Nurse leadership in global health: New opportunities, important priorities

Abstract

Image 1 In 2017, Peking Union Medical College (PUMC) celebrated its 100 year anniversary. The anniversary celebration provided an important opportunity to reflect on what PUMC nursing education has accomplished since its inception in the 1920s. The events also provided an opportunity to consider the future of health and health care, as it may be shaped by nurses in China and around the world. Across China, nursing education programs at PUMC and elsewhere successfully graduate thousands of nurses who are providing important health care services for the people of China. Increasingly, nurses in China are learning from nurses in other countries around the world, even as nurses in the United States and other countries are fortunate to learn from their Chinese nurse colleagues. It is very possible that some of the future transformations in nursing and health care, in both China and in other countries around the world, will begin with innovations that come from nursing students who are studying today at PUMC and in other Chinese nursing education programs. Already, nurses in the United States and elsewhere learn from research that Chinese nurses publish in nursing journals. Additionally, the opportunity to learn about Chinese and other nurses leading changes in health care is accessible through web based resources for professional nurses. Because of the connections made possible through social media and the internet, nurses do not need to act alone in their efforts to improve health and health care. Through the use of information technology, we are all able to quickly partner and learn from each other. Using this shared knowledge, nurses are better able to advance health and health care. Because of this value for example, it has been recommended that China's nursing educational bodies share knowledge both nationally and internationally [1]. Through the knowledge gained from country level and global information exchanges, the role of nurses will continue to change and, in many cases, expand. As a result, the scope of what the next generation of nurses is being taught about emerging nursing roles should also be changing. Preparing nurses for both leadership and expanded responsibilities is essential. Nursing education programs should ensure that graduates are prepared to influence both the health of one patient at a time and also be able to drive and actively participate in health system changes that influence the health of entire populations. Some of these health care transformations of the future will be driven by well prepared nurse researchers whose research drives improvement across a continuum of impact; from the point of delivering care to informing public policy. Whether nurses are fully engaged in health care delivery or public policy environments, in the future, contributions from the nursing profession can be even more substantial. When it comes to health care services, nurses are often the first providers that people see when they seek health care. Every day, nurses help to improve the health of millions of people. Every day, working in many different environments, nurses identify and solve problems. Nurses are health leaders and innovators. Increasingly, nurses create new pathways to deliver better care so that individuals, communities and even countries, can achieve better health. Because of the values and expertise of the nursing profession, nurses are well positioned to further expand their contribution to health. Some of these important contributions will come from nurse leaders who are prepared to develop and implement health care policies that broadly transform and improve health care. For example, as the Acting Deputy Secretary of the United States Department of Health and Human Services, I worked on some of the national health care and human service transformations in which the United States federal government was involved. I was asked to serve in this position by former United States President Barack Obama and I was the first nurse to serve in this high level senior executive position. Nurses working in roles like this one bring the expertise of the nursing profession to important public policy engagement. Employing nurses in these leadership and public policy roles helps to ensure that important and highly relevant nursing knowledge is fully used in transforming care that impacts the health of nations, and contributes to improving health worldwide. Today, challenges to global health are serious and prevalent. No expertise that can help to address these challenges should be overlooked, including the expertise of the nursing community. In fact, from outside of the nursing profession, key stakeholders have called for more nursing leadership and expertise in order to help address global health problems. For example, in 2015 the former Director General of the World Health Organization (WHO), Dr. Margaret Chan, spoke at the International Council of Nurses meeting in Seoul, Republic of Korea. She discussed serious inequalities that are evident around the world, ranging from income to health inequity. Dr. Chan warned the nursing audience that “a world that is so out of balance is neither stable nor secure” [2]. The instability and insecurity that she mentioned is tied to very serious challenges like poverty, and lack of health care and she saw a role for nurses to help address these problems. Dr. Chan viewed nurses as part of the solution to broader problems of inequity and she asked nurses to consider what the nursing profession can do to help solve these broad problems that create instability and compromise human health. In addition to the WHO leadership, national leaders also see significant value in nurses using their expertise to help to address broader societal challenges that affect the health of individuals and families. For example, in the United Kingdom, a recently released report from Members of the British government titled “Triple Impact” describes the importance of supporting nurses so that they can work to fulfill their potential [3]. The report highlights the importance of the nursing profession's values, including a strong orientation toward person centered care and humanitarian approaches. Politicians, non-nursing health leaders and others are also strongly encouraged to work with nurses to help change how nurses are viewed and also work to change what nurses are permitted to do. This government report asserts that further developing nursing will improve health, promote equality between men and women and help to support economic growth of countries. 