- Email: [email protected]
Global Health Competencies for Nurses in the Americas
GLOBAL HEALTH COMPETENCIES NURSES IN THE AMERICAS
FOR
LYNDA WILSON, RN, PHD, FAAN,⁎ DOREEN C. HARPER, RN, PHD, FAAN,† IRENE TAMI-MAURY, DRPH, DMD, MSC,‡ ROSA ZARATE, MSN,§ SUSANA SALAS, MSN,# JASON FARLEY, CRNP, MPH, PHD,| NICOLE WARREN, CNM, MPH, PHD,| ISABEL MENDES, RN, PHD,⁎⁎ AND CARLA VENTURA, BA, MBA, LLM, PHD§§ This article reports the findings from an online survey of nursing faculty from the United States, Canada, Latin America, and Caribbean countries to identify their perceptions about global health competencies for undergraduate nursing students. A list of global health competencies for medical students developed by the Association of Faculties of Medicine of Canada Resource Group on Global Health and the Global Health Education Consortium was adapted for nurses and translated from English to Spanish and Portuguese. The competencies were divided into six subscales, and respondents rated each competency on a 4-point Likert scale, with high scores reflecting strong agreement that the competency was essential for undergraduate nursing students. E-mail invitations and links to the online survey were distributed using a nonprobability convenience sampling strategy. This article reports findings only from the respondents to the English and Spanish surveys. The final sample included 542 responses to the English survey and 51 responses to the Spanish survey. Cronbach's alpha reliability coefficients for the subscales ranged from .78 to .96. The mean values for all 6 subscales and for each of the 30 items were greater than 3.0 for the respondents to the Spanish survey, and the mean values for 27 of the items were greater than 3.0 for the respondents to the English survey. These findings suggest that respondents perceived the competencies as essential global health competencies for undergraduate nursing students in the Americas. Narrative comments written by respondents indicate additional competencies and specific concerns about adding additional content to an already full curricula. Results of this study can be used to guide faculty deliberations about global health competencies that should be incorporated in the nursing curricula. (Index words: Global health; Competency; Nursing; education) J Prof Nurs 28:213–222, 2012. © 2012 Elsevier Inc. All rights reserved.
⁎Professor and Assistant Dean for International Affairs, The University of Alabama at Birmingham, Birmingham, AL. †Dean and Fay B. Ireland Endowed Chair in Nursing , The University of Alabama at Birmingham, Birmingham, AL. ‡International Affairs Program Coordinator, The University of Alabama at Birmingham, Birmingham, AL. §Coordinator of Research, World Health Organization/Pan American Health Organization Collaborating Center, The National University of Mexico, Mexico City, Mexico. #Professor and Former Dean, The National University of Mexico, Mexico City, Mexico. |Assistant Professor, Johns Hopkins University, Baltimore, MD. ⁎⁎Professor, Director WHO Collaborating Center for Nursing Research Development, The University of Sao Paulo, Ribeirao Preto, Brazil. §§Associate Professor, The University of Sao Paulo, Ribeirao Preto, Brazil. Address correspondence to Dr. Wilson: The University of Alabama at Birmingham School of Nursing, NB 420, 1530 3rd Avenue South, Birmingham, AL 35294-1210. E-mail: [email protected] 8755-7223/11/$ - see front matter
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NCREASED INTERNATIONAL MOBILITY and technological advances provide previously unimagined opportunities for global interdependence and collaboration. These opportunities also present new challenges for health care. It is no longer possible for students in any health discipline to remain focused on local or national health care problems: They must be prepared to the face health issues in any setting. To effectively address global health issues, health care students must provide their care in a clinically competent, safe, and culturally appropriate manner (Anderson et al., 2003; Bauman & Blythe, 2002; Bradbury-Jones, 2009; Callen & Lee, 2009; Carlton, Ryan, Ali, & Kelsy, 2007; Consortium of Universities for Global Health, 2009; Crigger, Brannigan, & Baird, 2006; Douglas et al., 2009; Falk-Rafael, 2006; Freda, 1998; Gerrish, 2004; Ogilvie, Paul, & Burgess-
Journal of Professional Nursing, Vol 28, No. 4 (July–August), 2012: pp 213–222 © 2012 Elsevier Inc. All rights reserved.
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Pinto, 2007; Parfitt, 2004). Nursing's critical role in meeting global health needs was reaffirmed by the development of the Nightingale Initiative for Global Health with its Declaration to create a healthy world by 2020, emphasizing nursing's potential to contribute to meeting the UN's Millennium Development Goals (MDGs; (http://www.nightingaledeclaration.net/). Global health refers to “…an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care” (Koplan et al., 2009, p. 1995). Merson and Page (2009) reviewed the expanded interest in global health in U.S. universities and suggested three root causes for this expanded interest: (a) increased student awareness and interest in global issues, (b) heightened visibility of global health and interest in global equity as a component of U.S. foreign policy, and (c) expansion of global health resources leading to new opportunities for faculty and new career opportunities for students. Ogilvie et al. (2007) suggested that universities that fail to internationalize their curricula, research, and community service “may lose relevance in the 21st century” (p. 1). The Institute of Medicine recently published a report describing the U.S. commitment to global health (Institute of Medicine Committee on the U.S. Commitment to Global Health, 2009), stressing the need for involvement by governmental agencies, foundations, universities, and commercial entities to achieve global health goals and contribute to the MDGs (United Nations, 2010). The purpose of this article is to present a brief review of literature related to the integration of global health concepts in nursing curricula and to present findings from a survey of nursing faculty in the United States, Canada, Caribbean countries, and Spanish-speaking Latin America to identify their perceptions of essential global health competencies for undergraduate nursing students. We hope our findings stimulate discussion and further research to generate guidelines for nursing curricula that will ensure that nursing graduates are prepared to contribute to meeting complex global health needs and promoting social justice and equity.
Background There have been several studies conducted in the past 15 years to identify ways in which nursing programs incorporate international or global health concepts in their curricula. Wright, Godue, Manfredi, and Korniewicz (1998) surveyed representatives from 100 university schools of nursing in the United States plus 15 schools with known international activities (10 from the United States and 5 from Latin America and the Caribbean) to identify the extent to which international health was addressed in the nursing curricula. Findings indicated that one third of the U.S. schools and all 5 Latin American
schools reported at least some international health activities. Respondents identified a variety of ways in which international health was integrated into the curriculum ranging from a single course (reported by 42% of U.S. and 20% of Latin American schools), incorporating international health issues in course syllabi (reported by 33% of U.S. and no Latin American schools), or incorporating international health in undergraduate or graduate objectives (reported by 40% of U.S. and 20% of Latin American respondents). These authors recommended that nursing curricula should focus on international health rather than international nursing and should address social, economic, and political factors affecting health systems (Wright et al., 1998). Carlton et al. (2007) sent two surveys to all 473 schools of nursing with bachelor of science in nursing (BSN) and master of science in nursing (MSN) programs that were accredited by the National League for Nursing to identify ways in which global health was addressed in nursing curricula. The first survey focused on identifying definitions or key components of global health and asked about ways in which global health was integrated into the curriculum. Only 8 of the 39 respondents indicated that global health was defined in their school's curricula. A shorter follow-up survey was distributed to the same sample including core ideas from responses to the first survey. Only 12 of the 23 respondents to the second survey indicated that global health was an identifiable concept in their schools' conceptual frameworks or identified student learning outcomes, although 17 indicated that global health was addressed in specific course outcomes. Ogilvie et al. (2007) reported on a survey of the 36 institutional members of the Canadian Association of University Schools of Nursing that was conducted from 1995 to 1996. Of the 27 respondents, 19 were from institutions with basic BSN programs, and 15 of these respondents indicated that all undergraduate students had opportunities for international experiences within their curricula, but only 104 of 12,735 students (0.81%) had such experiences during the 1995–1996 academic year. Only 2 of the respondents indicated that their schools required a transcultural nursing course, and only 7 respondents indicated that their schools offered an elective internationally oriented undergraduate course. More recently, Maughan et al. at Brigham Young University College of Nursing sent surveys to 700 schools of nursing to examine strategies used to teach cultural competency and global health to undergraduate students. A total of 100 responses have been received to date, and the survey is still in progress. The preliminary results indicate that only 47% of the schools integrated global health topics throughout the undergraduate curriculum. Only 29% of respondents indicated that global health was taught within a specific course, most often the community health course. The methods used to teach global health issues included hands-on care to diverse populations, class lectures, case studies, reflective journaling, and directed readings. (E. Maughan, personal communication, April 21, 2011).
