Exporting Care: Understanding What Nurses Bring to Global Health

Given at The Role of Nursing in Promoting Global Health: The Power of One Conference, September 21, 2009, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Introduction

It is a great delight for me to join you today. This is my first time to New Hampshire and it is beautiful…

I’m not sure how much you know about the history of the institution at which you serve. I always find it interesting to trace historical lines back to the beginning of any longstanding undertaking. I feel that in many ways, one can often find guidance and inspiration in the men, women, and circumstances that gave birth to great organizations, such as yours. In reading through the history of Dartmouth College and Medical School and the original Mary Hitchcock Memorial Hospital, I found many interesting facts. A few that I think should help inform your sense of who you are, globally, as nurses at the Dartmouth-Hitchcock Medical Center today.

First, way back when, in 1769, Eleazar Wheelock, a Congregational Minister from Connecticut, established Dartmouth College “for the education and instruction of Youth of the Indian Tribes in this Land… and also of English Youth and any others.” Dartmouth was regarded as a College with its roots in the colonial frontier.[1] Regardless of one’s views on colonization, we can appreciate that in Wheelock’s mind was a forward thinking vision that knowledge should be shared with all people. This core thought brought Dartmouth College in to existence.

Not too long after, Nathan Smith, a Harvard trained physician-legend in his own day (from Cornish, N.H.), singlehandedly began Dartmouth Medical School. Why did he undertake such a perilous mission that was almost certain to fail given the distance of Hanover from major urban centers? “Dr. Smith found that the distance among the scattered settlements [along the length of the Upper Connecticut River Valley] made it hard to reach the sick when he was needed, and he reasoned that a medical school at the new college in Hanover would bring more physicians and improved medical care to the area.”[2] Smith, not unlike Wheelock, believed that the best of what humankind had to offer should be widely distributed. In this case, Smith felt that access to health care should be shared with all people.

Fast forward about 100 years and you will find Hiram Hitchcock seeking to erect some type of memorium to his recently deceased wife, Mary Maynard Hitchcock (1834–1887). Through the persuasion of Carlton Pennington Frost, this resulted in the establishment of the original Mary Hitchcock Memorial Hospital. On the original cornerstone, Mr. Hitchcock has these words inscribed: “…It [MHMH] is a memorial of one of the noblest and best of God’s gifts to the human race. God grant this Hospital may be all, and more than all, that she would have it to be…”[3] What did Hitchcock have in mind when he penned these words? Mr. Hitchcock was an avid world traveler.[4] In his obituary, the New York Times reports[5] that he traveled extensively throughout the Middle East, Europe, and South America with a passion for the peoples and historical elements of other lands. Mr. Hitchcock was a man who understood he lived in a global context. The bounds of his existence were extended beyond the national and the domestic. It was his wish that what is now the Dartmouth-Hitchcock Medical Center be “more than all…” I think given Hitchcock’s high expectations for your institution, and his love and appreciation for foreign lands, there is every reason to believe that it was well within the scope of his vision that the healthcare leaders at DHMC would have a mission and vision with global proportions. In other words, that the best of DHMC, that is its’ all “and more than all” should be shared with all people. Hitchcock may not have had it in mind at the time, but I when I refer to the “best of DHMC,” I am unapologetically referring to nursing.

And this brings us to our topic today. Exporting Care: What Nurses Bring to Global Health. We do live in unprecedented times. More than ever the world’s health is characterized by three pervasive and world-flattening trends: globalization, urbanization, and “technoligization.” Globalization, though it has many definitions, can be broadly understood as the “increasing economic and social interdependence between countries… characterized by high mobility, economic interdependence, and electronic interconnectedness.”[6] [text that I wrote on original date of conference: May 2009]. We could take time to provide multiple examples, but I believe that we are all far enough into this phenomena now to have some intuitive sense of what is meant. In the past two weeks we could say one phrase that would bring all of the seemingly disparate aspects of globalization together in flash: swine flu. High levels of mass mobility make it a global threat. High levels of electronic communication make our fight against it a global endeavor. And, unfortunately, high levels of economic interdependence leads to plummets in pork prices[7] as Russia, China, and the Philippines stop imports of Mexican pork, significant declines in tourism revenue in Mexico,[8] and nervous global stock markets[9] pinching an already suffering world economy, making it a global financial distressor. Everyday, in hundreds of ways, we live in a globalizing world.

