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  1. 1. ONLINE CONTENTGlobalization and advances in information andcommunication technologies: The impacton nursing and healthPatricia A. Abbott, PhD, RN, FAAN, FACMIAmy Coenen, PhD, RN, FAANGlobalization and information and communication corners of the world.1 Friedman asserts that it is thetechnology (ICT) continue to change us and the world access to information and knowledge via ICT that iswe live in. Nursing stands at an opportunity intersec- contributing to this global transformation. This point istion where challenging global health issues, an inter- further supported, within the context of health, bynational workforce shortage, and massive growth of Deaton, who states that “The health and life expectancyICT combine to create a very unique space for nursingleadership and nursing intervention. Learning from of the vast majority of mankind, whether they live inprior successes in the field can assist nurse leaders in rich or poor countries, depends on ideas, techniques,planning and advancing strategies for global health and therapies developed elsewhere, so that it is theusing ICT. Attention to lessons learned will assist in spread of knowledge that is the fundamental determi-combating the technological apartheid that is already nant of population health.”2 The assertions of Friedmanpresent in many areas of the globe and will highlight combine with Deaton’s position at the intersection ofopportunities for innovative applications in health. ICT ICT, globalization, and health.has opened new channels of communication, creat- The global workforce crisis, large market growth ining the beginnings of a global information society that worldwide digital communications, pressing humanwill facilitate access to isolated areas where health health catastrophes, an increasing demand for healthneeds are extreme and where nursing can contributesignificantly to the achievement of “Health for All.” The outcomes data, and a flattening of barriers betweenpurpose of this article is to discuss the relationships nations are creating opportunity intersections for nurs-between globalization, health, and ICT, and to illumi- ing ICT application and research. The purpose of thisnate opportunities for nursing in this flattening and article is to discuss the relationships between globaliza-increasingly interconnected world. tion, health, and ICT, and to illuminate opportunities for nursing in this flattening and increasingly intercon- nected world.T homas Friedman, in his book The World is Flat, In what forms can these opportunities be realized? points to an increasingly globalized world where Information and communication technology can be playing fields are flattening, global connectivity has used to not only manage and distribute information tomade everyone into a next-door neighbor, and eco- impact health, improve efficiency and demonstratenomic engines are being driven from the most remote contributions to outcomes, but to offer a knowledge andPatricia A. Abbott, PhD, RN, FAAN, FACMI, is Co-Director of the communication lifeline to isolated providers, patients,PAHO/WHO Collaborating Center for Nursing Knowledge, Information and caregivers around the globe. Moreover, access toManagement, & Sharing; Johns Hopkins University School of Nursing, health care is increasingly viewed as a matter of humanBaltimore, MD. rights so, for those beyond the reach of adequate care,Amy Coenen, PhD, RN, FAAN, is Director, International Classificationfor Nursing Practice International Council of Nurses, Geneva, Switzer- the fair distribution of health services via ICT may be aland and is an Associate Professor, College of Nursing, University of self-evident aspect of fairness. The power and reachWisconsin-Milwaukee. afforded by ICT can be maximized by nurses toCorresponding author: Dr. Patricia A. Abbott, 525 North Wolfe Street, increase the efficiency, equity, and quality of healthSuite 415, The Johns Hopkins University School of Nursing, Baltimore,MD 21205. care, while lessening the impact of geographical dis-E-mail: tances. These potential benefits may fail to be realized,Nurs Outlook 2008;56:238-246.0029-6554/08/$–see front matter however, if ICT, conceived with a Western mindset,Copyright © 2008 Mosby, Inc. All rights reserved. flows into developing nations without concomitantdoi:10.1016/j.outlook.2008.06.009 attention to poverty reduction, global workforce chal-238 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
  2. 2. Globalization and advances in information and communication technologies Abbott and Coenenlenges, human rights, and consideration of local and Health Report. The 2007 report, Towards a Safercultural context. Nursing leadership, creativity, advo- Future, continues to emphasize the importance of ICTcacy, and experience are needed to provide stewardship in relation to health: “Today, the public health securityfor health ICT growth and application in the face of a of all countries depends on the capacity of each to actcomplex, interconnected, and increasingly globalized effectively and contribute to the security of all. Theworld. world is rapidly changing and nothing today moves faster than information. This makes the sharing ofGLOBALIZATION, HEALTH, AND ICT essential health information one of the most feasibleThe term globalization describes the increased mobility routes to global public health security.”13of goods, services, labor, technology and capital A widely held view, both within the WHO andthroughout the world.3 Most would agree that global- elsewhere, is that ICT in health enables rapid and globalization has a much broader impact than just an eco- access to new therapies, techniques, and knowledgenomic impact; its impact is also political, technological, resources, with the potential to forever change theand cultural—strongly influenced by information and health of nations. The role of ICT in the severe acute res-communication technology.4 Globalization, whether we piratory syndrome (SARS) crisis of 2003 is