International Nursing Presentation

International Nursing PresentationNUR587January 19, 2015Facilitator: Dr. Anna RiveraShelli Chernesky, Kelly Ewing, Kenneth Longbrake, Susan Mateo, Sharna Young

1Introduction Evidence-based care, policy development, and professional advocacyNurse leader role in international settingsNursing shortage and nursing migrationEffects of educational preparationNurse leader role in supporting diversity

The role of the nurse leader requires a vast knowledge base and a strong set of skills. Nurse leaders in the United States and internationally need to ensure the care delivered in their organizations is evidence-based. Leaders should use evidence-based research and practice when developing policies and practice standards. Nurses need to be advocates for the nursing profession. One way that leaders can advocate for the profession is by joining nursing organizations. The International Council of Nurses (ICN) is a nursing organization that advocates for nurses around the world and has established a code of ethics for nurses to follow in their practice (Whitten & Cameron, 2004). Nurse leaders need to participate in addressing the nursing shortage and developing standards for nursing education. In the United States, recent projections indicate that the gap between supply and demand of qualified nurses is expected to widen to over 1 million nurses by 2020 (Somers, Finch, & Birnbaum, 2010, p. 292). Nurse leaders should possess knowledge and skills to support cultural diversity in their workforce. The ethnic makeup of the nursing profession should mirror the public being served. Leaders need to focus on hiring a diverse workgroup and prohibiting discrimination and prejudice in their organizations. 2Evidenced-Based CareThe role of nurses in the United States and internationally is to:Seek out evidence-based practice researchDevelop sufficient training and practicesDecrease the gap between gaining knowledge and using the knowledge Have a positive attitude toward evidence-based practice changesAsk the clinical questions

Health care settings demands are increasing and nurses are expected to keep up with new trends to provide high-quality care based on research evidence. The role of nurses in the United States and internationally is to seek out the best evidence-based practice (EBP) research to develop the best care training practices and delivery to health care systems. It is the imperative role of nurses internationally to decrease the gap between knowledge gained and using the knowledge to increase the health and well-being of people. The concerns of rising health care costs and the principle and values to do things right has created a culture for the advancement of evidence-based health care delivery (Stokke, 2014).A study at Kenyatta National Hospital in Kenya looked at relative factors that influence evidence-based care delivery at the bedside. The study found that higher educated nurses are more receptive to EBP, had a better attitude toward the EBP changes, and had the ability to review the literature (Barako, 2012). A qualitative design study in Norway using bachelor's degree nurses looked to discover where nurses acquire their knowledge for their professional practice. The study revealed that the nurses use their personal experience, experiences of coworkers, knowledge from their nursing school education, and advices from experts to make decisions about their care practices. The study found that nurses seldom use research-based evidence when clinical decisions are made. The study findings highlights that nurses have an opportunity to increase and advance their practice through the use of evidence-based research (Berland, 2012). Nurses must take the leadership role to analyze research and initiate discussions that lead to the development of practice guidelines and protocols (Stokke, 2014). The European Commission and the World Health Organization (WHO) both confirm that health care services must have the foundation of research evidence found in the literature. Current research studies from different countries identify that nurses limit use of EBP because of obstacles such as lack of time to complete literature search, a lack of leadership support to change practice, and lack of resources (Stokke, 2014). Globally, evidence-based practice (EBP) and the delivery of high-quality care has been a high priority for the nursing profession for many years. The nurses role in the United States and internationally is to continually be involved in asking clinical questions, researching literature, collecting the best evidence, and integrating evidence-based care into health care delivery (Stokke, 2014).

