International Nursing



International Nursing

Jacqueline Mulder

Ferris State University

International Nursing

The professional nursing world spans countries, languages, and cultures. Nurses can be found all over the world, and are also trained in different areas of the world. As a profession, it is important that nurses share knowledge and research across the map for the betterment of the nursing environment around the world. Merriam-Webster (2014) defines international as “involving two or more countries” or “made up of people or groups from different countries.” Based on this definition, any practicing nurse is inevitably going to provide international nursing care. International nursing is a growing aspect of the profession.

Health and wellness are important aspects of life in each part of the world, just as disease and illness strike every country. Each country faces different diseases, outbreaks, and health risks. A vital part of the nursing profession is to learn about the patients within the nurse’s span of practice. The purpose of this paper is to assess the environment of nurses around the world, discuss theories pertinent to international nursing, and elaborate on the consequences of international nursing practice. Recommendations for quality and safety improvements will also be provided at the end of this paper.

Theory Base

Transcultural Nursing Theory

The first theory discussed in relation to international nursing is Leininger’s transcultural nursing theory. When crossing borders and cultures to provide care, nurses expect to encounter individuals who have different cultural backgrounds. On the other hand, nurses who remain in the city, state, or country of education may not be prepared to encounter patients from different cultures. Both local and international nurses need to have the cultural competence to provide nursing care to individuals from different countries and cultures.

The main components of this theory include culture, religion, ethnicity and race, and cultural awareness. The nursing focus and role follow up the discussion of these components (Leininger, 2012). According to this theory, culture is considered the values, beliefs, traditions, and rituals held by a group of people. Language is typically considered an aspect of culture, and culture is typically transmitted from generation to generation through language. The religious aspect of the theory also ties in well with culture, because religion is considered the belief system of a specific group of people from the same culture. The ethnicity and race is classified as the heritage and shared biological characteristics of individuals that create a sense of belonging to a group (Leininger, 2012). The world is composed of many individuals from different cultural backgrounds. A nurse could consider the various cultural backgrounds as obstacles if he or she is not able to provide culturally sensitive care based on the patient.

The first three components are mainly focused on the background of the patient as it relates to his or her cultural situation. The final component, cultural awareness, focuses on the nurse. Cultural awareness is being aware of one’s own background, and recognizing bias and judgments of other people (Leininger, 2012). A nurse must be aware of his or her own cultural background (which is typically done by evaluating the first three components of the theory), and assess his or her own personal biases against individuals from other cultures. Each individual has biases and judgments against other groups of people, but a practicing nurse must recognize these biases and create strategies to provide the best care to all patients regardless of background.

The nursing role in this theory (in addition to being culturally aware) is to reach three goals: preserve culture, accommodate care, and change care per culture (Leininger, 2012). The best way to reach these goals is for the nurse to develop an understanding and appreciation of his or her own culture. After establishing this understanding, the nurse can also appreciate the cultural differences of the patient. The nurse must integrate physical, emotional, and spiritual care per patient’s cultural considerations (Leininger, 2012).

Stages of Change Theory

The “stages of behavior change” theory is a psychological theory that is often utilized in the community health nursing practice to assist patients in changing health behaviors. The theory is composed of five typical stages an individual walks through in order to make a successful and lasting lifestyle change (Prochaska & DiClemente, 1982). The theory can be applied to the current international nursing environment in a variety of ways. The most important and useful application of this theory is in the general nurse’s mindset. In order for a nurse to provide culturally competent care, he or she must first change the mindset of providing the same care to each patient based on his or her diagnosis.

The first stage of this theory is the precontemplation phase, which is accompanied by denial and perhaps ignorance of the problem (Prochaska & DiClemente, 1982). In a nursing situation, the nurse may be unaware of the cultural considerations of the patient. The second stage is classified as the contemplation stage, where the problem is known but there is no movement towards changing the situation to solve the problem. This stage is typically characterized by mixed feelings of ambivalence and conflicting desires, and an important part of this stage is to identify the barriers to change. For instance, the nurse may identify communication barriers with the patient, but may not be willing to change because she is caring for the patient as she has always cared for patients with the diagnosed illness. The third stage is the preparation stage, when an action plan is formed, goals are set, and small steps are taken towards the action (Prochaska & DiClemente, 1982). The nurse may be compiling a list of questions regarding cultural concerns for the patient, to understand how to better provide culturally competent care.

