Nursing education in the path of globalization: Promotion or challenge?

Globalization has been attracted by great literature and papers of many disciplines in recent years. Although globalization has considerable social, political, and economic effects, it has turned to an important challenge in health-care systems. Nursing, as the largest part of the health system in the world, has also been affected by globalization. The purpose of the present paper is to critique globalization and its impacts on the nursing profession. This review article was conducted by searching for reliable internet resources in the English language on the impact of globalization on nursing. Published articles were searched until 2018, and related articles were extracted in three stages: 1-selection of articles by reading abstract, 2-selection with an overview of the text, and 3-selection with a full review of the article's text. According to the literature of globalization, we categorize and discuss the nursing areas that are affected by globalization in nine areas: global nursing development, nurses emigration,information interchange and interactions in nursing, higher education in nursing, professional territory, nursing specialization, professional ethics, management and supervision, and professional independence. The intensity of globalization effects on the nursing profession has not been the same in all societies, and factors such as compliance of society, culture, and technology are among the most important factors that affect it. Globalization is an inevitable process and brings with itself many prominent promotions such as global nursing development and important challenges such as nursing emigration and ethical issues. Copyright:

Introduction

Globalization is a phenomenon that has been rooted in economic and attracted considerable attention in literature at the international level in recent years. Some consider it is a novel phenomenon, and on the other hand, some believe that globalization, beyond its term, is a long-term process during years and centuries.[123] Aside from the question that is it a novel phenomenon or existed a long time ago, it is considered that the differences between societies and their development in addition to the philosophical viewpoint of people that has effects on their ideology-are also effective on attitude about this phenomenon. So that in developed countries and maybe western societies, this phenomenon has been more understood, although in developing countries it has been experienced recently and in under-developed countries, it will be proposed in future. This is why most of the papers about globalization from developed countries have been published in 1995–2010, but in developing countries, most of them have been published since 2005 till now (By advance search in Google scholar and checking the number of the published article).

Globalization is a process that connects nations, trades, and people by financial development, communication changes, cultural transformations, and travels.[45] The most appropriate definition of globalization for all fields of health is this definition: globalization is a process, in which the events, activities, and decisions of a region in the world can have important effects on people, societies, or connections of another region of the world. This definition can cover the spread of a disease from one part of the world to another, or that health decisions in one part of the world can have important outcomes in another part of the world.[6] Globalization and its impact on health have been discussed by a few experts, especially in the field of nursing. Keighley believes that globalization in healthcare is a complex concept that not only needs attention and knowledge of caring and health but also needs attention to other factors like immigration, financial development, having an international common language, and using technology in daily routine life.[7] Regarding the changes in the nursing system comparing to the past, such as nurses' immigration, technology development in the health-care area, and new fields in universities, it can be claimed that nursing is affected by globalization. However, there are little data available in the literature about this. Hence, considering the lack of information about the effects of globalization on the nursing profession, the purpose of the present study is to critique and discuss the impacts of globalization on nursing and review the opportunities and challenges.

Methods

The focus of this essay was to assess the impacts of globalization on the nursing profession. In this scholarly review study, related articles in web references were investigated. Published papers in scientific websites, PubMed, Science Direct, CINAHL, and Scopus, were searched by MeSH keywords including, “globalization,” “Internationality,” “opportunity,” “threat,” “global,” and “nursing,” separately and combined with no time limits till 2018 in English. With the three steps of 1-selection of articles by reading abstract, 2-selection with an overview of the text, and 3-selection with full review of the article's text, related articles were selected. In the first stage of searching, 1220 papers were obtained from which 121 papers were selected by overview of the texts. Then articles more related to the topic were selected, which counted 26 papers. Related subjects were also studied in library references and then appropriate contents were studied carefully, and summaries were prepared. After full understanding of the subjects, globalization in nursing, challenges, and opportunities were described and discussed. The inclusion criteria were: the relevancy and having the characteristics of a scientific paper based on the Critical Appraisal Skills Program. The exclusion criterion was: lack of access to the full text of articles (such as articles that presented at seminars and congresses) [Figure 1].