3Policy DevelopmentThe role of nurses in the United States and internationally is to:Be a leaderSpeak out on health care issues to policy changersBe a voterHave memberships in organizations, committees, and hospital administrative boardsLearn from other nurses around the worldBe aware of the strengths of nursing profession

Global economics of recent events have affected every industry including health care. Nursing leaders of the United Kingdom are confronted with demands and challenges of fixed budgets, a system that is centrally funded as a result of rationing health care. The health care system affects the deterioration in patients conditions adding to eventual higher costs of care and inefficient use of resources. These conditions impact the nurse ability to provide the standard of care they would like to achieve. Added to this challenge, is the target driven approach which measures the providers performance through quality measurement, forcing patients to be seen quicker and causing greater strain on the stretched nursing staff. Another challenge in Whales is the media attacks through storytelling and reports of poor quality patient care while health care budgets continue to shrink and needed health care improvements are unreachable (Gantz, 2012). Nurses continue to be the most engaged direct care providers of patients. They have positioned themselves to become leaders in developing systems and processes to decrease medical errors, avert nursing shortages, and improve the quality of care through better care coordination. Nurses also hold the knowledge and expertise to benefit governance within organizations, as committee and board members, fundraisers, and health policy and law changers (Gantz, 2012). The International Council of Nurses (ICN) empowers nurses to speak out with one voice to advance the nursing profession through the influence of health care policy development. The nursing voice shapes the foundation of policies that will then be established and applied in various countries (Benton, 2012).The nursing role in the United States is first to be a registered voter. The international nursing workforce can contribute to the development of their nation's health and social policies by speaking with one voice through organizational membership, speaking out to political leaders, supporting health projects and joining health movements. Nurses need to keep focused on issues that matter, build leadership skills, and advocate creatively for public policies (Gantz, 2012). Nurses must strive for higher education and increase the educational entry level into the profession (Ellenbecker, 2010). The role of the nurse is to learn from one another throughout the world and be knowledgeable about the nursing professions strengths to better our nations health (Gantz, 2012).

4Professional Advocacy The role of nurses in the United States and internationally is to:Act as advocates for the publicSpeak out on disparitiesMeet the challenges of workforce shortages and workforce divergenceBe a voice of the frontlineWork through professional organizations to improve patient careAdvocate to shaping policies and strengthening the influence of nursing

Globally, nurses are placed at the front line of delivering highly sensitive sophisticated care to deep-rooted disparities. Many nurses work closely with individuals, families, and communities that are chronically underserved and vulnerable. These examples lead to the fact that nurses are engaged in providing care in diverse environments. The nursing role in the United States and internationally is to act as advocates for the public. Nurses must ensure that the nurses within their profession are properly educated and prepared for their duty to provide care and speak out on disparities. Nurses must meet the challenges of workforce shortages and workforce divergence (Jackson, 2014). Chair for the Nurse in Washington Internship Program (NIWI) for the Nursing Organizations Alliance (NOA) presented how historical events, society changes, and the increase in nursing membership groups contribute to a stronger advocacy. The role of nurses is to work together to build support for needed changes and be a voice of the frontline heard by policy makers. Nursing leaders must promote healthy work environments, form professional identity, and be prepared as advocates (Sanford, 2012). The CEO of the International Council of Nurses (ICN) presented nursing updates from several developing countries. Nurses were working through their professional organizations to improve quality care in health care delivery. Admiration is given to nurses in Rwanda, who have joined movements to improve the quality of professional standards and education. Nurses of an El Salvador project led to combatting dengue fever. Papua New Guinea nurses provided testing for HIV and AIDS. The ICN acknowledges the need for leadership throughout the world to better health. Leadership involves advocating to shaping policies and strengthening the influence of nursing. Global nations are striving for ways to transform health care in economically challenged environments. The role in nursing is to be the advocate not only for the patients and families we care for, but the whole world (Sanford, 2012).

5Effects of the Nursing ShortageIdentify the ProblemCollaborationInternational Council of Nurses (ICN) American Nursing Association (ANA)Federal & State CongressFederal Bill S2353 Increase Number of Graduating NursesInternationallyNationally

