Today, it is easy to speak about globalization from an economics and political perspective, but too little is mentioned about the impact of global care delivery systems, nursing education and professional development, and clinical and organizational research. After an extraordinary experience visiting Taiwan and China, I returned with a novice sense of enlightenment about the similarities and differences that exist between American and Asian health system work cultures and the development needs therein. With an eye toward the clinical and organizational science and seeking solutions to workforce issues, The Journal of Continuing Education in Nursing is an important international reference that bridges professional development topics and strategies.
My experience began in Taipei, Taiwan, as a guest of the Taipei Veterans General Hospital and the Taiwan Nurses Association. Having visited a decade ago, it was amazing to see the rapid development of nursing in this nearly 3,000-bed hospital, with ambulatory services caring for 10,000 patients daily. When in Taiwan and China, it is important to think big—beyond what seems plausible in the United States in terms of service capacity. The purpose of my trip was to advance the knowledge of practice environments through the lens of leadership development. The topics addressed included the essence of leadership; rankism; the Institute of Medicine’s (2010) report, The Future of Nursing: Leading Change, Advancing Health; and gender acceptance in the discipline—all topics that have been addressed previously through this column.
In Taiwan, I interviewed key organizational leaders with differing levels of responsibility about issues in nursing professional development and the strategies employed to develop and advance nurses in their settings. Interviewed at Taipei Veterans General Hospital over the course of 3 days were Dr. Kwua-Yun Wang, Director of the Department of Nursing, Professor at the National Defense Medical Center School of Nursing, and President of the Taiwan Nurses Association; Fu Ling Shaw, Jin-Lain Ming, and Yu-Chu Pai, Deputy Directors in the Nursing Division (Ms. Shaw also is President of the Taiwan periOperative Registered Nurses Association); Deh-Ming Chang, MD, PhD, Superintendent of the hospital; Chen-Tzu Chi, Nurse Supervisor; Yen-Hua Li, Head Nurse; and Steven Tso-Kuang Wu, Assistant Head Nurse. Specific clinical units visited included the operating department, pediatrics, hospice, and gerontology services.
Nursing Workforce—Onboarding Practices
Not unlike in the United States, concerns exist around the supply of qualified nurses to meet current and future patient demands. This topic was prevalent in all conversations. In Taiwan, graduating nurses typically complete a 2-year transition program in an approved hospital setting before being issued their permanent nursing license. During these 2 years, a structured preceptorship is arranged, and the hospital provides education to strengthen the knowledge, skills, and abilities of these practicing nurses. At the end of the 2-year period, nurses are eligible to apply for a permanent position in an acute care setting, perhaps in the unit where they completed their developmental training, or, more likely, on a different service. There is status in gaining nursing employment in acute care, not unlike the American tradition where medical–surgical experience is often recommended to new graduates (although this is changing). Graduating nurses practicing in settings outside of acute care hospitals are seen as filling positions where the patient is less at risk, so these nurses are issued their permanent license at the onset of their non-acute care nursing careers.
During the 2-year preceptorship, emphasis is placed on integrating the use of evidence-based practice. In the decade since my last visit, the use of evidence-based practice has been transformative in Taiwan. The culture of inquiry and science has expanded with rapid uptake and zeal to improve the practice and science of nursing. The Taiwan Nurses Association ( http://www.ngo.e-twna.org.tw/) has developed a national center for evidence-based practice as a unifying model for advancing the nursing discipline.
With each person interviewed during my visit, an obvious pride in the expansion of nursing science and the willingness to use science to drive practice was pervasive and has become normalized as an expectation. Each unit displayed evidence-based posters, quality improvement projects, and innovations specific to their particular care delivery model. One example was the use of a decorative “sock” to block the use of invasive intravenous technology from the sight of young children receiving chemotherapy for cancer treatment on the pediatrics service. Although technology use is comparable to that available in the United States, there are intentional strategies to deemphasize its use in front of the patient to reduce anxiety and keep the patient experience at the forefront.
Care delivery models are standardized by specialties, and there is a striking clarity around professional work roles and functions. For instance, in hospice, the care model definitively supports the religious beliefs of the patients, and space is designed to accommodate holistic and spiritual care needs. Both Eastern and Western medicine ideals are incorporated and used in treatment according to principle, blending the standardization of care practices with individual accommodation for patients as needed. In hospice, each patient is gifted with the opportunity for fulfillment by nursing interventions that advance the following four concepts: (a) the generation and acceptance of love for the dying person by and to the family, (b) the opportunity to apologize for those who may have been offended in life, (c) the chance to say thank you for the gift of living, and (d) the opportunity to adequately say goodbye. Nurses are largely responsible for setting the milieu of the unit with their interprofessional colleagues.
