The increased movement of both goods and people increases opportunities for the spread of disease around the world. There are also concerns about the following: potential public health problems due to market liberalisation, the emergence of new diseases globally and worsening of existing ones due to climate change and governmental oversight over economic policies that can affect spending on healthcare. International cooperation as a result of globalisation has also had a great impact on health practices in many countries including Europe.
You are a health care worker in a management position at the WHO office in Geneva employed as medical technician responsible for supervising WHO activities in some central European countries.
Globalization describes increased global integration in the economic, social, technological, cultural, political and ecological spheres. It is the product of the emergence of the global economy, expansion of transnational linkages between economic units creating new forms of collective decision making, development of intergovernmental and quasi-supranational institutions, intensification of transnational communications and the creation of new regional and military orders. [Hershock, Mason& Hawkins, 2007, p.30] Over many centuries, human societies across the globe have established progressively closer contacts. Recently, the pace of global integration has dramatically increased. Unprecedented changes in communications, transportation, and computer technology have given the process new drive and made the world more interdependent than ever. Multinational corporations manufacture products in many countries and sell to consumers around the world. Money, technology and raw materials move ever more swiftly across national borders. Along with products and finances, ideas and cultures circulate more freely. As a result, laws, economies, and social movements are forming at the international level.

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Globalization is characterized by the circulation of goods and services between countries in response to criteria of efficiency. Such multilateral agreements between countries, unfortunately, often function to the detriment of the countries with less developed economies. Nevertheless, trade can also benefit developing countries. Outsourcing is one situation in which developing countries that are able to adopt standards, processes, and language of developed countries can benefit from the liberalization of the movement of goods and services. By undertaking some or all components of production or service provision for clients/consumers in the developed country, some economic benefits may occur to the developing country where the ‘outsourced’ service is provided.
But what, we might ask, is the impact of the process of globalization generally and outsourcing more particularly in the health care sector?
The movement of professionals in general tends to be detrimental to poorer countries. There are two aspects to this. The most classic is the settlement of young professionals, originally from less developed countries, in more developed countries from which they have graduated with professional credentials. A second phenomenon is the policy of some rich countries, who because they lack doctors and nurses, try to recruit recently trained graduates from poorer countries. The movement of professionals in this way is facilitated by systems that recognize degrees internationally.
We foresee at least two issues that should be considered. The first is the potential of such developments to improve the quality in health care within the world. The second relates to issues of access to health care and the ethical dimensions associated [Villa-Caballero L. Globalization and bioethics in health resources (Spanish). Gac Med Mex 2004; 140 (1): 103-106].
Developing international standards in medical education and health care delivery can help improving quality in health care all over the world. Nevertheless, two questions remain. To what extent can one be sure that international standards can be created that will fit the cultural, social, and economical contexts of very different countries? It is often assumed that, simply demonstrating compliance with quality processes, will lead to a result (of the education or of the treatment) that will be the same, whatever the country or the professionals involved. But to what extent can we be sure that applying, for example, North American (or European, or for that matter African or Asian) procedures and quality rules in other countries will lead to adequate quality?
Without doubt, globalization poses risks to global health, but it also provides benefits.
And although many non-governmental organizations (NGOs) decry the negative effects of increasing globalization, they have also clearly benefited from it to improve healthcare delivery and health policy in many developing countries. A recent key contribution of the global NGO movement lies with the adoption of the Framework Convention on Tobacco Control (FCTC). NGOs had an essential and vital role at the local, national and international levels in all development phases of the FCTC (Mackay, 2003) (Mackay J (2003) The making of a convention on tobacco control. Bull WHO 81: 551), and their contribution continues as they actively work with countries in the FCTC ratification process.
Globalization has also brought about improvements in research methodology, and some argue that clinical research has become more sophisticated as a result (Wassenaar, 2003) Wassenaar W (2003) Providing services globally: the experience of an internet pharmacy. Healthc Pap 4: 69−74. Other benefits of globalization include cross-border use of health services that benefit patients and provide much needed resources to national health systems (Jain, 2003) (Jain SC (2003) Globalization of medical services: antidote for rising costs. Healthc Pap 4: 39−44)and improved regulatory practices (Wassenaar, 2003) Wassenaar W (2003) Providing services globally: the experience of an internet pharmacy. Healthc Pap 4: 69−74. Finally, one should not underestimate the power of knowledge as it empowers populations and individuals and, in turn, allows them to hold to account their political and professional leaders (Ellis, 2003) (Ellis P (2003) Globalization of healthcare: a UK perspective. Healthc Pap 4: 45−49).