a primerecognize it or not, touches all parts of our lives— both example. During the first cases of SARS in China inpersonal and professional; it changes the way our 2003, the WHO initiated a digital virtual environmentnations and communities work. consisting of 11 laboratories in 9 countries connected Globalization and health have been discussed by via ICT. Using e-mail and a secure website, thesemany experts who have noted influences on wellness collaborators shared outcomes, post-mortem tissuethat are both promising and potentially devastating.5– 8 analysis, electron-microscope pictures of viruses, ge-Globalization in a positive sense has resulted in trade netic sequences and other related materials in real-timeexpansion, with an increase in living standards and to collaboratively identify and intervene in a markedlyimproved social and economic status, particularly for dangerous public health risk. Other examples exist thatwomen. Sachs, a global economist known for his work point to the impact that ICT has had on global healthin developing nations, repeatedly makes the important efforts, such as the Academic Model for the Preventionpoint that the health of a nation is directly tied to the and Treatment of HIV/AIDS Medical Record Systemwealth of a nation.9 Wealth is enhanced by heightened for Africa (AMPATH–MRS), the Partners in Healthcompetition, comparative advantage, economies of Electronic Medical Record in Peru, the HIV Electronicscale, and access to a greater range of products and Medical Record System in Haiti.14services in globalized markets, all enabled by access to Efforts such as those mentioned above and scores ofknowledge. Asymmetries of information have been others, too extensive to enumerate, have made signifi-reduced in an era of globalized knowledge exchange, cant impacts in the health of large regions of the globe.contributing to a reduction of isolation, an increase in However, it is important to realize that ICT can neverlife spans, and improved health.10 be viewed as a panacea or singular solution to the very Conversely, advances in globalization are blamed for multifaceted problem of worldwide health. The contrib-some health problems, including an increased adoption utors to global health are very complex, rooted inof unhealthy Western habits and lifestyle, resulting in societal structures, political agendas, and the presenceincreases in obesity and the increased prevalence of of marked global poverty. Solving one issue withoutchronic disease. Open borders and open access, hall- addressing the others will result in the same outcomemarks of globalization, have also resulted in faster experienced by Sisyphus; the summit is reached, only totransmission of infectious agents, the so-called “micro- have the boulder roll back down to the base. Inbial hitchhikers.” Many societies find globalization and particular, efforts to improve health without addressingopen information exchange threatening to current ide- the pressing problem of poverty will be unsustainable.ologies and social structure. Others view the concept of Poverty reduction as a precursor to improvements inglobalization, particularly via ICT, as a new age form of health is reflected in the 2007 World Health Report:electronic colonialism, where existent cultures are bull- “Hungry children easily acquire diseases, and easily diedozed and assimilated.11 from the diseases they do acquire. Dwellings without How does ICT fit in this discussion of health and sanitation provide fertile environments for transmissionglobalization? The World Health Organization (WHO) of intestinal infections. Hopeless life circumstancesbelieves that ICT holds great promise for improving thrust young girls into prostitution with its attendanthealth and health care around the world and is critical to risks of violence and sexually transmitted diseases.”13achievement of the Millennium Development Goals.12 Productivity drops when the human capacity that fuelsThe core beliefs that ICT will contribute significantly to economic growth declines due to morbidity and mor-the reduction of poverty, improve the delivery of tality, and the high financial burden of disease ineducation and health care, and make government ser- developing nations precludes economic advancementvices more accessible are prominent in the 2006 World and health improvement efforts.15 S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 239
  3. 3. Globalization and advances in information and communication technologies Abbott and Coenen The paradox is, of course, that declining health of ICT in health care in more industrialized nationsimpedes the climb out of poverty while poverty con- such as the United States, the United Kingdom, andtributes to declining health. Could further enhancement Australia continues to grow, albeit at modest rates,of global ICT for health care be a potential strategy for reaching a tipping point. As discussed earlier, there areescaping this paradox? What are the realities and many successful implementations of ICT-enabledreasoned approaches for application of ICT to impact health communications and electronic health recordthe health of nations? What roles and opportunities for systems in developing nations such as Kenya,nursing leadership exist in regards to ICT regardless of Malawi, Peru, Rwanda, Haiti, Tanzania, and others asgeographic location? part of efforts like the Open Medical Record System (Open MRS).14 Creative thinkers are already capitaliz-GLOBAL ICT FOR HEALTH: REALITIES ing upon widely available forms of ICT (such asAND WORK IN PROGRESS cellular telephony) to affect health.In many instances, the idealism of ICT potential and the Muhammad Yunus, whose work in microloans inreality of ICT application are discordant. Therefore, Bangladesh was honored in 2006 with a Nobel Prize, iswhile there is acknowledged need for ICT in the an excellent example of how the creative introductioncoordination and monitoring of treatment, surveillance, of ICT via simple cellular telephony into a low