Figure 1

The article search process

Results

Regarding the definition of globalization as a phenomenon that erodes conventional borders separating people from society, one of the considerable characteristics of globalization, mentioned above, is omitting borders. According to the literature review, we categorize and discuss the nursing areas that are affected by globalization in nine areas: Globalized nursing, nurses' migration, information interchange and interactions in nursing, higher education in nursing, professional territory, nursing specialization, professional ethics, management and supervision, and professionalism and independence, which are described in more detail below.

Globalized nursing

Globalization in the health-care system removes borders and brings systems, structures, and processes in the health care area closer in all over the world.[8] By removing borders, nursing systems of different countries come closer to each other, and they will become more similar in systems, structures, and processes. Acceptability of international nursing standards and health care guidelines in many countries, Nursing care based on the nursing process, North American Nursing Diagnosis Association nursing diagnoses, and then planning based on these diagnoses are examples of globalized nursing.

Removing borders and globalized nursing can be considered a desired opportunity in nursing because it produces health-care integration and makes nurses to act based on international standards in many countries. On the other hand, eradication of borders and union of health care standards in different countries regardless the rituals and beliefs of peoples who lived in this countries, can be a threat too, because the culture, ideas, and beliefs of people about health care and nursing in different countries are not the same, however, in the current century, when most of the countries are on their way for globalization, cultures, and beliefs are almost closer or it will be sooner or later. Thus, the above-mentioned challenge looks less important. The other critics about nursing globalization and removing borders are that similar systems, structures, and processes that can limit creativity in clinical and educational environments even more.

Nurses’ migration

Nurses’ migration can be considered as a feature of geographical borders erosion in nursing and one of the results of globalization. Nurses' emigration can also be considered as positive or negative consequences of globalization. In the 1950s, Philippian nurses emigrated and traveled mostly to America for education, and then, they traveled to middle-east countries or developed countries for a job so that during 1994–2003 about 84,000 nurses left Philippine[910] which is considerable statically. As a result of these migrations, Philippine has experienced a number of challenges and threats in its healthcare system in the last decade.[11] However, this problem is not limited to Philippine, and other countries are facing similar ones.[1213]

Today, the number of nurses who want to emigrate and are searching for a job in other countries is increasing, so that nurses immigrate to other countries searching for a job and employment. These migrations are mostly to developed countries such as England, News land, and Australia.[14] Woodbridge and Bland stated that in the last decade, the number of nurses immigrated to News land has increased so that 52% of nurses with work permission in this country has been graduated in another country.[15] Hence, a great number of skilled and experienced human resources go to developed countries, though in the past, skilled and experienced nurses moved from developed to underdeveloped countries.[14] The most threatening challenge for the source country is the lack of skilled and specialist labor force. On the other hand, countries have spent a lot of expense for training nurses that are needed, and by their emigration, the expenses that have been spent are spoiled. Moreover, by the emigration of specialists and skilled nurses, countries will have problems with achieving short-term and strategic goals for the health-care system.

Although, there are some advantages in these emigrations; many nurses who emigrate return to their countries at the end of their education or job course with lots of experiences and skills[14] that is a great advantage for their country in clinics, schools, and management.

Information interchange and interactions in nursing

One of the characteristics of globalization is the acceleration of interactions and processes. In a world that is on its way to globalization, not only communications and transportation but also ideas, data, goods, and decision distribution is revolutionized and accelerated.[16] Nursing has not been an exception, and nowadays, technology advances are observed in it. The question here is that can interactions and technology expansion be an opportunity or a threat in nursing. Regarding Siegal, communication technology results in improving the availability of health-care facilities.[17] Hence, it seems that technology entering nursing is advantageous since it results in expanding inter and intra-professional relations and also facilitates the availability of patients' information. Thus, meeting patient's needs for care will be easier. A global view that is accepted and approved by the WHO is that globalization and information technology and communication in healthcare can lead to rapid and global access to new treatments, technologies, and knowledge can resources. Abbott and Coenen have stated a good example by describing the role of information technology and communication in treating SARS in 2003. During the first cases of SARS in China in 2003, a virtual digital environment consisting of 11 labs in 9 countries connected by information technology and communication was developed and results of tissue analysis after death, electron microscope images of viruses, genetic sequences, and other related data were shared by E-mails and a safe website.[18] The above case is an obvious example of the role of technology entering health care. In the nursing profession, technology development and electronic communication have resulted in increasing nurses' knowledge, acceleration of data interchange, and improvement in time-saving. On the other hand, technology improvement and developing nursing services sites facilitate the availability of needed information and cares. Thus, nursing absolutely is affected by technology and information. Advances in education, telenursing, telemedical education, moving toward health electronic files, and nursing knowledge management are some examples of this claim. However, one of the concerns in this issue that seems logical is ignoring the spirituality, because human is a biological, psychological, and social entity and communication, caring, and treatment regardless of the human spirit and emotional relationship is incomplete. Hence, concern about less emotion due to technology development in the nursing profession, is a true critic.