Identification of the national nursing shortage is forecasted for the globe and American communities. Support from the International Council of Nurses (ICN) and the American Nursing Association (ANA) is benefical, along with other nursing organizations for discussion of the nursing need. Here within the United States, collaborating with both federal and state congress interjects this dangerous situation on the horizon as an intervention for community health. The importance of formalizing actions to help enhance both long-term and short-term plans of this problem is monumental to fade patients at risk for compromised care. Nurse staffing is an issue that nurses have dealt with for years, and is something that will continue to be a problem for years to come. The nursing shortage has been projected to continue to increase over the next few years, making ways to increase staff and retain staff imperative (ANA, 2014). With Federal Bill S2353, there are benefits such as allowing staff to the opportunity to look at skill mix and census, as well as patient acuity along with other positives. However, the need for nurses is the bottom line which requires an increase in nursing schools internationally and within the nation. It is important to ensure that the nursing shortage addresses and provides legislation such as Bill S2353 to assist with the nursing shortage for best patient health and outcomes within our nation, but works looking at the nursing shortage throughout the globe.

6Mission & Vision of Nurse MigrationCommission on Graduates of Foreign Nursing Schools (CGFNS) InternationalAuthentication and VerificationTesting and Evaluation of Education Outside of the US, including English ProficiencyCredential EvaluationEducation and LicensureImmigration/EmploymentResearch

CGFNS International (2014) states, The mission of CGFNS is to serve the global community through programs and services that verify and promote the knowledge-based practice competency of health care professionals. The vision of CGFNS is to be the premier source of credentials evaluation and professional development services that provide strategic value and direction to health care professionals worldwide (p. 1). The CGFNS has developed and administer a predictive testing and evaluation program for nurses educated outside the United States, which includes English proficiency with both written and oral. Credentials evaluation services for health care professionals educated and born outside the United States, along with serving as a clearinghouse for information on international nursing education and licensure. Assistance with immigration and employment guidelines after clearance from the CGFNS is obtained. Conducting research and publishing studies relevant to internationally educated nurses is relevant to the CGFNS as an assessment of services provided to the nation for the nursing shortage (CGFNS International, 2014). This model of a standardization of nursing education and practice will benefit global health with specific guidelines and policies. Nursing as a profession, requires some form of authenticity for best patient outcomes (Sherman, 2008).

7Future Nursing RegulationCGFNSNursing EducationTesting-NCLEXCertificationsPractice StandardsANAHospital Entity-Magnet

Future nursing propels towards a melting pot of cultures regulated by the CGFNS for standard nursing care delivery. This process is governed internationally by testing and certifications of nursing organizations. National testing of nursing knowledge is controlled by a testing tool called NCLEX influenced by the American Nursing Association (ANA, 2014). Standards of practice from the ANA influence the voice of nurses from the bedside with evidence-based data collection to drive nursing care delivery through nursing certifications and Magnet accreditation. Validation of knowledge is favorable for best patient outcomes (Manojlovich, 2009). A look at this model and transferring the processes internationally for best patient outcomes is monumental for the nurse, and the profession.8Educational PreparationLevels of nursing licensure and education within nationsVariances in licensing and education between nationsLack of international standards for ease of nurse migration between nations

In the U.S., there are several levels or types of nurses, defined by educational level and license. These include the Licensed Practical/Vocational Nurse (LPN/LVN), the Associate Degree Registered Nurse (ADN), the Bachelors Degree Registered Nurse, the Masters Degree Registered Nurse (MSN, also Advanced Practice RN or APRN), and recently, the Doctor of Nursing Science (DNS). In addition to the completion of their respective educational preparation, graduates must also pass an examination in order to legally practice at the given level (practical, registered or advanced practice) ("Wikipedia, The Free Encyclopedia",2014). The U.K. also has various designations within their nursing practice as well. These include Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Advanced Nurse Practitioner (ANP), Higher Level Practitioner (HLP) and more recently Nurse Consultant (NC) (Daly & Carnwell, 2003). Other countries as well, may have differing levels of education and licensure determining scope of practice within their nations. Because each country sets its parameters for what each level of nurse may do in the provision of its care, there exists a variance between nations in the levels of knowledge and skills. Nurses traveling from one nation to another to practice in their profession must meet the standards of their host country. The U.K. (as well as the U.S.) requires internationally educated nurses (IENs) to demonstrate knowledge and proficiency in order for them to practice (Allan, 2010). The U.K. has recognized that IENs face difficulties in transitioning related to lack of preparation of training facilities with respect to incoming nurses home cultures and experiences, lack of knowledge regarding transitioning nurses skill levels (that they are not students, but already licensed nurses), and the impact of the language barrier (Allan, 2010). Cheng, Spaling, & Song, (2013) recognized that IENs face the twin challenges of successfully learning the host nations language well enough to pass basic proficiency exams, but also to pass professional knowledge exams. 9Educational PreparationObstacles to transitioning to nursing in a new nationLanguage barrierSkills evaluation methodsTesting for clinical knowledge and knowledge of scope of practiceUse of technology to overcome barriersHandheld translatorsBuilt in translation software to organizational EMRs