But we also live in an urbanizing world. It is estimated by the World Bank that by 2015, ½ of the world’s developing population will live in cities. By 2030, the land area covered by these cities will have tripled.[10] In many countries, rapid and mass urbanization is coupled with an almost complete skipping over the process of industrialization and therefore a skipping over of the development of the infrastructure critical to sustaining densely populated areas. Nevertheless, in what seems like a countertrend in some parts of the world, we live in a rapidly technologizing world. Increasingly, things like cell phones, laptops, and wireless internet access are available in the most remote and undeveloped parts of the world. Therefore, it should not surprise us that developing countries now represent about 2/3 of all cell phone use. In many locales, cell phone use is normal while sewer systems and fresh water are still novelties. In some ways, advanced technologies have enabled this “skipping over the development of infrastructure” that we mentioned a moment ago. Each of these trends has a significant impact on health. The drops in child mortality and infectious diseases over the past several decades can be credited in part to globalization, urbanization, and technology. Yet at the same time, the rapid rise of chronic diseases which were previously unknown in developing countries can also be attributed to these trends.[11]

When we begin to discuss global health, however, we sometimes become overly focused on the trees and miss the forest. That is to say, swine flu or SARS or health care for immigrants become the main issues in an exclusive focus. And we fail to recognize that these issues are significant because we live in a world that is globalizing, urbanizing, and technologizing. Apart from these trends, such issues would merely be blips on our radar, if they ever even showed up at all. As a result, we may become well versed in discussing the issues, but are ignorant to the trends that will help us understand far more deeply our current situation, and even more importantly, our future challenges.

Nursing, unfortunately, is not an exception to this pitfall. In preparing for this talk, I conducted a number of literature searches using the terms “nursing,” “global,” “international,” “health,” etc. What types of articles do you think comprised the majority of the search results? (Pause). Roughly 80% of the articles I found had to do with the world’s nursing workforce as it was being influenced by immigration patterns. While we need these types of articles and conversations, it is symptomatic of the reality that nursing has not done enough, neither in our education nor in our profession to become globally minded. Therefore, we are not we are not playing a significant role in the global health scene which means all that we have to offer — which is an amazing amount of understanding and expertise — is not being exported to the world. It is my purpose, at least in some small way, to begin remedying this problem. To do so I want to speak with you about the Knowledge Required for Global Citizenship, The Connections Required for Global Community, and The Ambition Required for Global Action.

The Knowledge Required for Global Citizenship

Like me, many of you probably received a nursing education that dealt very little, if at all, with the idea of global health. If you discussed population health it was in the context of your course work on public or community health, competing for attention with school-based screenings and health fairs. The whole idea of having a professional consciousness that was expressed through global citizenship was simply not taught — or even exemplified. If nursing continues to think of itself as a non-stakeholder in the global health conversation, not only will we find ourselves marginalized, but worse yet, the health of the world will suffer as the largest group of health care providers in the world remains silent.

How do we begin to change this? We must begin by committing to educate both current and future nurses for global citizenry as healthcare professionals. Let me give you a few examples of what this could sound like. My research in the area of global health deals with what are commonly referred to as “determinants” of health. The World Health Organization (WHO) commonly refers to these as the “Social Determinants of Health[12].” A WHO commission on health equity and social determinants recently made its final report, the main findings are highlighted in this quote:

A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away. A girl in Lesotho is likely to live 42 years less than another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between — and within — countries result from the social environment where people are born, live, grow, work and age.

Inequities are killing people on a grand scale… This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But… it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place.[13]

If social determinants are really this important to health, then nurses ought to have command of the knowledge surrounding them… But what are they? Do we even know? Is it in our textbooks? Social determinants are the “circumstances in which people are born, grow up, live, work, and age, and the systems put into place to deal with illness. These circumstances are…shaped by a wider set of forces: economics, social policies, and politics.”[14] The research that I conduct with Drs. Hegyvary at the University of Washington, and Murua at the University of Montreal, takes these “wider sets of forces” and breaks them down into 60+ variables and asks questions like this, “Which variables actually produce the largest influence on the health of a nation?” Is it the amount of GDP dedicated to health spending? Or is it the number of children educated at the secondary level? Is it the numbers of hospitals, doctors, and nurses? Or is it the number of mothers who know how to provide oral rehydration solution to their infants? The answers to these questions might surprise you.[15] It is this kind of research that allows countries to make data-informed decisions about whether to spend their limited resources on paving roads or buying MRIs, if they are trying to improve the health of their peoples.

