2. Globalization and advances in information and communication technologies Abbott and Coenen
lenges, human rights, and consideration of local and Health Report. The 2007 report, Towards a Safer
cultural context. Nursing leadership, creativity, advo- Future, continues to emphasize the importance of ICT
cacy, and experience are needed to provide stewardship in relation to health: “Today, the public health security
for health ICT growth and application in the face of a of all countries depends on the capacity of each to act
complex, interconnected, and increasingly globalized effectively and contribute to the security of all. The
world. world is rapidly changing and nothing today moves
faster than information. This makes the sharing of
GLOBALIZATION, HEALTH, AND ICT essential health information one of the most feasible
The term globalization describes the increased mobility routes to global public health security.”13
of goods, services, labor, technology and capital A widely held view, both within the WHO and
throughout the world.3 Most would agree that global- elsewhere, is that ICT in health enables rapid and global
ization has a much broader impact than just an eco- access to new therapies, techniques, and knowledge
nomic impact; its impact is also political, technological, resources, with the potential to forever change the
and cultural—strongly influenced by information and health of nations. The role of ICT in the severe acute res-
communication technology.4 Globalization, whether we piratory syndrome (SARS) crisis of 2003 is a prime
recognize it or not, touches all parts of our lives— both example. During the first cases of SARS in China in
personal and professional; it changes the way our 2003, the WHO initiated a digital virtual environment
nations and communities work. consisting of 11 laboratories in 9 countries connected
Globalization and health have been discussed by via ICT. Using e-mail and a secure website, these
many experts who have noted influences on wellness collaborators shared outcomes, post-mortem tissue
that are both promising and potentially devastating.5– 8 analysis, electron-microscope pictures of viruses, ge-
Globalization in a positive sense has resulted in trade netic sequences and other related materials in real-time
expansion, with an increase in living standards and to collaboratively identify and intervene in a markedly
improved social and economic status, particularly for dangerous public health risk. Other examples exist that
women. Sachs, a global economist known for his work point to the impact that ICT has had on global health
in developing nations, repeatedly makes the important efforts, such as the Academic Model for the Prevention
point that the health of a nation is directly tied to the and Treatment of HIV/AIDS Medical Record System
wealth of a nation.9 Wealth is enhanced by heightened for Africa (AMPATH–MRS), the Partners in Health
competition, comparative advantage, economies of Electronic Medical Record in Peru, the HIV Electronic
scale, and access to a greater range of products and Medical Record System in Haiti.14
services in globalized markets, all enabled by access to Efforts such as those mentioned above and scores of
knowledge. Asymmetries of information have been others, too extensive to enumerate, have made signifi-
reduced in an era of globalized knowledge exchange, cant impacts in the health of large regions of the globe.
contributing to a reduction of isolation, an increase in However, it is important to realize that ICT can never
life spans, and improved health.10 be viewed as a panacea or singular solution to the very
Conversely, advances in globalization are blamed for multifaceted problem of worldwide health. The contrib-
some health problems, including an increased adoption utors to global health are very complex, rooted in
of unhealthy Western habits and lifestyle, resulting in societal structures, political agendas, and the presence
increases in obesity and the increased prevalence of of marked global poverty. Solving one issue without
chronic disease. Open borders and open access, hall- addressing the others will result in the same outcome
marks of globalization, have also resulted in faster experienced by Sisyphus; the summit is reached, only to
transmission of infectious agents, the so-called “micro- have the boulder roll back down to the base. In
bial hitchhikers.” Many societies find globalization and particular, efforts to improve health without addressing
open information exchange threatening to current ide- the pressing problem of poverty will be unsustainable.