Higher education in nursing

Baumann and Blythe stated that in today's world, the need for skilled and educated people like nurses has increased. Regarding them, America, Australia, and Britain have had vital roles in training nurses in higher-level educations. They described higher education development is possible in three ways: First, traveling and migration of students to receive these educations. Second, using distant learning, and third, educational institutes of one country that Have established branches in another country.[1] Regarding these statements, higher education of nurses is considerably affected by globalization, particularly if the three ways mentioned above are considered, it is obvious that they are affected by globalization. For example, in Iran, which is a developing country, the first way has been more common, but increasing in the other two ways as a result of globalization in the coming years is not surprising. Currently, in Iran, we have a master degree and doctorate. Based on the Iran Nursing Association website, attempts to get a doctorate degree began in the 1980s in Iran, and the first doctorate student began academic studying in 1995 in Tabriz, Iran.[19] Accepting doctorate students began about 20 years ago in Iran; however, it might be due to globalization because the first attempts for this purpose were by graduates of other countries who had returned to Iran. The authors could not find the exact statistics of graduates in Iran by using the nursing association and health ministry websites. Although currently higher education development is under critics by some criticisms and can be considered a threat or a challenge, because they believe that under current circumstances, we are in a lack of clinical nurses, accepting higher education students must be matched with colleges needs not more. Arani-Mansouri, in his paper, has stated that one of the biggest problems in higher education is the lack of regulations and scientific guidelines for using these specialists in clinics. Particularly in recruiting nursing doctorates, there is an obvious concern for mismanagement of them in a clinical position, and there is not yet enough potential job for them.[20] However, in the present paper, higher education development has been considered one of the positive consequences of globalization, considering its identity that is one of the facilitating elements of the professionalizing process, profession independence, and social prestige of nursing.

Professional territory

The other positive consequence of globalization is the expansion of nursing professional territory. Seloilwe believes that in the 1970s, nursing was limited to hospitals and clinics; however, today, there are a lot of fields for nurses to work.[14] Nowadays, the professional territory of nurses is more expanded than the past and in addition to hospitals, nurses can work in health clinics, schools, physician's offices, family clinics, Methadone therapy clinics, neonates and pregnancy care clinics, rehabilitation centers, sexually transmitted disease units, home care, and research centers.[1721] In many countries, due to globalization, the professional territory of nurses has expanded compared to the past, and in addition to hospitals and clinics, they are working in private sectors, outpatient clinics, health and hygiene training fields, schools, rehabilitation centers, insurance offices, teaching in academic centers, and research centers. Today, the expanded and variable professional territory of nursing is one of the attractions for students, and as mentioned above, it is one of the effects of globalization.

Nursing specialization

Regarding Haste, the specialist nurse concept was developed in North America and was entered to Britain in the 1970s.[22] Nevertheless, Scott states in his paper that there have been trends of nursing specialization in the 1950s and 1960s in Britain. He has pointed out the nursing specialty in Nursing Royal College in England and has described two purposes of nursing specialization in this college that were professional improvement and patient care improvement. Scott states that in held committees in this college, it is documented that in a time that medical sciences are specialized, specialization of nursing is essential too.[23] What is obvious to us in today's world is that nursing specialization is expanded and used in many countries due to globalization phenomenon and its interactions.

Nursing specialization has opponents and proponents too. There has some literature about evaluating specialist nurses roles[2425] that have shown specialized nursing services valuable and recommended specialist nurses training. Despite the advantages of nursing specialization, like higher skill and knowledge in one domain, some experts do not agree with specialization. They believed that nursing must be total-oriented and considered human as a whole, not an organ or a body.[23] Authors believe that it is true and can be a challenge for nursing specialization. However, specialist nurses' training has begun and is going on in many countries. Nevertheless, training total-oriented nurses must not be neglected because human is a biological, emotional, and social entity and attention to one organ or one disease hides another aspect.