resourceresponse, education, and communication in health care, area could institute profound change. Dr. Yunus and thein reality there are significant barriers in the application telecom company he founded20 were convinced thatof ICT that slow progress. These barriers are in no way economic and social development should begin at therestricted to the developing world. The United States grassroots level. Yunus believed that attacking povertyand other more technologically advanced nations have is essential to peace, that private enterprise is essentialtheir own sets of challenges. Cost, misalignment of to reversing poverty, and that peace and poverty reduc-incentives, resistance, an unskilled workforce, concerns tion are essential to health.21 Yunus’ microloans en-about impact on productivity, lack of standards and abled destitute village women in Bangladesh to pur-interoperability, and other issues contribute to a poor chase cell phones and become Village Phone Operatorslevel of healthcare ICT adoption in the industrialized (VPOs). The women then sold telecommunication ser-world.16 The digital divide has resulted in large seg- vices on a per-call basis to neighbors. This has resultedments of low income and/or other underserved groups in considerable wealth generation not only for thebeing excluded from online health resources.16 Eco- VPOs, but for the farmers and village dwellers who arenomic hardships and difficult tradeoff decisions in the using this technology to access the outside world andUS healthcare industry have further inhibited healthcare improve their businesses.20 The VPOs provide afford-information technology growth.17 able rates to their neighbors, preventing residents from In developing nations, the problem of ICT uptake is making (historically, in many locales) a 6-hour round-even further compounded. A lack of local expertise and trip to reach a telephone, which consequently impacteddecades of well-meaning but non-sustainable ICT community productivity and increased communityprojects in the developing world have left a legacy of wealth. The VPOs earned enough to invest in theirskepticism in their wake. Systems built for Westernized children’s health, nutrition, and education, and fundhealth care delivery often do not match the local other business growth. The improvement in communitycontext, resulting in a misalignment between need and wealth translated into improved community health, astechnology. Poverty and illiteracy in developing nations funds became available for the drilling of wells forstand as major barriers to the adoption and sustainabil- clean water and preventive health services. The VPOity of information technologies, and many believe it is model has been rolled out through much of Africa anddifficult to make the case for ICT when basic needs for is viewed by governments and development agenciessurvival are barely being met.18 The “e– health para- such as the United Nations, USAID (United Statesdox,” a term coined by Liaw and Humphries, refers to Agency for International Development), and the Worldthis seeming conundrum; populations that may have the Bank as a sustainable development tool. Wealth hasmost to gain from ICT in health are those who are impacted health, which is a welcomed consequence.thwarted in their use due to barriers of untrained The swell of cellular telephony has also expandedpersonnel, poor infrastructure, and lack of resources.19 directly into the realm of health and health care in otherIssues such as these have fueled technological apartheid ways, particularly as the use of short messaging serviceand continue to subvert the delivery of knowledge to (SMS)— otherwise known as text messaging— hasareas of the globe that most desperately need it. grown in popularity as a form of communication. For Are the current realities in global health ICT all bad? example, “Sexinfo,” a SMS-based health informationActually, they are not. From adversity often come new service offered by the San Francisco Department ofideas. New opportunities and avenues for access and Public Health, is being used to educate and assist teensinnovation in the use of ICT are emerging to improve who have questions about sexual health.22 The Centershealth and facilitate the delivery of health care. The use for Disease Control and Stanford University teamed up240 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
  4. 4. Globalization and advances in information and communication technologies Abbott and Coenenrecently to hold a conference called “Texting for Education and Collaborative LearningHealth” where public health initiatives using SMS were Information and communication technology has in-presented.23 South Africa is using SMS features in fluenced both traditional and non-traditional approachescellular telephony to issue reminders to patients and to education and the development of the next generationcaregivers in hopes of increasing adherence with anti- of nursing leaders. Distance education programs inretroviral therapies. Phones for Health, a Presidents nursing are exploding across the globe and are enablingEmergency Fund for Aids Relief (PEPFAR)-funded outreach to geographically distributed individuals. Theproject, is also using mobile telephony to combat use of ICT to elevate the educational level of nursesHIV/AIDS in Sub-Saharan Africa.24 This project al- worldwide is a crucial area for expansion, investigation,lows nurses and other health workers in the field to use and application, particularly as the nursing workforcea standard mobile phone handset to enter health data. crisis grows, global health declines, and medicallyThe system uses cellular methods to relay the data to a underserved areas increase.central database, where it is immediately available to Considering the issues of nurse migration and nurs-health authorities via the internet. The system also ing brain drain,12 ICT may be an effective strategy tosupports the delivery of health alerts and reminder reduce some of the contributors to out-migration, suchmessages to caregivers.24 