Great progress has been made in identifying global health competencies for the health care professions. Global health competencies have been identified for graduate and undergraduate medical education (Arthur, Battat, & Brewer, 2011; Dawe et al., 2017; Howard, Gladding, Kiguli, Andrews, & John, 2011; Williams, Morrissey, Goenka, Magnus, & Allen, 2014), oral health (Benzian et al., 2015), public health education (Ablah et al., 2014; Sawleshwarkar & Negin, 2017), physical therapy (Pechak & Black, 2015), communications sciences and disorders professions (Hyter, Roman, Staley, & McPherson, 2017), and nursing (Ventura et al., 2014; Warren, Breman, Budhathoki, Farley, & Wilson, 2015; Wilson et al., 2012; Wilson, Moran, et al., 2016). In addition, competencies have been identified for interprofessional education (Jogerst et al., 2015; Rowthorn & Olsen, 2014). However, a major gap identified in some studies addressing the identification of global health competencies is the lack of theoretical underpinnings (Torres-Alzate, 2018).
Although models of global health have been described in the literature (Bozorgmehr, Saint, & Tinnemann, 2011; Leffers & Mitchell, 2011), they were not focused on nursing global health competencies. The Nursing Global Health Competencies Framework (NGHCF) was created to guide a research study aimed to reach consensus among experts on global health domains and competencies for baccalaureate nursing education in the United States (Torres-Alzate, 2018). The NGHCF provided the theoretical underpinning for a modified Delphi study (intersected with a mixed-methods research approach) composed of three rounds.
In the first Delphi phase, revision of a previously developed list of competencies was completed. This first phase was based on: a) qualitative responses to the surveys conducted by Wilson et al. (2012), Ventura et al. (2014), and Warren et al. (2015); b) a pilot study performed by this author (Torres-Alzate, 2015); c) a review of literature; and d) the NGHCF. In this phase, nine global health domains and 52 competencies were identified. In Phase 2, using a group of six nurses with expertise in global health and BSN education, two surveys were conducted for validation of the revised list of global health competencies. Phase 2 produced modifications in the competencies used for the third phase of the study. In Phase 3, 41 participants completed a survey to rate the extent to which they thought the 40 competencies obtained in the second phase were essential for BSN students.
DEFINITION OF CONCEPTS
The term global health has evolved from earlier concepts of international health. The concept of international health arose during the colonial era (19th century) and focused on control of global epidemics and addressing the health needs of low-resource countries (Frenk, Gómez-Dantés, & Moon, 2014; Rowson, Smith, et al., 2012). In the 1990s, Bandaranayake (1993) referred to international health as “instruction in comparative morbidity or mortality, service provision, demographic change and disease prevalence in non-industrialized developing countries” (p. 360).
The term global health has evolved from a focus on unilateral development aid and charitable missions to a focus on international interdependency and rights to universal health care (Campbell, Pleic, & Connolly, 2012). The concept of global health has also evolved to imply an interdisciplinary approach to the study of health issues and a focus on determinants of health (Rowson, Willott, et al., 2012).
Koplan et al. (2009) developed a common definition of global health that has served as a major milestone in this field. The resulting definition was: “Global health is an area of study, research, and practice that places 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” (p. 1995).
The description of global health that Koplan et al. (2009) proposed includes health issues that transcend national boundaries, solutions that require global cooperation (disease and disasters), individual and population prevention and care, and, most importantly, health equity. Koplan et al. presented examples of global health issues, including nutritional problems, specific diseases, mental health problems, injuries, and health problems related to displacement and migration, noting that addressing these problems requires awareness of the impact of culture, limited resources, and social and economic inequities.
A more recent definition of global health, recommended by a taskforce of the Global Advisory Panel on the Future of Nursing, includes concepts that had not been in previous definitions. These include planetary health, holistic health, health promotion, and sustainability, among others (Wilson, Mendes, et al., 2016). Although these concepts have been reported in the literature in a discreet manner, the Global Advisory Panel on the Future of Nursing taskforce merged them together in a way that better explains what global health is from a wider and more modern perspective. This definition reads:
Global health refers to an area for practice, study and research that places a priority on improving health, achieving equity in health for all people (Koplan et al., 2009) and ensuring health-promoting and sustainable sociocultural, political and economic systems. Global health implies planetary health which equals human, animal, environmental and ecosystem health (Kahn et al., 2014) and it emphasizes transnational health issues, determinants and solutions; involves many disciplines within and beyond the health sciences and promotes interdependence and interdisciplinary collaboration; and is a synthesis of population-based prevention with individual holistic care (Wilson, Mendes, et al., 2016, p. 1536).
