CATALYSTS FOR CHANGE Harnessing the Power of Nurses to Build Population Health in the 21st Century Executive Summary September 2017 EXECUTIVE SUMMARY T he United States has never had a greater need for population health. Our nation spends more on health care than any other country, and those costs continue to increase. Yet the health of our nation’s ­residents and their life expectancy is declining, and the number of people struggling with chronic conditions continues to rise. All this occurs against a backdrop of decreasing spending on public health and an increasing demand by payers for quality and value over volume. Nurses are uniquely suited to play a significant role in building the best possible health and well-being for all in our nation. Consistently named as the most trusted profession, nurses are everywhere: in our communities, our schools, businesses, homes, and, yes, our hospitals. They are educated to see each person for whom they care in the context of his or her life—all the factors that impact that person’s life and well-being. Indeed, nurses have a responsibility and an obligation—by virtue of their education—to promote population health no matter where and how they practice. In the white paper of the same name, the authors set out to answer this question: How can nurses best help our nation reverse course on the declining health of its citizens and promote the health of the U.S. population in the 21st century? To answer this question, the authors: ■■ Conducted a comprehensive literature review, which included a survey of newsletters published by professional organizations. ■■ Interviewed thought leaders and experts in the field. ■■ Attended key regional and national meetings to gather research findings and promising models of care. © 2017 ROBERT WOOD JOHNSON FOUNDATION | ■■ Participated in a national consensus conference hosted by the Robert Wood Johnson Foundation and attended by 36 nursing leaders and educators, health care providers and payers, health economists, and researchers. Shared here are their findings, as well as recommendations and a call to action for moving this important work forward. DEFINING TERMS The terms population health and population management have been used in various ways, often interchangeably, to describe strategies to improve the health of communities or groups. For purposes of this work, the authors described the differences between the two terms: ■■ While the definition of population health initially focused on outcomes, today it is used more broadly to include the collaborative activities that result in an improvement of a population’s health status. Upstream factors (determinants of health)  —not just health outcomes—are included in measurement. There is a recognition that responsibility for population health outcomes is shared. ■■ Population management (sometimes called population health management) has a more narrow definition. According to the Institute for Healthcare Improvement, it “orients payment and the delivery of health care services toward the achievement of specific health-carerelated metrics and outcomes for a defined population.” These two terms describe a continuum beginning with the population management of a defined group of individuals for which a health care entity is paid to improve health outcomes—to a broader population-level focus in which health-related and civic organizations Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 2 work together to improve health outcomes for a specific population, with shared accountability and a commitment to addressing upstream determinants of health. ■■ Population-focused nursing draws on the rich legacy of nursing theory and practice, which has always under­stood individuals and their care in the larger context of their social, emotional and physical environ­ments. Populationfocused nursing integrates the tenets of public health with clinical care, thus contributing to improving the health of communities and populations. strategies can help provide more people the opportunity to make healthy choices, and for health to be much more accessible to all. ■■ Lack of access to affordable clinical care. In contrast to populations in other high-income countries, a large proportion of the U.S. population has been, until recently, uninsured. In addition, deductibles and co-pays are common in the United States for those who do have insurance coverage, and high out-of-pocket expenses make health care services, pharmaceuticals, and medical supplies increasingly unaffordable. POPULATION HEALTH: CURRENT CONTEXT AND TRENDS While the United States is a leader in developing cuttingedge medical technologies, pharmaceutical products, and health care treatment innovations — and has an inter­national role in biomedical and health services research—it also has the dubious distinction of having the highest health care costs per capita of any country. And although health status and life expectancy have continually improved over the past century, our nation is not keeping pace with other economically advanced countries. In fact, in 2015, U.S. life expectancy declined for the first time in 22 years. With health care reimbursement transitioning from a fee-for-service to a value-based approach, health care delivery organizations are being forced to change strategies and target high-risk populations and communities to reduce utilization and improve health. To be effective, population health strategies must focus on these key drivers: ■■ ■■ Social