ologies and social structure. Others view the concept of Poverty reduction as a precursor to improvements in
globalization, particularly via ICT, as a new age form of health is reflected in the 2007 World Health Report:
electronic colonialism, where existent cultures are bull- “Hungry children easily acquire diseases, and easily die
dozed and assimilated.11 from the diseases they do acquire. Dwellings without
How does ICT fit in this discussion of health and sanitation provide fertile environments for transmission
globalization? The World Health Organization (WHO) of intestinal infections. Hopeless life circumstances
believes that ICT holds great promise for improving thrust young girls into prostitution with its attendant
health and health care around the world and is critical to risks of violence and sexually transmitted diseases.”13
achievement of the Millennium Development Goals.12 Productivity drops when the human capacity that fuels
The core beliefs that ICT will contribute significantly to economic growth declines due to morbidity and mor-
the reduction of poverty, improve the delivery of tality, and the high financial burden of disease in
education and health care, and make government ser- developing nations precludes economic advancement
vices more accessible are prominent in the 2006 World and health improvement efforts.15
S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 239
3. Globalization and advances in information and communication technologies Abbott and Coenen
The paradox is, of course, that declining health of ICT in health care in more industrialized nations
impedes the climb out of poverty while poverty con- such as the United States, the United Kingdom, and
tributes to declining health. Could further enhancement Australia continues to grow, albeit at modest rates,
of global ICT for health care be a potential strategy for reaching a tipping point. As discussed earlier, there are
escaping this paradox? What are the realities and many successful implementations of ICT-enabled
reasoned approaches for application of ICT to impact health communications and electronic health record
the health of nations? What roles and opportunities for systems in developing nations such as Kenya,
nursing leadership exist in regards to ICT regardless of Malawi, Peru, Rwanda, Haiti, Tanzania, and others as
geographic location? part of efforts like the Open Medical Record System
(Open MRS).14 Creative thinkers are already capitaliz-
GLOBAL ICT FOR HEALTH: REALITIES ing upon widely available forms of ICT (such as
AND WORK IN PROGRESS cellular telephony) to affect health.
In many instances, the idealism of ICT potential and the Muhammad Yunus, whose work in microloans in
reality of ICT application are discordant. Therefore, Bangladesh was honored in 2006 with a Nobel Prize, is
while there is acknowledged need for ICT in the an excellent example of how the creative introduction
coordination and monitoring of treatment, surveillance, of ICT via simple cellular telephony into a low resource
response, education, and communication in health care, area could institute profound change. Dr. Yunus and the
in reality there are significant barriers in the application telecom company he founded20 were convinced that
of ICT that slow progress. These barriers are in no way economic and social development should begin at the
restricted to the developing world. The United States grassroots level. Yunus believed that attacking poverty
and other more technologically advanced nations have is essential to peace, that private enterprise is essential
their own sets of challenges. Cost, misalignment of to reversing poverty, and that peace and poverty reduc-
incentives, resistance, an unskilled workforce, concerns tion are essential to health.21 Yunus’ microloans en-
about impact on productivity, lack of standards and abled destitute village women in Bangladesh to pur-
interoperability, and other issues contribute to a poor chase cell phones and become Village Phone Operators
level of healthcare ICT adoption in the industrialized (VPOs). The women then sold telecommunication ser-
world.16 The digital divide has resulted in large seg- vices on a per-call basis to neighbors. This has resulted
ments of low income and/or other underserved groups in considerable wealth generation not only for the
being excluded from online health resources.16 Eco- VPOs, but for the farmers and village dwellers who are
nomic hardships and difficult tradeoff decisions in the using this technology to access the outside world and
US healthcare industry have further inhibited healthcare improve their businesses.20 The VPOs provide afford-
information technology growth.17 able rates to their neighbors, preventing residents from
In developing nations, the problem of ICT uptake is making (historically, in many locales) a 6-hour round-
even further compounded. A lack of local expertise and trip to reach a telephone, which consequently impacted
decades of well-meaning but non-sustainable ICT community productivity and increased community
projects in the developing world have left a legacy of wealth. The VPOs earned enough to invest in their
skepticism in their wake. Systems built for Westernized children’s health, nutrition, and education, and fund
health care delivery often do not match the local other business growth. The improvement in community
context, resulting in a misalignment between need and wealth translated into improved community health, as
technology. Poverty and illiteracy in developing nations funds became available for the drilling of wells for
stand as major barriers to the adoption and sustainabil- clean water and preventive health services. The VPO
ity of information technologies, and many believe it is model has been rolled out through much of Africa and
difficult to make the case for ICT when basic needs for is viewed by governments and development agencies
survival are barely being met.18 The “e– health para- such as the United Nations, USAID (United States
dox,” a term coined by Liaw and Humphries, refers to Agency for International Development), and the World
this seeming conundrum; populations that may have the Bank as a sustainable development tool. Wealth has
most to gain from ICT in health are those who are impacted health, which is a welcomed consequence.