The language barrier can impact the test scores as general proficiency exams, and the language level of professional exams are not equivalent. Learning an additional language is a long-term, multistage process that must also incorporate social and cultural aspects of the local society and the profession (Lum, Dowedoff, Bradley, Kerekes, and Valeo, 2015 p. 83). Due to the questionable credibility of some nations licensing practices and the commercialization of nursing education in some areas, there is likely to be significant variability in quality and quantity of education and competency among IENs. For this reason, the establishment of internationally recognized standards and regulation may well be necessary to ensure patient safety and quality of care (Xu, 2010).One step that could be implemented almost immediately, though the cost would require reallocation of funds within the budgets for hardware and software, would be to add hand held translators such as the Franklin Global Speaking EST 7014 or the Lingo Voyager 6, at a cost of 165.00 or 199.00 USD each (10TopTenReviews, 2015). A second option to assist IENs in documentation would be to add software into the EMR systems that would allow the nurse to enter the narrative or descriptor into the translator and see the correct written information to input into the actual EMR of the patient.

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Differences in International Nurse Leader RolesEducational level

Cultural affiliation

Contribution to policy development

Various levels of decision-making powers

There are differences in nurse leader roles from country to country. The one with the greatest impact is the educational level amongst the nurses of different countries. Here in the US nurse leaders have some training to deal with the complex issues that may confront them. The Magnet Recognition program for facilities has acknowledged the importance of training nurse leaders, which is linked to positive work environments (American Sentinel, 2014). In other countries, this may not be the case. Increased costs associated with healthcare, regardless of the proven positive outcomes due to more qualified nurses have not deterred some countries from not supporting higher education. "Despite research from economists demonstrating cost savings from care provided by RNs prepared at the baccalaureate level, as compared with care provided by lesser-educated workers, Fear of governmental support and pressure to replace RNs with lesser educated non-licensed workers (Zittel, Ezzeddine, Makatjane, Graham, Luangamornlert & Pemo, 2012, p. 51) is how they curtail costs. Zittel et. al. (2012) has cited that lack of uniformity internationally with educational levels for nurses introduction into the profession has put nursing at a political disadvantage (p. 53). As a result, nurse leaders in those countries may be in a position to effect change on a national scale.From a cultural standpoint, nurse leaders in some countries are not allowed to practice autonomously because their work is described as "women's work". This subservient role in some countries is still widely accepted. Sherman and Eggenberger (2008) reiterates "that nursing in other countries is significantly different, especially in the areas of nurse autonomy, accountability for patient assessment, and technology" (p. 538). They point out that because physicians were always present to direct patient care nurses could not act independently.Lack of autonomy and decision-making powers are also a major issue with nurse leader role differences from country to country. Some countries do not promote or allow nurses leaders to contribute to policy development. According to the World Health Organization (WHO) (2003) Nurses involvement in policy formulation, has been decreasing. Their suggestion is that governments should develop legal frameworks in which nurses would be allowed to make contributions (Shariff & Potgieter, 2012). Western countries have been able to play some role in policy development but still have ways to go in this endeavor. For other developing countries, this is not common. Analysis done by Kunaviktikul et. al and Phaladze uncovered that involvement in national health policy in Thailand and Africa by nurse leaders, were only during the implementation phase and not the developing stage (Shariff & Potgieter, 2012). Health policies in these countries, therefore, are lacking and puts the nursing profession back in its development. Nurses decision-making powers in countries like the United States (US) and the United Kingdom (UK) are more open to the idea of nurses having decision-making powers. Nurse Practitioners in the US can practice autonomously and make decisions that nurse leaders in other countries prohibited. The physician population is said to be the reason there is a rise in Nurse Practitioners (NP) in the United States. The smaller population of doctors has led to NPs practicing autonomously and having decision-making capabilities. The high number of physician has equally been the reason for other countries not seeing this type of practice (Zittel et. al, 2012). Decision-making capabilities are a form of power. Not having the ability to function entirely within your profession limits satisfaction for any individual. Powerlessness within nursing is also said to be responsible for poor patient outcomes (Manojlovich, 2009). The goal for the nursing profession is trying to have some uniformity, which can only improve the profession.

