Nursing in the International Community: A Broader View of Nursing Issues

Nursing in the International Community

A Broader View of Nursing Issues

Judith A. Oulton

“We cannot live for ourselves alone. Our lives are connected by a thousand invisible threads … our actions run as causes and return to us as results.”

—Herman Melville

In the late 1960s, Marshall McLuhan coined the term global village. McLuhan was referring to the fact that through advances in communications, time and space have vanished. Not only was there a new, multisensory view of the world in 1967, but people from around the world could communicate as if they lived in the same village. Yet when McLuhan outlined his vision over 40 years ago, the Internet did not exist, nor did the World Trade Organization (WTO) (Box 101-1) and its Global Agreement on Trade in Services (GATS). AIDS was a little-known wasting disease in Africa, and the world was celebrating its first heart transplant and bypass operations.

During the past 40-odd years, we have witnessed the increased globalization of commerce, travel, information, trade, and disease. In 1955, there were 51 million airline passengers (IATA, 2005). According to Airports Council International, by 2025 the number of air travelers worldwide will be more than 9 billion per year (Metrics 2.0, 2007). Today people, images, and messages move around the world with ease, and we truly have a sense of being a global village. As a result, we have a professional obligation to understand the village-world in its broader context and to base our decision-making on a broader understanding of ourselves, our patients, and our circumstances. By having a global view, we are capable of synthesizing a broad range of information to make informed decisions. It begins with understanding the policies and politics of globalization and of other key international health and nursing issues.


Globalization is the growing interdependence of the world’s people with an integration of economy, culture, technology, and governance. Globalization changes the way nations and communities work, shrinking time, space, and borders. It means that national policy and action are increasingly shaped by international forces. Globalization brings new people to our countries and communities. The increase in international travel means the ready spread of disease and threat to security as people move freely across borders and continents. SARS and H1N1 are two examples of global health risks. Today, nations and health professionals must learn to care for new as well as reemerging illnesses, deal with the added risks of exposure, and handle acts of terrorism.

With GATS and the general globalization of trade, health services and the health professions are increasingly seen as commodities. Health tourism is gaining popularity as nations vie for patients interested in traveling to another country for health care. As well, many countries are expressing an interest in mutual recognition agreements that lower barriers for health professionals to practice in other nations. Increased communication, easier air travel, and the easing of trade restrictions have made mobility and migration easier.

Migration: a Case in Point

Migration is a key issue for nursing. According to the International Organization on Migration (IOM), there were 214 million international migrants in 2005, which represents 3.1% of the world’s population. Of this number, 49% were women (IOM, 2010). People, including nurses, move around for many reasons: to work; to study; to have fun; to receive health care; or to escape violence, poverty, persecution, and famine in their native countries. This movement brings with it the problems of unemployment, discrimination, racial tension, and harmful cultural practices, such as female genital mutilation. Today’s nurses must understand health, illness, and coping mechanisms from the perspectives of many cultures. Equally important is the need for the profession to be an advocate for sound health and nursing policy that considers the well-being of the patient along with that of the profession and its practitioners.

Governments—bilaterally, regionally, or through the WTO—negotiate terms for the movement of goods and people for economic gain. With the global shortage of health professionals, individuals and institutions at all levels (i.e., governments, employers, policymakers, the public, the professions, and professionals) are interested in the movement of nurses. It affects policy, planning, and delivery of nursing education and patient care. It brings to the fore such issues as use of fraudulent credentials, ethical recruitment, and discriminatory workplace policy and practice.

While nursing migration has slowed recently, nurses are still on the move. The nursing community has been vocal nationally and internationally in addressing migration and workforce policy and practice. The following are examples:

• In 2001, the International Council of Nurses (ICN) (Figure 101-1) issued its policy on Ethical Nurse Recruitment, which supports the right of nurses to migrate but denounces unethical recruitment and condemns the practice of recruiting nurses to countries where authorities have failed to implement sound human resource planning. The ICN has called for regulated recruitment and implementation of 13 principles to support recruitment and retention (ICN, 2001) (Box 101-2).

• In line with the ICN Position on Nurse Migration, and its Position on Ethical Recruitment, nurses’ associations have condemned the practice of recruiting offshore rather than effectively addressing human resource planning, including the problems that cause nurses to leave the profession and discourage them from returning to nursing (ICN, 2007; ICN, 2001). As well, associations are monitoring employers to ensure that the rights of migrant nurses are upheld and that adequate support systems are in place.