as isolation and lack of educational opportunity. Meth- Each of these examples illustrates a movement using ods such as ICT for education to train rural providers inICT to enhance information distribution that empowers place can prove to be more cost effective and lessfinancial growth, health, and social betterment, in both disruptive to families, communities, and nations thandeveloped and developing nations. The success of such out-migration to more developed countries.25 More-initiatives opens the door to innovative global ICT over, collaborative learning opportunities are enabledmethods for enhancing education, public health moni- via ICT, where geography becomes irrelevant. Thetoring and surveillance, and delivery and management opportunity for students and faculty to interact, shareof health. It also speaks to opportunities for those who knowledge, discuss global health issues, and sharestand at the frontline of global health efforts to consider cultural perspectives across nations affords students andnew ways to reach and teach. faculty exposure to the world beyond them. Such experiences can increase cultural competency, raising awareness of and appreciation for global health issues.THE OPPORTUNITY INTERSECTION Although the promise in using ICT to reach andFOR ICT IN NURSING teach is great, there is also a need for caution andWhere is the opportunity for nurses to make a differ- careful consideration. As discussed earlier, the notionence in regards to health care in a digital world? When of Western solutions as being universally appropriate isone considers that 50 –90% of all health care provided erroneous. Understanding how information and knowl-“in country” is delivered by non-physician providers12 edge is relevant to context and culture is essential, so asand the accessibility of ICT is accelerating, the oppor- not to impose approaches or solutions that do not fit thetunities for nurses and midwives are vast. As those who learners’ reality. Approaches that seem appropriate formost often stand at the interface of the patient and the delivery in one environment may be offensive or totallyhealthcare system, there is a growing awareness of the unrealistic and unvalued in another, highlighting theneed for nursing leadership, nursing innovation, and need for local involvement, flexibility, and creativity.the nursing voice in global health ICT. This is particularly apropos when considering the vast differences between industrialized and non-industrialized nations or in nations that are in conflict.Nursing, ICT and Global Health Nursing has taken the lead in several successful A number of areas of development demonstrate how international collaborations involving education andnursing has already embraced ICT to harness its global collaborative learning. Two examples of the use of distri-potential and should illustrate potential areas for growth buted e-learning in industrialized and non-industrializedand further investigation. Examples of success stories nations are provided as a stimulus for further study andfrom a global perspective include: (1) advances in application:education and collaborative learning, (2) telenursing/telehealth, (3) movement toward electronic health International Virtual Nursing School (IVINURS)26 is anrecords (EHRs), (4) nursing knowledge management interesting example of a global nursing educationand knowledge generation. In consideration of the initiative facilitated by ICT in the industrializedchallenges and opportunities cited earlier, these exam- world. The IVINURS is working with the Interna-ples may stimulate critical and creative thinking about tional Council for Nursing (ICN) on the use of thehow these established examples and methods may be International Classification for Nursing Practiceextended and applied by the nursing community to (ICNP®) to catalogue learning resources in a digitaladdress the e-health paradox. repository that can be accessed by a number of S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 241
  5. 5. Globalization and advances in information and communication technologies Abbott and Coenen international partners. At the present time, the IT-enabled methods in rapidly digitizing developing IVINURS digital repository is shared by multiple nations—further illustrating an area of opportunity for global associates, including universities in Thailand, expansion. Considering the global workforce crises in Tasmania, Ireland, Denmark, the United States, and nursing, these models are worth further consideration. the United Kingdom. The IVINURS does not award degrees and is built on the principles of international collaboration and the global sharing of knowledge Telenursing/Telehealth and professional expertise. A central activity of Telenursing is the use of technology to deliver IVINURS is the building of its digital repository nursing care and conduct nursing practice.29 Telenurs- and the development of associated e-learning sup- ing is often used interchangeably with the term tele- port products, with the aim of providing quality, medicine or telehealth with the distinction implied that learning resources that can be shared on a global a nurse provides telenursing and a physician provides level by its partners, and used to enhance both telemedicine. The use of the term telehealth may be e-learning and traditional instruction in their respec- more appropriate, as the success of this modality tive settings. This not-for-profit entity, registered in requires multiple partners, including the professionals the United Kingdom as a Limited Company with delivering services, technical support personnel, and the charitable status, is still in formative stages, and client or patients themselves whose participation is expects to make available studies of its impact in the essential to successful outcomes. Telehealth, in all of its near future. definitions and permutations, has made large strides inAfrican Medical and Research Foundation (AMREF) in expanding healthcare services to underserved areas Uganda27 