There is growing recognition of the importance of competency-based education (CBE) (Anema & McCoy, 2010), defined as an approach to teaching, learning, assessment, and grading. It puts emphasis on students demonstrating the knowledge, skills, and attitudes that have been attained as a result of the education process, work, and life experiences regardless of a specific timeline, educational setting, or pace of learning (US Department of Education, n.d.).
CBE increases accountability of higher education institutions (Bedard-Voorhees, 2001), which have been criticized for the quality of undergraduate student outcomes (E. A. Jones, 2001). Even though many business leaders acknowledge that new graduates come to their jobs academically prepared, these new graduates often cannot apply their knowledge to daily tasks. Higher education institutions (providers and accrediting organizations) need to assure the community (parents, students, and industry) that new graduates are ready to enter the workforce (Anema & McCoy, 2010).
Concept of Competency
The definition of competency that was used in the conceptualization of the framework is the one provided by the International Council of Nurses (ICN, 2005): “Competency is the effective application of knowledge, skill, and judgment demonstrated by an individual in daily practice or job performance” (p. 9). The ICN suggested that competencies are the mixture of knowledge, skills, and personal attributes and attitudes that nurses need to demonstrate when performing in a job. An essential competency is the minimum set of knowledge, skills, and attitudes a learner needs to perform in a specific area.
Levels of Proficiency
Benner developed a classic theory to describe the progression of skill development in the publication From Novice to Expert. In Benner’s (1982) model, the nurse passes through five levels of skill acquisition or development: novice, advanced beginner, competent, proficient, and expert. In the novice stage, the nurse relies primarily on rules and prior knowledge rather than personal experiences, which are often limited at this level. Performance at this level is more task oriented than judgment oriented. The advanced beginner nurse, with more situational experience, recognizes recurrent patterns. In this stage, nurses are unable to decide what patterns or aspects require more attention than others. Competent nurses are able to base their actions “in terms of long range goals or plans” (Benner, 1982, p. 404). Competent nurses feel a sense of mastery and believe they are able to face different challenges in their practice. At the proficient level, nurses base their performance on principles or guidelines that are situation specific. Proficient nurses rely on the understanding of a specific set of principles before performing a needed action. At the expert level, nurses rely less on guidelines and principles and incorporate intuition in providing holistic care.
THE FRAMEWORK (NGHCF)
The NGHCF was created based on a scoping review of the literature. The framework incorporates concepts related to: a) what nursing is and what it can contribute to global health, b) concepts related to global health, c) concepts related to CBE, and d) Benner’s (1982, 2004) skills acquisition model. The NGHCF framework was leveled using Benner’s five levels of competency: novice, advanced beginner, competent, proficient, and expert.
When appraising how the conceptual framework fit with the parent study (Torres-Alzate, 2018) findings, the researcher critically reviewed the NGHCF framework created for the study and made slight modifications to the design. The framework did not need to be updated theoretically, but it seemed appropriate to make minor revisions in the graphic image to better represent the concepts and their relationships. This article describes the modified NGHCF version (see Supplementary Digital Content, available at http://links.lww.com/NEP/A158, for model).
The NGHCF framework contains one dimension, nursing core value and principles, which has seven subcategories: social justice and equity, holistic care, advocacy, health as human right, sustainability, advocacy, and collaboration. The global health domains and competencies identified in the parent study (Torres-Alzate, 2018) are located within the nursing core value and principles dimension. This framework contains four assumptions that exist concomitantly with the nursing core value and principles dimension:
- environmental focus: includes personal and local, national, and global levels;
- care focus: includes primary, secondary, and tertiary levels of prevention;
- education focus: includes societal needs and context; and
- competency leveling: Benner’s (1982) five levels of competency.
A scoping review of the literature, in addition to Grootjans and Newman's (2013) and Merry’s (2012) work, influenced the development of the NGHCF model. These authors described global health nursing as reflecting the values of social justice and equity, prevention, sustainability, advocacy, holistic care, and sustainability. These values are echoed in numerous articles that discuss global health in nursing and were validated by Torres-Alzate (2018).