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There have been numerous projects to identify general competencies to guide curricula for health professionals, although few of these projects have focused specifically on competencies related to global health. In the United States, the curricula of many BSN programs are guided by The Essentials of Baccalaureate Education for Professional Nursing document (American Association of Colleges of Nursing, 2008). The “Essentials” document lists global health as a content area to be included under one of the essentials related to population health but does not articulate specific global health competencies to be included in baccalaureate nursing curricula. Mill, Astle, Ogilvie, and Gastaldo (2010) challenged nurse educators to “move beyond the creation of international placement opportunities or the use of global examples within existing courses…(to) develop strategies and design innovative curricula to provide opportunities for all students to become engaged with the concept of global citizenship and the role of nurses in a global world” (p. E1). Archambault (2010) analyzed key global health concepts and recommended that undergraduate nursing programs should address the key global health concepts of global citizenship, social justice, health equity, and determinants of health. She further recommended that programs incorporate the following global health content: introduction to global health, global health goals, determinants of health, health care systems policy and politics, primary health care, global nursing issues, culture and health care, epidemics, communicable and noncommunicable diseases, epidemiology and health outcomes, and humanitarian emergencies. Chavez, Peter, and Gastaldo (2008) described an initiative at the University of Toronto to integrate global health content in the undergraduate nursing curriculum based on a postcolonial feminist framework. Although not specific to proposing competencies for undergraduate nursing education, there are several other resources that can be useful in guiding development of global health competencies for nursing. Veenema (2001) proposed an evidence-based global health curriculum for a combined MSN/master of public health program. The Association of Schools of Public Health (2009) has recently launched a comprehensive initiative (the Global Health core Competency Development) to identify core global health competencies expected of public health students. The resource guide and other publications from this initiative can provide useful guidelines for the development of nursing curricula to integrate global health competencies. Finally, the Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health and the Global Health Education Consortium (GHEC) launched a project to identify core global health competencies for medical students in the United States and Canada, building on work the Resource Group had previously done for Canadian medical schools. The competencies were developed by a joint committee composed of members from the AFMC Resource Group on Global Health and GHEC. The competencies were identified based on a review of literature, review of Web
sites of known global health, and interviews of experts in the field. The list of competencies was then posted on a Web page to solicit comments and feedback (http:// globalhealthcompetencies.wikispaces.com/; Timothy Brewer, Personal Communication, September 20, 2010). In summary, although there have been a number of initiatives to develop standards to guide nursing educational curricula and to promote cultural competence, these standards do not specify global health competencies for undergraduate nursing students. Although there is growing recognition of the importance of preparing health professionals to address global health needs, findings from several surveys indicate that many nursing programs do not integrate global health content in their curricula. Addressing global health needs requires that health professional students are prepared to work with multiple disciplines in diverse settings and have an understanding of the complex issues that influence global health issues. The purpose of this exploratory study was to survey nursing faculty in the Americas to identify their perceptions about whether the global health competencies developed by the GHEC/AFMC Resource Group for medical students, adapted for nurses, were essential competencies for undergraduate nursing students.
Methods This exploratory descriptive survey was led through a team of faculty members at four Pan American Health Organization (PAHO)/World Health Organization (WHO) Nursing Collaborating Centers: The University of Alabama at Birmingham (UAB), Johns Hopkins University, the National University of Mexico, and the University of Sao Paulo at Ribeirao Preto College of Nursing. The survey developed for the study was adapted for nurses from the GHEC/AFMC Resource Group list of global health competencies for medical students. After obtaining permission from GHEC and AFMC Resource Group representatives (Dr. Tom Hall and Dr. Timothy Brewer), the global health competencies were adapted by the members of the research team by deleting or modifying the competencies that focused on medical diagnoses or treatments. The 30 competencies that were adapted for the nursing survey were divided using the same six categories as the GHEC/AFMC competencies: (a) Global Burden of Disease, (b) Health Implications of Travel and Displacement, (c) Social and Environmental Determinants of Health, (d) Globalization of Health and Health Care, (e) Health Care in Low Resource Settings, and (f) Health Care as a Human Right and Development Resource. The list of GHEC/AFMC competencies included subcompetencies or skills at both the basic and advanced levels for each of the major competencies. The nursing survey included only selected subcompetencies to minimize the response burden for respondents to the survey. The wording, primarily verbs, of many of the competencies was modified slightly for consistency of format. Table 1 lists the competencies that were included in each of the six categories. The instrument was translated to Spanish and Portuguese by native speakers familiar with health
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Table 1. Means and Standard Deviations of Competencies and Subscale Reliabilities Competency I. Global burden of disease Internal consistency reliability: English, .81; Spanish, .78 A basic understanding of the global burden of disease is an essential part of a modern nursing education. This knowledge is crucial for participating in discussions of priority setting, health care rationing, and funding for health and health-related research. A nursing graduate should be able to demonstrate the following: I a. Describe the major causes of morbidity and mortality around the world and how the risk of disease varies with regions I b. Describe major public health efforts to reduce disparities in global health (such as Millennium Development Goals and Global Fund to Fight AIDS, TB, and malaria) I c. Discuss priority setting, health care rationing, and funding for health and health-related research II. Health implications of migration, travel and displacement Internal consistency reliability: English, .84; Spanish, .92 The appropriate management of patients necessitates taking into consideration perspectives and risks posed by international travel or foreign birth. A nursing graduate should be able to: IIa. Demonstrate an understanding the health risks posed by international travel or foreign birth IIb. Recognize when travel or foreign birth places a patient a risk for unusual diseases or unusual presentation of common diseases and make an appropriate assessment or referral IIc. Describe how cultural context influences perceptions of health and disease IId. Elicit individual health concerns in a culturally sensitive manner IIe. Communicate effectively with patients and families using a translator IIf. Identify world regions and/or travel activities associated with increased risk for life-threatening diseases including HIV/AIDS, malaria, and multidrug-resistant tuberculosis III. Social and environmental determinants of health Internal consistency reliability: English, .89; Spanish, .96 Social, economic, and environmental factors are important determinants of health; furthermore, health is more than simply the absence of disease. Nurses should understand how social, economic and environmental conditions affect health, both to recognize disease risk factors in their patients and to contribute to improving public health. A nursing graduate should be able to: IIIa. Describe how social and economic conditions such as poverty, education, and lifestyles affect health and access to health care IIIb. List major social determinants of health and their impact on differences in life expectancy between and within countries IIIc. Describe the impact of low income, education, and communication factors on access to and quality of health care IIId. Describe the relationship between access to clean water, sanitation, food, and air quality on individual and population health IIIe. Describe the relationship between environmental degradation and human health IV. Globalization of health and health care Internal consistency reliability: English, .89; Spanish, .94 Globalization is profoundly changing disease patterns and the availability of health care workers worldwide. Besides the direct effects of diseases, health care workers and patients moving around the world, global agreements and institutions affect governments' and health care systems' ability to meet populations' health needs. A nursing graduate should be able to: IVa. Analyze how global trends in health care practice, commerce and culture, multinational agreements, and multinational organizations contribute to the quality and availability of health and health care locally and internationally IVb. Describe different national models or health systems for provision of health care and their respective effects on health and health care expenditure IVc. Analyze how travel and trade contribute to the spread of communicable and chronic diseases
English, M (SD)
Spanish, M (SD)
3.32 (0.582)
3.50 (0.624)
3.40 (0.669)
3.53 (0.649)
3.32 (0.692)
3.45 (0.765)
3.25 (0.697)
3.51 (0.820)
3.52 (0.445)
3.48 (0.664)
3.33 (0.635)
3.31 (0.683)
3.30 (0.662)
3.25 (0.778)
3.78 (0.522) 3.78 (0.500) 3.61 (0.607) 3.32 (0.637)
3.69 (0.769) 3.65 (0.779) 3.55 (0.867) 3.43 (0.842)
3.61 (0.481)
3.64 (0.658)
3.77 (0.507)
3.75 (0.675)
3.44 (0.653)
3.53 (0.747)
3.70 (0.546)
3.60 (0.742)
3.69 (0.549)
3.70 (0.689)
3.46 (0.639)
3.62 (0.709)
3.02 (0.560)
3.34 (0.683)
2.95 (0.710)
3.40 (0.742)
3.07 (0.685)
3.32 (0.783)
3.24 (0.655)
