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Concept Analysis

The relevance of globalization to nursing:

a concept analysis inr_1022 78..85

J. Grootjans1 RN, PhD, M App Sci. (Soc. Ecol.), Grad Dip Adult Ed, B N (Adv) &
S. Newman2 RN, Int CareCert DipTeaching(Nursing), BEd(Nursing), MHA
1 Senior Lecturer, 2 Lecturer, The University of Sydney, Sydney Nursing School, Sydney, NSW, Australia

GROOTJANS J. & NEWMAN S. (2013) The relevance of globalization to nursing: a concept analysis.
International Nursing Review 60, 78–85

Background: This paper emerged alongside the development of learning materials for a new unit of study on
global health and nursing. The proposed unit was for inclusion in a graduate entry master of nursing course
leading to registration. It became evident that there has been growing attention within the nursing literature
to the demands of an increasingly globalized world and the subsequent challenges confronting nursing as a
profession. At the same time, the literature is inconsistent and contains mixed messages with regard to how
nurses and nursing might respond to these challenges.
Aim: This paper aims to (i) present the findings of a narrative analysis of the current nursing discourse on
globalization, and (ii) to identify directional cohesiveness for the nursing profession in the seemingly disparate
literature.
Method: Concept analysis following extensive literature review.
Findings: Several nursing authors argue that nurses globally are increasingly sharing concerns expressed by
nurses at a local level. Concerns such as the future sustainability of the profession and more specifically
practice concerns such as the continuing failure of nurses to adequately deal with social justice issues requires
careful consideration by every nurse. While strategies recommended for dealing with these concerns lack a
cohesive thread, some interesting themes and innovative recommendations have emerged. For example, the
need for nurses to consider replacing environmental considerations with ecological considerations and that
nurses consider preventative nursing practice beyond the immediate needs of clients and from a more global
perspective.

Keywords: Ecology, Globalization, Health Promotion, Nursing, Social Justice, Sustainability

Introduction learning material to be underpinned by both theoretical and

This paper emerged alongside the development of learning
materials for a new unit of study on global health and nursing in
a graduate entry master of nursing course. Early in the develop-
ment process for this unit, it was deemed essential for the
Correspondence address: Dr John Grootjans, The University of Sydney, Sydney
Nursing School, 88 Mallett St Camperdown, Sydney, NSW 2050, Australia; Tel:
61-2-9351-0615; Fax: 61-2-9351-0615; E-mail: john.grootjans@sydney.edu.au.
practical cohesiveness for the nursing profession in order for the
unit to be successful. Review of the nursing literature of the last
10 years revealed growing attention to the challenges of an
increasingly globalized world to both nursing as a discipline and
nurses as practitioners (Tschudin & Davis 2008). Equally appar-
ent was that the literature contains a number of disparate and
confusing messages with regard to how nursing might respond to
these challenges. This paper undertakes a comprehensive review
of literature by nurses about globalization to synthesize the

© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses 78
The relevance of globalization to nursing
apparently disparate responses. The main purpose is to analyse
the possibility of a cohesive response to how nurses can meet the
challenges faced by the profession in an increasingly globalized
world.
Background
There are a number of definitions of globalization (Hopkins
2004). Labonte & Torgerson (2005, p. 158) claim that in its sim-
plest form, globalization ‘describes a constellation of processes by
which nations, businesses and people are becoming more con-
nected and interdependent via increased economic integration
and communication exchange, cultural diffusion (especially of
Western culture) and travel’. They contend that globalization is a
‘function of technology, culture and economics leading to a com-
pression of time (everything is faster), space (geographic bound-
aries begin to blur) and cognition (awareness of the world as a
whole)’.
Within the nursing literature, a number of nurse authors have
expressed concern for how globalization has affected the nursing
profession and have begun to address the nursing issues emanat-
ing from globalization.1 For example, Tschudin & Davis’s (2008)
book on globalization and nursing provides an excellent ground-
ing for the profession because it clarifies a number of concerns
and provides a theoretical basis for action. The potential impact
of globalization on the health and well-being of people is used by
McMurray (1999) and Davidson et al. (2003) to explain its
importance to nurses. Bradbury-Jones (2009, p. 46) suggests that
nurses can no longer ignore the potential of their actions to have
global consequences because of the interconnectedness of our
planet – or to use an often quoted phrase ‘think globally, act
locally’. For example, actions by nurses to bring about social
inclusion at a local level will have global consequences.
This paper reports on what has been determined from a range
of publications on this topic and the relevance of the findings for
nursing in both the professional (disciplinary) and practice con-
texts. This paper is grounded in the question of whether or not
the nursing discourse on globalization contains a unified
message for nurses. It is primarily concerned with reporting the
nursing discourse on what globalization signifies for nursing and
nurses confronted by the daily pressures of clinical practice
(Davidson et al. 2003). In doing so, this paper examines the many
parallel conversations about globalization to situate some level of
meaningful discourse for the clinical interface. In particular, with
regard to what the role of nurses might be in a globalized world
while correspondingly achieving long-term sustainability of the
nursing profession.
1
Appendix S1 in Supporting Information presents the main findings of the
literature search under appropriate headings.
© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses
79
Approach and method
This review was conducted as a concept analysis (as described by
Walker & Avant 2011) because of the absence of primary
research. This research began by reading a number of seminal
articles and books on the topic of globalization and nursing to
gain an overview of the concept [Davidson et al. 2003; Tschudin
& Davis 2008; World Health Organization (WHO) 1994]. Search
terms chosen were ‘globalization combined with nursing’ later
followed with terms such as internationalization and worldwide.
The search was limited by a date restriction of the last 12 years, to
enable articles addressing challenges for the new millennium to
be included. Only articles authored by nurses were selected to
ensure that this is a concept analysis of nursing dialogue. Only
articles in English were considered. These terms were used to
search the databases CINAHL, Medline, Ebsco Host, Science
Direct and Google Scholar.
Through reading publications found in the initial search, a
number of characteristics of the concept of globalization became
apparent such as sustainability, health promotion and the envi-
ronment. To gain understanding of how these characteristics
were defined for the nursing context, additional searches were
conducted using the new terms combined with nursing and date
restricted to 5 years. The date restriction of 5 years was based on
our primary interest in including the most recent definitions. A
range of explanations for each term was recorded and synthe-
sized to enable an unambiguous definition to emerge. As initial
characteristics were better understood, opportunities for concep-
tual analysis and theoretical modelling became apparent. Early
drafts of theoretical models developed as a result of this process
were peer reviewed. Modifications have been incorporated into
what is presented here.
The literature search revealed a growing body of work focus-
ing on globalization written by and for nurses. The process of
analysis began by grouping the articles into two thematic catego-
ries: those that explored the issues for nursing (vis-à-vis recruit-
ment, migration and models of care) and those that posited a
nursing response to the changing world (vis-à-vis nursing prac-
tice and health promotion and the environment).
Findings
Overview of the literature
Analysis of published works revealed two major concerns for
nursing and nurses. First, a number of authors attempt to answer
the question ‘What is happening to nursing and nurses in this era
of globalization’. These authors described two challenges faced by
the nursing profession. These are (i) workforce and educational
issues (Baumann & Blythe 2009; Davies 2008; Khaliq et al. 2009,
