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In the new age of international markets, car manufacturers
take a close look at what's happening in Japan and Germany when
dreaming up new models for American consumers. Financial analysts
follow money matters in Asia, Europe and the developing world as
closely as events on Wall Street. Italian designers stay current
with German engineers, and everyone keeps an eye open for the
latest product out of Silicon Valley.
Yet for all the transnational economic activity that takes place each day, remarkably little effort has been devoted to assessing the quality, cost of care and cultural aspects of various national health care systems. Medical research and biotechnology may be truly international in scope; yet the ways in which those findings are applied and administered are often based largely upon parochial health care traditions.
Now a new School of Nursing program run in conjunction with institutions both here and abroad has begun to address the need for a greater understanding of international health care issues. A year ago, the U.S. Department of Education and members of the European community awarded the school and its partners a three-year $400,000 grant to fund the Global Dimensions in Health Care investigative study.
This summer, the first students began site visits in the United Kingdom, Ireland, Sweden and the United States, including Johns Hopkins.
"Health care is becoming more global," said Fannie Gaston-Johansson, Elsie M. Lawler Associate Professor of Nursing and principal investigator for the project. "Once, many health care issues were geographically unique, but this is no longer the case. Culture is interconnected with health, and understanding how health care is practiced and understood in other countries can lead to a much broader perspective on health issues."
To implement the project, a consortium was created including Hopkins, the School of Nursing at Winston-Salem State University in North Carolina, the International Nursing Center at the American Nurses Association, the Department of Advanced Nursing Education at Gothenburg University in Sweden, the Swedish Association of Health Officers, the Nightingale Institute at King's College in London and the Department of Nursing at the University of Ulster in Ireland.
The Hopkins-led grant was one of only eight chosen from 130 proposals to be the first official educational partnerships of the federal government's New Transatlantic Agenda. It was the only one selected in the health care field. Other partnerships are in areas such as engineering and business development.
The first year of the grant was spent in planning the study. This year, four nursing students at the undergraduate, graduate or doctoral levels from each of the participating universities were selected to visit sites in other countries to observe how culturally constructed health systems deal with familiar medical and nursing issues.
Next year, which will be the third and final year of the project, each university will enroll five students in the program, including non-nursing students from schools of public health or related institutions. Student participants at Hopkins earn four credits for the study, which includes wrap-up sessions and written project assessments after returning to the United States.
This year's program of international exchange and cross-cultural study ran from June 23 to July 11 after an initial group orientation.
"We began the program in London, where all the faculty and students involved met for one week," Gaston-Johansson said. "The focus of that week was on issues of quality, equity and structure of various health care systems. After that, the students went out to the sites. Two of the Hopkins students went to Sweden, one to Ireland and one stayed in London."
"It was fabulous; a mind-blowing experience" is how undergraduate senior Judith Sanford described her monthlong stint in London. Sanford's plan to pursue a career in nursing administration led her to study nursing practices in large institutional settings.
"I spent most of my time in Guy's Hospital, which is a 1,000-bed hospital run in conjunction with St. Thomas's Hospital, another 1,000-bed hospital, both in London," she said. "The British staff were very friendly and helpful. They took me everywhere and showed me everything and were very eager to answer any questions I had about how their system works."
Sanford reports that, by American standards, British nurses are less well paid and find less prestige in what they do. "They do it for the love of nursing and for the rewards of caring for their patients," she said. "There is no glory in a nursing staff position at a large London hospital."
But what they may lack in prestige they more than make up for in a strict code of professional behavior. "The thing that really impressed me about British nursing was the focus on the patient and the focus on working as a team," she said. "They are very team-oriented, something I think we could do more of here."
That approach is particularly evident during a crisis, Sanford said, when "the British medical teams tend to get very quiet and very focused. In a way they tend to play down the crisis a little bit, instead of running around shouting like they do on ER. It's part of their commitment to professionalism."
Senior Kristen Kanerva, who graduated in May, found the Swedish medical system every bit as professional, but less focused on patient choice than in the United States. Kanerva, who hopes to earn a master's in maternal and child public health one day, spent three weeks in Gothenburg, Sweden's second largest city, exploring community health sites ranging from child health clinics to midwifery centers.
"My group [which included students from Winston-Salem] did a little of everything. We went to clinics, visited all the major hospitals, went into surgery, assisted in the emergency room and spent a lot of time interviewing and observing health care providers," she said.
Although the scope and quality of Sweden's fully socialized medical system is renowned, Kanerva was struck by how little input the patient has traditionally had in making medical decisions. "The idea of choice has always been important in America," she said, "while in Sweden patients have generally not had the same options. In Sweden, things are the way they are, and it's generally accepted. While here in America, if we're not happy, we go elsewhere."
Like most medical systems around the world, the Swedish are coping with longer life expectancies, greater medical costs and shrinking resources.
"They are going through changes to introduce more patient options," reports Kanerva. "The Swedish have a very high standard of living and expect universal health care to be part of their birthright. Now with some of the changes both patients and care providers are having to find resources, where before everything was taken care of. It's a very difficult transition for them to make."
While Kanerva and her classmates were investigating European health care delivery systems, four students from London, Sweden and Ireland were visiting a wide range of projects in Baltimore and Washington, D.C. Their stay included an hour-long meeting with Rep. Ben Cardin, D-Md., to discuss health care reform efforts in the United States, and a visit to the National Institutes of Health in Bethesda.
At Project HEAL, an East Baltimore experiment in using community-based health workers to deliver culturally competent care, the visitors heard project co-director Lori Edwards, an instructor in the School of Nursing, talk about the need in the United States for stronger community health and preventive services. Afterward, the students shared their impressions of American medical health care with their hosts.
"You have to keep in mind that Sweden is very small--only about 9 million people," said visiting student Anders Jonsson of Gothenburg University, "so our problems are on a much smaller scale. But now in Sweden we have many immigrants who are making new and challenging demands on the health care system. One of my interests is learning how we can cope with these problems and coming to the U.S. has exposed me to similar issues on a much larger scale. It has been a very useful trip."
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