• The nursing shortage and lack of focus on nursing prompted the ICN to undertake a global study in 2004. The papers are available online at

• The ICN has created two new centers addressing workforce issues. The International Centre on Nurse Migration (ICNM) was launched in 2005 in partnership with the Commission on Graduates of Foreign Schools of Nursing. It serves as a global resource for the development, promotion, and dissemination of research, policy, and information on nurse migration (ICNM, 2010). The second center, the International Centre on Human Resources in Nursing (ICHRN), was established in 2006 as an online resource for information and tools on nursing human resources (ICHRN, 2010). The center produces papers, fact sheets, and case studies on a wide range of workforce issues.

• Beginning in 2006, the ICN, the World Health Organization (WHO), and the International Confederation of Midwives began hosting strategic biennial meetings in advance of the World Health Assembly, a body made up of representatives of ministries of health from 193 countries. Known as the Triad meetings and attended by government chief nursing officers, nursing and midwifery regulators, and leaders of national nursing and midwifery organizations, the group addresses key global issues, such as recruitment, retention, leadership, education, regulation, roles, and relationships. Triad statements are used in policy and advocacy at national and regional levels (Box 101-3).

• Migration has been on the WHO agenda for several years. In 2004, the World Health Assembly approved a resolution calling for a code of practice on the international recruitment of health personnel. The organization then spent 6 years discussing and drafting a code that, if approved, would be non-binding. It would, however, set out principles and guidelines for ethical recruitment (WHO, 2009). Several countries have developed guidelines for employers or introduced voluntary codes. In the United States, AcademyHealth, an organization that focuses on health services research and policy, and its partners created a voluntary code of conduct and a nonprofit organization—the Alliance for Ethical International Recruitment Practices—to increase transparency and accountability and monitor adherence to their Code (ICNM, 2009).

BOX 101-2

International Council of Nurses

The International Council of Nurses is a federation of national nurses associations (NNAs) representing nurses in more than 130 countries. Founded in 1899, the ICN is the world’s first and widest-reaching international organization for health professionals. Operated by nurses for nurses, the ICN works to ensure high-quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce.

The ICN advances nursing, nurses, and health through its policies, partnerships, advocacy, leadership development, networks, congresses, and special projects and its work in the arenas of professional practice, regulation, and socioeconomic welfare. The ICN is particularly active in ethics, AIDS, advanced practice, research, leadership development, the international classification of nursing practice, women’s health, regulation, human resources development, occupational health and safety, conditions of work, career development, and human rights.

The council works with agencies of the United Nations (UN) system, such as the WHO, UNAIDS, UNICEF, UNESCO, UNCTAD, and ILO; other intergovernmental organizations such as the World Bank, WTO, and the International Organization on Migration; and international, regional, and national nongovernmental organizations.

The Global Workforce Crisis and Millennium Development Goals

Migration and the shortage of health personnel have placed human resources for health care on the agenda as never before. In 2004, the Joint Learning Initiative (JLI) reported an estimated shortage of 4 million health workers globally. This figure is based on the density of 2.5 health workers (physician, nurse, midwife) per 1000 population that is required to achieve 80% coverage of measles immunization and skilled attendants at birth (JLI, 2004). It was supported in 2006 in the World Health Report, which identified 57 countries as falling below this threshold, 36 of them in sub-Saharan Africa (WHO, 2006). The crisis also saw the launch of the Global Health Workforce Alliance, a partnership with national governments, finance institutions, health workers, international agencies, professional associations, academic institutions and civil society, dedicated to identifying and facilitating solutions to the human resource crisis (GHWA, 2006). It champions universal access to health care and the message that a skilled, motivated, and supported health force is the cornerstone of a robust health system.

Attention to “health human resources” is part of the Millennium Development Goals (MDGs), launched in 2000. With a target date of 2015, the eight MDGs address poverty, education, women, child mortality, maternal health, HIV and malaria, the environment, and a global social compact (UN, 2005). Achieving the MDGs ultimately affects the health and well-being of the world’s 6.8 billion people. Governments and others (e.g., the G8, made up of the heads of state of Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the U.S.) who meet annually to deal with major national and international economic and political issues recognized that these ambitious goals could not be met unless two key issues were addressed: Africa and the global health human resource crisis, particularly the nursing shortage.