determinants of health (SDOH). “The social determinants of health are the factors outside of health care that can be influenced by social policies and shape health in powerful ways” (Braveman & Gottlieb, 2014). These are the conditions in which people are born, grow, live, work, play, and age; they affect health outcomes, functioning, and quality of life. These conditions in which people are born, grow, live, work, play, and age…affect health outcomes, functioning, and quality of life. ■■ with smoking cessation, reduced use of saturated fats, and increased use of seatbelts demonstrates that it is possible to change behavior. The models used for these population-level behavioral changes have been suggested as a way to reduce obesity—another major, preventable cause of death and disability in the United States. In addition to health care reform, trends that more specifically impact the role nursing plays in building population health include: ■■ © 2017 ROBERT WOOD JOHNSON FOUNDATION | An aging population. The 65-and-older U.S. population is expected to increase from 46 million today to 98 million by 2060. There will continue to be a need for nurses who can provide complex care coordination, participate in teams, and use technology in the care of older adults. Health inequities. The National Academies of Medicine (2017) defined health equity as “the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.” Population health Health behaviors. The United States’ positive experience ■■ Nurse retirements. The retirement of 1 million registered nurses (one-third of the nursing workforce) between now and 2030 means a tremendous loss of knowledge and experience in the nursing workforce at a time when the demand for nursing is increasing. Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 3 ■■ Public health system transformation. Public health agencies are expected to provide the core functions of assessment, assurance, and policy development through the delivery of essential public health services. Unfortunately, public health funding has been insufficient; subsequently, the public health workforce has been declining, with staffing down 22 percent between 2008 and 2016 in local public health departments alone. ■■ Technology. In the past few years, dramatic technological advancements—such as telehealth, electronic health records and mobile devices—have been developed. These advancements have the potential to change clinical care, prevention, and health communi­cation. As the pace of innovation accelerates, these developments will force strategic changes in every part of the health services continuum. ■■ doing holistic assessments, or planning for patients post-discharge. To be effective, therefore, population-focused nursing requires attention to several critical issues: ■■ population-focused vision of the future is strong nursing leadership, which will drive the monumental culture change required to improve health and reduce costs in our country. ■■ NURSING’S OBLIGATION TO IMPROVING THE HEALTH OF POPULATIONS The nursing profession has its origins in population health, beginning with nursing pioneers such as Florence Nightingale and Lillian Wald. Nurses provide services in homes, places of worship, factories and offices, schools, libraries, corrections facilities, and senior centers, as well as in nearly every clinical setting in the health care system. They are well-positioned to identify issues affecting the health and well-being of individuals, discern patterns across patient populations, link patients with community resources, and develop broad-based interventions. Regardless of their education level or their work assignment, all nurses have a responsibility and obligation to promote population health. Adequacy and diversity of the nursing workforce. Improving the diversity of the nursing workforce will require “… focus on each step along the professional pathway, from recruitment, to educational programs, to retention and success within those programs, to graduation and placement in a job, to retention and advance­ment within a nursing career” (National Academies of Sciences, Engineering, and Medicine, 2016). Consumerism. In most industries, consumerism has been a motivating influence for change and innovation. A consumer-friendly approach encourages individuals and families to play an essential role in their own health management. Nursing leadership. The key to implementing a ■■ Nursing’s value proposition. In economic terms, nurses must clearly communicate their “value proposition,” demonstrating their impact on the health and costs of populations, as well as individuals. ■■ Health data. Data fluency is a basic population health nursing competency required to make data-driven decisions and to translate research into practice. KEY POPULATION-FOCUSED NURSING COMPETENCIES To realize their full potential in population health, nurses must develop four key population-focused competencies: 1. A holistic approach: considering the physical, mental, social, and spiritual aspects in the context of an environment. 2. Coordination of care across providers and sites of care. 3. Collaboration with other professionals and community stakeholders. 