3.38 (0.768)
GLOBAL HEALTH COMPETENCIES FOR NURSES IN THE AMERICAS
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Table 1. (Continued) Competency IVd. Analyze general trends and influences in the global availability and movement of health care workers IVe. Describe national and global health care worker availability and shortages IVf. Describe the most common patterns of health care worker migration and its impact on health care availability in the country that the health care worker leaves and the country to which he or she migrates V. Health care in low-resource settings Internal consistency reliability: English, .84; Spanish, .93 Health care needs and resources markedly differ between high- and low-resource settings, yet much medical training occurs in high-resource settings. To effectively care for patients across a range of settings, a nursing graduate should be able to: Va. Articulate barriers to health and health care in low-resource settings locally and internationally Vb. Demonstrate an understanding of cultural and ethical issues in working with disadvantaged populations Vc. Demonstrate the ability to adapt clinical skills and practice in a resourceconstrained setting Vd. Identify signs and symptoms for common major diseases that facilitate nursing assessment in the absence of advanced testing often unavailable in lowresource settings (cardiovascular disease, cancer, and diabetes) Ve. Describe the role of syndromic management and clinical algorithms for treatment of common illnesses Vf. Identify clinical interventions and integrated strategies that have been demonstrated to substantially improve individual and/or population health in lowresource settings (e.g., immunizations, essential drugs, maternal child health programs) Vg. For students who participate in electives in low-resource settings outside their home situations, a demonstration that they have participated in training to prepare for this elective VI. Health as a human right and development resource Internal consistency reliability: English, .82; Spanish, .91 Human rights impact both individual and population health. Health also is an essential element of economic and social development. To effectively advocate for patients' and communities' health based on an understanding of the relationship between human rights, social and economic development, and health, a nursing graduate should be able to: VIa. Demonstrate a basic understanding of the relationship between health and human rights VIb. Demonstrate familiarity with organizations and agreements that address human rights in health care and medical research VIc. Describe role of WHO in linking health and human rights, the Universal Declaration of Human Rights, International Ethical Guidelines for Biomedical Research Involving Human Subjects (2002), Declaration of Helsinki (2008)
professions education, and the translations were validated by different native speakers. The English, Spanish, and Portuguese versions of the survey were placed online using the Survey Monkey platform. The study was approved by the UAB Institutional Review Board (IRB). A nonprobability voluntary convenience sampling procedure was used to recruit nursing faculty members from the United States, Canada, Caribbean countries, and Spanish-speaking Latin America. Information and links to survey were distributed via e-mail through a variety of contacts in the Americas including: (a) 492 participants at the October 2009 meeting of the Latin American Association of Nursing Schools (ALADEFE) held in Panama City, Panama, whose e-mail contact information
English, M (SD)
Spanish, M (SD)
2.93 (0.701)
3.30 (0.805)
3.02 (0.694) 2.91 (0.738)
3.36 (0.792) 3.56 (0.765)
3.41 (0.468)
3.66 (0.606)
3.48 (0.595)
3.61 (0.714)
3.69 (0.527)
3.67 (0.701)
3.45 (0.667)
3.70 (0.695)
3.44 (0.669)
3.70 (0.726)
3.04 (0.750)
3.65 (0.706)
3.46 (0.607)
3.76 (0.705)
3.33 (0.728)
3.52 (0.781)
3.34 (0.549)
3.57 (0.670)
3.53 (0.623)
3.57 (0.670)
3.22 (0.643)
3.52 (0.752)
3.26 (0.659)
3.54 (0.721)
was provided by the conference organizer; (b) 22 members of the Pan American Nursing & Midwifery Collaborating Centers; (c) 73 members of the PAHO Child Health Nursing Network (Red ENSI); (d) 2,238 members from 148 countries of the Global Alliance of Nursing & Midwifery; (e) 503 members from 73 countries of the Global Health Nursing & Midwifery Online listserves; (f) deans or directors of 545 baccalaureate and higher degree nursing schools in the United States listed on the Web site: http://www.a2zcolleges. com/Nursing/index.html; and (g) 23 directors of national-level associations of nursing faculty and directors of nursing programs in Latin America identified by the PAHO Regional Advisor for Nursing. In addition, the Canadian Association of Schools of Nursing (CASN)
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Table 2. Characteristics of Respondents to English and Spanish Surveys English respondents, n (%) Spanish respondents, n (%)
Characteristic Role of respondent * Dean Professor Other Types of nursing programs offered in respondent's school of nursing * Diploma Technical nursing Undergraduate nursing degree Specialization in nursing program Master's nursing program Doctoral program Other Country of respondent Belize Brazil Canada Caribbean countries Chile Colombia El Salvador Guyana Mexico Nicaragua Panama Paraguay Peru United States Uruguay Venezuela
59 (10.9) 460 (84.9) 23 (4.2)
9 (17.6) 40 (78.4) 3 (6.0)
7 (1.3) 10 (1.8) 542 (100.0) 125 (23.1) 409 (75.5) 243 (44.8) 44 (8.1)
11 (21.6) 16 (31.4) 51 (100.0) 26 (51.0) 37 (72.5) 4 (7.8) 8 (15.7)
0 0 62 (11. 4) 8 † (1.5) 0 0 0 0 1 (0.2) 0 0 1 (0.2) 1 (0.2) 465 (85.8) 0 4 (0.7)
0 3 (5.9) 0 5 ‡ (9.8) 4 (7.8) 2 (3.9) 1 (2.0) 0 31 (60.8) 1 (2.0) 2 (3.9) 1 (2.0) 0 0 1 (2.0) 0
* Some responses are overlapping. † Includes Antigua and Barbuda, the Bahamas, Cayman Islands, Jamaica, Puerto Rico, and Trinidad and Tobago. ‡ Includes the Dominican Republic and Puerto Rico.
posted the cover letter and survey link on the CASN Web site, and a CASN staff member sent a letter to deans and directors of Canadian nursing schools encouraging them to complete the survey. The survey was also posted on the GHEC Web site. Deans and directors were asked to
disseminate the survey to faculty members at their institutions, and others were asked to share the survey link with other nursing faculty members in the Americas. The cover letter indicated that the survey was being administered as part of a study to identify perceptions of
Table 3. Additional Competencies Identified in Narrative Comments Made by Respondents English respondent competencies
Spanish respondent competencies
Working in multidisciplinary teams Environmental issues (clean water, environmental degradation) Disaster planning Working with refugees and displaced people Care addressing disability in different countries Historical perspective Emancipatory knowledge development Food security issues Social justice Traditional healing practices Need a second language Impact of cultural and religious practices on health Impact of political instability and war on health Girl child issues (e.g., female circumcision, gender issues) Influence of policy on addressing health inequities
Health systems in different countries Fluency in second language Historical and philosophical context Universal precautions Work regulations in different countries Managing statistical data Knowledge of ethical issues Cross cultural nursing theories Effects of migration Dealing with emotional conditions Knowledge of personal health risks for nurses Dealing with disasters Traditional healing practices Nursing education and regulation in different countries International biosecurity measures Environmental protection and influence on health Natural and sociocultural adverse events
GLOBAL HEALTH COMPETENCIES FOR NURSES IN THE AMERICAS
nurses and nurse educators in the Americas (the United States, Canada, Latin America, and Caribbean) about global health competencies for basic or undergraduate nursing students that might be used to guide nursing curricula in the Americas to ensure that all graduating nurses have competencies in global health. The letter also indicated that the survey was for nurse educators in the United States, Canada, Latin America, or a Caribbean country who spoke Spanish, Portuguese, or English and that completion of the survey indicated consent to participate in the study. All responses were anonymous. The cover letter included the definition of global health proposed by Koplan et al. (2009) and explained that the competencies were adapted from the GHEC/AFMC draft Global Health Essential Core Competencies for Medical Students. Respondents were asked to rate their level of agreement that each competency was an essential global health competency for undergraduate or basic nursing students in the Americas using a 4-point scale: 1 = strongly disagree; 2 = disagree; 3 = agree; and 4 = strongly agree. The survey has not yet been distributed to all nursing schools in Brazil because of delays in obtaining IRB approval by the survey collaborators in Brazil. This article reports findings only from the respondents to the English and Spanish surveys. We received a total of 587 responses from the English survey and 56 responses from the Spanish survey. Because the focus of the survey was identifying global health competencies for basic nursing students, we did not include responses from participants who worked in nursing schools with diploma or technical but not undergraduate nursing programs. Thus, the final sample included in this analysis included 542 responses to the English survey and 51 responses to the Spanish survey from nursing faculty working in schools with undergraduate or higher level nursing programs. Table 2 describes characteristics of the respondents to the English and Spanish surveys.
Findings The data were analyzed using the PASW Statistics 17 software package. Means and standard deviations were calculated for the items in each of the six subscales and also for each of the 30 competencies. Data for the English and Spanish survey respondents were analyzed separately.
Findings Related to Instrument Reliability Table 1 includes the Cronbach's alpha reliability, as well as the means and standard deviations, for the six subscales and the 30 competencies for the respondents to both the English and Spanish surveys. The Cronbach's alpha reliability coefficients for five of the six subscales ranged from .81 to .96 for both the English and Spanish surveys. The only subscale with a reliability coefficient that was lower than .80 was the first subscale for the Spanish survey (with a reliability of .78). These findings suggest that the six subscales had acceptable levels of internal consistency.