thwarted in their use due to barriers of untrained The swell of cellular telephony has also expanded
personnel, poor infrastructure, and lack of resources.19 directly into the realm of health and health care in other
Issues such as these have fueled technological apartheid ways, particularly as the use of short messaging service
and continue to subvert the delivery of knowledge to (SMS)— otherwise known as text messaging— has
areas of the globe that most desperately need it. grown in popularity as a form of communication. For
Are the current realities in global health ICT all bad? example, “Sexinfo,” a SMS-based health information
Actually, they are not. From adversity often come new service offered by the San Francisco Department of
ideas. New opportunities and avenues for access and Public Health, is being used to educate and assist teens
innovation in the use of ICT are emerging to improve who have questions about sexual health.22 The Centers
health and facilitate the delivery of health care. The use for Disease Control and Stanford University teamed up
240 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
4. Globalization and advances in information and communication technologies Abbott and Coenen
recently to hold a conference called “Texting for Education and Collaborative Learning
Health” where public health initiatives using SMS were Information and communication technology has in-
presented.23 South Africa is using SMS features in fluenced both traditional and non-traditional approaches
cellular telephony to issue reminders to patients and to education and the development of the next generation
caregivers in hopes of increasing adherence with anti- of nursing leaders. Distance education programs in
retroviral therapies. Phones for Health, a Presidents nursing are exploding across the globe and are enabling
Emergency Fund for Aids Relief (PEPFAR)-funded outreach to geographically distributed individuals. The
project, is also using mobile telephony to combat use of ICT to elevate the educational level of nurses
HIV/AIDS in Sub-Saharan Africa.24 This project al- worldwide is a crucial area for expansion, investigation,
lows nurses and other health workers in the field to use and application, particularly as the nursing workforce
a standard mobile phone handset to enter health data. crisis grows, global health declines, and medically
The system uses cellular methods to relay the data to a underserved areas increase.
central database, where it is immediately available to Considering the issues of nurse migration and nurs-
health authorities via the internet. The system also ing brain drain,12 ICT may be an effective strategy to
supports the delivery of health alerts and reminder reduce some of the contributors to out-migration, such
messages to caregivers.24 as isolation and lack of educational opportunity. Meth-
Each of these examples illustrates a movement using ods such as ICT for education to train rural providers in
ICT to enhance information distribution that empowers place can prove to be more cost effective and less
financial growth, health, and social betterment, in both disruptive to families, communities, and nations than
developed and developing nations. The success of such out-migration to more developed countries.25 More-
initiatives opens the door to innovative global ICT over, collaborative learning opportunities are enabled
methods for enhancing education, public health moni- via ICT, where geography becomes irrelevant. The
toring and surveillance, and delivery and management opportunity for students and faculty to interact, share
of health. It also speaks to opportunities for those who knowledge, discuss global health issues, and share
stand at the frontline of global health efforts to consider cultural perspectives across nations affords students and
new ways to reach and teach. faculty exposure to the world beyond them. Such
experiences can increase cultural competency, raising
awareness of and appreciation for global health issues.
THE OPPORTUNITY INTERSECTION Although the promise in using ICT to reach and
FOR ICT IN NURSING teach is great, there is also a need for caution and
Where is the opportunity for nurses to make a differ- careful consideration. As discussed earlier, the notion
ence in regards to health care in a digital world? When of Western solutions as being universally appropriate is
one considers that 50 –90% of all health care provided erroneous. Understanding how information and knowl-
“in country” is delivered by non-physician providers12 edge is relevant to context and culture is essential, so as
and the accessibility of ICT is accelerating, the oppor- not to impose approaches or solutions that do not fit the
tunities for nurses and midwives are vast. As those who learners’ reality. Approaches that seem appropriate for
most often stand at the interface of the patient and the delivery in one environment may be offensive or totally
healthcare system, there is a growing awareness of the unrealistic and unvalued in another, highlighting the
need for nursing leadership, nursing innovation, and need for local involvement, flexibility, and creativity.
the nursing voice in global health ICT. This is particularly apropos when considering the vast
differences between industrialized and non-industrialized
nations or in nations that are in conflict.