Nursing Core Values and Principles
Six core values and principles, shared by all nurses regardless of their education level, can be used as an essential background for core global health competencies. They are as follows:
SOCIAL JUSTICE AND EQUITY
Codes of ethics for the nursing profession refer to social justice as one of the principles and responsibilities of nurses (American Nurses Association [ANA], 2015; ICN, 2012). In her introductory note for the ANA Guide to the Code of Ethics for Nurses,Fowler (2008) stated: “Within the Code for Nurses there is a truly abiding concern for the social justice at every level; for the amelioration of the conditions that are the cause of disease, illness, and trauma; for the recognition of the worth and dignity of all with whom the nurse comes into contact; for the provision of high quality nursing care in accord with the standards and ideals of the profession; and for the just treatment of the nurse” (p. xviii).
In the code of ethics published by the ICN (2012), social justice is addressed in one of the four elements of the code. Nurses are encouraged to advocate for social and health equity and to support initiatives that would promote meeting societal needs and, in particular, the needs of vulnerable populations. Nurses in all practice settings have the opportunity to advocate for social justice by providing interventions that help correct health inequities stemming from imbalances in power, gender and race disparities, and political views, among others. Nurses have the power and responsibility to shape national and global health policy that may affect their communities and the nursing profession itself.
Burris and Anderson (2010) described the emotional power of social injustice as a consequence of the world’s indifference to the health and survival needs of those who are most deprived of health. The concept of social justice is fundamentally the driving force behind public health work and essential to understanding the meaning of health in a global world. The authors called for a convention of stakeholders to promote the use of public health concepts in research and analysis to examine pathological social injustice and to scrutinize public health skills and resources to intervene. The convention could evoke the power of influence to address social injustices endangering global health through political pressure to address unjust social conditions.
Public health has something unique to offer in the application of social justice: insight into the impossible decisions between taking action after a health crisis and seeking the social inequities that precipitate the crises. Thus, global health issues and social justice are conceptually inseparable. Friedman and Gostin (2015) echoed this ideology in their discussion of global health law as a singular message of global health with justice. Improved global health requires closing the gap between the extensive domestic and global health inequities. These authors further posited that health must be integrated into public policies and global actions to overcome barriers to equity.
According to the World Health Organization (WHO, 1978), health is not only the absence of disease; the concepts of physical, mental, and social well-being are also contained in the definition. However, Merry (2012) stated that a definition of health that is more aligned to the goals of nursing should include the concepts of holistic care, quality of life, and well-being. Merry explained that a greater emphasis on quality of life and well-being are important considering the inability of Western medicine to cure many global illnesses and the availablity of other options, such as complementary therapies and nonmedical healing approaches. In many global health settings, Western medical approaches are not widely accepted. Implementing holistic care in these communities would benefit health by meeting medical, human, and spiritual needs through recognition of human rights, the empowerment of community systems, and recognition of human dignity.
Although holistic care is one of the attributes nurses need to exhibit while practicing in any setting, it is important to mention that holistic care not only includes the heath of humans but animals and ecosystems as well. The concept of One Health addresses health in a way that benefits other entities, besides humans. According to Evans and Leighton (2014), One Health is “a paradigm in which health is determined by a broad, inclusive and interdependent continuum of cause and effect across ecosystems and human and animal populations that fully embraces food security, biodiversity, economic prosperity, and emotional and mental well-being” (p. 414). These authors stated that health within the One Health concept can be understood as animals, humans, and ecosystems living together in harmony.
Nursing and advocacy are often discussed simultaneously. In global health, nurses, as global citizens, must advocate not only for the health of the patients and communities they serve but also for the broader population, considering the consequences of decisions relative to health care. In addition, nurses must advocate for the health of the planet as human, ecosystem, and animal health are essential to achieve planetary health. Long-term health risks associated with violence, climate change, poverty, and the myriad of environmental disasters are critical global issues. The goals for local- and global-level actions to address poverty, injustice, hunger, violence, and the disastrous sequelae of climate change have direct implications for nursing at the local, community, and global levels. This advocacy must focus on ensuring a competent workforce, maximizing nursing roles, intensifying capacities of nurses by collaboration, and promoting policies to ensure evidence-based practice (Rosa, 2017).
Since 2002, nurses have been considered as the professionals with the highest level of ethical integrity in the United States (J. Jones & Saad, 2016). However, according to Khoury, Blizzard, Moore, and Hassmiller (2011), nurses are not regarded as leaders in health care delivery and policy. Nurses can be an important resource to impact policy and advocate for global health issues locally and abroad.