4. Advocacy for the individual and the community. KEY ISSUES TO BE ADDRESSED POPULATION-FOCUSED NURSING ROLES Despite the best intentions and education, however, many nurses practicing in today’s high-tech, high-demand environment are too often task-oriented. They have little time for teaching, providing psycho-social support, Finally, to fully integrate nursing into population health— and population health into nursing—we must equip nurses to fill roles in both population health and population management. © 2017 ROBERT WOOD JOHNSON FOUNDATION | Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 4 Population health roles include: ■■ Leadership in state and local public health agencies ■■ Other population-focused public health nursing roles, including leadership for population health initiatives for health care systems ■■ School nursing ■■ Data analytics Health care is rapidly moving to the community, with a strong emphasis on managing chronic diseases. As a result, emerging population management nursing roles include: ■■ Chronic disease management ■■ Care coordination/management ■■ Leading community benefit and population health initiatives aspect for the successful development of a dynamic population health nursing workforce. Research Research is the foundation on which nursing practice is built; therefore, it is essential for a successful transition to effective population health and population-focused nursing, particularly as research provides actionable information on the value and effectiveness of emerging nursing roles and models of care. Policy Policy implications for population-focused nursing include the importance of addressing workforce gaps; public health infrastructure; funding for nursing education and research; scope of practice; reimbursement; develop­ment and testing of nursing roles; and new population health approaches. IMPLICATIONS RECOMMENDATIONS If we are to achieve widespread population-focused nursing, there are implications for nursing practice, education, research, and policy. This work is critical and urgent, and if it is to be successful, we must fully engage the nursing workforce. The five broad recommendations that emerged from this work are designed to do just that. Health care is rapidly moving to the community, with a strong emphasis on managing chronic diseases. 1. Transform nursing education. We must: ■■ Nursing practice As the largest and most trusted health care profession, nurses are essential to reversing the decline in health status and the increasing costs of health care. This dilemma should be viewed as a systemic crisis that requires the mobilization of all nurses in all capacities. In addition, strong nurse executives and managers are essential catalysts for improvement and change, building consensus, and developing cultures of health, lifelong learning, interprofessional collaboration, transparency, and wholeness. Integrate population-focused nursing concepts (holism, coordination, collaboration, and advocacy) into the curricula for all nursing students, and clarify which related competencies should be expected of students at each educational level: »» Collaboration with not only other health professions—but other professions and sectors in the community that impact health—should be a key component of all nurse education. »» Education should provide students with the skills they need to understand the impact of the community on patients’ health—and how they, as nurses, can influence change within their communities to improve health. ■■ Fully prepare nursing and health professional faculty to deliver population health curricula. Nursing education Population-focused nursing is a culture change for all nurses, and particularly nurse educators. Preparing nurses for population-focused interventions is the most critical © 2017 ROBERT WOOD JOHNSON FOUNDATION | ■■ Ensure that nurses and other health professional students are well-prepared to practice in a teambased care environment. Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 5 ■■ Develop programs to educate nurses for key evolving population-focused nursing roles in fields that include care management, chronic disease management, and population data analysis. ■■ Ensure the availability of nursing education that prepares nurses for advanced population health specialty practice. ■■ Collaborate with practice entities and schools of business and/or public health to prepare a pipeline of population-focused nursing leaders. ■■ Integrate population-focused competencies into This work is critical and urgent, and if it is to be successful, we must fully engage the nursing workforce. 3. Foster population-focused nurse leadership. We must: ■■ Promote and support nurses in new populationfocused executive and managerial roles in health systems, public health agencies, and payers as systems shift focus from volume to value; encourage their inclusion on decision-making committees, advisory councils, and boards. ■■ Nurture nurses and nurse leaders who consider individuals and families in the context of their environment—and advocate for individuals, families, and communities accordingly. ■■ Promote and support the development of a pipeline accreditation standards for schools of nursing. ■■ Ensure that licensure examinations (such as NCLEX) assess for population-focused knowledge. ■■ Develop lifelong population-focused learning strategies for all nurses and nursing leaders. ■■ Ensure the nursing student body reflects a diversity of perspectives, as well as the diversity of the patients they will serve. of population-focused nursing leaders with population-focused nurse leadership residencies, lifelong learning, and mentoring strategies. 