1 The United Nations Sustainable Development Goals It is appropriate that nurses are recognized as an important part of the solution to broader problems that impact health because of the nursing profession's values, skill, expertise and substantial reach in connecting with people worldwide in need of health care. A unifying focus for nurses around the world to work to their potential is to focus on global problems adversely affecting health that are the targets of the United Nation's (UN) Sustainable Development Goals. In September 2015, the UN General Assembly adopted 17 Sustainable Development Goals (SDGs) to address significant global challenges. Most of the 17 Sustainable Development Goals relate to serious problems that, if not fully addressed, put the health status of people around the world at greater risk [4]. For example, SDG 13 focuses on the need for climate action. The science on climate change is clear, changes are displacing entire communities and contributing to disease outbreaks that can affect the health of individuals and communities [5] Another goal, SDG 1, focuses on eliminating poverty. In this case, nurses working with women to help them move out of impoverished circumstances can impact the health of the mother and their entire family. Furthermore, members of the nursing profession from countries around the world who work alongside of others to address climate change or to eliminate poverty can impact both the health of people living today and the health of the next generations as well. Among the Sustainable Development Goals, SDG 3, explicitly focuses on health and promoting well-being for all, at all ages. One of the targets associated with this specific goal calls for efforts “to achieve universal health coverage including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medications for all [6]. Of the 17 SDGs, this goal has the most direct link to the nursing profession and health care systems. For almost all of the SDGs, nurse leaders and National Nurses Associations have the opportunity at country levels to contribute to those Sustainable Development Goals that individual nurses and the nursing profession prioritize, and that are the priorities of nurses' respective countries. Across many of the SDGs, more nurse researchers can help build the evidence that supports public policies and programs that are most effective in achieving these goals. Nurse educators can strengthen educational programs to ensure the next generation of nurses recognize nursing's important role in helping to achieve the prioritized goals. And, nurse leaders can communicate to all health stakeholders about the health benefits of doing more to achieve the SDGs in order to protect the health of communities, and of nations. An observation that is often attributed to the Greek philosopher Aristotle is this: Where the needs of the world and your talents cross, there lies your vocation. Nursing's vocation lies in addressing problems that can be identified and solved both within and outside of traditional health care settings. Working to achieve the Sustainable Development Goals crosses the talent of nurses as they work in education, research, practice and policy development. Recognizing the ability of the nursing profession to engage in this important work, the International Council of Nurses (ICN) has captured nurses' efforts from around the world in a toolkit titled “Nurses Role in Achieving the Sustainable Development Goals” [7]. The toolkit was released in May, 2017 in conjunction with International Nurses Day. Accessible through the ICN website, the toolkit includes innovations by nurse leaders that can be replicated and increase nursing's impact on complex global problems. In other words, by accessing the toolkit, nurses can identify and potentially adapt approaches to addressing problems that are similar across communities and countries around the world. Because the ICN is continuing to collect new models to add to the toolkit, nurses are able to learn and, when appropriate, adapt the transformative work of nurse leaders from almost anywhere around the world. This is the future of nursing, where the flow of information can now occur within minutes or months-not in years-- as was historically the case for nurses around the world. In addition to the important work of engaging the Sustainable Development Goals, going forward, more nurse led models are needed that focus on specific non-communicable and infectious disease burdens. Illustrating the interconnectedness of the SDGs and health, the occurrence of non-communicable disease and infectious disease, often can be traced to global problems like poverty, the very problems that the SDGs are designed to address. 2 Non-communicable diseases The global disease burden associated with non communicable diseases (NCDs) is a major driver of the need for health care transformation. In fact, this burden is explicitly recognized in one of the targets associated with the previously mentioned third Sustainable Development Goal that focuses on health. The target aims to decrease premature mortality from NCDs by one third and recommends achieving this target through initiatives that focus on prevention, treatment and also by promoting mental health and wellbeing. To illustrate the impact of NCDs, the largest causes of mortality in the world are cardiovascular disease, chronic obstructive pulmonary disease, diabetes and cancer. Worldwide, more than 40 million people die from these diseases each year [8]. In the United States, the National Academy of Medicine's report on “Global Health and the Future Role of the United States “ warned that globally, the increasing prevalence of non-communicable diseases threatens the gains that have been made in overall quality of life, productivity and life expectancy [9]. Regardless of where they work, nurses know the difference that preventing NCDs can make, both to the health of individuals and to holding down health care costs. And, nurses know how devastating these diseases can be when they are not effectively managed. Too often, NCDs that could be prevented with lower cost primary care-the very care that nurses often provide—are not prevented and are not effectively treated, leaving these diseases to become severe and costly. In fact, research indicates that cardiovascular disease accounts for the highest health expenditures in most countries around the world [10]. Imagine the improvements in health status of populations if nursing expertise contributed models that significantly decreased the prevalence and severity of this one disease category-cardiovascular disease. Imagine the financial resources that could be made available to meet other health care needs. Nurses know these health gains are possible because nurses know that many NCDs can be prevented, by modifying known factors such as smoking, obesity and high blood pressure. To effectively address NCDs, nurse led care transformation can begin with models that incorporate WHO's recommendation to “reform service models that concentrate on hospital care and refocus health services on prevention and on the provision of high quality, integrated community based and people centered primary and ambulatory care”. Nurses in particular, are well prepared to lead the complex work of integrating community based, ambulatory care with health system and point of care interventions. Nurses in community and public health work with