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Findings Related to Faculty Members' Level of Agreement About Whether the Competencies Were Essential for Nursing Students The mean values for all six subscales and for 30 items were greater than 3.0 for the respondents to the Spanish survey, and the mean values for 27 of the items were greater than 3.0 for the respondents to the English survey. These findings suggest that respondents perceived the competencies as essential global health competencies for undergraduate nursing students in the Americas (see Table 1). There was a question at the end of the survey that invited participants to provide narrative comments about any additional global health competencies that they believed were important for nurses. One hundred fortysix of the 542 respondents to the English survey and 27 of the 51 respondents to the Spanish survey added narrative comments, and the researchers used content analysis procedures to review these comments to identify common themes (see Table 3). Many of the comments reflected general support for the inclusion of more global health content in nursing curricula. For example, one respondent to the English survey wrote: Nurses in all facets of health care do not operate in a vacuum. The international climate of health care impacts the practice of us all. Nurses at all levels need to be alert to the circumstances affecting health care consumers. As the world becomes smaller, through globalization, immigration, etc. the problems and concerns are not “over there” or “those people.” Another respondent to the English survey commented: Unfortunately, we cannot teach everything to everyone. However, these competencies can be interwoven in the curriculum. Our students must understand that the world is a really small place— what happens in one area cascades to all areas. Many students have never had exposure to anything outside of their own little world. It is our responsibility to enlighten them! One of the respondents to the Spanish survey suggested that it would be helpful to clarify the levels of education appropriate for different competencies. Another commented that the competencies should be more holistic: The competencies reflect a biological perspective and not a holistic integrated perspective, focused more on the identification of illnesses which is not the focus of nursing…the competencies should be more holistic and focused on education for health and prevention of illness which is the focus of nursing of individuals and communities…. Three comments from respondents to the English survey reflected disagreement with the incorporation of global health competencies in nursing curricula:
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Global health should be an advanced practice major or perhaps we should just conclude that it will take six years to get a baccalaureate in nursing degree. None of the topics stated are unimportant and many are addressed already in BSN curricula. However, my negative responses were to those questions that while important and I would actually agree that a nurse should know and understand are unrealistic in terms of the accreditation constraints on what needs to be included in an undergraduate nursing curriculum. It is overwhelming already in terms of what has to be in an UG nursing curriculum. Perhaps what is more important is a discussion on what the future of nursing will be and what will be the “care” of nursing. In today's nursing schools I think including all the content r/t global health is beyond the pale! Undergraduate students are still trying to figure out how to survive in a med/surg setting…now they need to be competent in resource limited settings too. Give them a general education and basic professional education and they will figure it out. Some of the questions…are not applicable to students who will, in all likelihood, never practice in a deprived area…to add content just…strains the limits of what a generic student must learn…it goes against the recommendations from the IOM and recommendations for 21st century skills that are being suggested by accrediting bodies…It would be better for students who anticipate a need to work in disadvantaged areas to prepare by taking a separate elective course….
Discussion Although there have been several other studies examining the extent to which global health concepts are taught in nursing educational programs, to our knowledge, this project is the first survey to identify perceptions of nursing faculty about interprofessional global health competencies that should be addressed in nursing curricula. The quantitative findings indicate that the respondents perceive the adapted GHEC/AFMC competencies as important for undergraduate nursing students. The qualitative findings highlight additional competency areas that might be considered. Although there were only three narrative comments that reflected lack of support for including global health competencies in nursing curricula, it is important to consider the concerns that were raised about adding additional information to content-filled curricula. These comments highlight the importance of identifying basic and advanced competencies and exploring strategies to integrate these competencies into existing courses, rather than adding additional course requirement at all levels.
Limitations This was an exploratory study, and there are several limitations that must be acknowledged. Although the survey instrument had face validity and each of the six subscales had acceptable internal consistency reliability, there is a need for further validation of the English and Spanish versions of the survey. The GHEC/AFMC survey was designed for medical students, most of whom have completed requirements for an undergraduate degree in a specific major. However, the nursing survey was administered to nursing faculty from nursing schools with both undergraduate and graduate programs. The variability among these programs in requirements, prerequisites, scope, breadth, and depth of content may have influenced the survey findings. The study was also limited by the use of a convenience sample, and the small number of respondents from Latin America.
Recommendations for Future Research Despite the limitations noted, the findings from this study have several implications for future nursing research. Further work is needed to identify different competencies that should be included across the various levels of nursing education, from basic professional preparation through graduate-level preparation. There is also a need to identify strategies for teaching global nursing concepts across the curriculum. Such strategies might include international clinical and research experiences, using virtual technologies to promote interaction and collaboration between students and faculty in different countries, use of case studies that address key global health challenges, and curriculum mapping to identify ways that core competencies can be integrated into courses across the curriculum (Allen & Ogilvie, 2004; Archambault, 2010; Bradbury-Jones, 2009; Callen & Lee, 2009; Callister & Cox, 2006; Carlton et al., 2007; Crigger et al., 2006; Critchley et al., 2009; Falk-Rafael, 2006; Fitzpatrick, 2005; Freda, 1998; Kirkham, Van Hofwegen, & Pankratz, 2009; Lee, 2004; Messias, 2001; Mill et al., 2010; Parfitt, 2004; Thompson, Boore, & Deeny, 2000; Veenema, 2001; Wright et al., 1998). There is also a need to further clarify which competencies are “nursing specific” and which might be integrated into other more general courses taken by students from other disciplines in addition to nursing. Future research might build on the findings from this study and use Delphi survey methods to seek consensus among the professional nursing community about global health competencies for nurses at different levels of nursing education. The qualitative comments from respondents can help to identify additional competency areas that might be included in a revised survey and used in future research. Future adaptations of this survey might also be strengthened by reviewing the work of the Association of Schools of Public Health Global Health Core Competency Development Project (Association of Schools of Public Health, 2009) and more clearly
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articulating specific knowledge, skills, attitudes, and behaviors associated with each competency. There is also a need for further research to replicate the survey using a probability sample to ensure a greater representation of nursing faculty from throughout the Americas. It would also be useful to replicate the survey in other regions including Africa, Asia, and the Western Pacific. Two of the coauthors (Warren and Farley) are currently working to implement the survey in Englishand French-speaking African countries.
Association of Schools of Public Health. (2009). Global health core competency development project: Resource guide. Retrieved from http://www.asph.org/document.cfm?page=1084. Bauman, A., & Blythe, J. (2002). Globalization of higher education in nursing. Online Journal of Issues in Nursing, 13, (2 (Manuscript 4)), 1–13. Bradbury-Jones, C. (2009). Globalisation and its implications for health care and nursing practice. Nursing Standard, 23, 43–47. Callen, B. L., & Lee, J. L. (2009). Ready for the world: Preparing nursing students for tomorrow. Journal of Professional Nursing, 25, 292–298. Callister, L. C., & Cox, A. H. (2006). Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing and Health Sciences, 8, 95–102. Carlton, K. H., Ryan, M., Ali, N. S., & Kelsy, B. (2007). Integration of global health concepts in nursing curricula: A national study. Nursing Education Perspectives, 28, 124–129. Chavez, F. S., Peter, E., & Gastaldo, D. (2008). Nurses as global citizens: A global health curriculum at the University of Toronto, Canada. In V. TschudinA. J. Davis (Eds.). The globalisation of nursing. (pp. 175–188). Oxford-New York: Radcliffe Publishing. Consortium of Universities for Global Health. (2009). Saving lives: Universities transforming global health. Washington, DC: Consortium of Universities for Global Health (Ed.). Retrieved from http://www.bu.edu/cghd/files/2009/12/SavingLives.pdf. Crigger, N. J., Brannigan, M., & Baird, M. (2006). Compassionate nursing professionals as good citizens of the world. Advances in Nursing Science, 29, 15–26. Critchley, K. A., Richardson, E., Aarts, C., Campbell, B., Hemmingway, A., Koskinen, L., et al. (2009). Student experiences with an international public health exchange project. Nurse Educator, 34, 69–74. Douglas, M. K., Pierce, J. U., Rosenkoetter, M., Callister, L. C, Hattar-Pollara, M., Lauderdale, J., et al. (2009). Standards of practice for culturally competent nursing care: A request for comments. Journal of Transcultural Nursing, 20, 257–269. Falk-Rafael, A. (2006). Globalization and global health: Toward nursing praxis in the global community. Advances in Nursing Science, 29, 2–14. Fitzpatrick, J. J. (2005). Beyond our usual boundaries. (From the Editor). Nursing Education Perspectives, 26, 141. Freda, M. (1998). International nursing and world health: Essential knowledge for the 21st century nurse. MCN - The American Journal of Maternal Child Nursing, 23, 329–332. Gerrish, K. (2004). The globalization of the nursing workforce: Implications for education. International Nursing Review, 51, 65–66. Institute of Medicine Committee on the U.S. Commitment to Global Health. (2009). The U.S. Commitment to global health: Recommendations for the public and private sectors. Retrieved from http://www.nap.edu/catalog.php?record_id=12642. Kirkham, S. R., Van Hofwegen, L., & Pankratz, D. (2009). Keeping the vision: Sustaining social consciousness with nursing students following international learning experiences. International Journal of Nursing Education Scholarship, 6, (1 (Article 3)), 1–15. Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., et al. (2009). Towards a common definition of global health. Lancet, 373, 1993–1995. Lee, N. J. (2004). The impact of international experience on student nurses' personal and professional development. International Nursing Review, 51, 113–122.
Implications for Nursing Education and Practice Findings from this study have implications for nursing practice and education. With the increasing geographic mobility and with emerging infectious diseases, nurses in all settings must have competence to address global health issues. The findings can be used to stimulate dialog among nursing educators in North America, Latin America, and the Caribbean about core global health competencies that should be integrated into curricula for basic or baccalaureate nursing programs. These competencies could also be used to guide staff development and continuing nursing education programs to ensure that nurses in all clinical settings are prepared to meet global health challenges. As we move further into the 21st century, nurse educators have a responsibility to ensure that students are prepared to assume their roles as global citizens to address emerging global health challenges and contribute to the goal of Health for All articulated in the 1978 Alma Ata conference (WHO, 1978). Mill et al. (2010) noted that “It is incumbent on nurse educators therefore to develop additional strategies to ensure that all students are exposed to, and have an awareness of, the concept of global citizenship and their role as professionals in a global world. In order to move toward this end, nurse educators and researchers, must participate in the theorizing required on global citizenship to inform nursing curricula” (p. E9). The findings of this survey offer beginning descriptive data that support their work and reinforce the need for academic nursing to identify and define the competencies expected as outcomes of undergraduate and graduate nursing programs.