Preston 2009); and (ii) professional issues (Björnsdottir 2001;
80 J. Grootjans & S. Newman
Holt et al. 2000; Lutzen 2000; Pang et al. 2004; Puzan 2003).
Workforce issues focus generally on global shortages of nursing
staff and the impact of nurse migration on home countries as the
local skilled workforce migrates (Kingma 2001, 2006). Corre-
spondingly, works focusing on educational issues speak to con-
cerns surrounding national and international standards of
nursing graduates. The second challenge highlighted by authors’
is to do with professional issues and the impact of globalization
on the development and articulation of nursing knowledge (vis-
à-vis nursing as a discipline; Björnsdottir 2001; Holt et al. 2000;
Lutzen 2000; Pang et al. 2004; Puzan 2003).
Two generic attributes of nursing in a globalized world
Two broad characteristics of nursing practice in a globalized
world were revealed: (i) sustainability of the environment and
the nursing profession; and (ii) equity and social justice for
clients and nurses.
Sustainability for nurses
Kirk (2002 p. 67) explains sustainability as
The environmental problems created by human activities have
to be addressed through international effort in developing
appropriate and sustainable policies, and nurses, as a part of a
global community, have to contribute proactively to this.
There are two socially acceptable usages of the term ‘sustainabil-
ity’. In the main, it refers to the potential of something to survive
over long periods. However, the recently emerged alternative
interpretation refers directly to action that promotes ecological
resilience or survival of our ecosystem. These two fundamentally
different uses of the term sustainability were found in the
nursing literature. Authors describe issues confronting the sur-
vival of nursing as a profession such as nursing shortages, nurse
migration and emerging roles for nurses (Buchan 2002;
Johnstone 2007; Khaliq et al. 2009; Little & Buchanan 2007;
Parish 2003). Indeed, the article by Alliex (2009) titled ‘Sustain-
ability of future professionals’, directly focuses what the nursing
profession will need to consider if it is to survive the challenges of
a globalizing world.
McMurray (1999) attempts to link the two meanings in an
editorial. She argues that sustainability of the profession is linked
to its ability to incorporate sustainability of global ecology into
the way nurses think. While the concept of ecological sustain-
ability has been in evidence for at least 15 years, what nurses can
do about ecological sustainability is new to nursing and not yet
well understood. In response to this lack of clarity, a number of
authors have attempted to describe the nursing response to eco-
logical sustainability (Davidson et al. 2003; Falk-Rafael 2006;
Hilfinger Messias 2001; McMurray 1999; Tschudin & Davis
© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses
2008). Both ecological sustainability and globalization were
observed by these authors to have a major impact on the health
and well-being of our clients and correspondingly, affect the way
nurses provide care.
The report by the World Commission on Environment and
Development (1987) titled ‘Our Common Future’, defines sus-
tainability as ‘meeting the needs of the present without compro-
mising the ability of future generations to meet their needs’.
Thorne (2006 p. 614) expounded this concept for nurses with the
statement ‘nurse for today with an eye on tomorrow’. The impli-
cation of this statement is that nursing actions today have the
potential to paradoxically threaten or promote the well-being of
future generations. Johnston et al. (2005 p. 152) also attempts to
raise nurses’ consciousness about the consequences of failing to
come to grips with ‘global planetary health’ with this statement:
. . . to ask whether the human race as a whole is making
progress or whether we are simply hastening our
demise . . . Indeed, can the nursing profession risk the conse-
quences of ignoring it (this question)?
Kirk (2002) suggested that nurses in the past have focused their
attention on the immediate needs of their clients and this focus
has served nursing well over the years. However, Kirk argues that
in our increasingly globalized world nurses cannot simply con-
tinue to respond just to the immediate needs of clients. Rather,
nurses need to include considerations of how their actions may
impact on the future needs of local communities and the planet.
Kirk’s suggestion places the catch cry of the environmental move-
ment, ‘act locally, think globally’, firmly in the hands of every
nurse as they gain knowledge about how their actions may nega-
tively or positively influence global sustainability.
Social justice and equity and nursing
Nurses have always offered their services without hesitation to
people needing help and many authors reiterate equity and social
justice for clients to be a cornerstone of the nursing profession
and nursing care (Austin 2001; de Chesney 2005; Crigger et al.
2006; Law & Muir 2006). Davidson et al. (2003, p. 169), explain
the relationship between nursing and social justice and equity
claiming that
[n]ursing as a profession has had a long history of social
advocacy; it also has political influence to inform and promote
social change. Many of our professional advances have been
achieved by challenging the status quo, while promoting a
culture of caring and advocacy for vulnerable members of
society.
Social justice is an important aspect of nursing care in a global
context where inequities and inequalities are all too common
The relevance of globalization to nursing
(Austin 2001). Indeed, Anderson et al. (2009, p. 283) highlights