In delivering geriatric or pediatric care, very different cultures exist, and attention is paid to linking past cultural traditions with current practices. In pediatrics, the idea of hope and joy was palpable and varied, based on the clinical prognoses. In geriatrics, clear attention is paid to socialization, exercise, and balance, with full awareness of integrating acute services in the home. In each setting, leaders take responsibility for the culture, the processes and practices used, and clinical and organizational outcomes.
Leadership Voice and Gender Imbalance
In cultures where male and female roles are proscribed by social tradition and hierarchy, challenges exist for emerging professions to strike a balance with tradition and contemporary professional practice. Such is the case in Taiwan, where gender and role balance is stretching to reach professional norms. Development sessions with nurse leaders on the topics of rankism and nonhierarchical change management were of keen interest. An important thread of conversation was that all nurses must lend their voice to decision making and be seen as leaders in point-of-care delivery.
Organizational leadership, with a heavy orientation to physician-led disease management and clinical research, is important in the health system in the United States and in Asia. From my observations, it appeared that nursing was expected to provide leadership for care model development and execution, assuming the majority of accountability for the patient experience.
Nurses expressed that they remained silent about hierarchical mandates and adhered to them when ordered. Too often, a consciousness existed that speaking up and providing advocacy for an idea or way of implementing change would be confrontational; therefore, communication strategies were explored on how to provide assertive, fact-based communication, void of aggression or confrontation—neither of which would be plausible within cultural norms. Top leaders were interested in learning about nursing, its growing science, and its role in health care transformation because cost, technology, aging, and workforce shortages loom. Shared governance, often used in the United States, may well have a place in Asian nations, as it provides a mechanism that offers structure, which is revered, and a collective voice.
Regard for Lifelong Learning
In Taiwanese culture, educators are revered in all fields, and this is equally true in nursing. The advancement of the entire culture within Taiwan is an interesting blend of bringing together knowledge and tradition, art and science. There is honor in achieving higher levels of education and equal honor in using education to inform practice. The number of nurses with higher education at the master’s and doctoral levels who practice in both academic and service settings is increasing. Nursing career ladders exist as a tool to foster longevity within the hospital and to achieve the honor that goes along with goal attainment. The career ladder is also a mechanism to retain mid-careerists, who often experience career disengagement consistent with compassion fatigue and burnout. The concern about retaining mid-careerists and reviving their dedication to nursing strikes a universal concern.
Advanced practice nursing is growing rapidly in Taiwan—another sign of new career trajectories for nurses. Currently, the role is less oriented to primary care delivery, but rather to medical specialization, which is congruent with the physician’s assistant role. Similar to the United States, the advanced practice role is being negotiated with political influence from the physician community, with regulatory norms under development.
Lessons for Professional Development Educators
What are the lessons learned from this international perspective that can inform professional development educators globally?
- Leadership and management are emerging traits ascribed to being a nurse in any role or position, not just those in formal organizational positions. Cultural norms that engender timid responses to patient care and the design of care delivery systems are being replaced with nurses’ voices and holistic perspectives for issues and concerns. Professional development educators play important roles in stimulating the conversation and behavioral changes needed for professional nursing practice to flourish.
- Global lessons can be shared about care delivery that accommodate massive scalability. Professional development educators have technology tools available to share global perspectives on massively scalable care delivery systems that are becoming increasingly large and complex in the United States but are less developed than in some Asian nations.
- Multiple global models exist for exploring transition-to-care programs, often referred to as residency programs. The focus on acute care is shifting to care across the continuum, which requires new ideas for aiding professional career moves. International sharing of residency program content and competencies will have surprising similarities and differences which, if known, could fill in developmental gaps.
- Opportunities for the international exchange of human resources for learning and development are plausible and should be encouraged. The use of this journal as a vehicle for the exchange of ideas and perspectives should be further advanced, with its unique focus on being a resource for professional development educators globally.
- Organizational and leadership research will increasingly come from Asian nations and will require adaptation to U.S. cultures. The nexus for an international research agenda that explores care model impact, work cultures and satisfaction, technology impact on workforce development, and the best use of nursing knowledge and abilities in emerging massive care systems are among the topics this agenda could address.
In the next issue of The Journal of Continuing Education in Nursing, I will explore the experiences gained during a symposium held at the new Penn Wharton China Center in Beijing, China, which was cosponsored by the University of Pennsylvania School of Nursing and CGFNS International® (also known as the Commission on Graduates of Foreign Nursing Schools). The topic, relative to this column, was Nursing Leadership Across the Care Continuum. Stay tuned and lead on!
- Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.