Nursing, ICT and Global Health Nursing has taken the lead in several successful
A number of areas of development demonstrate how international collaborations involving education and
nursing has already embraced ICT to harness its global collaborative learning. Two examples of the use of distri-
potential and should illustrate potential areas for growth buted e-learning in industrialized and non-industrialized
and further investigation. Examples of success stories nations are provided as a stimulus for further study and
from a global perspective include: (1) advances in application:
education and collaborative learning, (2) telenursing/
telehealth, (3) movement toward electronic health International Virtual Nursing School (IVINURS)26 is an
records (EHRs), (4) nursing knowledge management interesting example of a global nursing education
and knowledge generation. In consideration of the initiative facilitated by ICT in the industrialized
challenges and opportunities cited earlier, these exam- world. The IVINURS is working with the Interna-
ples may stimulate critical and creative thinking about tional Council for Nursing (ICN) on the use of the
how these established examples and methods may be International Classification for Nursing Practice
extended and applied by the nursing community to (ICNP®) to catalogue learning resources in a digital
address the e-health paradox. repository that can be accessed by a number of
S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 241
5. Globalization and advances in information and communication technologies Abbott and Coenen
international partners. At the present time, the IT-enabled methods in rapidly digitizing developing
IVINURS digital repository is shared by multiple nations—further illustrating an area of opportunity for
global associates, including universities in Thailand, expansion. Considering the global workforce crises in
Tasmania, Ireland, Denmark, the United States, and nursing, these models are worth further consideration.
the United Kingdom. The IVINURS does not award
degrees and is built on the principles of international
collaboration and the global sharing of knowledge Telenursing/Telehealth
and professional expertise. A central activity of Telenursing is the use of technology to deliver
IVINURS is the building of its digital repository nursing care and conduct nursing practice.29 Telenurs-
and the development of associated e-learning sup- ing is often used interchangeably with the term tele-
port products, with the aim of providing quality, medicine or telehealth with the distinction implied that
learning resources that can be shared on a global a nurse provides telenursing and a physician provides
level by its partners, and used to enhance both telemedicine. The use of the term telehealth may be
e-learning and traditional instruction in their respec- more appropriate, as the success of this modality
tive settings. This not-for-profit entity, registered in requires multiple partners, including the professionals
the United Kingdom as a Limited Company with delivering services, technical support personnel, and the
charitable status, is still in formative stages, and client or patients themselves whose participation is
expects to make available studies of its impact in the essential to successful outcomes. Telehealth, in all of its
near future. definitions and permutations, has made large strides in
African Medical and Research Foundation (AMREF) in expanding healthcare services to underserved areas
Uganda27 is an example of using ICT in the devel- around the globe.
oping world for nursing education and scale-up. In a recent study, 719 nurses representing 36 coun-
This public-private partnership plans to increase the tries responded to a survey querying their telenursing
basic education level of 22 000 Kenyan nurses up to competencies and skills.30 Patients with chronic ill-
the level of “registered” (diploma) from the current nesses were those most often cared for using telenurs-
level of “enrolled” (certificate) within 5 years. At ing services. Although most telenurses worked in hos-
present, 70% of the nursing workforce in Kenya is pitals, the settings varied widely, including traditional
comprised of “enrolled” nurses, whose level of work places such as clinics to community-based set-
education leaves them ill-prepared to handle the tings such as schools and prisons. Several countries
complex health needs of the Kenyan population. have well-developed telenurse programs, including
The AMREF’s “Virtual Nursing College” currently Canada31 and New Zealand.32 The trend towards ex-
has 4000 nurses enrolled at 100 computer-equipped pansion of this nursing specialty is expected to con-
training centers in 8 provinces, including several tinue, particularly as ICT continues to reach all areas of
refugee camps. The curriculum is delivered via ICT the globe and as the medically underserved areas of the
and, in October of 2007, the first class of ICT- world are illuminated.
trained Kenyan nurses completed the program.28 Telehealth/telenursing in the traditional sense may
While too early to discuss program outcomes, the conjure up visions of expensive computer workstations,
fact that 70% of all nurses enrolled in this program call-centers, or a nurse in a chat room. While these
are from rural areas speaks to a great potential for visions are perfectly realistic in the developed world,
communities outside of urban centers. This model is they are quite unrealistic in many parts of the globe.