is an example of using ICT in the devel- around the globe. oping world for nursing education and scale-up. In a recent study, 719 nurses representing 36 coun- This public-private partnership plans to increase the tries responded to a survey querying their telenursing basic education level of 22 000 Kenyan nurses up to competencies and skills.30 Patients with chronic ill- the level of “registered” (diploma) from the current nesses were those most often cared for using telenurs- level of “enrolled” (certificate) within 5 years. At ing services. Although most telenurses worked in hos- present, 70% of the nursing workforce in Kenya is pitals, the settings varied widely, including traditional comprised of “enrolled” nurses, whose level of work places such as clinics to community-based set- education leaves them ill-prepared to handle the tings such as schools and prisons. Several countries complex health needs of the Kenyan population. have well-developed telenurse programs, including The AMREF’s “Virtual Nursing College” currently Canada31 and New Zealand.32 The trend towards ex- has 4000 nurses enrolled at 100 computer-equipped pansion of this nursing specialty is expected to con- training centers in 8 provinces, including several tinue, particularly as ICT continues to reach all areas of refugee camps. The curriculum is delivered via ICT the globe and as the medically underserved areas of the and, in October of 2007, the first class of ICT- world are illuminated. trained Kenyan nurses completed the program.28 Telehealth/telenursing in the traditional sense may While too early to discuss program outcomes, the conjure up visions of expensive computer workstations, fact that 70% of all nurses enrolled in this program call-centers, or a nurse in a chat room. While these are from rural areas speaks to a great potential for visions are perfectly realistic in the developed world, communities outside of urban centers. This model is they are quite unrealistic in many parts of the globe. planned to be extended to other African nations However, with the growth of cellular telephony, who are experiencing similar nursing crises. The particularly in Africa, tremendous opportunities exist AMREF program is also important because of an for nurses to creatively apply telehealth modalities to important but less publicized goal—that all 22 000 long-standing patient care issues. For example, Elder nurses will be computer literate. This very unique and Clarke cite the following examples for the and vital component leaves Kenya ready to lead in potential use of cellular telephones and Personal the movement towards e-health in the developing Digital Assistants (PDAs) for telehealth in Africa and world. This could accelerate the achievement of the Asia:33 ● Automation of demographic surveillance activities WHO Resolution WHA58.28, an e-health strategy such as those at the core of pioneering health care adopted by the Fifty-eighth World Health Assembly initiatives (e.g., the Tanzanian Essential Health Inter- in May 2005 that articulates the preparation of an ventions Project) ICT-competent global health workforce. ● Testing of the use of SMS (short message service) These 2 brief examples, while using different meth- reminders in the treatment of tuberculosis in Capeods and addressing 2 different audiences of nurses, Town, South Africademonstrate the potential of ICT within the nursing ● Delivery of continuing medical education and pro-education realm. It also demonstrates the reach of fessional development via PDA242 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
  6. 6. Globalization and advances in information and communication technologies Abbott and Coenen● Delivery of time-sensitive alerts to patients and locales. While this is an open source and freely avail- health care workers able system, there are no documented examples of● Maintenance of patient records for HIV-positive nursing use—which is puzzling when one considers the patients’ lifelong drug treatments number of nurses who are responsible for clinic oper-● Management of specific health care initiatives such ations around the globe. It is important to note that, as the roll-out of antiretroviral therapy and tubercu- even in developed nations, nursing involvement in losis treatment initiatives EHRS specification and development is disappointingly Again, realizing the numbers of nurses who are in low. Such lack of EHRS involvement by nursing inthe frontline of primary care around the globe and in both developed and developing nations makes it thatlight of the massive growth of ICT for health, tremen- much easier for nursing data to remain invisible anddous opportunity awaits those who are primed to inconsequential to determination of health outcomes.capitalize upon these factors. Making the application oftelehealth/telenursing successful in developing coun- EHRS Standardstries will require strong nursing partnerships and lead- Healthcare, both nationally and internationally, is aership, however. Nurses are in a position to drive the product of teams (including the patients), and suchdevelopment of science in this area, since many aspects teams are reliant upon the sharing of information andof nursing care are naturally amenable to virtual deliv- knowledge. Standards facilitate sharing of data, infor-ery, especially in areas of assessment, patient teaching, mation and knowledge and are a foundational under-decision support, and early identification of problems.34 pinning for system interoperability. Those who do not participate in standards development, implementation,Interoperable Electronic Health Record and use face the prospect of exclusion in EHRS. As is,Systems the contributions that nurses make to patient outcomes Globalization is driving the need to communicate and the achievement of larger health care goals areand share healthcare data and information across na- frequently invisible in EHRS because the standards thattional borders. Many countries are focusing on interop- exist to represent nursing