the importance of this issue to nurses contending that
It is our lack of concern about the social disadvantages of
‘others’ at local, national, and global levels that lead to serious
health disparities. While such lack of concern is not necessarily
intentional, it does reflect a level of endemic blindness to the
complex contexts of people’s lives.
There is a plethora of public health literature that speaks about
social justice recently culminating in the ‘Closing the Gap in a
Generation’ report (Commission on Social Determinants of
Health 2008). Nursing needs to consider the inclusion of a
number of social justice issues in the Millennium Development
Goals [United Nations (UN) 2000], which are of direct relevance
to the nursing profession. The nursing profession takes prides in
being a long-term advocate of social inclusion (de Chesney
2005). To explain the nurse’s role in social justice, Thorne (2006)
suggests that nursing has historically planned care based on
assessment of the needs of the individual. This is further clarified
by Schall & Flannery (2000 p. 18) who state that
[t]he phenomena of concern of nurses and nursing care for
the late 1990’s through the beginning of the new millennium
are human experiences and responses to birth, health and
illness (not disease), and death.
To understand how this relates to social justice in nursing, we
can revisit the work of Eisenberg (1977) in which there is a
critique of the medical model. Eisenberg claimed that
[t]echnical virtuosity reifies the mechanical model and widens
the gap between what patients seek and doctors provide.
Patients suffer ‘illnesses’; doctors diagnose and treat ‘disease’
(1977, p. 9).
The concept of illness care provides the distinction between
nursing and the medical model, which in spite of a long history
of reform retains a focus on disease and disease treatment
(Burkhart & Sommer 2007; Schall & Flannery 2000). The
medical model potentially excludes individuals who for whatever
reason do not fit the mould because it has at its core a ‘one shoe
fits all’ mentality, with failure blamed on the victim (Radzymin-
ski 2007 p. 38). Nursing needs to distinguish the idea of ‘equal
care’ as the basis for approaching individualized nursing care.
This distinction between nursing and medicine (vis-à-vis the
medical model) helps us understand why nurses spend so much
time endeavouring to unravel the subjective experience of a cli-
ent’s illness. Our deep understanding of our client is often jux-
taposed with antagonistic knowledge about the biological
explanation of disease. Nursing, as defined by numerous nursing
theorists such as Leininger & McFarland (2002), has retained a
© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses
81
focus on respecting and valuing the uniqueness of each individu-
al’s illness experience. The level of uncertainty and complexity in
nurses caring for clients’ illnesses becomes profound, when com-
pared to the apparent certainty of the medical model and the
diagnosis and treatment of disease.
Continuing respect for individuals at the local level (Schall &
Flannery 2000) but also considering how our actions locally
impact on the well-being of people globally (Anderson et al.
2009) is the ultimate representation of equity and social justice in
nursing. This reorientation of the importance of social justice
refocuses the uniqueness of our job. Through the provision of
care, nurses act as mediators between a frequently inaccessible
treatment regime and the client’s uniquely personal expecta-
tions. It is through actions locally such as making sure a client
understands their diagnosis and accordingly does not misuse
their antibiotic, thereby adding to the problem of antibiotic resis-
tance globally, that we demonstrate our respect and value for the
needs of our clients both locally and globally.
The three essential attributes of what nurses need to know to
practise in a globalized world
Different authors, each of whom advocated a particular solution,
have introduced three innovative solutions to the question of
how nursing might respond to these challenges. These solutions
have focused on changing the way nurses:
1 understand the environment (Laustsen 2006),
2 prioritize health promotion (Falk-Rafael 1999), and
3 respond to the globalization of health by including global
considerations in their actions locally (Bradbury-Jones 2009).
However, this conceptual analysis suggests that each solution
has merit and is equally important to the future of the profes-
sion. This article therefore argues that each is a dimension of
nursing practice and can be presented as a unified framework for
a sustainable nursing practice (Thorne 2006). It is these
attributes that Buchanan (2005) suggests are ‘undervalued and
largely overlooked’ in enhancing the nursing profession’s
response to the challenges of globalization. The model (Fig. 1)
shows how the three elements of each dimension are linked and
mutually important. Nursing is a complex profession and nurses
focus on at least one aspect of each dimension in considering the
care they provide to each client.
A number of authors suggest that in a globalized world nurses
need to consider the ecology of health (dimension 1). Buchanan
(2005), Larsson & Butterfeild (2002) and Laustsen (2006) advo-
cate the importance of environmental considerations to nursing.
They remind nurses that the profession has its roots in Nightin-
gale’s ideas on manipulation of the physical environmental to
construct a safe and health-promoting setting for the sick. It is
argued that until recently, the environment was understood as
82 J. Grootjans & S. Newman

