Health Emergency and Disaster Nursing (2014) 1, 29–33

SPECIAL CONTRIBUTION: HIGHLIGHTS FROM THE 2ND INTERNATIONAL SEMINAR

OF THE DISASTER NURSING GLOBAL LEADER DEGREE PROGRAM

Leading nursing globally

Judith A OULTON, DSc (hon), MEd, RN
Oulton & Associates, Nova Scotia, Canada

Table 1 Definitions of global versus international health

INTRODUCTION
Global Health International Health
Today’s reality is global interdependence—of cultures,
Geography Health issues that Focus on issues outside
economies and technologies. Nations are no longer acting transcend national of one’s own country
independently and are increasingly looking at ways to boundaries
work together—ASEAN is a good example in the Asia- Cooperation Global Bi-national
Pacific region. Population Prevention and clinical Prevention and clinical
Leadership in this context, especially global leadership care care
in health, requires certain skills and competencies, such Access Health equity among Help other nations
as vision, strategic skills, self knowledge, strong inter- nations
personal skills, credibility, ability to take risks and the Disciplines Highly interdisciplinary Embraces a few
ability to work with and influence others. But it also and multidisciplinary disciplines
requires the leader to be a global citizen.

What is global citizenship? and concerns of individual nations. It may be influenced

A global citizen is anyone who works to make the world
a better place. That is, who is aware of the wider world,
who respects and values diversity, and is outraged by
social injustice from the local to the global level. To be a
leader, especially a global leader, requires an under-
standing of all of the things we do within a global
context, within a world that’s bigger than our own. A
global citizen has an understanding of how the world
works, economically, politically, socially, culturally,
technologically and environmentally, and is willing to
act to make the world a more sustainable place, while
taking responsibility for their actions (Oxfam, 2006).
Global health and the context for leadership
Global health is the health of populations—the problems,
issues, and concerns that transcend national boundaries
Correspondence: Judith A. Oulton, Oulton, Oulton & Associates
Tatamagouche, NS, Canada. Email: jaoulton@gmail.com
This article includes highlights from a lecture that was given at the
2nd International Seminar of the Disaster Nursing Global Leader
Degree Program held at Awaji Yumebutai International Conference
Center, November 24, 2013.
by circumstances or experiences in other countries and is
best addressed by cooperative actions and solutions. This
is in contrast to ‘international health’, which was often
simply the wealthy helping the poor (Table 1). Now it is
about different relationships: ‘south to south’ (south
meaning developing nations), ‘north to north’, north to
south’. People are searching for more equity and for
interdisciplinary ways of cooperating (Koplan et al, 2009).
The global health context
Leadership does not occur in a vacuum, so it is essential
to understand the context within which decisions are
made, policy is set, and advocacy and action take place.
This includes understanding the players and the rules. For
now, health is part of the foreign policy agenda—what
does this mean?
The health of populations is no longer determined
solely by domestic conditions that the nation state can
control. Protecting and enhancing health requires engage-
ment of those outside the health sector. Health must be
considered alongside the most pressing issues on national
and global agendas (e.g., security, the economy, human
rights).

