Globalization is a relatively new term that refers to increased interaction among people from different societies across the globe. The evolution of the internet and advances in travel are two major factors that have greatly increased access to information and the subsequent sharing of ideas and influence. Global health is an emerging field. Due to increasing globalization and the emergence of the United Nations (UN) sustainable development goals (SDGs), global health has become a topic of increased concern within nursing education. Global health refers to the health and well-being of the world's population and the interdependence of human health and the SDGs (i.e., environmental and economic factors, as well as equality issues) (UN, 2015). Human health and environmental health are not mutually exclusive but are, in fact, interconnected and mutually reliant (Gimbel et al., 2017). Global health is both local and international; it refers to the promotion of health for the world's environment and population.
In 2015, the UN General Assembly adopted the 2030 Agenda for Sustainable Development. This document outlined the 17 SDGs and specific targets to be achieved by 2030, stipulating that successful achievement of these goals depends on active participation from all countries (UN, 2015). The UN SDG agenda was implemented in January 2016 to address global challenges and basic human rights. The SDGs expand upon the UN millennium development goals, eight goals that were adopted in the year 2000 (UN, 2015). SDG number 3 targets health priorities, including access to care through universal health coverage; reducing communicable, noncommunicable, and environmental diseases; ensuring access to safe, effective, and affordable medicines and vaccines; and the promotion of maternal and child health (UN, 2017).
Globalization has a specific impact on health care providers and nurses. The SDGs address the fundamental components for promoting and achieving health and wellness. Physical and mental health are the cornerstones of the SDGs, as are environmental issues such as access to clean water, sustainable farming and consumption, and protection of marine life (UN, 2015). Additionally, the SDGs promote gender equality, access to education, and economic growth opportunities.
Nurses are health educators, frontline care providers, and patient advocates. Nurses influence clinical outcomes and are often the face of the patient experience. As advocates, nurses speak and act for those who do not have a voice. It is estimated that nurses now provide nearly 80% of health care worldwide (Kulage et al., 2014). Nursing is poised to lead the world's efforts in promoting health and human rights for everyone. Therefore, it is crucial that the next generation of nurses be educated so they can become advocates for global health. The global health knowledge and skills of nurse faculty are key to the inclusion of global health concepts in basic nursing education programs.
The purpose of this study was to evaluate the global health competence (knowledge and skills) of prelicensure nursing faculty. Given the considerable influence faculty has over the nursing workforce, the results can provide a baseline from which to measure global health competency of nurses.
There is considerable expert opinion but limited empirical literature regarding nurse faculty competency in global health. Related areas of research have been described in the nursing literature. For example, researchers have identified the importance of and strategies for developing global health curricula. Factors necessary to the success of any program include resourcefulness, financial prudence, administrative support, and strategic partnerships (Gimbel et al., 2017). Shishani et al. (2012) recommended the establishment of a centralized repository for nursing faculty to build high-quality global health education programs that would provide worldwide access to global health curriculum resources for educators, including lectures and teaching materials. McKinnon and Fitzpatrick (2017) proposed implementation of a “knowing, valuing, and acting framework” to integrate the SDGs into nursing curriculum (p. 179). They described strategies to promote students' awareness of the SDGs. Parcells and Baernholdt (2014) and Mill et al. (2010) described approaches used to introduce global citizenship into their respective schools of nursing' curriculum. Other literature described the development of global health competencies and application of the SDGs in local communities during nursing students' community health clinical rotations (Upvall & Luzincourt, 2019). Thus, global health is a local community concern.
Factors influencing global clinical experiences for nursing students have also been studied. Impediments to establishing global clinical experiences included poor preparation of faculty, lack of funding, lack of interest, and safety concerns (McKinnon & McNelis, 2013; Visovsky et al., 2016).