HEALTH AS A HUMAN RIGHT
According to the United Nations, health is a right of every person. Article 25 of the United Nations (1948) Universal Declaration of Human Rights reads: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care, and necessary social services” (p. 5). The ICN (2011) and ANA (2010) have also endorsed the concept of health as a human right. Although international and national organizations have made statements about supporting the notion of health as a human right, Merry (2012) suggested that, in order to strengthen the perception of health as human right, this concept should be incorporated in the definitions of health and global health.
In their review of the literature about nurses and globalization, Grootjans and Newman (2013) found that sustainability was one of the generic attributes of nursing practice in a globalized world. The concept of ecological sustainability in nursing is well explained by Anåker and Elf (2014). In their concept analysis work, the authors stated: “The concept of sustainability in nursing can be defined from a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels” (p. 387).
Grootjans and Newman (2013) reported that the nursing shortage, nurse migration, and emerging roles of nurses are some of the issues affecting the sustainability of nursing. Sustainability of the profession also rests on the ability of nurses to procure self-care. In her pilot study, Alliex (2010) found that self-care strategies that were useful to nursing students were valuable in their personal and future professional lives.
In global health, as in any other practice setting, interprofessional collaboration (to include patients and communities) is important to attain positive patient and health outcomes. In order to achieve quality patient care, nurses need to work collaboratively with members of the same discipline and members of the health care team in a way that fosters teamwork, mutual respect, shared decision-making, and communication (Disch, n.d.). The Institute of Medicine (2011) recommended that nurses work in teams (including patients, family, providers, social workers, community health workers, etc.) in order to address the nursing shortage and “maximize the available resources in care environments” (p. 270).
Collaboration in global health initiatives is an enormous challenge that encompasses cultural differences, territorial or tribal control, and basic language differences. The World Health Organization commissioned a study to examine the themes common to collaborative practice across the WHO regions and 10 countries (Mickan, Hoffman, & Nasmith, 2010). Collaboration in global health practice was determined to be requisite.
Assumptions of the Model
This assumption reflects the focus of global health practice (personal, local, national, regional, global, or planetary). Grootjans and Newman (2013) stated that when nurses consider health determinants such as the environment, biological, social, and behavioral issues, they cannot focus only on the local level. It is important to understand that local, national, and global determinants of health may affect the health of patients and communities in different ways.
In a globalized world, local problems are complex and exceedingly interconnected. For example, when the Ebola outbreak ravished West Africa in 2014, the first patient to be diagnosed with the virus in the United States was cared for by a young nurse who did not have the knowledge or training to care for the patient and was infected days later. The nurse survived, but the patient did not. This event happened in Texas after the Centers for Disease Control and Prevention (CDC) had warned health institutions to institute policies and train health care providers to deal effectively with this disease. Protocols were not in place in this hospital. Nurses need to become aware of events elsewhere in the world and work with others to identify dangers that may occur in the communities they serve.
Nurses play critical roles in health promotion regardless of practice setting. Grootjans and Newman (2013) suggested that nurses doing a dressing change are able to do primary prevention by means of preventing infection, secondary prevention by assessing the wound for any signs of infection, and tertiary prevention while doing patient teaching on how to change the dressing following discharge. They noted that, because of the demands imposed by a globalized world, nurses need to revise the way they think in terms of health promotion. Nurses working in any care setting (e.g., emergency room, critical care unit) have the important opportunity to promote well-being.
This assumption has to do with how nursing actions need to be oriented to address societal needs and the current context and settings in which nurses are applying their knowledge and skills. The Commission on Education of Health Professionals for the 21st Century devised a framework with specific recommendations aimed to improve health within and between countries by developing and “nurturing” a different type of health care professional (Frenk et al., 2010). The overarching framework works as a system that incorporates the population (society), the education system, and the health system as interdependent drivers working together to maintain balance. In this framework, society is the driver of the demand and supply of health care workers, which means that people are on both the receiver and provider ends of health services. Nurses need to be cognizant about societal needs and the context in which competencies are being applied.
Benner’s (1982) five levels of competency (novice, advanced beginner, competent, proficient, and expert) are used to level the competencies in the model to different levels of knowledge and expertise.
The final component of the conceptual model includes domains and competencies. These were developed for baccalaureate nursing students in the United States in the parent study (Torres-Alzate, 2018).
CONCLUSION AND IMPLICATIONS
The main contribution of this framework is twofold: It provides a theoretical basis for global health education in nursing and lays a foundation for research exploring the relationships of the concepts. In addition, the framework links core nursing values with concepts related to CBE and skills acquisition. The NGHCF can help shape future research in global health competencies in nursing and other professions. In addition, the framework may be an important asset in curriculum development.
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