11Differences in International Nurse Leader RolesInvolvement in government

Some nurse leaders only have consultative functions in the nursing profession

Professional knowledge in leadership

Research has shown that there are differences in nurse leaders and their power. The larger more industrialized countries are more open and lenient in having nurse leaders involved in government. Here in the US this is a practice that is encouraged and not always easy, but is effective. Governmental involvement is largely done through nursing associations and is considered a suitable vehicle for influencing policies (Benton, 2012). The International Council of Nursing (ICN) also acknowledges this method of garnering support for policy-making in government. This entire premise leads back to the differences seen in nurse leader roles in other countries where nurses do not have the freedom to act independently or have roles in policy development. Their involvement in governmental issues directly affecting nurses relates possibly to the minimum education some receive in countries that do not see the nurse beyond the subservient role. At the same time, nurse leaders are creative thinkers. Dr. Brenton, the Chief Executive Officer of the ICN, reported that the nurse leaders in Papua, New Guinea, although limited with how they can improve the communitys health, they followed requirements of the Leadership for Change Action-Learning Project. The ICN program allowed for "advocating the nursing profession by coordinating nursing actions to develop both public and healthcare service policies" (Brenton, 2012). These nurses were able to work together and in collaboration with governmental agencies to improve health on a grander scale. This action proves that given the opportunity to work collaboratively with the government, nurse leaders, thinking creatively, can enhance clinical outcomes more effectively with nurse leaders involvement. The ICN promotes this goal.It is also important to add that some countries only give their nurse leaders consultative powers. "Tornquest (1997) notes that the government in some countries does not see policy-making as an appropriate nursing role. In others countries, the role is limited to providing advice on nursing issues only"(World Health Organization, 2001). Although having consultative power is a step in the right direction, it still does not offer enough control to nurses in either making decisions or developing policies in their profession. Professional knowledge on leadership is a recommendation in nursing in the US however; there are still some countries that do not have the means to provide such skills. Research done in the UK, and North America have shown that leadership training is of value for both staff and patients (Lipley, 2003). Unfortunately, this is not a common practice in some countries and professional barriers are cited as the culprit. According to the American International Health Alliance (2015) barriers identified were "lack of professional standards and guidelines, absence of an independent nursing structure based on critical thinking, systemic inability to engage clinical or administrative decision-making processes and a dearth of training and educational opportunities at all levels". These are supporting evidence for the nursing profession again to realize the benefit of uniformity in nursing education to meet global needs of a changing population.12Cultural Diversity Nurse leader roleAwareness training and diversity educationOpen communicationExamine cultural climateReduce discrimination Reduce prejudice