Global health competency (knowledge and skills) has been addressed among other health professional groups, including students in health professional education programs and medical residents (Kim et al., 2017; Veras et al., 2013) and health care volunteers (Herring et al., 2019). Although the literature supports the fact that global health is a timely topic and important to nursing education, prior research on the global health competencies of nursing faculty does not exist.
A descriptive design was used for this quantitative study to determine the self-reported global health competency (knowledge and skills) of nursing faculty who teach in prelicensure nursing education programs in the United States. The research questions were: What is the level of global health knowledge among nursing faculty of prelicensure, basic nursing programs? What is the level of global health skills among nursing faculty of prelicensure, basic nursing programs?
Sample and Procedure
Following approval from the appropriate institutional review board, a convenience sample of nursing faculty members was obtained from the attendees of the National League for Nursing 2017 Education Summit. Potential participants were screened prior to being provided a survey to ensure that they were currently teaching as a nursing faculty member in a prelicensure nursing program. After returning of a completed survey, participants received a $5 Starbucks™ gift card. The data collected were analyzed using SPSS® (version 24.0).
The Global Health Competencies survey developed by Veras et al. (2012) was used. The survey is a 46-item questionnaire composed of three subsections. The first section is a 17-item self-assessment of knowledge and interest in global health and health equity. Each item is scored on a 3-point Likert scale (1 = not at all confident to 3 = very confident). A higher confidence score indicates a greater understanding of and interest in global health and health equity. The Cronbach's alpha was .93 (Table 1). The second section is a 14-item self-assessment of global health skills with patients from different backgrounds. Each item is scored on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). A higher score indicates a higher self-confidence in one's skill in caring for patients from different cultural and/or socioeconomic backgrounds. The Cronbach's alpha for this section was .72. The third section has 15 questions related to the respondents' needs regarding global health. It uses a 6-point Likert scale (1 = not at all important and 6 = extremely important). A higher score indicates the respondents' perception of increased importance of a global health curriculum. The Cronbach's alpha for this section was .94.
Cronbach's Alpha for Global Health Competencies Survey
Several background questions were also included in the survey. Items included age, gender, ethnic background, educational preparation, years of nursing experience, employment status (full time, part time, didactic or clinical or both), country of birth, supervision experience with international clinical rotations, prior employment outside of the United States, and familiarity with UN SDGs.
One hundred sixty-one nurse faculty members participated in the study. Most were female (91.3%) and White (82.6%), with an average age of 53 years (SD = 8.6) (Table 2). The top three highest degrees obtained were Master of Science in Nursing (49.1%), PhD (23.0%), and Doctor of Nursing Practice (18.6%), with five nurses indicating another degree (one Doctor of Nursing Science, one Master's in Education, one Master's in Science, and two PhD candidates). The majority (86.3%) of the faculty were nurses who were born in the United States. Approximately one third (32.3%) of the respondents reported that they had supervised students on international clinical rotations and 21.8% had experience working outside of the United States. Only 29.4% of the respondent nurses reported that they were familiar with UN SDGs.
Description of the Sample (N = 161)
Overall, the study participants had an average of 13.6 (SD = 8.5) years of experience as faculty. Most faculty taught in an associate's degree (38.5%) and Bachelor of Science in Nursing (57.1%) program, with 83.9% teaching clinical nursing. Of this 83.9%, 77% taught in the classroom and 62.1% taught clinical rotations.
Results Related to Research Questions
To determine the level of global health knowledge among U.S. nursing faculty of prelicensure basic nursing programs, means and standard deviations were calculated using sections 1 and 2 of the Global Health Competency survey (Table 3). The mean section 1 score (self-reported knowledge) was 66.76 (SD = 21.1), with a range of 14.7 to 100. The mean section 2 score (self-reported skills) was 61.4 (SD = 12.9), with a range of 32.1 to 94.6. Section 3 was the faculty assessment of global health needs. The three global health needs with the highest rating were (a) the relationship between access to clean water, sanitation, and nutrition on individuals (54.7%); (b) cultural competency—understanding how cultural background, socioeconomic status, and language barriers can influence access to care and health outcomes (54%); and (c) understanding the relationship between health and human rights (47.8%).
