In a world with increased global opportunities for sharing substantive content between and among nations and cultures, health care leaders are increasingly invited to contribute to knowledge acquisition and dissemination. Such was the case with the authors of this article—the same authors who address the core concepts derived from the work of Quality and Safety Education for Nurses (QSEN) when they collaborated with members of the Beijing Nurses Association and Perking University First Hospital. The Teaching Tips column has presented QSEN content. This article addresses the complement to that work by presenting the leadership lessons learned to help others when presenting in a global forum.
Preparation for delivering a presentation in another country or culture is substantial. When accepting the responsibility for international speaking engagements, consideration of the content and how it will transcend geopolitical, economic, and health care roles, and patient and family expectations is paramount. Time must also be allocated for travel arrangements, including obtaining a passport or visa, immunizations, or other country-specific requirements. Any contractual negotiations surrounding service exchange or honoraria, if applicable, must meet host and visitor country standards, with consideration to monetary currency. Once these details are in order, travel can begin, and the speaker's focus can be on the experience itself, validating or dispelling any preconceived notions that may have been formed. From our experience, these are four leadership lessons that we chose to share with our readers.
Leadership Lesson One: Humility and Acceptance
Most speakers are invited to do an international presentation because they possess expertise and reputation built on relationships. When accepting the invitation to present, do so expecting to learn as much as you will share. There may be intractable problems that have been solved in unique ways or resources that may be better organized and used than in the speaker's native land. Learn from and express validation for how these contributions are useful globally and offer to help with dissemination of new ideas. In many Eastern countries, hospitality is a dominant value, so one is advised to not interfere with the many courtesies that are extended to you as a speaker. These courtesies often are a sign of respect to the guest, so they should be accepted with a spirit of appreciation. Small token exchanges of gifts build trust and symbolize collaboration.
Leadership Lesson Two: Allow Time for Translation
If language is a barrier, translation will play a critical role in the success of a presentation. If a PowerPoint® presentation is used, send it or any other print documents in advance, realizing that translation into the native language requires time and effort. With the worldwide use of telephones and other technologies, translation is enriched with applications that can be used in real time. For instance, in Beijing, we used the WeChat application that translated Chinese language slides into English by simply scanning each displayed slide. The impact was an ability to connect language with emotion and nonverbal expressions that advanced understanding.
As a speaker, determine what up-front accommodations have been made for translation and the skill level of the translators. Simulcast translation, such as what can be observed in the United Nations, is sometimes used in more formal settings. Most likely, translation will occur with the translator listening to the speaker, followed by the translator repeating the message in the native language. It is advantageous to meet and establish a relationship with the translator, which permits the speaker to assess the translator's abilities and build trust. For formal presentations, a preparatory meeting is best, ensuring the concepts and ideas are understood and are translatable—not all ideas have meaning in another culture, an issue addressed more fully below. The cadence of the speaker requires intentional thought, speaking in sentences or short paragraphs, grouping together ideas that give the translator time to process and determine how to best share the content presented. Speaking in this style is not natural, and it does take practice and concentration so that while the translation is taking place the next ideas are formulated. Remember, providing a 1-hour talk is reduced to 30 minutes to accommodate translation.
The translators working with us in China had the benefit of being well-educated nurses, some trained in the United States. Their English was fluent, and they were accommodating in every manner during presentations and during social interactions that occurred outside of the conference. This is not always the case. For instance, out of deference and respect, some translators will nod or agree as though they understand the subject matter even though they may not. Again, advanced opportunity to establish mutual understanding between the translator and speaker is the preferred practice.
Leadership Lesson Three: Do Not Make Assumptions About Job Roles
Job roles vary from country to country. The status of nursing varies from place to place within a country but also across nations, ranging from a vocational to a professional orientation. Presenters should not assume that nursing as a discipline or as a function is universal, and they should account for these differences. Similar to in the United States—where the nursing profession has been more or less standardized based on a common NCLEX® examination—roles and functions vary across institutions or within the specialized areas of hospital or community settings, as well as in other nations. For instance, not all RNs administer chemotherapy, yet some have this as a routine aspect of their work with oncology patients.