The nurse leader needs to possess skills and knowledge to support cultural diversity in the workplace. Leaders need to have an understanding about the cultures of the employees that they manage. They should understand the different beliefs and practices of the groups and how they could impact the organization. A diverse staff should be the goal of a leader. Employees should know that their leader values them for their differences and the qualities that they bring to the team. Awareness training and diversity education is essential for all employees. Focusing on the common needs for inclusion, opportunity, and respect can help close the gaps among diverse employee groups (Whitten & Cameron, 2004, p. 203). The training and education sessions provide an opportunity for open communication and allow the nurse leader to examine the cultural climate. The leader should encourage employees to share their thoughts/feelings and provide guidance on the importance of establishing a diverse workforce. Open communication allows leaders to examine the cultural climate of the organization and determine what the additional training needs are of the staff. Discrimination occurs when employees are judged by individual qualities and not their work performance. Others can discriminate employees for their gender, skin color, or age. Nurse leaders need to have a zero tolerance policy for discrimination in their organizations. When leaders recognized discrimination, they need to react quickly and provide discipline/support. Prejudices are the individuals beliefs about a certain group of people. The leader can reduce prejudices over time by implementing these measures. 13Cultural Diversity Nurse Leader RoleIncreasing diversity in nursingHiring diverse workforceEstablish organizational goalsMinority employeesAttracting men into nursing

Nurse leaders need to participate in developing a diverse workforce. There are several initiatives that nurse leaders can partake in to reach this goal. Nurse leaders need to participate in educating minority groups about the possibilities that are available to registered nurses. They need to provide education to ethnic diverse populations in high school/college on the nursing profession. Leaders need to establish organizational goals for hiring a diverse workforce and work with human resources to recruit/hire an ethnic diverse workforce that represents the community being served. The majority of nurses are white females, and the current nursing workforce does not represent our society. Nurse leaders need to encourage minority employees who are working in entry level positions to attend nursing school. To resolve disparities in education, colleges, universities, and healthcare organizations must allocate funds to assist nurses with advancing their education (Walters & Davis, 2014, p. 12). Men consist of less than 7% of the nursing workforce. Leaders should also target men to encourage them to pursue an education in nursing (Walters & Davis, 2014).

14Conclusion Nursing Supports Communities Around the World for Best HealthMelting Pot of International NursesStandards of EducationRegulations of Testing Evidence-Based PracticeValidation of Knowledge with CertificationsMigration of Nurses

The profession of nursing supports local communities and their people for best health outcomes around the globe. Internationally, nurses join hands serving the populations in need of health care. This melting pot of international nurses requires a framework of support for delivery of best health for all with a common set of standards and regulations. This process is strengthened with evidence-based practice for optimal outcomes, including examinations for validation of knowledge. The nursing shortages throughout the world and within individual nations place pressure on the nursing profession both locally and internationally. The ease of nursing migration is necessary to meet the health needs of an entire planet.15ReferencesAmerican International Health Alliance (2015). Nursing. Retrieved from www.aiha.comen/whatwedo/nursing.asp

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18ReferencesLibrary of Congress. (2014). S.2353 - Registered nurse safe staffing act of 2014. Retrieved from https://www.congress.gov/bill/113th-congress/senate-bill/2353/textLipley, N. (2003). Research shows benefits of nurse leadership training. Nursing Management-UK, 10(2), 4. Retrieved from http://web.b.ebscohost.com.ezproxy.apollolibrary.com/ehost/pdfviewer/pdfviewer?vid=3&sid=fcae15e4-041d-417a-9b26-9006b5d125d0%40sessionmgr113&hid=102

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Stokke, Kjersti , Olsen, Nina R, Espehaug , Birgitte (2014). Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nursing , 13(8) http://www.biomedcentral.com/1472-6955/13/8 Walters, S., Davis, C. (2014). Promoting diversity in nursing. Nursing Made Incredibly Easy, 12(6), 10-13. DOI: 10.1097101.NME.0000454753.66874.32

21ReferencesWhitten, D., & Cameron, K. (2004). Developing management skills (6th ed.) Upper Saddle River, NJ: Prentice Hall

World Health Organization (2001). The ideal attributes of chief nurses in Europe, a Delphi study for WHO: Europe. Retrieved form www.euro.who.int/_data/assets/pdf-file/10008/10230/E74525.pdf

Zittel, B., Ezzeddine, S., Makatjane, M., Graham, I., Luangamornlert, S., & Pemo, T. (2012). Divergence and convergence in nursing and health care among six countries participating in ICNs 2010 Global Nursing Leadership Institute. International Nursing Review, 59(1), 48-54. Doi: 10.1111/j.1466-7657.2011.00952.x

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