Self-Assessment Score Results
Additional analyses were undertaken to determine differences between master's-prepared faculty and doctorally prepared faculty on sections 1 and 2 of the Global Health Competency survey. Seventy-nine nurses had a master's degree in nursing and four had a Master of Science in Nursing degree. Two additional nurses had other degrees, listed as a master's, Doctor of Education, and Master of Science. All master's degrees were combined for a total of 85 master's-prepared faculty members. For doctoral degrees there were 30 Doctor of Nursing Practice, five Doctor of Education, 37 PhD, and one other (listed as Doctor of Nursing Science). All doctoral degrees were combined for a total of 73 doctorally prepared faculty. An independent samples t test was conducted to analyze the difference between the master's- and doctorally prepared faculty for sections 1 and 2 of the Global Health Competency survey (Table 4). The result for section 1 (global health knowledge) was significantly higher [t (156) = 2.0, p < .05] among doctorally prepared faculty (M = 70.7; SD = 20.9) as compared with master's-prepared faculty (M = 64.0; SD = 21.0). This indicates that doctorally prepared faculty have a greater understanding of and interest in global health and health equity compared with master's-prepared faculty; however, it is important to note that the master's-prepared faculty had a relatively high score of 64. The result for section 2 (global health skills) was not statistically significant [t (149) = 1.0, p = .31).
Independent Samples t test
Nursing faculty were also asked about their familiarity with the UN SDGs. Less than 30% of the sample reported familiarity with the UN SDGs. Those faculty with knowledge of the SDGs scored significantly higher in self-assessment scores for both section 1 (self-reported knowledge) [t (157) = 2.89, p < .01] and section 2 (self-reported skills) [t (148) = 3.71, p < .001] compared with those faculty who were not familiar the SDGs.
This study contributes to the current knowledge surrounding global health competency (knowledge and skills) of nursing faculty in the United States. The findings of the current study are consistent with studies among other health professionals. Prior studies of physicians and physical and occupational therapists also demonstrated a need for increased education regarding global health and the UN SDGs (Jogerst et al., 2015; Veras et al., 2013; Walpole et al., 2016; Wilson et al., 2014). The results of this study indicate that although doctorally prepared nursing faculty members have a higher level of global health knowledge compared with master's-prepared faculty, the majority of participants identified areas for increased learning about the concepts of global health and the UN SDGs, regardless of the educational background.
Results from this study and prior literature indicate that there is a need for both increased knowledge and skills regarding global health and specifically the SDGs (Herring et al., 2019; Veras et al., 2013). Global health competency among nursing faculty in the United States has significant opportunity for improvement. This study demonstrated a perceived lack of knowledge and confidence with the concepts of global health and the UN SDGs for U.S. nursing faculty. This shortfall could become a significant health care problem and warrants greater attention from the nursing profession. The world is becoming more integrated as societies are blending and interacting more. Greater emphasis on global health and population health among faculty would lead to better preparation of future generations of nurses. This is particularly important as health care professionals are called on to care for an increasingly diverse patient population. Given that nurses represent the largest group of health care providers, it is imperative they are prepared to provide the highest quality patient care for all people.
Like previous studies with the same survey questionnaire, a weakness of the current study was reliance on self-reporting. Study participants could have overestimated their confidence with understanding of the various aspects of global health. The convenience sample was also a limitation; only faculty who attended the national conference participated in the study.
The sample consisted primarily of middle-aged, master's prepared, White women who had access to the conference. Although this may accurately represent U.S. nursing faculty, the study findings may not be as generalizable to the overall nursing faculty population. Personal experiences, education, access to resources (e.g., health care, food, water, housing), and exposure to under-served populations will likely affect one's knowledge and perception of the issues affecting global health and thus, the importance of increasing educational awareness. Studying a more culturally diverse sample may provide a more accurate assessment of the nursing workforce.