Speakers must give even more attention to describing advanced practice nursing roles, particularly the nurse practitioner role. Even within the United States, state-by-state variations exist for advanced practice registered nurse (APRN) roles, despite national standards for education and certification being in place. For those countries just beginning to develop the nurse practitioner role, even greater variation can be expected. Consider midwifery, a global term but one with a broad range of interpretations depending on geographic location. The clinical nurse specialist and nurse anesthetist roles, common to APRN practice in the United States, may not be present in some countries.
RNs who move across country boundaries are required to have their education and proficiency validated according to each country's regulations before a license to practice is obtained. Presenters should consider the scope of practice and the authority and responsibility of nursing within the health professions of the audience being addressed. Avoid presenting information that is prohibited in practice as it may create unnecessary confusion.
Leadership Lesson Four: Conceptual Clarification and the Use of Acronyms
QSEN initiatives have been developed with careful operational definitions to ensure a common language and standardized usage. Presenters offering other subject matter content may not be so fortunate, so thoughtful reflection is needed to ensure that the meaning behind terms and acronyms used is unified.
Some examples help draw attention to the uniform meanings behind critical ideas. In the United States, the term just culture has been strongly linked to patient safety. In 2010, the American Nurses Association released its first position statement on this concept and determined that when a patient error occurs, blame should not be placed immediately on the care provider but rather it could be ascribed to a breakdown in the design of a process of care (American Nurses Association, 2010). In a just culture, removing blame and analyzing the root of the problem creates more favorable scenarios for reporting and improving the processes of care. Although the term is common in U.S. health care, not every organization or country has processes and structures in place to ensure that a just culture is supported. The concept may be completely foreign in some countries where practices of immediate blame-placing overshadow the enlightened attitudes that recognize just culture affects safety reporting and subsequent mitigation of safety risks.
Patient-centered care, which focuses on processes designed with the patient and family in mind, may not be a priority in countries where the focus is less on individualized and patient-sensitive care and more on care efficiency. Similarly, the concept of collaboration may look more like tolerance, coordination, or cooperation based on role, gender, and other cultural factors (Kinnaman & Bleich, 2004). The point is this: as a presenter, one must use language through the lens of the receiver of information and that is congruent with the mental models that are dominant in a society. Validating assumptions, when possible, is best done as advance work. It is not always possible to validate assumptions, so being aware of jargon, acronym usage, and other high-stakes risks for miscommunication is essential to ensure accurate understanding and translation of important learning.
Thoughtful and careful preparation went into preparing and delivering QSEN content to nurses in China, and the overall feedback was positive. The need for nurses to assume an integral role in quality and safety that led to the development of QSEN competencies laid the foundation for key content. The central ideas shared addressed systems thinking, communication for addressing concerns about potential error, approaches to support teamwork and collaboration, and the development of rapid response teams and safety huddles as interventions. Participants particularly enjoyed active learning and role-play as a teaching strategy. Content areas are more completely described in Teaching Tips.
China is a country on the move. The United States and other countries are building health care facilities in a country whose aging and workforce shortage demographics are more extreme than in the United States. China has increased the number of nursing schools and the number of students needed to provide for a workforce that has been shaped by past policies around childbearing. Eastern and Western forms of medicine are valued, creating more expansive treatment options than what may be available in the United States. Additionally, the role of the family and attitudes toward aging shift expectations about who and how care will be delivered. In China, the government can prioritize initiatives in a manner that shapes behaviors and shifts resources—quality and safety is now one such governmental priority. We suspect that this is a time to ensure that operational definitions of the knowledge, skills, and attitudes defined by the QSEN competencies are advanced, in the spirit of continuous improvement and partnership with China's needs.
Our experience with QSEN in China has sharpened our insights into what makes for a successful global presentation. Sharing these leadership lessons advances considerations for others who work with global audiences, here and abroad.