The first three steps are before action is taken, and the final two steps involve the action-taking part of the theory. The fourth step is the action step, where direct action is taken and support is needed. The nurse may begin to ask culturally considerate questions of the patient, and may be receiving positive feedback about care. The fifth and final step is maintenance, which is the key step of continuing action. This is a working, continual phase to sustain the behavior change (Prochaska & DiClemente, 2012). For the nurse in the scenario, she may be implementing this questionnaire into her daily patient care practice to ensure continued culturally competent care.

Assessment of the Healthcare Environment

The international health care environment is very broad, and is actually composed of many different health care settings. Even solely in America, there are a variety of health care delivery methods. Due to variety in health care environments around the world, there is not much information on global health policies. However, there is a lot of information about resources and the quality and safety issues in various health care settings around the world. The research provided in this section will discuss these issues.

The differences in health care resources from country to country can be shocking. In some third world countries, the only access to health care may be a local clinic with limited resources and staff. A patient with a life threatening condition may not receive the necessary care to survive in this situation. On the other hand, a patient with the same condition may enter an emergency room in the US and immediately receive full nursing and medical care, and be stabilized within minutes. Because of the varying levels of resources and personnel available, patient and nursing outcomes must be evaluated on a case-by-case basis. Nurses in different countries face a variety of issues, and must set realistic patient goals based on the resources and support available.

Ferris State’s Professor Borello served as a missionary nurse in Haiti for thirteen years. In an interview, she discussed the main differences between nursing in Haiti, a third world country, and nursing in America. A big difference she noted was the fact that a nurse can be the only medical professional in the country, so he or she may be responsible for providing care outside of the nursing scope of practice (S. Borello, personal communication, April 4, 2014). As an addition to this challenge, the common disorders are much different than those seen here. The medications and treatments available are also typically limited in a third world country, so a nurse must be resourceful and creative when trying to provide the best care to patients (Personal communication, April 4, 2014). Another issue with these limitations is that multiple patients may need the last bottle of antibiotics left at the clinic. In these situations, the nurse is faced with an ethical dilemma about the distribution of resources.

Another issue most nurses do not anticipate is the difference in the customs, culture, and foods of the country. Professor Borrello advises any nurse planning to practice in a different country to learn about these differences before traveling. Also, the belief systems about disease and treatment options may differ from country to country. Professor Borrello gave a great example about this from her experience with the Haitians. A majority of the patients in her community had stomach worms due to the unsanitary environment. When Professor Borrello was explaining how the antibiotics work in killing the worms that inside of the patients, most of the people refused to take the antibiotic. Professor Borrello realized that the culture believed that inside each person was the worm of life, and if that worm was killed then the individual died. Because of this miscommunication, Professor Borrello had to communicate the mechanism of action of the antibiotic in a different manner (Personal communication, April 4, 2014). This example represents the importance of nurse to patient communication, and it’s effectiveness on health care around the world.

A survey was also conducted of the Ferris State nursing students about the medical environments in third world countries. 86% of the students reported that they were aware of the medical needs in third world country, and a little over a quarter of the students have been on a mission trip. Also, 67% of the students are interested in serving as a nurse in a third world country upon graduation (Personal communication, April 4, 2014). Because of the high rate of students interested in serving in a third world country upon graduation, an international clinical rotation might be useful to incorporate into nursing school. Research will be discussed in the implications section about the incorporation of international clinical rotations into undergraduate nursing education.

Although nursing in a third world environment comes with it’s own set of challenges, there are also many challenges faced on a daily basis by nurses in the top hospitals around the world. Patient and nursing outcomes were evaluated in twelve European countries, and in the US (Aiken et al., 2012). In the study, improved work environments and decreased patient to nurse ratios improved care quality and patient satisfaction. There was also a link between nursing burnout, intention to leave profession, and poor or fair quality patient care. In the countries where poor or fair quality patient care was reported, there was a higher nurse burnout rate and a larger percentage intended to leave the current position or the profession as a whole (Aiken et al., 2012). The biggest assumption when it comes to the international health care environment relates to the wealth of the country. As evidenced by this study, even the wealthiest countries with the best health care systems have quality and safety issues.