Copyright © 2014 Disaster Nursing Global Leader Degree Program

J. A Oulton
In 1996, global health came onto the agenda of the G8
and we began to see a relationship between health and
foreign policy; that is, health and wealth are related.
However, it has also become obvious that, to effect
change, we as nurses need to act in concert with other
organizations and create lobby groups, such as the Health
Action Lobby in Canada.
Increasingly, aid is tied to trade, and the health
workforce is viewed as a ‘commodity’. Developed
nations are driving their healthcare systems on an
economic basis only and not investing enough in nurses,
so staff are recruited from developing nations, where the
healthcare systems are already stressed. But worldwide,
healthcare systems are stressed and stretched from
serious, chronic underfunding and investment, and the
underdevelopment of community/home care, resulting in
rising costs to both the system and users. Other stressors
on healthcare systems are:
: Climate change (floods, drought, food, water)
: Unemployment (mental health, violence, unrest)
: Poverty, which mainly affects women and leaves1.2.
billion people living in extreme poverty; i.e., on
US$1.25 a day (World Bank, 2013)
: Population growth with a rise to 9.5 billion
predicted by 2050
: Migration: in 2013 there were 232 million interna-
tional migrants, nearly half of them women (UN,
2013a).
: Growing gap between rich and poor: 20% of the
world’s population have 75% of the income
: Aging populations in the West, declining life spans
in Africa
: Clean water/sanitation: nearly 1 billion people have
no access to clean water and 2.5 billion people live
without even basic sanitation (UN, 2013b)
: Access to health care: 1 billion people lack access to
services (UN, 2013b).
In addition, there is the as yet unquantifiable effect of
communications (e-commerce/social networks/privacy/
cybercrime and bullying/identity theft).
Natural disasters
In 2012, there were fewer disasters than on average (394
vs. 400; Fig. 1), but five countries bore the brunt during
the past decade: China, the USA, the Philippines, India,
and Indonesia (Table 2) (Prevention Web, 2013).
Not all challenges to the global health system are
natural disasters. Others are:
: Obesity and malnutrition
: Noncommunicable diseases, which are the 2nd most
severe threat to the global economy, but are an area
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Health Emergency and Disaster Nursing (2014) 1, 29–33
where nurses can have a significant effect both from
a prevention and a treatment perspective
: New and re-emerging diseases
- 34 million people are living with HIV or AIDS
(WHO, 2013)
- 8.7 million new cases of tuberculosis (13%
co-infected with HIV) and 1.4 million deaths
(WHO, 2012).
: Health security—counterfeits and corruption
: Patient acuity
: Underinvestment in technology
: Underutilization of nurses
: Unmet health targets
: Innovation deficits, especially in pharmaceuticals
: Diverse lobby interests
: Priorities aligned with election cycles
: Consumer expectations
: Maternal and child health
: Human Resources crisis: in 2006, 57 countries
experienced acute shortages of health care personnel
: Weak management
: New power groups and ways of working.
In 1990, health policy was mainly dictated by the UN
and national governments, but now, multiple partners—
governments and nongovernmental organizations—come
together to address major global problems such as HIV,
TB, and malaria. Today we see many other players
including Global Health Initiatives (GHI). These are
alliances of public and private organizations which have
a major impact on decision-making. As a result global
health policy making and leadership are marked by
competition and confusion, with increasing skepticism
about aid.
Global Nursing Leadership
Global leadership requires a bridging of the divides of
race, class, gender, culture and country, which happens to
be part of the nursing ethic. Beechler and Javidan define
it in terms of influence:
“Of influencing individuals, groups, and organizations
that represent diversity again, cultural, political and
institutional systems, but always toward a goal.”
(Beechler and Javidan, 2007, p. 140)
Global leaders are different from other leaders (e.g.,
corporations) because they share three common charac-
teristics: they have a global mindset, they are driven to
create new solutions and to seize new opportunities, and
they are global citizensGlobal leaders have a natural
curiosity about the world; they are interested in people
different from themselves and they recognize the impact
of their actions on others. They are highly flexible and
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Health Emergency and Disaster Nursing (2014) 1, 29–33 Leading Nursing Globally

Figure 1 Natural disaster reported 1975–2011.

Source: EM DAT Natural Disaster Trends. http://www.emdat.be/natural-disasters-trends

Table 2 Natural disasters in 2012 by country

Country Disasters
different cultures and different backgrounds. Cultural
competence is very important at both the national and
China 23
international levels. It is a combination of emotional and
Philippines 20
cultural intelligence.
United States 17
Indonesia 12 Emotional intelligence þ Cultural intelligence
Afghanistan 11 ¼ Cultural competence
India 10
Emotional intelligence is the ability to perceive, control
Russia 8
and evaluate emotions Cultural intelligence is recog-
Japan 6
nizing and understanding the beliefs, values, attitudes,
Bangladesh 5
and behaviors of a group of people and the ability to
Pakistan 5
apply that knowledge toward achieving specific goals
Source: http://www.preventionweb.net/files/31685_factsheet2012.pdf (Rosenthal, 2012).

comfortable dealing with uncertainty. They play a role in Learning leadership

transforming societies and are culturally competent
(Unruh, 2012).
Cultural competence
One of the ways of describing “cultural competence” is
that it is saying the right thing to the right person at the
right time, with the right intensity (Empowerful Changes,
2013). It’s the ability to interact effectively with people of
Leadership is done through people, as something to be
shared. It is about empowering others. We are not leading
if we are not empowering. Leadership is hard work but it
can be learned. Many sets of leadership competencies
have been developed. For example, the National Student
Nurses Association in the USA has set out 27 different
traits of nurse leaders while the ICN describes 16.
Essentially a global leader is an individual who is:

Copyright © 2014 Disaster Nursing Global Leader Degree Program 31

J. A Oulton
: Strategic: knows the system, understands the whole
system
: Culturally competent
: Visionary
: Able to work alone as well as collaboratively.
Such a person is also a critical thinker—one who is
disciplined and thinks rationally with an open mind and
informed by evidence. He or she has good interpersonal
skills, is caring and is both mentored and mentoring.
Global leaders are accountable risk takers and inspiring
change agents. They are also results oriented.
Good leadership depends in part on the leader, the
situation and the followers. Good leadership traits and
practices need to be shared across professions, industries,
and countries. Unfortunately, women leaders continue to
endure discrimination, so ongoing global leadership
development, research and advocacy are essential.
Global nursing leadership competency framework
An example of a competency framework is the Global
Nursing Leadership Competency Framework developed
by a consortium of 4 universities—two in America and
two in Europe—as part of the Atlantis Project. It
comprises 7 areas of competency and serves as a basis
for creating individual frameworks from an analysis of
the strengths and weaknesses as they apply to specific
situations. The competencies are:
: Moral & ethical agency
: Interpersonal qualities
: Strategic & systems skills
: Knowledge management & decision making skills
: Patient safety
: Workforce development
: Quality improvement
Moral and ethical agency is leadership underpinned by
moral/ethical agency that comprise key metrics associ-
ated with accountability, responsibility, authority, hon-
esty, justice, and fairness, valuing and upholding the
caring nature of professional practice, advocacy for, and
valuing, the needs and concerns of patients/families/
communities, and accurate and honest self appraisal.
The interpersonal qualities required by a global
nursing leader are inspirational, motivational, and change
leadership; an ability to create conditions in which others
can lead and be empowered to act; emotional intelligence
and political astuteness; collaboration with other partners
and stakeholders; ability to prevent, reduce, and manage
conflict; and the ability to build strategic alliances and
networks within organizations, among national and
international, public and private institutions, and across
relevant professional and sectors.
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Health Emergency and Disaster Nursing (2014) 1, 29–33
Strategic and systems skills comprise having a vision
and being able to articulate it so that it is accessible to all;
being able to operate in resource-limited political
systems; responding effectively to public policy and
having the ability to explain policy to both the nursing
and non-nursing communities; and strategic planning and
tactical abilities.
A global nursing leader deeply knows and appreciates
global health and health workforce challenges, so is able
to anticipate, recognize, and manage the health needs of
diverse and different populations. As a leader, coaching,
mentoring and teaching are used to facilitate learning by
others, and to foster the creation, collection, analysis,
interpretation, management, dissemination and use of
knowledge/data, making creative use of new technolo-
gies. Expert knowledge ensures skilled questioning and
evidence-based decision making that is effectively
communicated.
Patient safety is paramount to the efficacy of a
healthcare system. A global nursing leader ensures staff
are clinically competent and trained in their role in patient
safety, as well as supporting organization-wide patient
safety programs and designing safe clinical systems,
processes, policies, and procedures. Clinical activities are
monitored to identify both expected and unexpected risks
and a non-punitive reporting environment and a reward
system for reporting unsafe practices are instituted.
Ongoing workforce development involves participation
in workforce planning and employment decisions,
corrective discipline to mitigate workplace behavior
problems and opportunities for employees to be involved
in decision-making. Aspiring clinicians and leaders are
provide with mentorship and career counseling so they
may develop required skill sets (succession planning) and
the leader continually identifies future skill sets needed to
remain competitive.
Finally, a global nursing leader works to ensure quality
improvement through customer satisfaction principles and
tools, data collection, measurement and analysis tools and
techniques, medical staff peer review and disciplinary
processes, national quality initiatives (including patient
safety) and quality planning and management (Atlantis
Project, 2013).
Another application of nursing competencies can be
found in the ICN/WHO Disaster Nursing Competency
Framework (Fig. 2). This was created by ICN and the
WHO Western Pacific Regional Office. (ICN, 2009)
Future challenges: overcoming weaknesses
When we are leading, we are trying to improve things, we
are trying to move the profession forward, we are trying
Copyright © 2014 Disaster Nursing Global Leader Degree Program
Health Emergency and Disaster Nursing (2014) 1, 29–33
Figure 2 Disaster Nursing Competency Framework.
Source: ICN Disaster Nursing Competency Framework 2009.
to move some aspect of healthcare forward or a system
forward and so we have to understand our weaknesses.
There are 6 main areas where nursing leadership can be
improved.
1. Policy: how to develop, use, influence, and change it
(i.e., how to get to the table!)
2. Presence: how to make ourselves memorable
through body language, dress, speech and content.
3. Building alliances.
4. Being recognized for our expertise: we need to be
able to develop, package and disseminate the
evidence.
5. Appreciating cultural diversity; leading a culturally
and generationally diverse workforce
6. Sustaining relevant roles, creating new roles and
opportunities.
CONCLUSION
The characteristics of a global nurse leader can be
summarized as follows. It is a leader who:
: Sees the big picture
: Has a global mindset
: Has a vision for nursing and health
: Knows how to network, partner, build strategic
alliances
: Has strong advocacy, policy and people skills
: Has presence, perseverance, patience
: Possesses integrity, a thick skin and sense of humor
: Is prepared to support and mentor others
: Is prepared to take weighed risks and speak out
: Is strategic, realistic, and respectful of others
: Knows and utilizes the strengths of technology.
Traditionally, we have seen ourselves as “patient
advocates” but we need to have a bigger, global vision
Copyright © 2014 Disaster Nursing Global Leader Degree Program
Leading Nursing Globally
of what we believe nursing is and what we believe health
is. Now is the time to act.
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