Today nearly all nations face a nursing shortage brought about by increasing demand and diminishing supply, an aging nursing workforce, a shortage of other professional and ancillary staff, increasing acuity of illness, a poor image of nursing, and continuing health sector reform. For Africa, HIV/AIDS further complicates the shortage. Shortages vary by field of nursing, geography, level of care, sector, and organization; but one commonality exists: there are two shortages—a real shortage and a pseudo-shortage.

Pseudo-shortages exist in both developed and developing countries and occur when there are enough nurses in the country but when posts are not funded and/or nurses are not willing to work under the conditions available. For example, South Africa is said to have 31,000 vacant public sector nursing posts and 35,000 unemployed nurses. The lack of a positive practice environment (low salaries, poor benefit packages, lack of supplies and equipment, inadequate nurse/patient ratios, unsatisfactory patient and staff safety, lack of access to professional development and promotions, lack of family-friendly policies, and lack of decision-making input) remains the most critical element everywhere and particularly in Africa.

Africa is in dire straits. As former Prime Minister Tony Blair noted, “Africa is the only continent which, without change, will not meet any of the Millennium Development Goals” (Blair, 2005). While mortality rates are improving, in 2008 the mortality rate among children under 5 years of age in sub-Saharan Africa was 144/1000 live births compared with 6/1000 in industrialized countries (UNICEF, 2009). This means that an Ethiopian child was 30 times more likely to die by age 5 than a child in Western Europe (UNICEF, 2010). In 2008, malaria killed approximately 850,000 people, 90% of which were in Africa, mostly among children under 5 years of age (UN, 2010). In 2008, over 30 million African children were not attending primary school (UN, 2010), and 14 million were AIDS orphans (UNAIDS, 2009b).

During this past decade, successive meetings of the G8 have focused on aid to Africa. In 2005, they agreed to increase annual aid to Africa by $25 billion per year and overall aid by an estimated $50 billion by 2010. They have since reaffirmed these commitments as well as specific commitments for health and the health workforce, especially in Africa (DFID, 2009; Guebert, 2009). It will be important that nurses and other stakeholders monitor and lobby national governments to keep these commitments. Ultimately, we need to decrease poverty and increase health for all nations.


Today, poverty is the world’s most devastating scourge. The World Bank estimates that there are about 1.4 billion extremely poor people in the world, with women representing 70% of the absolute poor (World Bank, 2008). According to the UN Secretary General, the number of extreme poor in sub-Saharan Africa has risen by 92 million between 1990 and 2005, and by 8 million in West Asia. Children living in absolute poverty are 5 times more likely to die before the age of 5 than children who are not poor (WHO, 1999). Every day, almost 16,000 children die from hunger-related causes—1 child every 5 seconds; and 947 million people in developing countries are undernourished—a condition that affects one’s health and well-being, hinders fetal development, and contributes to mental retardation (Bread for the World, 2009) (Box 101-4).

BOX 101-4

World Bank Group

The World Bank, established in 1944, is composed of the International Bank for Reconstruction and Development, the International Development Association, the International Finance Corporation, the Multilateral Investment Guaranty Agency, and the International Centre for Settlement of Investment Disputes. The World Bank Group is owned by its member countries, whose numbers vary according to the agency. The International Bank for Reconstruction and Development (IBRD) is the largest, with 186 member countries. While governed by its members, day-to-day operations fall to the leadership of the president and the work of over 10,000 employees in more than 100 offices worldwide.

The Bank’s mission is to fight poverty for lasting results and to help people help themselves and their environment by providing resources, sharing knowledge and building capacity, and forging partnerships in the public and private sectors. It is a development Bank that provides low-interest loans, interest-free credits, and grants to developing countries for a wide array of purposes that include investments in education, health, public administration, infrastructure, financial and private sector development, agriculture, and environmental and natural resource management. Also, it offers policy advice, technical assistance, and knowledge-sharing services to low- and middle-income countries to reduce poverty (WB, 2010).

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Mar 18, 2017 | Posted by in NURSING | Comments Off on Nursing in the International Community: A Broader View of Nursing Issues

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