References Allen, M., & Ogilvie, L. D. (2004). Internationalization of higher education: Potentials and pitfalls for nursing education. International Nursing Review, 51, 73–80. American Association of Colleges of Nursing. (2008). Essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing. Anderson, J., Perry, J., Blue, C., Browne, A., Henderson, A., Khan, K. B., et al. (2003). “Rewriting” cultural safety within the postcolonial and postnational feminist project: Toward new epistemologies of healing. Advances in Nursing Science, 26, 196–214. Archambault, N. (2010). Incorporating global health into undergraduate nursing education. Vancouver, British Columbia: MSN, University of British Columbia.
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Merson, M. H., & Page, K. C. (2009). The dramatic expansion of university engagement in global health: Implications for U.S. policy. Washington, DC: Center for Strategic and International Studies. Messias, D. K. H. (2001). Globalization, nursing, and health for all. Journal of Nursing Scholarship, 33, 9–11. Mill, J., Astle, B. J., Ogilvie, L., & Gastaldo, D. G. (2010). Linking global citizenship, undergraduate nursing education, and professional nursing: Curricular innovation in the 21st century. ANS Advances in Nursing Science, 33, E1–E11. Ogilvie, L. D., Paul, P., & Burgess-Pinto, E. (2007). International dimensions of higher education in nursing in Canada: Tapping the wisdom of the 20th century while embracing the possibilities for the 21st century. International Journal of Nursing Education Scholarship, 4, (1 (Article 7)), 1–22. Parfitt, B. (2004). Cultural sensitivity: The soft option? International Nursing Review, 51, 1–2.
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Thompson, K., Boore, J., & Deeny, P. (2000). A comparison of an international experience for nursing students in developed and developing countries. International Journal of Nursing Studies, 37, 481–492. United Nations. (2010). Millennium development goals. Retrieved August 26, 2010, from http://www.un.org/ millenniumgoals/. Veenema, T. G. (2001). An evidence-based curriculum to prepare students for global nursing practice. Nursing and Health Care Perspectives, 22, 292–298. World Health Organization. (1978). Primary health care: Report of the international conference on primary health care. Geneva, Switzerland: World Health Organization. Retrieved from http://whqlibdoc.who.int/publications/9241800011.pdf. Wright, G., Godue, C., Manfredi, M., & Korniewicz, D. M. (1998). Nursing education and international health in the United States, Latin America, and the Caribbean. Image: Journal of Nursing Scholarship, 30, 31–36.
FOR
LYNDA WILSON, RN, PHD, FAAN,⁎ DOREEN C. HARPER, RN, PHD, FAAN,† IRENE TAMI-MAURY, DRPH, DMD, MSC,‡ ROSA ZARATE, MSN,§ SUSANA SALAS, MSN,# JASON FARLEY, CRNP, MPH, PHD,| NICOLE WARREN, CNM, MPH, PHD,| ISABEL MENDES, RN, PHD,⁎⁎ AND CARLA VENTURA, BA, MBA, LLM, PHD§§ This article reports the findings from an online survey of nursing faculty from the United States, Canada, Latin America, and Caribbean countries to identify their perceptions about global health competencies for undergraduate nursing students. A list of global health competencies for medical students developed by the Association of Faculties of Medicine of Canada Resource Group on Global Health and the Global Health Education Consortium was adapted for nurses and translated from English to Spanish and Portuguese. The competencies were divided into six subscales, and respondents rated each competency on a 4-point Likert scale, with high scores reflecting strong agreement that the competency was essential for undergraduate nursing students. E-mail invitations and links to the online survey were distributed using a nonprobability convenience sampling strategy. This article reports findings only from the respondents to the English and Spanish surveys. The final sample included 542 responses to the English survey and 51 responses to the Spanish survey. Cronbach's alpha reliability coefficients for the subscales ranged from .78 to .96. The mean values for all 6 subscales and for each of the 30 items were greater than 3.0 for the respondents to the Spanish survey, and the mean values for 27 of the items were greater than 3.0 for the respondents to the English survey. These findings suggest that respondents perceived the competencies as essential global health competencies for undergraduate nursing students in the Americas. Narrative comments written by respondents indicate additional competencies and specific concerns about adding additional content to an already full curricula. Results of this study can be used to guide faculty deliberations about global health competencies that should be incorporated in the nursing curricula. (Index words: Global health; Competency; Nursing; education) J Prof Nurs 28:213–222, 2012. © 2012 Elsevier Inc. All rights reserved.
⁎Professor and Assistant Dean for International Affairs, The University of Alabama at Birmingham, Birmingham, AL. †Dean and Fay B. Ireland Endowed Chair in Nursing , The University of Alabama at Birmingham, Birmingham, AL. ‡International Affairs Program Coordinator, The University of Alabama at Birmingham, Birmingham, AL. §Coordinator of Research, World Health Organization/Pan American Health Organization Collaborating Center, The National University of Mexico, Mexico City, Mexico. #Professor and Former Dean, The National University of Mexico, Mexico City, Mexico. |Assistant Professor, Johns Hopkins University, Baltimore, MD. ⁎⁎Professor, Director WHO Collaborating Center for Nursing Research Development, The University of Sao Paulo, Ribeirao Preto, Brazil. §§Associate Professor, The University of Sao Paulo, Ribeirao Preto, Brazil. Address correspondence to Dr. Wilson: The University of Alabama at Birmingham School of Nursing, NB 420, 1530 3rd Avenue South, Birmingham, AL 35294-1210. E-mail: [email protected] 8755-7223/11/$ - see front matter
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NCREASED INTERNATIONAL MOBILITY and technological advances provide previously unimagined opportunities for global interdependence and collaboration. These opportunities also present new challenges for health care. It is no longer possible for students in any health discipline to remain focused on local or national health care problems: They must be prepared to the face health issues in any setting. To effectively address global health issues, health care students must provide their care in a clinically competent, safe, and culturally appropriate manner (Anderson et al., 2003; Bauman & Blythe, 2002; Bradbury-Jones, 2009; Callen & Lee, 2009; Carlton, Ryan, Ali, & Kelsy, 2007; Consortium of Universities for Global Health, 2009; Crigger, Brannigan, & Baird, 2006; Douglas et al., 2009; Falk-Rafael, 2006; Freda, 1998; Gerrish, 2004; Ogilvie, Paul, & Burgess-
Journal of Professional Nursing, Vol 28, No. 4 (July–August), 2012: pp 213–222 © 2012 Elsevier Inc. All rights reserved.
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Pinto, 2007; Parfitt, 2004). Nursing's critical role in meeting global health needs was reaffirmed by the development of the Nightingale Initiative for Global Health with its Declaration to create a healthy world by 2020, emphasizing nursing's potential to contribute to meeting the UN's Millennium Development Goals (MDGs; (http://www.nightingaledeclaration.net/). Global health refers to “…an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care” (Koplan et al., 2009, p. 1995). Merson and Page (2009) reviewed the expanded interest in global health in U.S. universities and suggested three root causes for this expanded interest: (a) increased student awareness and interest in global issues, (b) heightened visibility of global health and interest in global equity as a component of U.S. foreign policy, and (c) expansion of global health resources leading to new opportunities for faculty and new career opportunities for students. Ogilvie et al. (2007) suggested that universities that fail to internationalize their curricula, research, and community service “may lose relevance in the 21st century” (p. 1). The Institute of Medicine recently published a report describing the U.S. commitment to global health (Institute of Medicine Committee on the U.S. Commitment to Global Health, 2009), stressing the need for involvement by governmental agencies, foundations, universities, and commercial entities to achieve global health goals and contribute to the MDGs (United Nations, 2010). The purpose of this article is to present a brief review of literature related to the integration of global health concepts in nursing curricula and to present findings from a survey of nursing faculty in the United States, Canada, Caribbean countries, and Spanish-speaking Latin America to identify their perceptions of essential global health competencies for undergraduate nursing students. We hope our findings stimulate discussion and further research to generate guidelines for nursing curricula that will ensure that nursing graduates are prepared to contribute to meeting complex global health needs and promoting social justice and equity.
