
health interventions.
THE GLOBAL PUBLIC HEALTH SECTOR
Multilateral Organizations
• The World Health Organization is the
main public health arm of the United
Nations. It is “responsible for providing
leadership on global health matters, shaping
the health research agenda, setting norms
and standards, articulating evidence-based
policy options, providing technical support
to countries and monitoring and assessing
health trends.” There are 194 WHO member
states, and all member states of the UN are
eligible to become members of the WHO.
Regional offices covering the Africa, the
Americas, Southeast Asia, Europe, the
Eastern Mediterranean, and the Western
Pacific oversee WHO programming in their
region (World Health Organization, n.d.).
• United Nations Children's Fund
(UNICEF), the UN body dedicated to
protecting children’s rights, also supports
public health programming globally. The
organization has programs in approximately
190 countries in all regions of the world.
UNICEF’s health programs encompass
children with disabilities, early childhood
development, HIV/AIDS, immunization,
nutrition, and water and sanitation.
UNICEF also responds to health needs of
children in humanitarian emergencies. As
part of its health programming, UNICEF
supports nurse-led clinics and nurse
training globally. International nurses are
generally employed as technical advisors
and trainers (UNICEF, n.d.).
• The UN Development Program (UNDP)
works with national governments to
eradicate poverty in many different
sectors, including health. It has programs
in more than 170 countries, working with
both national governments and NGOs. The
UNDP provides overall leadership for
efforts to achieve the MDGs. In the health
sector, its programs are generally limited to
those related to its poverty eradication and
equality mandates, including HIV/AIDS and
tuberculosis prevention and treatment
programs. Nurses might find employment
with the UNDP through technical
 consultancies, internships, and volunteer
opportunities.
• Bilateral Organizations and Donors
• Bilateral organizations may fund
programs directly, by working with
national governments, or through national
or international NGO partner organizations.
Funding priorities generally reflect foreign
policy priorities of the donor country as well
as the needs of the recipient countries
THE NURSE IN GLOBAL PUBLIC HEALTH
Nongovernmental organizations (NGOs)
• is a broad category that comprises nonprofit
development organizations, civil society
organizations, faith-based organizations,
universities, and for- profit contracting
firms that collaborate with donors to
implement development projects,
including global public health projects.
• They may operate globally, in one region, or
in just one country, and may work in a
variety of technical areas, from food
assistance to microfinance to HIV, or focus
on only one.
• In the realm of international health, nurses
play various roles: as advisors, trainers,
program managers, researchers, and
humanitarian response workers. In all of
these roles, transcultural nursing skills are
essential to success, as they all require the
ability to communicate, work, and adapt
interventions to cultures different than one’s
own.
• Technical advisors are experts in a specific
technical area, such as infection
prevention, who are called upon by NGOs
or multilateral organizations to serve as a
resource for local organizations, ministries
of health, or project staff.
• Trainers and educators devise in-service
and continuing education and training
opportunities for providers in evidence-
based practice. They work with ministries of
health to implement policies and preservice
education systems to produce qualified
health professionals, and also may train
trainers at the local level.
• Program managers do not play a technical
role, but their understanding of the technical
area contributes to their success. They
facilitate project design, build and sustain
relationships with partner organizations,
obtain and manage funding, and coordinate
all project activities, including monitoring
and evaluation.
• Researchers and monitoring and
evaluation specialists conduct ongoing
research, assessment, monitoring, and
surveillance of projects. They are critical
players in establishing the need for
 interventions, and help program
managers and technical advisors make
timely course corrections if projects are
failing to meet their intermediate results.
• Nurses working in humanitarian relief
respond rapidly to emergencies around the
globe to provide medical care to affected
communities and support to health care
colleagues in the affected country. They
generally have expertise in emergency and
trauma care, but may also have expertise in
infectious diseases, hunger and starvation,
health care logistics, and maternal and child
health. These individuals must be flexible,
have a high risk tolerance, and have strong
communication skills.
PREPARING FOR A CAREER IN
INTERNATIONAL NURSING AND GLOBAL
PUBLIC HEALTH
• Nurses working outside their home countries
should have certain knowledge, skills, and
attitudes to ensure their success. Although
technical knowledge of nursing is important
to working as an international nurse, it is
also critical that international nurses have
knowledge of history, international and
community development, and the culture in
their host country.
• Successful international nurses will have a
basic understanding of international
development theory and community
development theory, which will help them
minimize the “reinvention of the wheel” and
ensure that their work is sustainable.
• International nurses must have strong
transcultural nursing skills, such as those
described in previous chapters. It can also be
helpful to have a general understanding of
anthropology, especially the difference
between relativism and absolutism, the
various types of cultures, and the impact
culture can have on individual and
community decision making.
• The international nurse should become
familiar with the unique culture or
cultures of the host country with these
things in mind before traveling to the host
country. Familiarity with the three action
and decision modes from Leininger’s
Culture Care Theory may be particularly
helpful, as international nurses frequently
need to decide if cultural practices can
safely be maintained, need to be
accommodated or negotiated, or must be
repatterned (Leininger, 2006).
• The international nurse should be able to
contribute unique experience and expertise
with the humility to respect local
knowledge and expertise.
• In addition to having appropriate nursing
skills, international nurses should have skills
in training and education,
communication, and language. Even if his
or her job does not directly require training,
every international nurse serves as an
educator by virtue of the unique expertise
that he or she contributes. Being able to
successfully pass on this expertise to local
counterparts contributes to the sustainability
of the international nurse’s contribution.
International nurses should ensure that the
knowledge and skills they pass on are
evidence-based and appropriate for the local
context.
• Even when working in a country that speaks
the same language as the nurse’s country of
origin, it is important to have good
communication skills.
• Nurses working internationally share several
important attitudes that facilitate their
professional success: willingness to live in
less than comfortable conditions;
openness to the perspective of others;
flexibility; willingness to share or give
leadership to the host partners; and
energy to take personal risks to advocate
for social justice and achieve morally
sound outcomes (Leffers & Mitchell,
2011).
OTHER NURSING ROLES
INTERNATIONALLY
• Nurses who are not interested in pursuing a
career in international nursing but are
interested in gaining international
experience have a number of options,
including medical missions or short-term
assignments, military nursing, and long-
term volunteerships.
• Medical mission trips may be organized by
universities, churches, faith-based
organizations, or independent nonprofit
organizations. Assignments are generally
short, lasting from a few weeks to a few
months. These are volunteer experiences,
and the nurse generally has to pay for his or
her own travel, insurance, vaccinations, and
lodging. Nurses may find themselves
 providing care in isolated communities or
major hospitals or training local health
care professionals. Organizations
sponsoring medical mission trips have
varying requirements that may specify
education, clinical skill, language, or
technical area expertise, based on their
organizational mission and the specific
project for which volunteers are being
recruited.
• Before committing to an organization, the
nurse should research each opportunity to be
sure that he or she will be safe and able to
contribute to the host community. This may
include asking to speak with returned
volunteers or contacting host community
partner organizations to investigate the
reputation and relationships of each
sponsoring organization.
• Medical mission trips can contribute to
improving the health and well-being of host
communities, but they are often faulted for
not being sustainable or for creating a
burden on host communities that is not
offset by the contributions of the volunteers.
The nurse should keep this in mind while
researching opportunities and sponsoring
organizations.