Implications

There are a variety of health care environments within the scope of international nursing practice. Each nurse must assess the resources, personnel, and environment in which he or she is practicing to ensure the highest quality care provided to the patients. As mentioned in previous research, nursing is a vital profession in all countries, and there are quality and safety improvements that can be made in nursing around the world.

Over half of Ferris State nursing students are interested in becoming a nurse in an underdeveloped country overseas (Personal communication, April 4, 2014). Due to this statistic, Ferris State’s nursing school board of directors may consider incorporating international nursing rotations into the nursing school curriculum. Nursing programs are beginning to offer more international clinical rotations. A survey of bachelor’s level nursing programs in Canada showed that 54% of schools offer an international clinical placement (Burgess, Reimer-Kirkam, & Astle, 2014). The results of the study revealed the recurring reasons for these placements: to develop global awareness, global engagement, global citizenship, and social justice. The students gained valuable life experiences from these clinical placement opportunities, and gained a broader health care perspective. The international clinical rotations will be continued (Burgess et al., 2014).

In a review of research study about international nursing education, twenty-three papers were reviewed to compare the educational experiences of various international clinical participants (Kulbok, Mitchell, Glick, & Greiner, 2012). In these research articles, nursing students traveled abroad to gain intercultural experience. The studies reported to have enhanced personal growth and knowledge about multicultural care. The global health goal of these programs mainly focused on learning about the various healthcare systems, health problems, and nursing practice in other countries. Unfortunately, very few of the articles focused on or discussed the fulfillment of these goals. Aside from the lack of understanding about the global healthcare systems, the nursing students were able to fulfill the goals of personal growth and learning (Kulbok et al., 2012).

There are many opportunities for nurses to serve internationally. The International Council of Nursing (ICN) is an organization that provides great resources for nurses around the world, and allows nurses from all countries to become members. The mission of the ICN is to represent nursing worldwide to advance the profession, and to influence health care policy (ICN, 2014). The American Red Cross provides nurses with opportunities both locally and internationally to serve underserved populations. The American Red Cross is often involved in disaster relief, and sends medical teams to regions who experience emergencies. The Peace Corps provides opportunities for nurses to serve in other countries. This organization typically provides long-term opportunities (typically two years) in over 60 different countries.

In underdeveloped countries, the health care needs are much more basic, and are often life or death situations. There is also a large need for health teaching, even about simple things such as hand washing and how to prevent the transmission of a deadly disease. In these countries, children are also at risk for being disadvantaged from birth. According to a study published in the Lancet, over 200 million children under age five in developing countries aren’t developing fully (Grantham-McGregor et al., 2007). The highest percentage of these underdeveloped children are born in African countries. The reason for the developmental challenges is that children are not held, are malnourished, and are exposed to many infectious diseases that compromise their immune systems. All of these issues, either separately or combined, are difficult for newborns to overcome. The research showed a strong correlation with poverty to these issues (Grantham-McGregor et al., 2007). The exposure to acute illness in third world countries is extremely high, and many individuals die each day from treatable diseases.

Wealthier countries around the world still face life-threatening diseases of a different nature, namely cancer. Some patients still face the life or death situations each day; these individuals are classified as having a chronic disease. On a daily basis, the typical American does not worry about being exposed to an individual with malaria or yellow fever. For the most part, America has used vaccination to rid the population of deadly disease outbreaks.

As developed countries such as the US continue to make healthcare advancements, do those countries have an obligation to assist underdeveloped countries in healthcare? If these countries do provide aid to countries in need, is there any chance the health care improvements will be sustained? These questions are important to ask in light of the health care disparities between countries. As noted in the previous section, America and other developed countries still face many health care issues in the hospital setting. From medication errors to misdiagnosis in first world countries, to deadly disease outbreaks in third world countries, all health care environments need quality and safety improvements.