Why is this kind of discussion important to nursing? Because health is important to nursing. And increasingly we understand that it is social determinants that make so much of the difference in health. For most of us however, we are still primarily focused on individuals and illness versus populations and prevention. We know very little about social determinants and therefore, our potential for global influence and impact is limited.

Here is another example of the kind of content we need to teach if we are to prepare nursing for global citizenry. How many of you are familiar with, or have heard of, the concept of “burden of disease.” Burden of disease is a concept that was first made popular by some Harvard researchers in the early 1990s. Today, is it a major conceptual measure of the “load” that a disease process places on a whole society. One of the most common ways of estimating this “load” is through a measure called the disability-adjusted Life Year, otherwise known as the DALY. In plain language, the DALY tells us the number of years of productive life that are lost because of a disease. These years of life could be lost to death, such as the effect of a myocardial infarction, or they could be lost to disability, such as the effect of a mental illness. So, for example, what types of diseases do you think create the greatest burden on the world? In middle and high income countries, it is depression. Surprised? How about low income countries? It is lower respiratory infections and diarrheal diseases.[16] As nurses, we are intensely interested in not only quantity of life, but perhaps more importantly, quality of life. Understanding the leading causes of burden of disease should cause us to view the world differently. And by the way, how many times have you given inpatient care for a person whose primary diagnosis is depression? Unless you are psychiatric mental health nurse, probably not many… this may say something to us about how instep, or out of step, with the health problems that are most significantly burdening people.

Recommended Actions

So what can we do? Stand tall, read much, and think big. By stand tall I mean realize that nursing brings a lot to the table when it comes to global health. Two strengths in particular — we understand systems and we understand holism. We understand systems not so much because we have wanted to, but because we have been made to. We are the 24/7 arbiters of care in a very complex healthcare system. We understand that it is the social worker, the physician, the respiratory therapist, the daughter, the chaplain, the insurer, the pharmacy, etc. that are all going to have to work together to deliver top drawer care to mother. No one part can function in isolation.

Nurses also get the fact that care must extend well beyond cure. It is often not the presenting disease that is the real problem. People, just like populations, are whole organisms that are constantly in dynamic interaction with their environments. As nurses, we excel in seeing the big picture and thinking about holistic care. We may assist in the replacement and rehab of an old and dysfunctioning knee but we understand that apart from a home environment that enables and encourages the individual to get back up to speed, the problem of reduced mobility remains. The same type of thinking applies to populations. We may supply the drugs to treat AIDS, but apart from an educational approach that transforms societal norms, we have not solved the problem. People, like populations, cannot be divided up into neat and discreet problems. All parts are connected. So we must stand tall and be clear about what we can offer when it comes to global health.

For those of us who have already completed our education, it is unlikely we are going to go back to school just to learn a little about global health. That does not prevent us, however, from teaching ourselves about global health. Therefore, read much. As nurses we are continually engaged in learning — hopefully we’ve developed the value of lifelong learning. Through reading, you can really develop a substantial level of knowledge in the area of global health. You don’t need to go to another country to become informed in this area. Let me recommend some readings to you on the subject:

1. The American Journal of Public Health: Readings in Global Health (2008)

2. Global Health: An Introductory Textbook (2006) (Lindstrand, et al.)

3. WHO, Commission on Social Determinants of Health FINAL REPORT (2008). Closing the gap in a generation: Health equity through action on the social determinants of health.

4. Awakening Hippocrates: A Primer on Health, Poverty, and Global Service (2006). (O’Neil, AMA)

Engaging books and articles on this topic will change the way you hear the news and the way you look at the world.

Next we need to think big. As a discipline, we must maintain all our expertise in working with individuals and illness and at the same time begin to teach into existence a new kind of expertise dealing with prevention and populations. Public health and community nursing are not sufficient in size or scope to address the health care needs of an entire globe. It will take every nurse, and every nurse, therefore, must be able to see and engage the bigger picture. To do so, she will need the connections required for global community.

The Connections Required for Global Community

So we have a lot to offer the world as nurses. How will we get it out there? I want to take just a very brief amount of time here to press upon you the importance of making connections locally, nationally, and globally. And we can think of connections under three areas: stakeholding, networking, and spanning with technology.