at risk patients to prevent NCDs. Nurses care for individuals with these chronic conditions in a variety of settings. Because of their practice settings and their knowledge, nurses collectively are well positioned to design continuous care models that are patient and population centered. Nurses developing, testing and sharing innovative models to prevent and treat NCDs means health status will improve, lives will be saved and money will be wisely spent. These are all outcomes that matter to nurses, to government officials, and most importantly, to the people that are potentially impacted by NCDs. 3 Infectious disease While reshaping health care to more effectively address non-communicable diseases is a high priority, over the past decade, it has become clear that better prevention and management of infectious disease outbreaks is also an important focus for nurses and other health care providers. The experiences associated with SARS, Ebola and Zika underscore the importance of having strong public health and health care systems that are tightly aligned. Both within and outside health care settings, nurse expertise is needed to help develop new approaches that strengthen health infrastructure in order to limit the spread of infectious disease and ensure that health resources, including human and financial capital, are used effectively. Nurses can do this by developing and sharing nursing practice models and nursing knowledge that strengthens our public health and health systems. For example, National Nurses Associations, collaborating with local and national governments, should consider developing communication and other plans that bring the breadth of the nursing community to respond to infectious disease outbreaks. In the United States, as concern about Ebola increased, I reached out to national nursing organizations to request their assistance in communicating about the disease to the public. As a nurse working in the federal government, I knew that nurses in communities across the country, equipped with accurate information, could extend the reach of the United States government to ensure that the American public had current information. Nurses are often viewed as trusted professionals and because of their widespread presence in communities, incorporating them into broader communication strategies with the public can help to allay unfounded fears associated with infectious disease. Perhaps most important for nurses to continuously communicate to the public and to policymakers is that to fully protect people in our own countries from infectious disease outbreaks, we need to protect people in all countries. 4 Approaches for transforming care Whether nurses commit to being at the forefront of work on the Sustainable Development Goals, or new models for transforming care around non-communicable or infectious disease, three cross-cutting areas merit consideration First, these complex issues require innovative solutions that may benefit from engaging non-traditional partners. Second, nurses need to consider the relevance of digital health technology, and third the next generation of nurses needs to have education that prepares them for working at the forefront of care transformation. 5 Health innovation that includes non-traditional partners In the United States (U.S.), about 16 years ago, 2 major reports were released by the National Academy of Medicine; To Err is Human [11] and Crossing the Quality Chasm [12]. The reports documented medical errors and problems in quality of care in U.S. hospitals. Since the reports, many new efforts have been taken in health care facilities across the United States to keep patients safe and free from harm. There were many physicians on the committee that produced these reports and I was the only nurse on the committee. In addition to having traditional health providers to consider how best to eliminate errors in medical care, we also enlisted help and lessons on safety from experts outside of health care. We looked closely at other industries like aviation that has a high priority on keeping passengers safe. Based on expertise from aviation, we considered and recommended a number of that industry's practices and concepts including team training and situational awareness. Innovations to achieve SDGs or lessen the presence of non-communicable and infectious diseases may be informed by experts not just from within health care but external to health care as well. Nurses at the forefront, transforming care, should not overlook innovative processes and structures from outside of health care that can improve what we do in health care. 6 Health innovation through technology The second consideration in care transformation is the opportunity for nurses to champion new applications of digital health technology. The nursing profession needs to be an active participant in conversations regarding digital health technology, conversations that are occurring now, with health and information technology experts. Digital health opportunities range from connecting care to vulnerable populations through telehealth, to applying new technologies to support patients engaged in self care. Digital technology holds promise to help address an array of problems ranging from fragmented care to inefficient care processes to shortages of health care providers. Expanded nurse training in new digital technology that can be embedded into care systems can help prepare nurses to improve the performance of the organizations and systems where they work. 7 Health innovation through Nursing's next generation Third, nurses need to champion new pathways for the next generation of nurses; pathways that fully capitalize on new nursing knowledge and skills. When health care and health policy underuse nursing knowledge, precious resources are wasted. Nurses can work to educate policymakers about the value of expanded nurses roles ranging from primary care to public policy. A favorable trend across many countries shows that between 2007 and 2012, a number of countries expanded scopes of practice for various providers, including nurses [13]. To ensure that health systems have structures and processes in place that support the delivery of efficient, safe and high quality care, nurse educators needs to ensure that the next generation of nurses are well equipped to be at the forefront transforming care. Nursing students need cutting edge leadership content, education in social and environmental determinants of health to recognize the links between health and efforts like the SDGs, and a substantive orientation to global health problems. Nursing students need to know that developing creative solutions to health care problems, for example, by harnessing digital technology or working with experts from other industries, is an expectation of the profession. With this orientation and knowledge, the next generation of Chinese nurses and nurses around the world, will have the opportunity to do even more to improve health and health care by being a transformative force for change.