Recommendations for Quality and Safety Improvements

Quality and safety improvements in third world countries should focus on prevention of disease outbreaks, basic health care teaching, and other similar community health issues. As discussed throughout this paper, individuals in the third world are more prone to acute disease, and are at high risk of dying from those diseases. In developed countries, improvements should be focused on improving the quality of patient care in the hospital setting, decreasing the amount of medical errors, and improving patient teaching about chronic illness. Quality and safety must be assessed and improved based on the individual health care environment of each nurse.

The QSEN competencies assess various aspects of nursing care. In order to provide patient-centered care in the international health care environment, the nurse must provide culturally competent care based on the culture of the patient (QSEN Advisory Board, 2005). Teamwork varies from country to country; in some cases, an entire interdisciplinary team is available, and the nurse’s job is to delegate the correct tasks to the correct person. In a third world country, the nurse may be responsible for making all medical decisions, and also implementing those decisions. Evidence-based practice may change from country to country, based on the evidence available and provided for each country. It is important for the nurse to understand the evidence within the country, and practice within the defined nursing scope (QSEN Advisory Board, 2005). A nurse also may be able to add to the evidence-based practice of a country. If a nurse from America travels to Africa, he or she is able to teach African nurses about the recent evidence from America.

The American Nurses Association (ANA) has created a set of standards for American nurses to abide by within their scope of practice (ANA, 2010). ANA Standard seven involves the ethical situations in which a nurse is placed. Any nurse will be faced with multiple ethical situations throughout his or her lifetime, and an international nurse may face unique ethical dilemmas. A nurse in a third world country may have all the knowledge to provide best care for the patient, but may not have the resources to treat them. A nurse also may be the only medical professional, and could have two critical patients that need immediate care. These ethical dilemmas leave a nurse with a difficult choice to make, where there may not be a right or wrong answer. The eighth ANA standard is education (ANA, 2010), and international clinical rotations are being incorporated into nursing school. The 15th ANA standard is resource utilization. In any nursing setting around the world, a nurse must utilize his or her resources that are available. A nurse could be faulted for not using, incorrectly using, or not having the necessary resources to provide the best patient care. A nurse must recognize the availability of resources, and make the best use of the resources he or she has. Environmental health is the 16th ANA standard of nursing (ANA, 2010). The international nursing environment spans environmental health for all countries. From the nursing perspective, providing care for the entire community is greatly beneficial. In a third world country, providing patient teaching about the risks and preventative measures of infectious disease may decrease the chance of an outbreak. The international nurse plays a key part in the environmental health of the world.

Conclusion

International nursing is an important and growing field of practice for nurses. In the professional nurse’s career, he or she will be expected to care for patients from culturally diverse backgrounds. Nurses should be prepared to encounter and provide high quality care to patients from all backgrounds. The best way to provide this high quality care is to be educated about the patients background, understand his or her own cultural background and biases, and understand the best practice within his or health care environment. Nursing is a valuable profession in all areas of the world, and each nurse can make a difference in the community he or she serves.

References

Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., & Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in europe and the united states. Bmj, 344.

American Nurses Association. (2010). Nursing: Scope and standards of practice. (2nd ed.) Silver Spring, MD: American Nurses Association.

Burgess, C. A., Reimer-Kirkham, S., & Astle, B. (2014). Motivation and international clinical placements: Shifting nursing students to a global citizenship perspective. International Journal Of Nursing Education Scholarship, 11(1), 1-8. doi:10.1515/ijnes-2013-0056.

Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P., Richter, L., & Strupp, B. (2007). Developmental potential in the first 5 years for children in developing countries. The Lancet, 369(9555), 60-70.

International. 2014. In merriam-. Retrieved September 19, 2014, from .

International Coucil of Nurses. (2014). Our mission. Retrieved September 22, 2014, from .

Kulbok, P. A., Mitchell, E. M., Glick, D. F., & Greiner, D. (2012). International experiences in nursing education: A review of the literature. International Journal Of Nursing Education Scholarship, 9(1), 1-21. doi:10.1515/1548-923X.2365.

Leininger, M. (2012). Transcultural nursing. In Nursing Theories. Retrieved September 19, 2014 from .

Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276.

QSEN Advisory Board. (2005). Competencies. QSEN Institute. Retrieved September 22, 2014, from

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