Background There have been several studies conducted in the past 15 years to identify ways in which nursing programs incorporate international or global health concepts in their curricula. Wright, Godue, Manfredi, and Korniewicz (1998) surveyed representatives from 100 university schools of nursing in the United States plus 15 schools with known international activities (10 from the United States and 5 from Latin America and the Caribbean) to identify the extent to which international health was addressed in the nursing curricula. Findings indicated that one third of the U.S. schools and all 5 Latin American
schools reported at least some international health activities. Respondents identified a variety of ways in which international health was integrated into the curriculum ranging from a single course (reported by 42% of U.S. and 20% of Latin American schools), incorporating international health issues in course syllabi (reported by 33% of U.S. and no Latin American schools), or incorporating international health in undergraduate or graduate objectives (reported by 40% of U.S. and 20% of Latin American respondents). These authors recommended that nursing curricula should focus on international health rather than international nursing and should address social, economic, and political factors affecting health systems (Wright et al., 1998). Carlton et al. (2007) sent two surveys to all 473 schools of nursing with bachelor of science in nursing (BSN) and master of science in nursing (MSN) programs that were accredited by the National League for Nursing to identify ways in which global health was addressed in nursing curricula. The first survey focused on identifying definitions or key components of global health and asked about ways in which global health was integrated into the curriculum. Only 8 of the 39 respondents indicated that global health was defined in their school's curricula. A shorter follow-up survey was distributed to the same sample including core ideas from responses to the first survey. Only 12 of the 23 respondents to the second survey indicated that global health was an identifiable concept in their schools' conceptual frameworks or identified student learning outcomes, although 17 indicated that global health was addressed in specific course outcomes. Ogilvie et al. (2007) reported on a survey of the 36 institutional members of the Canadian Association of University Schools of Nursing that was conducted from 1995 to 1996. Of the 27 respondents, 19 were from institutions with basic BSN programs, and 15 of these respondents indicated that all undergraduate students had opportunities for international experiences within their curricula, but only 104 of 12,735 students (0.81%) had such experiences during the 1995–1996 academic year. Only 2 of the respondents indicated that their schools required a transcultural nursing course, and only 7 respondents indicated that their schools offered an elective internationally oriented undergraduate course. More recently, Maughan et al. at Brigham Young University College of Nursing sent surveys to 700 schools of nursing to examine strategies used to teach cultural competency and global health to undergraduate students. A total of 100 responses have been received to date, and the survey is still in progress. The preliminary results indicate that only 47% of the schools integrated global health topics throughout the undergraduate curriculum. Only 29% of respondents indicated that global health was taught within a specific course, most often the community health course. The methods used to teach global health issues included hands-on care to diverse populations, class lectures, case studies, reflective journaling, and directed readings. (E. Maughan, personal communication, April 21, 2011).
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There have been numerous projects to identify general competencies to guide curricula for health professionals, although few of these projects have focused specifically on competencies related to global health. In the United States, the curricula of many BSN programs are guided by The Essentials of Baccalaureate Education for Professional Nursing document (American Association of Colleges of Nursing, 2008). The “Essentials” document lists global health as a content area to be included under one of the essentials related to population health but does not articulate specific global health competencies to be included in baccalaureate nursing curricula. Mill, Astle, Ogilvie, and Gastaldo (2010) challenged nurse educators to “move beyond the creation of international placement opportunities or the use of global examples within existing courses…(to) develop strategies and design innovative curricula to provide opportunities for all students to become engaged with the concept of global citizenship and the role of nurses in a global world” (p. E1). Archambault (2010) analyzed key global health concepts and recommended that undergraduate nursing programs should address the key global health concepts of global citizenship, social justice, health equity, and determinants of health. She further recommended that programs incorporate the following global health content: introduction to global health, global health goals, determinants of health, health care systems policy and politics, primary health care, global nursing issues, culture and health care, epidemics, communicable and noncommunicable diseases, epidemiology and health outcomes, and humanitarian emergencies. Chavez, Peter, and Gastaldo (2008) described an initiative at the University of Toronto to integrate global health content in the undergraduate nursing curriculum based on a postcolonial feminist framework. Although not specific to proposing competencies for undergraduate nursing education, there are several other resources that can be useful in guiding development of global health competencies for nursing. Veenema (2001) proposed an evidence-based global health curriculum for a combined MSN/master of public health program. The Association of Schools of Public Health (2009) has recently launched a comprehensive initiative (the Global Health core Competency Development) to identify core global health competencies expected of public health students. The resource guide and other publications from this initiative can provide useful guidelines for the development of nursing curricula to integrate global health competencies. Finally, the Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health and the Global Health Education Consortium (GHEC) launched a project to identify core global health competencies for medical students in the United States and Canada, building on work the Resource Group had previously done for Canadian medical schools. The competencies were developed by a joint committee composed of members from the AFMC Resource Group on Global Health and GHEC. The competencies were identified based on a review of literature, review of Web
sites of known global health, and interviews of experts in the field. The list of competencies was then posted on a Web page to solicit comments and feedback (http:// globalhealthcompetencies.wikispaces.com/; Timothy Brewer, Personal Communication, September 20, 2010). In summary, although there have been a number of initiatives to develop standards to guide nursing educational curricula and to promote cultural competence, these standards do not specify global health competencies for undergraduate nursing students. Although there is growing recognition of the importance of preparing health professionals to address global health needs, findings from several surveys indicate that many nursing programs do not integrate global health content in their curricula. Addressing global health needs requires that health professional students are prepared to work with multiple disciplines in diverse settings and have an understanding of the complex issues that influence global health issues. The purpose of this exploratory study was to survey nursing faculty in the Americas to identify their perceptions about whether the global health competencies developed by the GHEC/AFMC Resource Group for medical students, adapted for nurses, were essential competencies for undergraduate nursing students.
Methods This exploratory descriptive survey was led through a team of faculty members at four Pan American Health Organization (PAHO)/World Health Organization (WHO) Nursing Collaborating Centers: The University of Alabama at Birmingham (UAB), Johns Hopkins University, the National University of Mexico, and the University of Sao Paulo at Ribeirao Preto College of Nursing. The survey developed for the study was adapted for nurses from the GHEC/AFMC Resource Group list of global health competencies for medical students. After obtaining permission from GHEC and AFMC Resource Group representatives (Dr. Tom Hall and Dr. Timothy Brewer), the global health competencies were adapted by the members of the research team by deleting or modifying the competencies that focused on medical diagnoses or treatments. The 30 competencies that were adapted for the nursing survey were divided using the same six categories as the GHEC/AFMC competencies: (a) Global Burden of Disease, (b) Health Implications of Travel and Displacement, (c) Social and Environmental Determinants of Health, (d) Globalization of Health and Health Care, (e) Health Care in Low Resource Settings, and (f) Health Care as a Human Right and Development Resource. The list of GHEC/AFMC competencies included subcompetencies or skills at both the basic and advanced levels for each of the major competencies. The nursing survey included only selected subcompetencies to minimize the response burden for respondents to the survey. The wording, primarily verbs, of many of the competencies was modified slightly for consistency of format. Table 1 lists the competencies that were included in each of the six categories. The instrument was translated to Spanish and Portuguese by native speakers familiar with health
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Table 1. Means and Standard Deviations of Competencies and Subscale Reliabilities Competency I. Global burden of disease Internal consistency reliability: English, .81; Spanish, .78 A basic understanding of the global burden of disease is an essential part of a modern nursing education. This knowledge is crucial for participating in discussions of priority setting, health care rationing, and funding for health and health-related research. A nursing graduate should be able to demonstrate the following: I a. Describe the major causes of morbidity and mortality around the world and how the risk of disease varies with regions I b. Describe major public health efforts to reduce disparities in global health (such as Millennium Development Goals and Global Fund to Fight AIDS, TB, and malaria) I c. Discuss priority setting, health care rationing, and funding for health and health-related research II. Health implications of migration, travel and displacement Internal consistency reliability: English, .84; Spanish, .92 The appropriate management of patients necessitates taking into consideration perspectives and risks posed by international travel or foreign birth. A nursing graduate should be able to: IIa. Demonstrate an understanding the health risks posed by international travel or foreign birth IIb. Recognize when travel or foreign birth places a patient a risk for unusual diseases or unusual presentation of common diseases and make an appropriate assessment or referral IIc. Describe how cultural context influences perceptions of health and disease IId. Elicit individual health concerns in a culturally sensitive manner IIe. Communicate effectively with patients and families using a translator IIf. Identify world regions and/or travel activities associated with increased risk for life-threatening diseases including HIV/AIDS, malaria, and multidrug-resistant tuberculosis III. Social and environmental determinants of health Internal consistency reliability: English, .89; Spanish, .96 Social, economic, and environmental factors are important determinants of health; furthermore, health is more than simply the absence of disease. Nurses should understand how social, economic and environmental conditions affect health, both to recognize disease risk factors in their patients and to contribute to improving public health. A nursing graduate should be able to: IIIa. Describe how social and economic conditions such as poverty, education, and lifestyles affect health and access to health care IIIb. List major social determinants of health and their impact on differences in life expectancy between and within countries IIIc. Describe the impact of low income, education, and communication factors on access to and quality of health care IIId. Describe the relationship between access to clean water, sanitation, food, and air quality on individual and population health IIIe. Describe the relationship between environmental degradation and human health IV. Globalization of health and health care Internal consistency reliability: English, .89; Spanish, .94 Globalization is profoundly changing disease patterns and the availability of health care workers worldwide. Besides the direct effects of diseases, health care workers and patients moving around the world, global agreements and institutions affect governments' and health care systems' ability to meet populations' health needs. A nursing graduate should be able to: IVa. Analyze how global trends in health care practice, commerce and culture, multinational agreements, and multinational organizations contribute to the quality and availability of health and health care locally and internationally IVb. Describe different national models or health systems for provision of health care and their respective effects on health and health care expenditure IVc. Analyze how travel and trade contribute to the spread of communicable and chronic diseases