planned to be extended to other African nations However, with the growth of cellular telephony,
who are experiencing similar nursing crises. The particularly in Africa, tremendous opportunities exist
AMREF program is also important because of an for nurses to creatively apply telehealth modalities to
important but less publicized goal—that all 22 000 long-standing patient care issues. For example, Elder
nurses will be computer literate. This very unique and Clarke cite the following examples for the
and vital component leaves Kenya ready to lead in potential use of cellular telephones and Personal
the movement towards e-health in the developing Digital Assistants (PDAs) for telehealth in Africa and
world. This could accelerate the achievement of the Asia:33
● Automation of demographic surveillance activities
WHO Resolution WHA58.28, an e-health strategy
such as those at the core of pioneering health care
adopted by the Fifty-eighth World Health Assembly
initiatives (e.g., the Tanzanian Essential Health Inter-
in May 2005 that articulates the preparation of an
ventions Project)
ICT-competent global health workforce.
● Testing of the use of SMS (short message service)
These 2 brief examples, while using different meth- reminders in the treatment of tuberculosis in Cape
ods and addressing 2 different audiences of nurses, Town, South Africa
demonstrate the potential of ICT within the nursing ● Delivery of continuing medical education and pro-
education realm. It also demonstrates the reach of fessional development via PDA
242 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
6. Globalization and advances in information and communication technologies Abbott and Coenen
● Delivery of time-sensitive alerts to patients and locales. While this is an open source and freely avail-
health care workers able system, there are no documented examples of
● Maintenance of patient records for HIV-positive nursing use—which is puzzling when one considers the
patients’ lifelong drug treatments number of nurses who are responsible for clinic oper-
● Management of specific health care initiatives such ations around the globe. It is important to note that,
as the roll-out of antiretroviral therapy and tubercu- even in developed nations, nursing involvement in
losis treatment initiatives EHRS specification and development is disappointingly
Again, realizing the numbers of nurses who are in low. Such lack of EHRS involvement by nursing in
the frontline of primary care around the globe and in both developed and developing nations makes it that
light of the massive growth of ICT for health, tremen- much easier for nursing data to remain invisible and
dous opportunity awaits those who are primed to inconsequential to determination of health outcomes.
capitalize upon these factors. Making the application of
telehealth/telenursing successful in developing coun- EHRS Standards
tries will require strong nursing partnerships and lead- Healthcare, both nationally and internationally, is a
ership, however. Nurses are in a position to drive the product of teams (including the patients), and such
development of science in this area, since many aspects teams are reliant upon the sharing of information and
of nursing care are naturally amenable to virtual deliv- knowledge. Standards facilitate sharing of data, infor-
ery, especially in areas of assessment, patient teaching, mation and knowledge and are a foundational under-
decision support, and early identification of problems.34 pinning for system interoperability. Those who do not
participate in standards development, implementation,
Interoperable Electronic Health Record and use face the prospect of exclusion in EHRS. As is,
Systems the contributions that nurses make to patient outcomes
Globalization is driving the need to communicate and the achievement of larger health care goals are
and share healthcare data and information across na- frequently invisible in EHRS because the standards that
tional borders. Many countries are focusing on interop- exist to represent nursing practice in automated systems
erable Electronic Health Record Systems (EHRS) as a are either underused or excluded. Nurse-sensitive mea-
solution for sharing data and information among vari- sures are frequently omitted from EHRS for a multitude
ous sources (e.g., clinical information systems, personal of reasons, and they will continue to be, unless the case
health records, public health surveillance systems, and is made for inclusion. As nurses accelerate their utili-
knowledge repositories). For EHRS to reach full poten- zation of and leadership in ICT-based efforts such as
tial, however, interoperability and connectivity to dis- the EHRs, the chance to share perspectives, experi-
tributed data repositories is fundamental, particularly in ences, and best practices via standardized and ex-
light of distributed healthcare services, geographical changeable data must not be missed. Nursing experi-
challenges, and migrating populations. ence, leadership, and the nursing voice are needed.