practice in automated systemserable Electronic Health Record Systems (EHRS) as a are either underused or excluded. Nurse-sensitive mea-solution for sharing data and information among vari- sures are frequently omitted from EHRS for a multitudeous sources (e.g., clinical information systems, personal of reasons, and they will continue to be, unless the casehealth records, public health surveillance systems, and is made for inclusion. As nurses accelerate their utili-knowledge repositories). For EHRS to reach full poten- zation of and leadership in ICT-based efforts such astial, however, interoperability and connectivity to dis- the EHRs, the chance to share perspectives, experi-tributed data repositories is fundamental, particularly in ences, and best practices via standardized and ex-light of distributed healthcare services, geographical changeable data must not be missed. Nursing experi-challenges, and migrating populations. ence, leadership, and the nursing voice are needed. In a global sense however, there are vastly different Interoperability from a global perspective requireslevels of EHRS readiness and capacity for EHRS international standards in many dimensions such asinteroperability. In many places, EHRS are unknown messaging, security, language, ethical information use,yet the need for health data (in any fashion) is great. ICT management, and other areas—all of which impactEven the most remote of locales often have reporting nursing and EHRS. Again, nursing involvement is cri-requirements, either from Ministries of Health or donor tical. One challenge is that there are multiple standards-agencies. Accountability for receipt and utilization of setting agencies and, most likely, always will be due togoods and services, demonstration of outcome achieve- the complexity of stakeholders, which increases thement, and measurement of milestones are resulting in difficulty of nursing participation, particularly in con-increasing pressures on nurses, other providers, and sideration of the dearth of qualified standards-literateadministrators for improved information management nurses. While there are many standards organizationsand tracking. Quick fixes or one-off solutions, charac- around the globe, the International Standards Organi-teristic of many health data tracking efforts, often result zation (ISO) and Health Level 7 (HL7) are 2 of thein unusable, non-interoperable, and unsustainable sys- major standards-setting organizations where nursing istems that are soon abandoned, threatening clinic viabil- represented (albeit in small numbers), and it mustity and leaving service providers frustrated. continue to be so. Efforts such as Open MRS are gaining in popularity, An example of successful nursing involvement anddue to its open source (free) and interoperable nature, leadership in global standards work is the ICNP®.and its well-established success in many clinical set- Initiated in 1989 by the International Council of Nursestings across the global south. Open MRS is an example (ICN), ICNP® is defined as a unified nursing languageof an EHRS system, built to agreed-upon standards that system to represent nursing diagnoses, interventions,enable interoperability, data exchange, and the ability to and outcomes. The vision of ICNP® is to be an integraluse it in many different settings in many different part of the global information infrastructure informing S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 243
  7. 7. Globalization and advances in information and communication technologies Abbott and Coenenhealth care practice and policy to improve patient care a Hospital, “In attempting to arrive at the truth, I haveworldwide.35 Through standardizing the clinical termi- applied everywhere for information, but in scarcely annology nurses use to describe their practice, ICNP® can instance have I been able to obtain hospital records fitimprove nursing practice and contribute to the advance- for any purposes of comparison. If they could bement of nursing science. The ICN also recently part- obtained . . . they would show subscribers how theirnered with the International Medical Informatics money was being spent, what amount of good wasAssociation—Nursing Informatics and the international really being done with it, or whether the money was notnursing informatics community to establish an interna- doing mischief rather than good . . .” In 2008, 143 yearstional standard through ISO. This standard, Integration later, we are still struggling to determine the amount ofof a Reference Terminology Model for Nursing,36 good that is being provided, largely because the nursingprovides a framework which can be used to map data that is foundational to a full understanding ofconcepts across different terminologies, thereby in- nursing contributions to outcomes, both good and bad,creasing communication and comparability of data is still unfit and unavailable for comparison. Theacross languages and countries.37 This ISO standard is opportunities and critical need for nursing leadershipcurrently under routine review and is expected to are growing exponentially.contribute to ongoing harmonization across multipleinternational standards, giving structure to nursing data Knowledge Management and Knowledgein global EHRS efforts. This work is critical to under- Generation in Nursingstanding the full processes of and contributors to health Information itself is becoming a major commodity incare. Analysis of data that does not include nurse- health; there are multiple stakeholders interested insensitive measures, nursing interventions, and nursing access to and sharing of data and information. Access tocontributions to outcomes is deficient, incomplete, and reservoirs of experiential knowledge and collections ofprone to spuriousness. explicit information allows for the development of new The International Telecommunication Union (ITU) knowledge based on identified needs, to refine knowl-is another organization involved in standards develop- edge that already exists, to avoid