English, M (SD)
Spanish, M (SD)
3.32 (0.582)
3.50 (0.624)
3.40 (0.669)
3.53 (0.649)
3.32 (0.692)
3.45 (0.765)
3.25 (0.697)
3.51 (0.820)
3.52 (0.445)
3.48 (0.664)
3.33 (0.635)
3.31 (0.683)
3.30 (0.662)
3.25 (0.778)
3.78 (0.522) 3.78 (0.500) 3.61 (0.607) 3.32 (0.637)
3.69 (0.769) 3.65 (0.779) 3.55 (0.867) 3.43 (0.842)
3.61 (0.481)
3.64 (0.658)
3.77 (0.507)
3.75 (0.675)
3.44 (0.653)
3.53 (0.747)
3.70 (0.546)
3.60 (0.742)
3.69 (0.549)
3.70 (0.689)
3.46 (0.639)
3.62 (0.709)
3.02 (0.560)
3.34 (0.683)
2.95 (0.710)
3.40 (0.742)
3.07 (0.685)
3.32 (0.783)
3.24 (0.655)
3.38 (0.768)
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Table 1. (Continued) Competency IVd. Analyze general trends and influences in the global availability and movement of health care workers IVe. Describe national and global health care worker availability and shortages IVf. Describe the most common patterns of health care worker migration and its impact on health care availability in the country that the health care worker leaves and the country to which he or she migrates V. Health care in low-resource settings Internal consistency reliability: English, .84; Spanish, .93 Health care needs and resources markedly differ between high- and low-resource settings, yet much medical training occurs in high-resource settings. To effectively care for patients across a range of settings, a nursing graduate should be able to: Va. Articulate barriers to health and health care in low-resource settings locally and internationally Vb. Demonstrate an understanding of cultural and ethical issues in working with disadvantaged populations Vc. Demonstrate the ability to adapt clinical skills and practice in a resourceconstrained setting Vd. Identify signs and symptoms for common major diseases that facilitate nursing assessment in the absence of advanced testing often unavailable in lowresource settings (cardiovascular disease, cancer, and diabetes) Ve. Describe the role of syndromic management and clinical algorithms for treatment of common illnesses Vf. Identify clinical interventions and integrated strategies that have been demonstrated to substantially improve individual and/or population health in lowresource settings (e.g., immunizations, essential drugs, maternal child health programs) Vg. For students who participate in electives in low-resource settings outside their home situations, a demonstration that they have participated in training to prepare for this elective VI. Health as a human right and development resource Internal consistency reliability: English, .82; Spanish, .91 Human rights impact both individual and population health. Health also is an essential element of economic and social development. To effectively advocate for patients' and communities' health based on an understanding of the relationship between human rights, social and economic development, and health, a nursing graduate should be able to: VIa. Demonstrate a basic understanding of the relationship between health and human rights VIb. Demonstrate familiarity with organizations and agreements that address human rights in health care and medical research VIc. Describe role of WHO in linking health and human rights, the Universal Declaration of Human Rights, International Ethical Guidelines for Biomedical Research Involving Human Subjects (2002), Declaration of Helsinki (2008)
professions education, and the translations were validated by different native speakers. The English, Spanish, and Portuguese versions of the survey were placed online using the Survey Monkey platform. The study was approved by the UAB Institutional Review Board (IRB). A nonprobability voluntary convenience sampling procedure was used to recruit nursing faculty members from the United States, Canada, Caribbean countries, and Spanish-speaking Latin America. Information and links to survey were distributed via e-mail through a variety of contacts in the Americas including: (a) 492 participants at the October 2009 meeting of the Latin American Association of Nursing Schools (ALADEFE) held in Panama City, Panama, whose e-mail contact information
English, M (SD)
Spanish, M (SD)
2.93 (0.701)
3.30 (0.805)
3.02 (0.694) 2.91 (0.738)
3.36 (0.792) 3.56 (0.765)
3.41 (0.468)
3.66 (0.606)
3.48 (0.595)
3.61 (0.714)
3.69 (0.527)
3.67 (0.701)
3.45 (0.667)
3.70 (0.695)
3.44 (0.669)
3.70 (0.726)
3.04 (0.750)
3.65 (0.706)
3.46 (0.607)
3.76 (0.705)
3.33 (0.728)
3.52 (0.781)
3.34 (0.549)
3.57 (0.670)
3.53 (0.623)
3.57 (0.670)
3.22 (0.643)
3.52 (0.752)
3.26 (0.659)
3.54 (0.721)
was provided by the conference organizer; (b) 22 members of the Pan American Nursing & Midwifery Collaborating Centers; (c) 73 members of the PAHO Child Health Nursing Network (Red ENSI); (d) 2,238 members from 148 countries of the Global Alliance of Nursing & Midwifery; (e) 503 members from 73 countries of the Global Health Nursing & Midwifery Online listserves; (f) deans or directors of 545 baccalaureate and higher degree nursing schools in the United States listed on the Web site: http://www.a2zcolleges. com/Nursing/index.html; and (g) 23 directors of national-level associations of nursing faculty and directors of nursing programs in Latin America identified by the PAHO Regional Advisor for Nursing. In addition, the Canadian Association of Schools of Nursing (CASN)
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Table 2. Characteristics of Respondents to English and Spanish Surveys English respondents, n (%) Spanish respondents, n (%)
Characteristic Role of respondent * Dean Professor Other Types of nursing programs offered in respondent's school of nursing * Diploma Technical nursing Undergraduate nursing degree Specialization in nursing program Master's nursing program Doctoral program Other Country of respondent Belize Brazil Canada Caribbean countries Chile Colombia El Salvador Guyana Mexico Nicaragua Panama Paraguay Peru United States Uruguay Venezuela
59 (10.9) 460 (84.9) 23 (4.2)
9 (17.6) 40 (78.4) 3 (6.0)
7 (1.3) 10 (1.8) 542 (100.0) 125 (23.1) 409 (75.5) 243 (44.8) 44 (8.1)
11 (21.6) 16 (31.4) 51 (100.0) 26 (51.0) 37 (72.5) 4 (7.8) 8 (15.7)
0 0 62 (11. 4) 8 † (1.5) 0 0 0 0 1 (0.2) 0 0 1 (0.2) 1 (0.2) 465 (85.8) 0 4 (0.7)
0 3 (5.9) 0 5 ‡ (9.8) 4 (7.8) 2 (3.9) 1 (2.0) 0 31 (60.8) 1 (2.0) 2 (3.9) 1 (2.0) 0 0 1 (2.0) 0
* Some responses are overlapping. † Includes Antigua and Barbuda, the Bahamas, Cayman Islands, Jamaica, Puerto Rico, and Trinidad and Tobago. ‡ Includes the Dominican Republic and Puerto Rico.
posted the cover letter and survey link on the CASN Web site, and a CASN staff member sent a letter to deans and directors of Canadian nursing schools encouraging them to complete the survey. The survey was also posted on the GHEC Web site. Deans and directors were asked to
disseminate the survey to faculty members at their institutions, and others were asked to share the survey link with other nursing faculty members in the Americas. The cover letter indicated that the survey was being administered as part of a study to identify perceptions of
Table 3. Additional Competencies Identified in Narrative Comments Made by Respondents English respondent competencies
Spanish respondent competencies
Working in multidisciplinary teams Environmental issues (clean water, environmental degradation) Disaster planning Working with refugees and displaced people Care addressing disability in different countries Historical perspective Emancipatory knowledge development Food security issues Social justice Traditional healing practices Need a second language Impact of cultural and religious practices on health Impact of political instability and war on health Girl child issues (e.g., female circumcision, gender issues) Influence of policy on addressing health inequities
Health systems in different countries Fluency in second language Historical and philosophical context Universal precautions Work regulations in different countries Managing statistical data Knowledge of ethical issues Cross cultural nursing theories Effects of migration Dealing with emotional conditions Knowledge of personal health risks for nurses Dealing with disasters Traditional healing practices Nursing education and regulation in different countries International biosecurity measures Environmental protection and influence on health Natural and sociocultural adverse events
GLOBAL HEALTH COMPETENCIES FOR NURSES IN THE AMERICAS
nurses and nurse educators in the Americas (the United States, Canada, Latin America, and Caribbean) about global health competencies for basic or undergraduate nursing students that might be used to guide nursing curricula in the Americas to ensure that all graduating nurses have competencies in global health. The letter also indicated that the survey was for nurse educators in the United States, Canada, Latin America, or a Caribbean country who spoke Spanish, Portuguese, or English and that completion of the survey indicated consent to participate in the study. All responses were anonymous. The cover letter included the definition of global health proposed by Koplan et al. (2009) and explained that the competencies were adapted from the GHEC/AFMC draft Global Health Essential Core Competencies for Medical Students. Respondents were asked to rate their level of agreement that each competency was an essential global health competency for undergraduate or basic nursing students in the Americas using a 4-point scale: 1 = strongly disagree; 2 = disagree; 3 = agree; and 4 = strongly agree. The survey has not yet been distributed to all nursing schools in Brazil because of delays in obtaining IRB approval by the survey collaborators in Brazil. This article reports findings only from the respondents to the English and Spanish surveys. We received a total of 587 responses from the English survey and 56 responses from the Spanish survey. Because the focus of the survey was identifying global health competencies for basic nursing students, we did not include responses from participants who worked in nursing schools with diploma or technical but not undergraduate nursing programs. Thus, the final sample included in this analysis included 542 responses to the English survey and 51 responses to the Spanish survey from nursing faculty working in schools with undergraduate or higher level nursing programs. Table 2 describes characteristics of the respondents to the English and Spanish surveys.