In a global sense however, there are vastly different Interoperability from a global perspective requires
levels of EHRS readiness and capacity for EHRS international standards in many dimensions such as
interoperability. In many places, EHRS are unknown messaging, security, language, ethical information use,
yet the need for health data (in any fashion) is great. ICT management, and other areas—all of which impact
Even the most remote of locales often have reporting nursing and EHRS. Again, nursing involvement is cri-
requirements, either from Ministries of Health or donor tical. One challenge is that there are multiple standards-
agencies. Accountability for receipt and utilization of setting agencies and, most likely, always will be due to
goods and services, demonstration of outcome achieve- the complexity of stakeholders, which increases the
ment, and measurement of milestones are resulting in difficulty of nursing participation, particularly in con-
increasing pressures on nurses, other providers, and sideration of the dearth of qualified standards-literate
administrators for improved information management nurses. While there are many standards organizations
and tracking. Quick fixes or one-off solutions, charac- around the globe, the International Standards Organi-
teristic of many health data tracking efforts, often result zation (ISO) and Health Level 7 (HL7) are 2 of the
in unusable, non-interoperable, and unsustainable sys- major standards-setting organizations where nursing is
tems that are soon abandoned, threatening clinic viabil- represented (albeit in small numbers), and it must
ity and leaving service providers frustrated. continue to be so.
Efforts such as Open MRS are gaining in popularity, An example of successful nursing involvement and
due to its open source (free) and interoperable nature, leadership in global standards work is the ICNP®.
and its well-established success in many clinical set- Initiated in 1989 by the International Council of Nurses
tings across the global south. Open MRS is an example (ICN), ICNP® is defined as a unified nursing language
of an EHRS system, built to agreed-upon standards that system to represent nursing diagnoses, interventions,
enable interoperability, data exchange, and the ability to and outcomes. The vision of ICNP® is to be an integral
use it in many different settings in many different part of the global information infrastructure informing
S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 243
7. Globalization and advances in information and communication technologies Abbott and Coenen
health care practice and policy to improve patient care a Hospital, “In attempting to arrive at the truth, I have
worldwide.35 Through standardizing the clinical termi- applied everywhere for information, but in scarcely an
nology nurses use to describe their practice, ICNP® can instance have I been able to obtain hospital records fit
improve nursing practice and contribute to the advance- for any purposes of comparison. If they could be
ment of nursing science. The ICN also recently part- obtained . . . they would show subscribers how their
nered with the International Medical Informatics money was being spent, what amount of good was
Association—Nursing Informatics and the international really being done with it, or whether the money was not
nursing informatics community to establish an interna- doing mischief rather than good . . .” In 2008, 143 years
tional standard through ISO. This standard, Integration later, we are still struggling to determine the amount of
of a Reference Terminology Model for Nursing,36 good that is being provided, largely because the nursing
provides a framework which can be used to map data that is foundational to a full understanding of
concepts across different terminologies, thereby in- nursing contributions to outcomes, both good and bad,
creasing communication and comparability of data is still unfit and unavailable for comparison. The
across languages and countries.37 This ISO standard is opportunities and critical need for nursing leadership
currently under routine review and is expected to are growing exponentially.
contribute to ongoing harmonization across multiple
international standards, giving structure to nursing data Knowledge Management and Knowledge
in global EHRS efforts. This work is critical to under- Generation in Nursing
standing the full processes of and contributors to health Information itself is becoming a major commodity in
care. Analysis of data that does not include nurse- health; there are multiple stakeholders interested in
sensitive measures, nursing interventions, and nursing access to and sharing of data and information. Access to
contributions to outcomes is deficient, incomplete, and reservoirs of experiential knowledge and collections of
prone to spuriousness. explicit information allows for the development of new
The International Telecommunication Union (ITU) knowledge based on identified needs, to refine knowl-
is another organization involved in standards develop- edge that already exists, to avoid duplication of effort,
ment that has direct bearing on nursing practice, par- to increase alignment with local circumstances, and
ticularly as related to communications protocols used in enhance the creation of actionable knowledge.39 The
disaster relief and community-based services in the value to nursing of such collections of knowledge and
aftermath. As the leading United Nations agency for experience becomes quite obvious, particularly when
information and communication technologies, ITU considered in the global context and in the face of
plays a prominent role in the development and deploy- asymmetries of information. Effken and Abbott have
ment of global ICT standards. For example, in the identified ICT solutions for knowledge management in
aftermath of the Indian Ocean tsunami in 2004, ITU nursing, including the creation and participation in
played a major role in pushing for standards for public communities of practice (CoPs).40
warnings (called CAP or Common Alerting Protocol), CoPs trace their roots back to constructivism where
disaster management, prevention, and relief.38 There is the control of learning shifts from the instructor to the
a great need for the nursing perspective in these learner. Wenger discusses ICT supported CoPs specif-
concerns, particularly since a great deal of the care in ically, stating “Every group that shares interest on a
disaster relief efforts is provided by teams heavily website is called a community today, but communities
infused with nursing personnel. Nurses, as first re- of practice are a specific kind of community. They are
sponders and those often managing the ongoing health focused on a domain of knowledge and over time
needs of a community after disaster teams have left, accumulate expertise in this domain. They develop their
have a vested interest in ICT that supports information shared practice by interacting around problems, solu-
and workflow needs. Unfortunately, nursing is often tions, and insights, and building a common store of
absent from the development and deployment of such knowledge.”41 From a global nursing perspective, es-
standards and are frequently left to deal with sub- pecially in light of the scarcity of nursing resources,
optimal systems. reusable and accessible nursing knowledge empowered
Nursing leadership is critical to break the chicken by ICT is a powerful tool for the profession.