2. Transform nursing practice. We must: ■■ ■■ ■■ Ensure that all nursing roles and specialties, in all practice settings, include population-focused concepts as an integral component of practice. Foster true collaboration between nursing and other health care professions, as well as with other disciplines, to promote coordination of care, reduce fragmentation of health and social services, and support cross-sector collaboration to promote well-being. 4. Recognize nursing’s unique contribution to population health-related research. We must: ■■ Evaluate the impact of population health nursing initiatives on health outcomes and costs. ■■ Facilitate population health research by ensuring access to adequate funding and interoperable datasets. ■■ Provide nurses in all practice settings with the tools to of populations. promote learning and behavior change and connect patients and families with local resources that promote ■■ ■■ Support and promote access to population-focused nurses for all schools. 5. Foster nurse advocacy and support policy efforts Promote increased data fluency and data-based already in motion. decision-making regarding population needs ■■ and trends. ■■ Promote and support the development of a pipeline of expert nurse health services researchers, informaticists, and population-focused data analysts. health and meet social and emotional needs. ■■ Promote the rapid dissemination of research findings and articulate nursing’s value in improving the health education and research. Promote interprofessional teams that include nurses as leaders and equal partners in improving the efficiency and effectiveness of health care systems and process. © 2017 ROBERT WOOD JOHNSON FOUNDATION Advocate for funding for population-focused nursing | ■■ Support the recommendations laid out in the Institute of Medicine’s 2010 report. In that report, The Future of Nursing: Leading Change, Advancing Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 6 Health, the Institute of Medicine declared: “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.” If we are to achieve true population health, we must also support the ongoing efforts to build those policy changes at the local, state, and national levels. Here’s the catch: These recommendations are not merely boxes we can check. We believe they are the building blocks for the culture change our nation needs—within nursing and health care, within our communities, and across sectors and disciplines—to truly achieve the best possible health and well-being for the U.S. population. If these recommendations are to be realized, it will take more than goodwill and willpower. It requires action. We call upon: ■■ ■■ Accrediting bodies to begin the process of integrating population health concepts and competencies into accreditation standards and licensing examinations. ■■ ■■ ■■ ■■ Health systems to fully integrate meeting community and population health needs into their strategic planning processes and collaborate with health departments and other sectors in developing strategies that impact upstream factors affecting health. If these recommendations are to be realized, it will take more than goodwill and willpower. It requires action. ■■ Other health professionals to develop mechanisms for collaborating with nurses as full partners in promoting the health of populations. ■■ Payers to develop reimbursement strategies for tasks and tools—such as care coordination—that promote the health of populations. This work has never been more crucial, and we urge you to join us. Academic institutions to make population-focused competencies an integral component in both classroom and clinical experiences for all students, and prepare nurses for emerging population-focused roles by training them to monitor trends, advocate for solutions, and collaborate with other sectors to implement those solutions. ■■ ■■ Businesses to bring nurses to the table when considering Acknowledgments This executive summary is based on the white paper of the same name, authored by Judith Lloyd Storfjell, PhD, RN, FAAN, Betty Wehtje Winslow, PhD, RN, and Jasmine S.D. Saunders, MPH, with support from the Robert Wood Johnson Foundation (funding ID 73852). The full paper can be found at www.rwjf.org/en/ the health of employees and communities. our-focus-areas/topics/nurses-and-nursing.html. Researchers to evaluate the impact of population- Our thanks to the authors, as well as this project’s advisory focused nursing initiatives, to ensure access to data, and to disseminate results in ways that reach policymakers and thought leaders. committee (Betty Bekemeier, PhD, RN, FAAN, Beth Ann Swan, PhD, Policymakers to give nurses the tools to practice to RN, FAAN, and Shanita D. Williams, PhD, RN) for their dedication and commitment to the nursing profession, to population health, and the vision of a Culture of Health. the full extent of their education and training in order to achieve population health. References Nurse leaders to take up leadership roles in population Public Health Reports, 129 (1_suppl2), 19–31. health and population management. National Academies of Sciences, Engineering, and Medicine. (2017). Nurses on the front lines to develop improved Communities in action: Pathways to health equity. population-focused understanding and competencies. National Academies of Sciences, Engineering, and Medicine. (2016). Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Assessing progress on the IOM report on the future of nursing. © 2017 ROBERT WOOD JOHNSON FOUNDATION | Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century 7 Hindawi Publishing Corporation BioMed Research International Volume 2016, Article ID 3127543, 5 pages http://dx.doi.org/10.1155/2016/3127543 Review Article Call to Action for Nurses/Nursing Shahirose S. Premji1,2,3,4 and Jennifer Hatfield2,5 1 Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada T2N 1N4 Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6 3 O’Brien Institute for Public Health, Calgary, AB, Canada T2N 4Z6 4 Alberta Children’s Hospital Research Institute, Calgary, AB, Canada T2N 4N1 5 Institute for Gender Research, Calgary, AB, Canada T2N 1N4 2 Correspondence should be addressed to Shahirose S. Premji; premjis@ucalgary.ca Received 28 October 2015; Revised 8 February 2016; Accepted 29 March 2016 Academic Editor: Sten H. Vermund Copyright © 2016 S. S. Premji and J. Hatfield. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The 13 million nurses worldwide constitute most of the global healthcare workforce and are uniquely positioned to engage with others to address disparities in healthcare to achieve the goal of better health for all. A new vision for nurses involves active participation and collaboration with international colleagues across research practice and policy domains. Nursing can embrace new concepts and a new approach—“One World, One Health”—to animate nursing engagement in global health, as it is uniquely positioned to participate in novel ways to improve healthcare for the well-being of the global community. This opinion paper takes a historical and reflective approach to inform and inspire nurses to engage in global health practice, research, and policy to achieve the Sustainable Development Goals. It can be argued that a colonial perspective currently informs scholarship pertaining to nursing global health engagement. The notion of unidirectional relationships where those with resources support training of those less fortunate has dominated the framing of nursing involvement in low- and middle-income countries. This paper suggests moving beyond this conceptualization to a more collaborative and equitable approach that positions nurses as cocreators and brokers of knowledge. We propose two concepts, reverse innovation and two-way learning, to guide global partnerships where nurses are active participants. 1. Background The eight Millennium Development Goals (MDGs), established during the Millennium Summit of the United Nations in 2000, marked a pledge by 189 nations to foster international relations with shared values of freedom, equality, solidarity, tolerance, respect for nature, and shared responsibility [1]. As global citizens determined to accelerate progress towards MDGs, nurse clinicians have been sharing knowledge and partnering with colleagues in low- and middle-income countries to identify effective ways of working within the context of their healthcare systems. The practice-based process and strategies applied to improve individuals’, organizations’, or communities’ ability to address health issues is referred to as capacity building [2, 3]. Historically, this process was characterized by knowledge transfer from “north to south” or from “developed to developing countries” or “colonizer to colonized” and was framed as “transporting” of knowledge to build capacity [4, 5] in different parts of the globe; it is now passé. Recently, global health orientations that seek to address these enduring approaches to north-south collaborations have challenged the unidirectional flow of knowledge and skills [6] and follow more equitable partnership models [2]. We urge the nursing community to embrace a new ideology that is not based on or concerned with distinctions—north and south, low- and middle-income countries and highincome countries, and developing and developed countries— but is rather concerned with One World, One Health. This opinion paper explains the concept One World, One Health and takes a historical and reflective approach that invites consideration of concepts that can inform the way nursing responds to the challenges in global health engagement. 2 We examine terms such as capacity building and explicate how they have been reframed and advanced in the global health and nursing literature including the transformative nature of concepts such as reverse innovation and two-way learning. We conclude by examining implications for nursing, and policy to instill a new perspective—One World, One Health. 2. One World, One Health Beyond the expiry of the MDGs, it is argued that “the health of people in all countries” must be an overarching goal of a post-2015 framework [7]. Emerging trends, for instance, majority (70%) of the world’s poor now reside in middleincome countries [7], and associated challenges necessitate applying post-2015 goals to all countries, with modification of targets and indicators depending on country context [7]. The sentiment of our shared health concerns and coming together of experts and disciplines to address global challenges is implied in the term “One World, One Health.” One World, One Health was coined in 2008 in reference to a consultation document reviewed at the Sixth International Ministerial Conference on Avian and Pandemic Influenza in Egypt [6]. One World, One Health typifies our interconnectedness, between not only humans but nonhumans (i.e., animals) and our ecosystem and emphasizes coequal collaborations and partnerships [6], providing a privileged intersection in which the capacity of healthcare providers, regardless of geographical boundaries, is enhanced for