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Assess the influence of international institutions in healthcare settings
The term ‘globalization’ describes the integration of economic systems through improved communication, but it also represents increased insecurity for those with few resources – particularly refugees. This article examines why people migrate, their numbers, constraints on their movement and their particular health care needs. Immigrants have much to contribute to their recipient countries, but at some loss to their homelands. Both economically and morally, more liberal immigration policies would be beneficial. Policies towards asylum seekers should not be more restrictive in the aftermath of 11 September 2001 and detention should be the exception rather than the rule. Globalization should be managed so as to improve people’s lives throughout the world.
Quantifying the effect of the EU on the healthcare sector is impossible. For every concrete example, such as the standardization of pacemakers or urinary catheters, there is an intangible one where the benefits cannot be measured. How, for example, do you measure the benefit of the EU-supported exchange and cooperation among hospitals, medical schools, and universities? European Union-funded programs, such as the Socrates-Erasmus Program to promote exchange of teachers and students, and the Leonardo da Vinci Program supporting exchange between healthcare professionals, have unforeseen spin-offs. Health telematics is another huge domain where there has been extensive collaboration. Electronic healthcare records, common European health cards, international data exchange, and the plethora of high-tech telemedicine projects – the scope and potential for co-operation and exchange if not total harmonization are endless.
The greatest challenge facing the EU, however, is undoubtedly European enlargement. To join the ‘club’, applicant countries need to meet stringent requirements. In its turn, the EU, and its institutions, will have to transform into a more transparent and workable entity. Considerations other than health will continue to dominate its business for the foreseeable future. But striving to create greater equality between western Europe and the poorly resourced member states of central and eastern Europe (with their notably worse morbidity and mortality) is a challenge to rise to. For what is the European dream about, if not that?
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Evaluate the impact of European Union membership on workplace health practices.
The European Union (EU) is obliged to improve public health and to ensure a high level of health protection in all fields of Community policy. In a few areas, namely workplace health and safety and consumer protection, it is even entitled to set minimum standards for the Member States. However, even in the few fields where the EU exerts explicit regulatory authority, it only plays a subsidiary role, limited to promoting cooperation among Member States and complementing national policies. In general it is only allowed to take action where European activity is supposed to produce better results, rather than act at the Member State level. Moreover, member states still retain the competence to shape their national health care systems, e.g. the organization of health care delivery including the institutional organization of care and the division of labor among the various occupational groups.
Nevertheless, the EU is not unimportant in the field of health policy. The EU derives its influence mainly from the provisions of the Common Market and the Economic and Monetary Union (EMU). The creation of the Common Market in 1992 not only provided for the free movement of capital and goods, but also of people and services, the so-called “four freedoms”. These principles also apply specifically to the health care sector.
Therefore, the authority of Member States to shape their health care systems cannot be equated with unlimited freedom of action. The European Court of Justice has ruled that Member States must abide by the principles of free movement of goods, services, capital, and persons when exercising their authority. Thus, economic integration limits the member states’ freedom of action in health policy. The current text analyzes the effects of European integration on transnational migration of health professionals and the attempts to regulate it.
Finally, some countries have restricted the immediate unlimited free movement for employees from the newly admitted member states because of concerns that the job market may not be able to handle immigration from neighboring countries. Thus, Germany and Austria have introduced a five-year transition period during which immigration from Member States is not allowed. This period may be extended for another two years. Other Member States like Italy have restricted the total number of immigrant professionals to an annual maximum. Spain and Greece are especially interested in limiting immigration of foreign physicians and nurses because they already have quite a large supply of qualified health care employees. Thus, free movement of persons has not materialized completely for all Member States.
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Question 2
You are employed by Sahara oil company based in Qatar as their Occupational Health expert. You have responsibilities for the environmental health issues of Sahara oil’s operations in Qatar. As well, you are responsible for maintaining a healthy work force.
Identify the economics of adopting a policy of environmental awareness in heath care settings.
The healthcare industry produces millions of tons of waste each year and is one of the largest consumers of energy in the United States. This article focuses on how nurses can facilitate “green” hospitals and work toward environmental sustainability. The authors critically approach the topic from the perspectives of nursing, environmental health, psychology, politics, international health, economics, and ethics. Specifically, the article addresses the critical role of the professional nurse as a leader in the creation of environmentally friendly and holistic clinical practice.