By stakeholding, I mean figuring out our place at the table with those who would influence global health. This of course requires you to find the table and then to show up to it ready to participate. Finding the table is not so difficult, there are many places you could go. Consider nursing organizations with international reach such as STTI, ICN, NLN, AACN (GANES), or the ANA. Getting outside of nursing into multidisciplinary organization can often hold even more opportunities. Consider contacting NGOs who focus on global health such as CARE or World Vision or Doctors Without Borders. There are also the very large entities, like UNICEF, WHO, or World Bank, who, after you wade through the mazes of programs, names, numbers, and phone trees, often have very innovative work going on. Finally, consider looking around your institution. It is no secret to you that your institution has “brand power.” Capitalize on that. Phone calls and emails stating that the global health nursing council at DHMC is interested in working with you to… Can send a very strong and positive message to organizations that often have far more work than they can handle.

Next, you must be continually engaged in the process of networking. No opportunity is too small. Some of you may have friends and associates who are from other countries. Often these people know people, who know people, and some of those people might be just the type of person you are looking to get a hold of. A personal introduction, even by email, can make all the difference. It is also likely that between DHMC, the Medical School, and the College, there is a steady stream of international guests who you could invite to speak with you as part of their visit. I’ve noticed while browsing your website that there is a department of health policy at the College, an International Health and Global Health Center in the Medical School (in which at least 3 other globally minded organizations exist[17]) and an International Health Group[18] which seems to be connected to DHMC, the Medical School and the College. These are places for you to begin — but you must get clear about what you have to offer and what you would like to do. But remember what was suggested earlier — read much. Showing up is not enough, you must bring something to the table. And we will talk a little more about that in a moment.

There is an excellent article that was published in 2008 in Nursing Outlook by Abbott and Coenen[19] on the topic of spanning with technology. They discuss how information and communication technologies can be used by nursing in the realm of global health:

Information and communication technology can used to not only manage and distribute information to impact health, improve efficiency and demonstrate contributions to outcomes, but to offer a knowledge and communication lifeline to isolated providers, patients, and caregivers around the globe.[20]

In reference to our earlier discussion about determinants, they draw on an external reference who makes an interesting observation:

The health and life expectancy of the vast majority of mankind, whether they live in rich or poor countries, depends on ideas, techniques, and therapies developed elsewhere, so that it is the spread of knowledge that is the fundamental determinant of population health.[21]

If there is any truth in this, and there is probably some, then as nurses we have an incredible amount of power to influence health in far flung places, simply by sitting down at our computers.

Between the internet and smart phones, the possibilities are many. Consider this, cellphones can be used as mobile microscopes today. The clinician in a remote village can diagnose malaria in a very short amount of time by preparing a wet mount, taking a picture with his cell-scope, and then emailing it to the lab for reading.[22] Who developed this technology? Students. How much did it cost? Less than $100. How much are its applications worth? Priceless. We no longer live in an era where geography is the largest obstacle to overcome. Convention is now our largest obstacle. Thinking outside of the box through the enablement of technology will allow us to span continents and make connections with those we never thought possible.

Recommended Actions

What are specific steps that can be taken to establish the connections for global community? Early in your development I think the most important thing you can do is simply put yourself forward. Here are a few specific examples — but don’t let these limit your thinking. I believe that the opportunities available are limited only by your creativity.

1. Establish a subcommittee on your council that is specifically tasked to develop relationships with international nursing organizations, international/global groups on campus, and overseas partners that may already be established through DHMC. Put together a small introductory packet on who you are and what you hope to do. Send it out to those you hope to work with and then schedule follow up conversations.

2. If your group is interested in actually making service trips and developing longstanding relationships with groups abroad, you will find that the resources and opportunities are unlimited. Here are a few places to start: Sigma Theta Tau maintains a list of links to international volunteer opportunities, from the front page click “Global Connect.” The International Council of Nurses continuously updates a database of nursing partnerships which involve two or more countries. I think you will be surprised at both the scope and diversity of the partnerships. You may find opportunities here that inspire your own ideas or partnerships that you work to become part of.