society’s well-being [8]. One World, One Health is a relatively new frame of reference in nursing, despite nurses’ unique position to address disparities in healthcare to attain health for all people around the world. There are 13 million nurses worldwide who are front-line healthcare providers and, by virtue of their roles and responsibilities, have prolonged encounters with patients and their families [9]. Nurse clinicians require an inquiry approach situated within a cultural-competency framework that promotes behaviors, attitudes, and practices to come together in interpersonal and interprofessional relationships that (a) acknowledge and view cultural differences as strength, (b) promote self-reflection to develop an understanding of their own culture, attitudes, and prejudices, (c) avoid assumptions and stereotypes, and (d) facilitate empathy, despite language or communication barriers [10, 11]. Moreover, knowledge, skills, attitudes, and core values of nurses are fluid [5]—borderless. We assert that for the nursing profession to occupy a forceful role in promoting the aspirations of the Sustainable Development Goals we must see ourselves as partners with our international colleagues, cocreating knowledge and sharing ideas and best practices with a view to seeking innovative solutions to shared health challenges. 3. Transformative Nature of Knowledge Transfer, Reverse Innovation, and Two-Way Learning The term capacity building, dominant in the development literature since the 1970s, has a historical trajectory informed BioMed Research International by colonial perspectives and unequal power relationships. Capacity building has been reframed to include notions such as working collaboratively to enhance people’s leadership and commitment (i.e., dynamic capabilities) to effect change in the conditions of their communities through action (e.g., discovering new ways of doing things) or responsiveness to the changing environment [3, 12–14]. Moving beyond the colonial perspective to a more ethical, equitable approach leads to framing this process in terms of the quality of the relationships that are nurtured between nurses. This spirit and approach are best characterized by the concept of knowledge transfer [4]. Knowledge transfer promotes access to new knowledge, generally created through research, to those who will use this knowledge. The use of this knowledge is intended to improve outcomes of health and ensure effective use of resources and time [4, 15]. Knowledge transfer entails a social process in which a knowledge manager or broker seeks out existing evidence or seeks to bring research activities more in line with users of knowledge [4, 15]. Nurses need to participate in new ways within this social process, developing competencies to promote social, economic, and political action that not only exposes the health inequalities (e.g., social determinants of health) [16] but identifies innovative approaches to reform healthcare delivery. The knowledge transfer experience should be transformative to all individuals engaged in the experience: creator of knowledge, broker of knowledge, and user of knowledge. With growing awareness of the transformative nature of international activities, concepts such as reverse innovation and two-way or shared learning have also been advanced in the literature. Reverse innovation is a term that appeared in 2009 and is more prominent in the business literature. It entails applying successful innovative approaches originating from low- and middle-income countries (driven by limited resources) to high-income countries in order to transform healthcare systems and improve health outcomes of patients and communities [17–19]. For example, North Wales implemented a Brazilian family health strategy—universal primary care services—in which primary care teams comprising a doctor, nurse, nurse auxiliary, and four community health workers delivered primary care services to households within their defined geographic area, whether or not the household express a need for service [20]. A number of barriers, however, influence reverse innovation, including weak flow infrastructure, narrow-mindedness, and early failures [17]. Overcoming these barriers is important to realize that the goal of reverse innovation is “to contribute to the countless health challenges faced by populations across the world” [17, p. 2]. The 13 million nurses worldwide can promote a “global innovation flow” that is bidirectional, sharing knowledge, skills, ideas, and lessons learned around the world in order to cocreate clinical practice solutions for the world [17, 21]. Moreover, this global innovation flow should be linked to the Sustainable Development Goals (e.g., “ensure healthy lives and promote well-being for all at all ages”) in a way that seeks to achieve economic, social, and environmental development with hopes of eliminating all forms of poverty [17, 22]. As such, nurses need to embrace new ways of doing, a paradigm shift, which entails examining problems across situations or BioMed Research International 3 Table 1: Key recommendations for nursing engagement in global health. Stakeholder group Nurses Professional nursing education programs Interprofessional education programs Nurse clinicians Nursing community Recommendation Need to participate in the conversation at every level (e.g., academic, association, and policy) and develop emotional intelligence Help nurses develop competencies and attributes for engagement in global