Professional ethics

Since Florence Nightingale, nursing was formed based on ethical rules.[26] In today's world in which migrations are increasing, and there are a variety of cultures, ethical and professional responsibilities of nursing seem to be much more complex than ever. The challenge here is the effect of globalization. On the one hand, by editing ethical codes by Nursing International Association, globalization can be considered an effective step toward ethics improvement, and on the other hand, many believe that after globalization, ethics are less pronounced, and obtaining profit and wealth are replacing that. Today, western culture distribution affected by borders' opening and migrations seem to be challenging in Iran. Many experts of nursing in Iran have ethical concerns. Some consider ethical codes and law charters, emphasis on justice, private domain, health-care services availability, and international supervising organizations as positive consequences of globalization. They believe that globalization caused ethical improvement in the profession. For example, in the past in Iran, there was a negative image of HIV affected patients even among health-care staff, and there was the possibility of information disclosure outside of health-care system so these patients were taunted and thrown from society. However, today patients' data protection is an ethical code, and negligence of it is a crime. On the other hand, those who believe that globalization has a negative effect on ethics state the cause of their concern Western culture spreading. Xu, in his paper for establishing the difference between West and East, says that many Asian nurses have more empathy than American nurses, and American nurses follow caring because of fear from rules and being sued.[27] Thus, those who believe that globalization is a challenge considered mechanical care, fear from rules and being sued instead of empathy and altruism, increased financial motives, and Loss of traditional Eastern cultures relationship as a major threat due to globalization. Reviewing paper by Visovsky et al.,[28] can be helpful in this issue. They described that societies need students with cultural awareness and international competencies, so in this way, they will be better able to meet their complex needs of health-care system.

Do aside from agreeing or disagreeing with ethical issues that have been described above, what is obvious is that currently in the nursing profession due to globalization, nurses are facing ethical dilemmas more than ever. For example, in today's world, in some countries, suicide is considered a right, but in others it is not. An immigrant nurse to a culture in which suicide is a human right faces an ethical dilemma. Assume a nurse from a country where euthanasia is a sin enters a country in which it is allowed, and now he/she is facing a patient that his/her family asks for euthanasia. These are ethical issues that challenge nursing more than the past due to globalization, nurses' migrations, and working in places with different culture, religion, and values. Although there has always been an ethical dilemma in the nursing profession and many nurses, have faced them, today they seem to be more pronounced because of globalization and its effects on nursing.

Management and supervision

Globalization, which has expanded management knowledge, has challenges with itself that make managers and supervisors concerned. One of them is diseases' burden and its management. Meier believes that globalization has caused an increase of infectious diseases such as AIDS, SARS, drug resistance, non-communicable diseases, and chronic diseases such as cardiovascular diseases, cancers, and diabetes by increasing traveling and removing borders.[29]

It should be noted that globalization does not always have similar effects on countries. Lack of healthy food and water in underdeveloped countries like African countries causes a high mortality rate and high birth rate, so poor will become poorer, and rich will become richer. As one of the results of globalization is diseases and infectious factors distribution due to open borders and open relationships, it should be noted there is a need for a management and supervision system in international, national, and hospital levels. On the other hand, regarding bioterrorism, there is a need for supervision systems more than the past, and this is a challenge which affects nursing too.

In today's world, societies need nursing leaders who trained about technology knowledge and communications and globalization process. While globalization is deploying, nursing can use this phenomenon as a step forward to better serving and creating a unique environment for nursing leadership and nursing cares. So, although globalization, associated with management challenges mentioned above, but new technologies can create creative opportunities in health-care domain that facilitate the availability of isolated and remote areas. Hence, this challenge can be an opportunity for nurses and increases productivity, justice, and quality of health care and decreases the effect of geographical distance.

Professional independence

Today, nursing is considered a profession and steps are taken for its professionality.[30] Professional interactions, initiative, and academic educations[31] are among factors that have a role in nursing professionality. Factors like academic education deployment and professional interactions and many other effective factors in nursing professionality are globalization characteristics. Thus, it seems that nursing professionality, although formed in developed countries a long time ago, but in developing countries, is deploying and under evolution by the effect of globalization and its characteristics. So, based on the opinion of the authors, globalization could improve knowledge, competence, and skills of nurses, particularly in developing countries and nursing is considered today or will be considered in the coming years, not as a job, but as a profession, however, there are problems considering the cultural and social background in these countries.