duplication of effort,ment that has direct bearing on nursing practice, par- to increase alignment with local circumstances, andticularly as related to communications protocols used in enhance the creation of actionable knowledge.39 Thedisaster relief and community-based services in the value to nursing of such collections of knowledge andaftermath. As the leading United Nations agency for experience becomes quite obvious, particularly wheninformation and communication technologies, ITU considered in the global context and in the face ofplays a prominent role in the development and deploy- asymmetries of information. Effken and Abbott havement of global ICT standards. For example, in the identified ICT solutions for knowledge management inaftermath of the Indian Ocean tsunami in 2004, ITU nursing, including the creation and participation inplayed a major role in pushing for standards for public communities of practice (CoPs).40warnings (called CAP or Common Alerting Protocol), CoPs trace their roots back to constructivism wheredisaster management, prevention, and relief.38 There is the control of learning shifts from the instructor to thea great need for the nursing perspective in these learner. Wenger discusses ICT supported CoPs specif-concerns, particularly since a great deal of the care in ically, stating “Every group that shares interest on adisaster relief efforts is provided by teams heavily website is called a community today, but communitiesinfused with nursing personnel. Nurses, as first re- of practice are a specific kind of community. They aresponders and those often managing the ongoing health focused on a domain of knowledge and over timeneeds of a community after disaster teams have left, accumulate expertise in this domain. They develop theirhave a vested interest in ICT that supports information shared practice by interacting around problems, solu-and workflow needs. Unfortunately, nursing is often tions, and insights, and building a common store ofabsent from the development and deployment of such knowledge.”41 From a global nursing perspective, es-standards and are frequently left to deal with sub- pecially in light of the scarcity of nursing resources,optimal systems. reusable and accessible nursing knowledge empowered Nursing leadership is critical to break the chicken by ICT is a powerful tool for the profession.and the egg cycle that comes from unstructured, non- One such ICT-supported CoP is the Global Alliancestandardized, and invisible nursing data in the rapidly for Nursing & Midwifery,42 a project initiated out of thedigitizing world. Without comprehensive, rigorous and WHO Department of Human Resources for Health, theaccessible digital nursing data from large healthcare WHO Office for Nursing & Midwifery, and the Johnsdatasets, nursing practice remains largely invisible, and Hopkins University School of Nursing Collaboratinginvisible nursing contributions lead to false assump- Center for Nursing Knowledge & Information Manage-tions of low nursing contribution to health and health ment. This platform designed for nurses and midwivesoutcomes. In reality, much has not changed since serves as an open knowledge exchange CoP with aFlorence Nightingale wrote in her 1863 book Notes on current membership of 1,500 from approximately 123244 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
  8. 8. Globalization and advances in information and communication technologies Abbott and Coenendifferent countries. The Alliance has served as a learn- approaches not yet realized to managing, sharing, anding platform, a library, and a knowledge exchange generating nursing knowledge. The ultimate benefac-forum for global nurses to exchange best practices, tors include not only the patients and communities thatparticipate in open continuing education, and manage we serve, but the profession of nursing itself.knowledge. The Global Alliance is unique in that it runsover very low-bandwidth, standard telephone service to FUTURE OPPORTUNITIESallow participation by those in areas without full Inter- Some scholars suggest that there is a leadership void innet connectivity. Participation from low-resource areas nursing, particularly in the global south, where theis surprisingly robust. needs are the greatest.46 Leadership for strategic use of Other CoPs exist for nursing, and growth in this area ICT and informatics in nursing, and strategic partner-is expected. For example, Hara and Hew in studying an ships to support mutual enhancement of ICT is anonline CoP for critical care nurses in the Pacific Rim important strategy for the promotion of global health.found that an e-CoP helped not only to reinforce the Entrepreneurial opportunities exist for those proactiveidentity of the practice of critical care nursing among and creative thinkers who stand ready to capitalize uponparticipants, but that it also served as an important them.avenue for information and knowledge exchange within Nurses cannot wait for ICT to bring answers to thethe context of everyday work.43 These authors believe problems faced in today’s world; rather, they need to bethat: “Communities of practice can be described as engaged in problem-solving activities, testing and eval-groups of people who are informally bound together by uating solutions to global health issues using ICT. Theshared expertise and a passion for joint enterprise. They pace at which ICT seeps into health care is onlycan be viewed as informal networks that support pro- expected to increase, and reasoned action by the nursingfessional practitioners to develop a shared meaning and community is imperative. The nursing informaticsengage in knowledge building among members. The arena has provided avenues for nurses to serve astheoretical construct of communities of practice is leaders, including multiple roles in nursing and throughgrounded in an anthropological perspective that studies participation in professional organizations. However,how adults learn through everyday social practices nursing informatics, like