3. Lastly, I believe you may have a significant opportunity to develop a relationship with the office of the new president at the college that bears your namesake, Dartmouth College. His name is Jim Yong Kim. The physician-anthropologist is a former director of the HIV/AIDS department of the World Health Organization and has been dedicated to providing healthcare around the world to underserved populations for over two decades. There is no doubt in my mind that even a brief audience with President Kim would prove to be very stimulating… Invite him to speak at your next meeting.

The Ambition Required for Global Action

What have we heard thus far? We must increase our knowledge for global citizenry as nurses and we must make connections to participate in global community. So perhaps you leave this meeting and you pick up one of the recommended texts and you develop a working knowledge of the terms and concepts important to global health today. Perhaps you begin a discussion group where you can interact about these ideas with others. And then maybe you take it a step further, you begin to intentionally and systematically reach out to others — perhaps you make connections with international groups on campus, or begin following the blog of an NGO. Is this enough? No.

I liken the next steps to a phase during which I was dating my now-wife. We were separated by distance and found ourselves writing letters — or at least I was writing letters. I’d often ask her to write me and one of her most frequent responses was, “I meant to write…” Finally I told her that, “You cannot put a stamp on intentions.” In other words and we can be informed, connected, and still be ineffective. So what else is needed? If nursing is going to have an influence in global health, we will need to have more than good intentions. We will need to take action. I’d like to spend the rest of our time together focusing on concrete steps that can be taken by you to begin acting as players on the global health scene. We’ll discuss these under the headings: Working from the upside of group strength: Optimizing your effectiveness; Working outside the traditional healthcare setting: Separating nursing from the hospital; Working inside the educational system: Tracing traditional paths; and Working alongside present and future leaders: Considering an innovative intervention.

Working from the upside of group strength: Optimizing your effectiveness

The first and most important step you have already taken. You have formed a group, and that is to be commended. Cooperative actions are almost always more effective than solo efforts which are often unbalanced and difficult to sustain. Your group should work to establish its identity. Hosting events like this one is a good step in the right direction. Consider creating a website through your host institution, or beginning a group Facebook page, or developing some medium that allows you to have a continual and ubiquitous (or global) presence.

Identify a mission and vision for your group and establish some one, two, and five year goals. Agree upon what you will be and what you will do. Help others to see that you are a serious-minded group that believes you have something to offer to the effort to improve global health. Keep in mind that it is not important that your group ever leave New Hampshire. Fantastic if it does! But certainly not necessary. There is much you can accomplish from right here.

Do some recruiting among your peers and help those who have interests in this area find you. Look to identify an administrative champion here at DHMC. Engage your participants in meaningful activity as soon as possible. Many groups die not for lack of interest or attendance, but for lack of meaningful activity. Scan the environment for some low-hanging fruit that will give you early opportunities to work together. These will not only help you to establish some norms for your group, but it will also give you something to talk about to your public relations department and others in the institution. Once your group develops some sense of self, you will have to decide about where to focus your energies.

Working outside the healthcare setting: Separating nursing from the hospital

Bradbury-Jones[23] provides a very helpful summary of the effects of globalization that are of concern to nurses in a recent article published in the Nursing Standard. I want to share these with you because I believe that as we consider them, you will begin to see that so many of the opportunities for the nurse in a globalizing world are going to exist outside of the hospital and the clinic. It is good for us to remind ourselves that nursing and hospital are not synonymous. The main focus of our discipline is a phenomena, not a setting, and that phenomena is health. Wherever and whenever health related things are taking place, nurses should be part of the conversation. So as you begin to consider the global health arena, even if all of your experience is based in a hospital, give yourself the freedom to wander far, very far, from this “way” of interacting with health. Hopefully, one day we will all wake up and find that the “hospital” as we know it, has gone away. In the meantime, we need not restrict ourselves to its confines.

One of the main effects of globalization is the growth in non-communicable diseases such as hypertension, diabetes, and obesity, to the extent that non-communicable diseases now represent the principal cause of death (as opposed to communicable/infectious diseases) in the world. Contributing to this trend is the increase in length of life and the introduction of western conditions to developing countries leading to in increases in obesity and tobacco consumption (think more urban and sedentary vs. rural and agrarian life habits).

We know well that the key to preventing diseases such as hypertension, diabetes, and obesity, is lifestyle choices. Many developing countries have spent years improving programs to prevent malaria, to provide basic vaccinations, and to reduce the transmission of HIV/AIDS, but the quick growth of non-communicable and chronic diseases is a health phenomena that these countries are very poorly equipped to deal with.