health reform Promote networking, collaboration, nonhierarchical relationships, and common goals Need inquiry approach situated within a cultural-competency framework Embrace One World, One Health contexts, being inclusive of other disciplines to explore the complex nature of the problem, and finding alternate and creative solutions. At the forefront of these solutions should be the principles of dignity, prosperity, justice, partnership, planet, and people [7]. Similarly, two-way learning is synonymous with reverse capacity development, which refers to the altered perception, particularly awareness and understanding, of these perspectives or worldviews that can be “translated” into action that can potentially inform practice “at home” [14]. Only one article in the policing literature precisely referred to the concept of reverse capacity development [14]. The authors reflected on Australian police officers’ experiences related to peace keeping and capacity building in Solomon Islands, Timor-Lester, and Papua New Guinea. Harris and Goldsmith [14] refer to a “positive effect” of these reverse capacity building experiences, such as enhanced repertoire of skills to improve structures or processes in their workplace, that go beyond enhancing one’s own clinical and culturalcompetency skills. Cross-cultural competencies are one strategy to improve patient outcomes and eliminate racial and ethnic disparities in health outcomes [10]. Health inequities, however, are also rooted in social determinants of health (e.g., social status, income, gender, disability, or sexual orientation) [23]. Nursing involvement in the global innovation flow offers an opportunity to support learning in utilizing the social determinants of health framework “at home” to increase access to not only quality care but health resources thereby reducing health inequities [23, 24]. Indirectly, it increases nursing workforce diversity, which has been identified as an important strategy to overcome health inequities [23, 24]. Nursing engagement in the “global innovation flow” is an innovative strategy to reduce inequality within countries—nursing’s contribution to moving towards Sustainable Development Goal (e.g., Goal 10 “reducing inequality within and among countries”) [1]. To ensure an effective healthcare system that is accessible, safe, effective, and affordable around the world, nurses also need to change the conversion to influence policy (health and social) [25]. 4. Nursing: Engagement in Changing Conversation Nurses have the potential and often the interest to participate in addressing many of the global health issues (e.g., noncommunicable disease) [9] through engagement in areas of healthcare reform that are common across all countries, despite contextual differences [26, 27]. They are uniquely positioned to facilitate shared learning globally and engage in reverse innovation and reverse capacity development (i.e., two-way learning). Reports and studies [9, 26–28] suggest that nurses are viewed as trusted professionals who have the ability to influence elements of healthcare reform. Though there is an appreciation that nurses will need to increase their visibility in shaping international practice and policy decisions (e.g., international agencies, national capitals) [9, 26– 28]. The International Council of Nurses realizes that nurses will need to better understand the global health discourse and shape and reshape the conversations at multiple levels (i.e., intrapersonal, interpersonal, organizational, and sociocultural) to inform world views and promote behavior change, that is, involvement in healthcare reform that will lead to health for all [27]. The Global Advisory Panel for the Future of Nursing convened by Sigma Theta Tau International has created a platform for these conversations to increase nurses’ contribution to global health [29]. Reverse innovation and two-way learning create an openness to “change the conversation” [30], that is, engage in discourse to promote change in thinking and behavior (i.e., taking action in global healthcare reform). Reverse innovation and two-way learning can promote respect for intellectual partnerships and shared exchange of knowledge, ideas, skills, and innovation across borders [19]. It does not, however, dispel the power dynamics or the view of them and the “other.” Moreover, reverse innovation and capacity development although helpful concepts are not sufficient and must be complemented by an understanding that embodies the complex interrelationship between community engagement and core values of social responsibility, justice, and equity. 5. Implications for Nursing and Health Policy Access to high-quality and high-value care should be a fundamental right of every patient, regardless of the country in which they are receiving healthcare services. The post2015 United Nations Sustainable Development Goals aspire to this agenda in ways that differ from the “donor-recipient” paradigm of the MDG as it empowers every individual to action [7, 31]. Participation of nurses, a key principle of the Sustainable Development Goals, at every level (see Table 1) will be imperative to reform healthcare to move towards this agenda (i.e., improving access and quality while making healthcare affordable) [32]. 