Dimension 3: Health promotion

Tertiary prevention
Secondary prevention
Primary prevention

Environment
determinants

Dimension 1: Ecology of
Social and
health
behavioural
determinants

Biological
determinants
Personal and National Global
local level level level

Dimension 2: Thinking globally

Fig. 1 Framework for sustainable nursing knowledge in a globalized world.

the physical setting, which supported life. Nightingale used the
best available evidence in the 1850s and 1860s to understand the
nexus between environment and health and rose to the challenge
of devising a theoretical response for nurses, which changed the
very nature of illness care. The question that arises among some
authors is ‘Can nurses rise to the challenge of our modern day
understanding of environment? To do this, it has been argued
that nurses need to replace the concept of environment with
ecology (Laustsen 2006). Ecology is more than just environment,
which in common language is associated with physical space.
Ecology also encapsulates social, behavioural, biological and
environmental determinants of health. Other authors suggest
that the evidence for the importance of ecology to nursing can be
found in the emerging and re-emerging diseases that our planet
is now experiencing (Hilfinger Messias 2001).
Other nursing authors suggest that nurses need to learn to
think globally (dimension 2). When nurses’ shift to ecology as
their focus, they can no longer function entirely at the local level.
The statement ‘act locally, think globally’ implies an understand-
ing of the idea that what people do has global consequences. This
suggests that nurses need to accept that it is necessary to consider
local, national and global determinants of health to understand
what makes us healthy (Minkler 1994; Thorne 2006). As Thorne
(2006) suggests, expanding nursing knowledge to consider the
global impact of nursing action locally will influence nursing
diagnosis and subsequent care.
Since Alma Ata (WHO 1978), there have been repeated calls
for a reorientation of health services to the promotion of health
and well-being. Various authors suggest that nurses focus their
practice on the promotion of health and well-being (dimension
3). Woolf (2009) argues that if health promotion is to become
one of the attributes of what nurses do, then this suggests that as
an outcome of nursing care, we must measure wellness or quality
of life not the absence to determine the success of our interven-
tions. Nurses who act to maximize the client’s well-being with
an eye to the future are acting within a framework of health
promotion.
In practice, nurses with ongoing contact with clients have
always taken a key role in health education, building health lit-
eracy and promoting the clients’ capacity to behave in a healthy
manner (Byrd & Thompson 2008; Peerson & Saunders 2009).
The plethora of health-promoting activities that underpin
nurses’ routine work in current healthcare systems is best
explained within a framework of primary, secondary and tertiary
prevention (Burkhart & Sommer 2007). The reorientation of
nursing towards health promotion will promote the idea that a
nurse completing a dressing is promoting health in a number of
ways. They are doing primary prevention as they are acting to
prevent infection. They are doing secondary prevention as they
undertake surveillance of the wound to see any early signs of
infection that can be dealt with rapidly, thus preventing any
negative consequences. They are doing tertiary prevention when
educating the client to care for their wound when discharged.
This example allows us to see that the principles of reorienting
nursing towards prevention can be applied to all nursing activi-
ties. Viewing nursing care as either primary, secondary or tertiary

© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses
The relevance of globalization to nursing
prevention ties together every moment of nursing as a moment
of health promotion.
We argue that the nursing focus on promoting well-being has
a profound impact on the reorientation on nursing care to health
promotion. If we include early and appropriate treatment of
disease as a component of promoting well-being, then all the
natural history of disease can become a component of a nurse’s
preventative practice. Everything a nurse does with clients from
early childhood immunization to interventions within the acci-
dent and emergency department through to the critical care unit,
on to the medical ward and out into the community, can be
framed as health promotion. Nursing care provided in a global-
ized world demands a reorientation of the way nurses think and
demands that they orient everything they do in and for the
prevention of disease.
Defining a unified model for nursing in a globalized world
This article presents a unique position on globalization and
nursing as it attempts to synthesize major themes that have
emerged from an array of nurse authors. Each of these authors
offers different and sometimes personal perspectives on what
could be. An attempt to analyse these perspectives into a single
theoretical position at first glance seemed an impossible task;
however, once the exercise was underway, a cohesive unified
outcome seemed increasingly feasible (Fig. 1).
Two characteristics of nursing in a globalized world that
emerged in this analysis were social justice and equity. These two
characteristics of nursing are all too often silent in nursing dis-
course and yet have always been fundamental to the nursing
profession. As they are not new, they are not included in the
model below. The next characteristic to emerge was the idea of
sustainability, which this analysis now suggests is underpinned
by three newly defined dimensions that are included in the
model presented below. The model attempts to unite the three
dimensions into a cohesive framework for practice. By high-
lighting one dimension, we attempt to show that no matter
where nurses practise, they need equal knowledge from each
dimension.
The model presented in the graphic above has emerged from
the analysis of the voice of nursing scholars about globaliza-
tion. Various authors argue the proposition that broad charac-
teristics of nursing should include a commitment to social
justice and sustainability. There is a call within the nursing lit-
erature for a reconnection with the three essential attributes of
nursing:
1 All nursing practice can be defined within three levels of pre-
vention and if this is to be achieved, nurses need to acknowledge
that absence of disease is not their primary goal; rather, it is
well-being after illness.
© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses
83
2 Nurses need to move from understanding the environmental
to understanding the ecology of illness. Nurses have always been
well informed about the biological determinants of disease.
However, it is recommended that nurses move beyond concen-
trating on human biology and the physical environment to a
consideration of human ecology, consisting of not only the psy-
chosocial and biological but also the environmental determi-
nants of disease.
3 Nurses need to look beyond local influences on the well-being
of clients towards national and global events that have direct
impact on people’s lives.
Each of these elements forms the basis of what nurses need to
know to practise in a globalized world.
The nursing profession, that is, nurses and nursing practice,
will be effective in a globalized world when we focus not only on
the clients of today but consider the clients of tomorrow in our
actions. Nurses need to know that living sustainably is not just
about global warming, saving trees or any of the other single-
issue interventions that appear in the mass media – it is about the
very nature of the way we live and work as nurses on this planet
(Brown 2008). The model presented (Fig. 1) provides insight
into what nurses who wish to act under a framework of practice
in a globalized world may think about when practising nursing.
What this article presents is an integrated framework to explain
nursing action in a globalized world.
A limitation of this analysis is that while many of the articles
included important editorials and opinion pieces by internation-
ally respected nurses, very little discussion on the topic has come
from practising nurses. This paper puts the issues for nurses of
working in a globalized world back into the hands of people in
the field and is intended to trigger an ongoing discussion on the
topic.
Conclusion
There is little doubt that our world is globalized; nurses have
responded to this new world challenge in various and often
disparate ways. While this paper helps to better understand a
cohesive framework for curriculum development on the topic of
globalization, it more importantly offers an analysis of literature
that contributes to the broad dialogue on the topic of how nurses
might respond to the challengers of a globalized world. Respond-
ing to globalization is essentially about what each of us does
locally but now also includes a broader context for nurses who
now need to reflect on the idea that to act locally is to have a
global impact.
Acknowledgements
No funding has been received for this research. We acknowl-
edge the help and support of Sydney Nursing School of the
84 J. Grootjans & S. Newman
University of Sydney, in particular Mary Chiarrella, who offered
helpful critical comments on the early drafts of this
manuscript.
Author contributions
John Grootjans: Initial concept development, substantial contri-
butions to conception and design, undertook the acquisition of
data as well as analysis and interpretation of data, undertook
preliminary drafting of the article, undertook ongoing critical
revision for important intellectual content and has given final
approval of the version to be published.
Stuart Newman: Substantial contributions to conception and
design, participated in the acquisition of data as well as analysis
and interpretation of data, undertook ongoing critical revision
for important intellectual content and has given final approval of
the version to be published.
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Supporting information
Additional Supporting Information may be found in the online
version of this article:
Appendix S1 Key themes to emerge from this concept analysis
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