What do you have to offer in such situations? Cynically, we might say that we have much to offer! As a nation our experience with gluttony, inactivity, and denial of personal responsibility for health is unparalleled. On a more positive note, however, as a result of these problems in our society, we have years of research and experience regarding public health and prevention intervention efforts. Developing countries are in need of evidence-based education and training around the prevention of non-communicable diseases. And, they need it now. Not when their health care systems have matured into well-oiled machines that deftly deal with the consequences of a super-sized life and the economic and social incentives for living healthy, for practicing prevention, have become almost non-existent. Why let more societies become what we are in the health arena? Surely we can call them to learn from our mistakes.

Interventions in most of these areas, however, do not happen in hospitals and clinic settings. We are generally dealing with the consequences in those settings. Prevention interventions often happen at the community level. So when you consider exporting your care expertise, think broader than the acute care setting. Think of caring beyond the bedside, into neighborhoods and communities, into policies and programs, and into protecting whole societies from the unintended consequences of development (such as high blood pressure, cerebral vascular accidents, and coronary artery disease). I am certain that you will quickly set yourselves apart if as you begin to form relationships with other global partners, you focus on prevention of non-communicable diseases through interventions designed to address the determinants of health.

Working inside the educational system: Tracing traditional paths

There are many, many, many collaborations that go on between university-based programs of nursing in the US and programs abroad. Many of these exchanges happen around needs for curriculum development, professional development, degree development, and clinical skill development. As a large health care institution, DHMC has rich resources dedicated to the education of nurses, whether it be training through simulation, nurse residency programs, OR training, or developing skills to care for the elderly. These staples of your experience may be educational products that are wanted, needed or beneficial to developing programs abroad. Adopting a university or hospital based nursing program in another country can be an enriching experience that allows for a mutual exchange of knowledge and skills. And as we discussed earlier, sharing your expertise does not always mean getting on a plane anymore. Quite often much can be done through technology at a much lower cost. If you begin looking around, I believe that you will find it quite easy to find programs of nursing in your region who are already working with programs abroad. It is my guess that they may be very happy to partner with you in serving their international partners. Alternatively, you could simply work toward establishing your own contacts and relationships.

This is probably a good place to remind you that we must be careful to not become ethnocentric in our thinking about international partners. What we want to export is caring — the best of nursing. Not necessarily Americanism or our cultural norms. Key questions to ask ourselves are, “What are the actual nursing principles we are working to export?” And, “How do those principles fit into the settings and culture of the recipients?” The principles will always remain the same across cultures and settings. The expression of these principles, however, needs to be as flexible and as varied as possible. As nurses, we are famous for being able to adapt and innovate. Teaching and helping those from cultures other than our own gives us the opportunity to really have our skills tested in this area. [example: gloving in Africa]

A second reminder. No one ever got rich off of global partnerships in nursing. To partner with countries in need often means an equal sharing of the financial burden. The intangibles, however, far exceed in value anything that is made or lost in terms of dollars. Move into the global arena with a service mentality, especially if you plan to target nurses in parts of the world which have the greatest need.

Working alongside present and future leaders: Considering an innovative intervention

A final area that can be considered is one that we do not think much about in nursing: leadership development. If we accept the maxim that people rise or fall to the level of leadership, then developing nurse leaders globally is likely to deliver a maximum return on investment. I personally have not heard of many global partnerships which have their focus in this area. There are plenty of programs doing exchanges, many offering advanced degrees, an abundance of volunteering opportunities, but very few focusing specifically on leadership development. Some might argue that the offering of advanced degrees is essentially the same thing — but I would strongly disagree. Very few Masters or PhD programs have built into them courses designed with the express intent of developing leaders who will function as change agents in society. Even programs with an administrative focus often emphasize management training, not necessarily leadership.

Consider the following focuses identified by the 2008 WHO’s Bangkok Charter for Health Promotion in a Globalized World[24]:

1. Advocate for health based on human rights and solidarity

2. Invest in sustainable policies, actions, and infrastructure to address the determinants of health

3. Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy

4. Regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people

5. Partner and build alliance with public, private, nongovernmental and international organizations and civil society to create sustainable actions

These focuses are developed around the idea of specifically addressing health determinants, those factors we discussed earlier which are responsible for the creating of conditions which lead to health or disease. When we begin to consider shaping health determinants versus dealing solely with responding to disease, it becomes clear that the type of changes needed are those that effect large groups of people. Hence, competent nurse leaders will be required to shape the future. If a nurse practicing with excellence at the bedside is a powerful force for change in her immediate setting, consider what a recognized nurse leader has the potential to do on a much broader scale.