and the egg cycle that comes from unstructured, non- One such ICT-supported CoP is the Global Alliance
standardized, and invisible nursing data in the rapidly for Nursing & Midwifery,42 a project initiated out of the
digitizing world. Without comprehensive, rigorous and WHO Department of Human Resources for Health, the
accessible digital nursing data from large healthcare WHO Office for Nursing & Midwifery, and the Johns
datasets, nursing practice remains largely invisible, and Hopkins University School of Nursing Collaborating
invisible nursing contributions lead to false assump- Center for Nursing Knowledge & Information Manage-
tions of low nursing contribution to health and health ment. This platform designed for nurses and midwives
outcomes. In reality, much has not changed since serves as an open knowledge exchange CoP with a
Florence Nightingale wrote in her 1863 book Notes on current membership of 1,500 from approximately 123
244 V O L U M E 5 6 ● N U M B E R 5 N U R S I N G O U T L O O K
8. Globalization and advances in information and communication technologies Abbott and Coenen
different countries. The Alliance has served as a learn- approaches not yet realized to managing, sharing, and
ing platform, a library, and a knowledge exchange generating nursing knowledge. The ultimate benefac-
forum for global nurses to exchange best practices, tors include not only the patients and communities that
participate in open continuing education, and manage we serve, but the profession of nursing itself.
knowledge. The Global Alliance is unique in that it runs
over very low-bandwidth, standard telephone service to FUTURE OPPORTUNITIES
allow participation by those in areas without full Inter- Some scholars suggest that there is a leadership void in
net connectivity. Participation from low-resource areas nursing, particularly in the global south, where the
is surprisingly robust. needs are the greatest.46 Leadership for strategic use of
Other CoPs exist for nursing, and growth in this area ICT and informatics in nursing, and strategic partner-
is expected. For example, Hara and Hew in studying an ships to support mutual enhancement of ICT is an
online CoP for critical care nurses in the Pacific Rim important strategy for the promotion of global health.
found that an e-CoP helped not only to reinforce the Entrepreneurial opportunities exist for those proactive
identity of the practice of critical care nursing among and creative thinkers who stand ready to capitalize upon
participants, but that it also served as an important them.
avenue for information and knowledge exchange within Nurses cannot wait for ICT to bring answers to the
the context of everyday work.43 These authors believe problems faced in today’s world; rather, they need to be
that: “Communities of practice can be described as engaged in problem-solving activities, testing and eval-
groups of people who are informally bound together by uating solutions to global health issues using ICT. The
shared expertise and a passion for joint enterprise. They pace at which ICT seeps into health care is only
can be viewed as informal networks that support pro- expected to increase, and reasoned action by the nursing
fessional practitioners to develop a shared meaning and community is imperative. The nursing informatics
engage in knowledge building among members. The arena has provided avenues for nurses to serve as
theoretical construct of communities of practice is leaders, including multiple roles in nursing and through
grounded in an anthropological perspective that studies participation in professional organizations. However,
how adults learn through everyday social practices nursing informatics, like nursing in general, stands at
rather than focusing on environments that are intention- the edge of a workforce crisis that threatens nursing
ally designed to support learning.” participation in the rapidly progressing world of ICT.