About professional independence, Ballou quoted by Freidson (1970) has said that all characterized factor of professionality is originated from independence and go back to it.[32] In a part of Ballou's article, independence is considered as ability, capacity, and competence. In previous sections, it was mentioned that globalization increases the knowledge, ability, and skills of nurses. Regarding the previous discussion, the authors believe that globalization, by increasing professional knowledge and awareness, has increased the nursing profession's independence. On the other hand, entering men to nursing, industrialization, advances in hospitals, and nurses' socialization[33] are factors that effective in professional independence, and many characteristics like industrialization and advances are hidden in globalization nature. Of course, the development and deployment of independent nursing organizations are the factors enhancing professional independence.

Another discussion is the professional authority, which is seemed by achieving professional identity and independence, can achieve professional authority. Authority, power, knowing one as a competent nurse, and self-satisfaction are consequences of independence.[32] However, it should be noted that in Iran and maybe other developing countries, achieving professional authority is under question because Professional nursing and professional independence still not been achieved 100%.

Discussion

Based on the results, globalization can affect nursing in nine areas. Table 1 summarizes these results.

Table 1

Effects of globalization on nursing

Effects of globalization	Opportunity/challenge	Considerations
Global nursing development	Strong opportunity/week challenge	Need for more research and studying opponents and proponents comments in different countries
Nurses emigration	Weak opportunity/strong challenge	Comments are different in various countries based on quality of health care system and need for nursing services but many of these challenges can be transferred to opportunity
Information interchange and interactions in nursing	Medium opportunity/week challenge	By teaching spirituality many challenges are removed
Higher education in nursing	Medium opportunity/medium challenge	Its effect is different in different countries and needs individualized study
Professional territory	Medium opportunity
Nursing specialization	Medium opportunity/medium challenge
Professional ethics	Medium opportunity/strong challenge
Management and supervision	Medium opportunity/week challenge
Professional independence	Medium opportunity

According to the literature review, globalization is the dynamic process, and it seems that no discipline or profession does not be affected by the effects of globalization. Although the intensity and deepness of these effects are not the same in different parts of the world and have not similar results for all countries, all health professions, including nursing, are affected by globalization. The intensity of globalization effects on the nursing profession has not been the same in all societies, and factors like compliance of society, culture, and technology are among the most important factors that affect it.[34]

The ways to turn challenges into opportunities are not included in this discussion, but in the following, some examples of these strategies briefly mentioned in some area:

Nursing instructors should address challenges in the global nursing development area by putting critical thinking principles in the core curriculum. They must Foster social values, solidarity, sensitivity, and political literacy in nursing students.[35] For example, they can teach students about the values, cultures, and beliefs of different people in the community health nursing class through some methods such as brainstorming, strengthening students 'creativity. In the same tutorials and discussions, there are even opportunities for entrepreneurship, like inspiration from the cultural coverage for a hospital dressing company.

In nurse's emigration area, as mentioned, countries of origin experience more challenges. These countries can turn this challenge into a viable opportunity by attracting education and employment conditions, such as providing short-term scholarships to go to the requested countries in the fields required and by bail. In this way, nurses return home with expertise, experience, and satisfaction. Therefore, the challenges of shortage of workforce will be eliminated, clinical conditions will be improved, and expert nurses with high perception will work.

Nurses can turn challenges into opportunities in the Professional independence area by working in a systematic and comprehensive manner, strengthening knowledge in the field of their work, along with experience and autonomy in practice.[36] They must be self-employed and should be responsible for their own policies and regulations.[37] In the Professional ethics area Nursing instructors should address challenges by educating students with cultural awareness and international nursing competences (28).

Conclusion

Consequently, it can be concluded that globalization is inevitable, and the nursing profession is not an exception to be affected by this phenomenon. It means that by increasing global awareness and communication deployment, which are results of globalization, even conversations in the nursing system are affected. One of the limitations of this study is searching in English that it can limit our findings, but because of the main and global language of nursing literature is English, we conducted this searching strategy.

In conclusion, Nursing can consider globalization as a threat or an opportunity, what is desirable in nursing about globalization is using opportunities, decreasing challenges, and changing them to opportunities by creative and principled management.

Financial support and sponsorship

Iran University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.