If nurses at DHMC are interested in seeing their efforts result in maximal impact for the maximum numbers of people, training nurses to be leaders will be a key plank in their platform. Such nurses will have the ability to change and create policy, advocate effectively for human rights, build capacity in communities and institutions for changing determinants, and to partner to build key alliances which allow for sustainable actions that impact the health of whole populations.

How can DHMC be involved in that? I think that the answer is best left to your own creativity, but do consider that here at your institution you have the capacity to expose nursing leaders from around the world to top notch clinical nurse leaders, executive nurse leaders, and community nurse leaders. Establishing a program that in some way focuses on leadership development would be a unique and innovative development for a clinically-based organization, such as your own, to undertake.

Conclusion

As we close, I believe it is prudent to return to the legacies of the leaders we began this talk with. Consider again those responsible for your beginnings, Wheelock, Smith, and Hitchcock.

Wheelock, the founder of Dartmouth College, believed knowledge should be shared with all people, cutting across societal and cultural divisions.

Smith, the founder of Dartmouth Medical School, believed that access to health care should be shared with all people, reaching beyond geographic boundaries.

Hitchcock, the founder of the Mary Hitchcock Memorial Hospital, the forerunner of DHMC, believed that the best of DHMC, that is its’ all “and more than all” should be shared with all people, benefitting those that DHMC can reach.

It seems a very natural extension of these men’s visions that DHMC nurses would begin to reach out past the edges of their own communities to exercise their goodwill and influence beyond the borders of their own country. In the spirit of Wheelock, disseminating knowledge; in the spirit of Smith, improving the reach of quality healthcare; and in the spirit of Hitchcock, exporting the best of DHMC, to a global audience. I wish you the best of luck as you begin your journey.

[1] http://www.dartmouth.edu/home/about/history.html

[2] http://dms.dartmouth.edu/about/history/history.shtml

[3] http://www.dhmc.org/webpage.cfm?site_id=2&org_id=566&morg_id=0&sec_id=39&gsec_id=42&item_id=41403

[4] http://www.dhmc.org/webpage.cfm?site_id=2&org_id=566&morg_id=0&sec_id=0&gsec_id=42&item_id=41404

[5] http://query.nytimes.com/mem/archive-free/pdf?_r=1&res=9F03E5DC143FE433A25752C3A9649D946197D6CF

[6] Scriven, 2005; WHO, 2007; Bradbury-Jones (2009). Globalisation and its implications for health care and nursing practice. Nursing Standard 23 (25), 43–47.

[7] http://voices.washingtonpost.com/44/2009/04/28/with_eye_on_industry_ag_secret.html?wprss=44

[8] http://www.washingtonpost.com/wp-dyn/content/article/2009/04/29/AR2009042904650.html

[9] http://online.wsj.com/article/BT-CO-20090428-717883.html

[10] http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTURBANDEVELOPMENT/EXTURBANHEALTH/0,,contentMDK:20485964~menuPK:1090912~pagePK:148956~piPK:216618~theSitePK:1090894,00.html

[11] Davey, 2005

[12] http://www.who.int/social_determinants/thecommission/en/

[13] http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

[14] http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html

[15] Hegyvary, S., Berry, D.M., & Murua, A. (2008). Clustering countries to evaluate health outcomes globally. Journal of Public Health Policy 29 (3), 319–339.

[16] http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part4.pdf

[17] http://www.dartmouth.edu/~globalhealth/

[18] http://dms.dartmouth.edu/dihg/fellows/

[19] Abbott & Coenen, 2008

[20] ibid, p. 238

[21] Deaton, T. Health in an Age of Globalization. Available at https://muse.jhu.jounrals/brookings_trade_forum/v2004/2004.1deaton.pdf Accessed June 2, 2008.

[22] http://www.wired.com/gadgetlab/2008/05/microscope-enab/

[23] Bradbury-Jones (2009). Globalisation and its implications for health care and nursing practice. Nursing Standard 23 (25), 43–47.

[24] http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/