Another limitation to the study is that it did not address the critical impact of climate change on global health. Although it was not part of our study, it must be stated that to be competent in global health, one must understand the impact of environmental conditions on human well-being. Nurses need to be well-versed in the role of climate change on the environmental determinants of health. Catastrophic weather events have significant negative outcomes that affect sanitation and access to clean water and sustainable food sources that has resulted in flooding, migration of populations, and disruption in available resources. Wildfires are occurring more frequently, and the aftermath of these devastating events may affect the local population's access to quality health care, education, clean water, and food. These events are happening here in the United States and around the world. To truly care for the local and global populations, all nurses must understand how these climate issues affect human health and well-being.
Recommendations for Future Research
These results emphasize the need for continued education of nursing faculty regarding global health concepts and the UN SDGs. Research regarding health outcomes has not kept pace with the expansion of global health care. The results of this study documented variances in faculty competence with global health concepts. In future studies, it would be interesting to consider other variables that could affect global health competency and knowledge of the SDGs. These variables could include primary setting (rural, suburban, urban) and different regions of the United States. Also, as previously noted, this was a homogenous sample that may not represent the U.S. nursing workforce and researchers should consider studying a more balanced, culturally diverse sample. People from different races may have different world views and thus, a racially diverse sample may yield results that identify different needs.
Other future research efforts should be focused on global health competencies of students and practicing nurses at various points in their careers (i.e., practice experience versus classroom experience). As nurses advance in their career, they may have increased contact with people from different backgrounds and this experience may alter their perspective and thus, their knowledge of population and global health. Prospective studies should seek to compare global health competency among nurses and nursing faculty in different countries and to identify the challenges of incorporating these concepts into an already overwhelming undergraduate curriculum.
The researchers would also like to study nursing faculty from different countries and regions of the world and compare the results to this study. As previously noted, personal experiences may affect one's interest in and knowledge of global health and the SDGs. Studying nursing faculty from across the globe may identify areas for future study as well as highlight best practices for improving understanding of global health concepts.
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Cronbach's Alpha for Global Health Competencies Survey
|Global Health Competencies Subsection||Item||Cronbach's Alpha|
|Knowledge and Interest in Global Health and Health Equity||17||.93|
|Global Health Skills with Patients from Different Backgrounds||14||.72|
|Learner's Needs About Global Health||15||.94|
Description of the Sample (N = 161)
|Mean age||52.7 years (SD = 8.6 years; range = 31 to 72)|
| Master's degree||(49.1%)|
| Doctor of Nursing Practice||(18.6%)|
|Teach in primary Bachelor of Science in Nursing program||57.1%|
|Born in the United States||86.3%|
|Supervised international clinical rotations||32.3%|
|Worked outside the United States||21.8%|
|Reported familiarity with the United Nations Sustainable Development Goals||29.4%|
Self-Assessment Score Results
|Section 1: Knowledge of Global Health||66.76||21.1|
|Section 2: Global Health Skills||61.4||12.9|
Independent Samples t test
|Differences between master's-prepared versus doctorally prepared|
| Section 1||t(156) = 2.0, p < .05|
| Section 2||t(149) = 1.0, p = .31|
|Differences between PhD versus Doctor of Nursing Practice|
| Section 1||t(65) = 0.6, p = .55|
| Section 2||t(62) = 0.9, p = .35|
|Faculty who supervised international clinical rotations versus general sample|
| Section 1||t(159) = 0.81, p = .42|
| Section 2||t(152) = 1.59, p = .12|
|Faculty who have worked outside the United States versus general sample|
| Section 1||t(157) = 1.85, p = .07|
| Section 2||t(150) = 1.32, p = .19|
|Faculty with knowledge of sustainable development goals versus general sample|
| Section 1||t(157) = 2.89, p < .01|
| Section 2||t(148) = 3.71, p < .001|