4 Nursing academic and professional institutions are integral to creating an enabling environment for nurses to develop the skills and competencies to participate in addressing inequities in health and healthcare delivery. Professional nursing education programs must help nurses develop competencies (e.g., political leadership, team work) and attributes (e.g., influence, professional credibility) that are fundamental for nursing engagement in global health and health reform [32–34]. To improve health system performance, leadership, critical reasoning, and data management skills are required to generate and use data to inform decisions regarding clinical, research, and education practice and policy [25, 33]. Nurses are apt at adopting and implementing policy but appear to be peripheral in informing and shaping policy [35]. Interprofessional education to promote networking, collaboration, nonhierarchical relationships, and common goals will resolve issues related to professional silos and exclusion of nurses at the policy table [32, 33]. Emotional intelligence (i.e., selfawareness and social astuteness) will enable nurses to manage social and cultural factors that impede their involvement in promoting changes in practice, education, and policy [32]. Professional institutions maintain the responsibility of (a) ensuring nursing presence during policy decision-making, (b) preserving a united front, and (c) guiding nurses to remain proactive in lobbying government and stakeholder to address social determinants of health, which influence health, and access to healthcare [32]. Nurses will need to hold governments, nongovernmental organizations, private sectors, and academic and professional institutions, among others, accountable to the commitments made in delivering priorities in the Post-2015 Development Agenda [36]. 6. Conclusion This paper intends to begin conversation among nurses about their engagement in global health and identify actions to participate in health reform required to promote health for all. Grounding nursing conversation in the concepts articulated above will guide change [30], in that it will enable nurses to be accountable to both patient care and healthcare leadership [27]. In so doing, nurses can influence organizational and political context of care, cocreate global solution for care through “global innovation flow,” and emphasize primary care to promote well-being of populations [27]. 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[36] United Nations Development Groups, Developing the Post-2015 Development Agenda: Opportunities at the National and Local Levels, United Nations Development Groups, New York, NY, USA, 2014, https://docs.google.com/gview?url=http://sustainabledevelopment.un.org/content/documents/1909UNDP-MDGDelivering-Post-2015-Report-2014.pdf&embedded=true. 5 MEDIATORS of INFLAMMATION The Scientific World Journal Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Gastroenterology Research and Practice Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Journal of Hindawi Publishing Corporation http://www.hindawi.com Diabetes Research Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 International Journal of Journal of Endocrinology Immunology Research Hindawi Publishing Corporation http://www.hindawi.com Disease Markers Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed Research International PPAR Research Hindawi Publishing Corporation http://www.hindawi.com Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Volume 2014 Journal of Obesity Journal of Ophthalmology Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Evidence-Based Complementary and Alternative Medicine Stem Cells International Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Journal of Oncology Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Mathematical Methods in Medicine Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 AIDS Behavioural Neurology Hindawi Publishing Corporation http://www.hindawi.com Research and Treatment Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Oxidative Medicine and Cellular Longevity Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Copyright of BioMed Research International is the property of Hindawi Publishing Corporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Nies, M. A., & McEwen, M. (2019). Community/Public health nursing: Promoting the health of populations (7th ed.). St. Louis, MO: Saunders/Elsevier. • Chapter 15: Health in the Global Community, pp. 275-278, 281-284 Required Article Robert Wood Johnson Foundation. (2017). Catalysts for change: Harnessing the power of nurses to build population health in the 21st century (executive summary). Retrieved from https://www.rwjf.org/content/dam/farm/reports/reports/2017/rwjf440286 Optional Premji, S. S., & Hatfield, J. (2016). Call to action for nurses/nursing. Biomed Research International, 2016, 3127543. doi:10.1155/2016/3127543. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=mdc&AN=27144160&site=eds-live&scope=site u Week 8: Future Directions (graded) This week's graded topics relate to the following Course Outcome (CO). • C09: Examine future trends in community health nursing, including the impact of information systems and evidence-based practice. (POS) Review this week's lesson and assigned reading on the nurses' role in population health, and reflect on what you have learned in this course. Address the following questions. • What future concerns are likely to impact public health? • How do you see global health concerns impacting your community? • Identify one way that you can implement population health in your community or workplace. Please share specific examples.
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