nursing in general, stands atrather than focusing on environments that are intention- the edge of a workforce crisis that threatens nursingally designed to support learning.” participation in the rapidly progressing world of ICT. Information and communication technology has also Nursing as a profession cannot leave the progressstimulated the growth of other approaches to knowl- needed in the face of accelerated global ICT solely inedge generation and nursing research. For example, the hands of nurse informaticians. Informatics practiceICN recently initiated an electronic International Nurs- is quickly becoming part of the expected competency ofing Partnership Database Project.44 The goal of this every nurse and, therefore, is becoming not only aproject is to document and share ongoing and new responsibility of every nurse, but as an opportunity forinternational partnerships, as a tool to encourage similar every nurse. The absence of the nursing voice andinitiatives and aid in planning new ventures. Rather nursing leadership as global e-health explodes is fore-than relying on the traditional literature sources for boding.networking and proposal development, this database In addition to leadership, strong partnerships arecan provide researchers and others with pre-publication essential to advancing health globally. These partner-information about existing projects in process. Similar ships should not only include corporate and philan-to the CoP concept, the ICN shared database allows the thropic organizations, but partnerships within thesharing of partnership experiences and results to max- healthcare team as well. Interdisciplinary work is crit-imize efficiency and effectiveness. The ICN has also ically important and the major contributions that nursesdeveloped a portal called the International Nursing make to global health must be acknowledged andNetwork to facilitate the exchange of ideas, experience, supported at levels much higher than they currently are.and expertise for the nursing profession crossing a Similar to the efforts undertaken by the Robert Woodvariety of areas from advanced practice nursing to Johnson Foundation’s Commitment to Nursing,47 itdisaster preparedness.45 This open access portal serves would seem appropriate that major foundations andas a mechanism to encourage global nursing interaction. funding agencies would support the investigation and The management and generation of new nursing and growth of ICT as a strategy to support frontline nursinghealthcare knowledge is deepened and advanced as new care, since nurses are such a vital source for the deliveryevidence, new perspectives, and new discoveries are of health services worldwide. It is also important toshared among global nurses and midwives. Information emphasize that the agenda for using ICT to advanceand communication technology provides an opportunity global health is in no way limited to experts in infor-to facilitate participation and to establish partnerships matics. Nursing expertise in practice, education, admin-using technology that connects those otherwise not istration, research, and policy are all required to ad-connected. Enabling these connections will promote vance this agenda. The nursing profession, as partners S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 245
  9. 9. Globalization and advances in information and communication technologies Abbott and Coenenin improving global health care, has much to contribute, future? What shall be the legacy of the current gener-particularly in this new interconnected and flattened ation of nursing leaders in this rapidly digitizing world?world. To answer these questions, we need nurses who have Entrepreneurial opportunities for nurses who are what Henry Ford classified as those with an “infiniteinterested in global health and who understand and are capacity to not know what can’t be done.”intrigued by digital innovation abound. The authorshave highlighted examples of first steps that the nursing CONCLUSIONcommunity has already taken in applying ICT to health Nursing has a long-standing history of advocacy, inno-and healthcare. Following the example of AMREF in vation, and education. The growth of ICT in the healthUganda and the online training of 22 000 nurses— and healthcare sector should be looked at as an oppor-could this model not be built upon and expanded to the tunity for nursing to use a new medium to meet the mission of our profession, not as something to beglobal nursing workforce? Could nurses, long known approached with trepidation and fear. As globalizationfor their crucial role in patient education, develop expands, nursing has the opportunity to step forwardICT-supported solutions to reach patients, their families and harness the power of ICT to serve the greater good.and caregivers—regardless of geographic location? Can While it is often difficult to make the case for ICT inwe use ICT to provide lifelines to isolated nurses, areas where running water and electricity are consid-midwives and others who are serving their communi- ered a luxury, access to information must be viewed asties? Can we deploy simple ICT solutions to combat the a basic tenet of a developing nation, with efforts toproblems of collecting critical individual and popula- increase ICT and decrease poverty as complementary,tion health data in remote locations? Considering that not competitive activities.18 As nurses, we have thethere are more mobile telephones in use in China today opportunity to renovate and innovate, as we shepherdthan there are people in the United States,1 what developments in a way that promotes health for all.innovative mobile methods could be developed todeliver health messages, answer questions, or collect REFERENCESdata? What role might social networking (e.g., wikis, Available in the online version of this article at theblogs, virtual communities) play in nursing of the Nursing Outlook Website: V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
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