Findings The data were analyzed using the PASW Statistics 17 software package. Means and standard deviations were calculated for the items in each of the six subscales and also for each of the 30 competencies. Data for the English and Spanish survey respondents were analyzed separately.
Findings Related to Instrument Reliability Table 1 includes the Cronbach's alpha reliability, as well as the means and standard deviations, for the six subscales and the 30 competencies for the respondents to both the English and Spanish surveys. The Cronbach's alpha reliability coefficients for five of the six subscales ranged from .81 to .96 for both the English and Spanish surveys. The only subscale with a reliability coefficient that was lower than .80 was the first subscale for the Spanish survey (with a reliability of .78). These findings suggest that the six subscales had acceptable levels of internal consistency.
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Findings Related to Faculty Members' Level of Agreement About Whether the Competencies Were Essential for Nursing Students The mean values for all six subscales and for 30 items were greater than 3.0 for the respondents to the Spanish survey, and the mean values for 27 of the items were greater than 3.0 for the respondents to the English survey. These findings suggest that respondents perceived the competencies as essential global health competencies for undergraduate nursing students in the Americas (see Table 1). There was a question at the end of the survey that invited participants to provide narrative comments about any additional global health competencies that they believed were important for nurses. One hundred fortysix of the 542 respondents to the English survey and 27 of the 51 respondents to the Spanish survey added narrative comments, and the researchers used content analysis procedures to review these comments to identify common themes (see Table 3). Many of the comments reflected general support for the inclusion of more global health content in nursing curricula. For example, one respondent to the English survey wrote: Nurses in all facets of health care do not operate in a vacuum. The international climate of health care impacts the practice of us all. Nurses at all levels need to be alert to the circumstances affecting health care consumers. As the world becomes smaller, through globalization, immigration, etc. the problems and concerns are not “over there” or “those people.” Another respondent to the English survey commented: Unfortunately, we cannot teach everything to everyone. However, these competencies can be interwoven in the curriculum. Our students must understand that the world is a really small place— what happens in one area cascades to all areas. Many students have never had exposure to anything outside of their own little world. It is our responsibility to enlighten them! One of the respondents to the Spanish survey suggested that it would be helpful to clarify the levels of education appropriate for different competencies. Another commented that the competencies should be more holistic: The competencies reflect a biological perspective and not a holistic integrated perspective, focused more on the identification of illnesses which is not the focus of nursing…the competencies should be more holistic and focused on education for health and prevention of illness which is the focus of nursing of individuals and communities…. Three comments from respondents to the English survey reflected disagreement with the incorporation of global health competencies in nursing curricula:
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Global health should be an advanced practice major or perhaps we should just conclude that it will take six years to get a baccalaureate in nursing degree. None of the topics stated are unimportant and many are addressed already in BSN curricula. However, my negative responses were to those questions that while important and I would actually agree that a nurse should know and understand are unrealistic in terms of the accreditation constraints on what needs to be included in an undergraduate nursing curriculum. It is overwhelming already in terms of what has to be in an UG nursing curriculum. Perhaps what is more important is a discussion on what the future of nursing will be and what will be the “care” of nursing. In today's nursing schools I think including all the content r/t global health is beyond the pale! Undergraduate students are still trying to figure out how to survive in a med/surg setting…now they need to be competent in resource limited settings too. Give them a general education and basic professional education and they will figure it out. Some of the questions…are not applicable to students who will, in all likelihood, never practice in a deprived area…to add content just…strains the limits of what a generic student must learn…it goes against the recommendations from the IOM and recommendations for 21st century skills that are being suggested by accrediting bodies…It would be better for students who anticipate a need to work in disadvantaged areas to prepare by taking a separate elective course….
Discussion Although there have been several other studies examining the extent to which global health concepts are taught in nursing educational programs, to our knowledge, this project is the first survey to identify perceptions of nursing faculty about interprofessional global health competencies that should be addressed in nursing curricula. The quantitative findings indicate that the respondents perceive the adapted GHEC/AFMC competencies as important for undergraduate nursing students. The qualitative findings highlight additional competency areas that might be considered. Although there were only three narrative comments that reflected lack of support for including global health competencies in nursing curricula, it is important to consider the concerns that were raised about adding additional information to content-filled curricula. These comments highlight the importance of identifying basic and advanced competencies and exploring strategies to integrate these competencies into existing courses, rather than adding additional course requirement at all levels.
Limitations This was an exploratory study, and there are several limitations that must be acknowledged. Although the survey instrument had face validity and each of the six subscales had acceptable internal consistency reliability, there is a need for further validation of the English and Spanish versions of the survey. The GHEC/AFMC survey was designed for medical students, most of whom have completed requirements for an undergraduate degree in a specific major. However, the nursing survey was administered to nursing faculty from nursing schools with both undergraduate and graduate programs. The variability among these programs in requirements, prerequisites, scope, breadth, and depth of content may have influenced the survey findings. The study was also limited by the use of a convenience sample, and the small number of respondents from Latin America.
Recommendations for Future Research Despite the limitations noted, the findings from this study have several implications for future nursing research. Further work is needed to identify different competencies that should be included across the various levels of nursing education, from basic professional preparation through graduate-level preparation. There is also a need to identify strategies for teaching global nursing concepts across the curriculum. Such strategies might include international clinical and research experiences, using virtual technologies to promote interaction and collaboration between students and faculty in different countries, use of case studies that address key global health challenges, and curriculum mapping to identify ways that core competencies can be integrated into courses across the curriculum (Allen & Ogilvie, 2004; Archambault, 2010; Bradbury-Jones, 2009; Callen & Lee, 2009; Callister & Cox, 2006; Carlton et al., 2007; Crigger et al., 2006; Critchley et al., 2009; Falk-Rafael, 2006; Fitzpatrick, 2005; Freda, 1998; Kirkham, Van Hofwegen, & Pankratz, 2009; Lee, 2004; Messias, 2001; Mill et al., 2010; Parfitt, 2004; Thompson, Boore, & Deeny, 2000; Veenema, 2001; Wright et al., 1998). There is also a need to further clarify which competencies are “nursing specific” and which might be integrated into other more general courses taken by students from other disciplines in addition to nursing. Future research might build on the findings from this study and use Delphi survey methods to seek consensus among the professional nursing community about global health competencies for nurses at different levels of nursing education. The qualitative comments from respondents can help to identify additional competency areas that might be included in a revised survey and used in future research. Future adaptations of this survey might also be strengthened by reviewing the work of the Association of Schools of Public Health Global Health Core Competency Development Project (Association of Schools of Public Health, 2009) and more clearly
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articulating specific knowledge, skills, attitudes, and behaviors associated with each competency. There is also a need for further research to replicate the survey using a probability sample to ensure a greater representation of nursing faculty from throughout the Americas. It would also be useful to replicate the survey in other regions including Africa, Asia, and the Western Pacific. Two of the coauthors (Warren and Farley) are currently working to implement the survey in Englishand French-speaking African countries.
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Implications for Nursing Education and Practice Findings from this study have implications for nursing practice and education. With the increasing geographic mobility and with emerging infectious diseases, nurses in all settings must have competence to address global health issues. The findings can be used to stimulate dialog among nursing educators in North America, Latin America, and the Caribbean about core global health competencies that should be integrated into curricula for basic or baccalaureate nursing programs. These competencies could also be used to guide staff development and continuing nursing education programs to ensure that nurses in all clinical settings are prepared to meet global health challenges. As we move further into the 21st century, nurse educators have a responsibility to ensure that students are prepared to assume their roles as global citizens to address emerging global health challenges and contribute to the goal of Health for All articulated in the 1978 Alma Ata conference (WHO, 1978). Mill et al. (2010) noted that “It is incumbent on nurse educators therefore to develop additional strategies to ensure that all students are exposed to, and have an awareness of, the concept of global citizenship and their role as professionals in a global world. In order to move toward this end, nurse educators and researchers, must participate in the theorizing required on global citizenship to inform nursing curricula” (p. E9). The findings of this survey offer beginning descriptive data that support their work and reinforce the need for academic nursing to identify and define the competencies expected as outcomes of undergraduate and graduate nursing programs.
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