Information and communication technology has also Nursing as a profession cannot leave the progress
stimulated the growth of other approaches to knowl- needed in the face of accelerated global ICT solely in
edge generation and nursing research. For example, the hands of nurse informaticians. Informatics practice
ICN recently initiated an electronic International Nurs- is quickly becoming part of the expected competency of
ing Partnership Database Project.44 The goal of this every nurse and, therefore, is becoming not only a
project is to document and share ongoing and new responsibility of every nurse, but as an opportunity for
international partnerships, as a tool to encourage similar every nurse. The absence of the nursing voice and
initiatives and aid in planning new ventures. Rather nursing leadership as global e-health explodes is fore-
than relying on the traditional literature sources for boding.
networking and proposal development, this database In addition to leadership, strong partnerships are
can provide researchers and others with pre-publication essential to advancing health globally. These partner-
information about existing projects in process. Similar ships should not only include corporate and philan-
to the CoP concept, the ICN shared database allows the thropic organizations, but partnerships within the
sharing of partnership experiences and results to max- healthcare team as well. Interdisciplinary work is crit-
imize efficiency and effectiveness. The ICN has also ically important and the major contributions that nurses
developed a portal called the International Nursing make to global health must be acknowledged and
Network to facilitate the exchange of ideas, experience, supported at levels much higher than they currently are.
and expertise for the nursing profession crossing a Similar to the efforts undertaken by the Robert Wood
variety of areas from advanced practice nursing to Johnson Foundation’s Commitment to Nursing,47 it
disaster preparedness.45 This open access portal serves would seem appropriate that major foundations and
as a mechanism to encourage global nursing interaction. funding agencies would support the investigation and
The management and generation of new nursing and growth of ICT as a strategy to support frontline nursing
healthcare knowledge is deepened and advanced as new care, since nurses are such a vital source for the delivery
evidence, new perspectives, and new discoveries are of health services worldwide. It is also important to
shared among global nurses and midwives. Information emphasize that the agenda for using ICT to advance
and communication technology provides an opportunity global health is in no way limited to experts in infor-
to facilitate participation and to establish partnerships matics. Nursing expertise in practice, education, admin-
using technology that connects those otherwise not istration, research, and policy are all required to ad-
connected. Enabling these connections will promote vance this agenda. The nursing profession, as partners
S E P T E M B E R / O C T O B E R N U R S I N G O U T L O O K 245
9. Globalization and advances in information and communication technologies Abbott and Coenen
in improving global health care, has much to contribute, future? What shall be the legacy of the current gener-
particularly in this new interconnected and flattened ation of nursing leaders in this rapidly digitizing world?
world. To answer these questions, we need nurses who have
Entrepreneurial opportunities for nurses who are what Henry Ford classified as those with an “infinite
interested in global health and who understand and are capacity to not know what can’t be done.”
intrigued by digital innovation abound. The authors
have highlighted examples of first steps that the nursing CONCLUSION
community has already taken in applying ICT to health Nursing has a long-standing history of advocacy, inno-
and healthcare. Following the example of AMREF in vation, and education. The growth of ICT in the health
Uganda and the online training of 22 000 nurses— and healthcare sector should be looked at as an oppor-
could this model not be built upon and expanded to the tunity for nursing to use a new medium to meet the
mission of our profession, not as something to be
global nursing workforce? Could nurses, long known
approached with trepidation and fear. As globalization
for their crucial role in patient education, develop
expands, nursing has the opportunity to step forward
ICT-supported solutions to reach patients, their families
and harness the power of ICT to serve the greater good.
and caregivers—regardless of geographic location? Can
While it is often difficult to make the case for ICT in
we use ICT to provide lifelines to isolated nurses, areas where running water and electricity are consid-
midwives and others who are serving their communi- ered a luxury, access to information must be viewed as
ties? Can we deploy simple ICT solutions to combat the a basic tenet of a developing nation, with efforts to
problems of collecting critical individual and popula- increase ICT and decrease poverty as complementary,
tion health data in remote locations? Considering that not competitive activities.18 As nurses, we have the
there are more mobile telephones in use in China today opportunity to renovate and innovate, as we shepherd
than there are people in the United States,1 what developments in a way that promotes health for all.
innovative mobile methods could be developed to
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