According to the World Health Organization, close to one fourth of the diseases experienced by the world’s population can be attributed to environmental exposures.( Wilburn S. Overview and summary: environmental health: important choices for a greener world. Online J Issues Nurs [serial online]. 2007;12(2). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN?TableofContents/Volume122007/May31/EnvironmentalHealthImportantChoicesforaGreenerWorld.aspx ) The healthcare industry contributes to this by producing more than 2.4 million tons of waste each year and is one of the largest consumers of energy in many communities.2(Sattler B, Hall K. Healthy choices: transforming our hospitals into environmentally healthy and safe places. Online J Issues Nurse [serial online]. 2007;12(2). http://journal.medscape.com/mjm
Hospital waste and energy consumption affect the health of the environment and, consequently, the health of each human being within the environment. While hospitals have the responsibility to treat the sick within their walls, they are also responsible to make sure their “walls,” their environmental practices, promote the health of clients, staff, and the environment. The duty of maintaining an environmentally friendly hospital is shared among numerous stakeholders within the organization.
Nurses, having a holistic viewpoint, responsibility to serve the public, and strong desire to care, have a duty and, importantly, the opportunity to make the hospital an environmentally sustainable environment. On the basis of the holistic perspective of nursing, this article examines how environmental, psychological, ethical, political, and international health issues directly affect hospital efforts to go green. The article provides specific ideas for how nurses can become vanguards for hospital greening initiatives, in both hospital and community settings.
Assess the actions that need to be taken by organisations to maintain the environment.
One of the greatest psychological barriers for hospitals to consider when going green is the myth that creating healthy buildings costs more money.5 According to H2E,21 the accounting processes of a majority of hospitals focus on the up-front costs of what it would take to “go green” and disregard the essential “life cycle costs” of green products. Laustsen3 describes the life cycle cost as the cost benefit of a product over the span of its life. He and other specialists agree that while improving current hospital systems will initially require additional funding, after a few years, the additional amount spent is returned via energy and time-savings and increased product longevity.3 The EPA notes that every dollar a nonprofit healthcare organization saves on energy is equivalent to generating $20 in new revenues for hospitals or $10 for medical offices.22
Two specific methods exist for a hospital organization to introduce both green products and cost savings to the hospital. Environmentally preferable purchasing (EPP) is defined by H2E as choosing those products and services whose environmental impacts are preferable to those of others.23 The EPP involves considering the amount of packaging per product, whether or not the product is single use, and the extent to which the product is made from recycled materials. The Energy Star for Healthcare program exists as a wonderful resource for obtaining EPP products and information, and numerous state organizations sponsor energy-efficient programs that partner with Energy Star for Healthcare. H2E can help hospitals perform EPP through their portfolio planner, available on the organization’s Web site. CleanMed conferences provide any easy, hands-on method for hospitals to know how much they will spend and what EPP products they will receive. Along with EPP, the H2E also promotes pay-as-you-throw contracts for waste management. In these contracts, hospitals are charged on the basis of the actual amount of waste disposed. Pay-as-you-throw contracts entice hospitals to reduce solid waste, which consequently decreases disposal costs.24 These contracts also easily allow hospitals to track exactly how much waste they produce and dispose of, which provides necessary data for greening program evaluations (see Table 2).
Hospitals worldwide face dilemmas in the process of becoming environmentally sustainable, and evidence suggests that developing nations experience more obstacles in this area. One of the most influential obstacles is the lack of hospital infrastructure to control waste disposal. In Gaza, limited administrative responsibilities toward environmental and public health are attributed to deficient organizational structures in managing hospital waste.26 This phenomenon is similar to the lack of hospital environmental health enforcement personnel.6 Yet, unlike the United States, national policies and guidelines regarding medical waste management and standardized disposal methods are often scant in many countries.27 Even when government regulations are in place, it may be difficult for low-income countries to enforce them because there is little public pressure to do so.28,29 Also, hospitals in developing countries often lack proper supplies, personal protective equipment, and appropriate refuse collection services and storage facilities.26,29 Lack of equipment contributes to pollution and undoubtedly predisposes hospital staff to contracting various pathogens, creating a public health concern.
Patil and Pokhrel30 explain that, in India and other developing countries, lack of environmental awareness and insufficient appreciation among staff make waste management initiatives difficult to implement. The authors also acknowledge that the bedside nurse is responsible for the initial segregation, disposal, and storage of hospital waste and thus possesses a crucial position in minimizing environmental harm. In Indonesia, awareness among staff, including the experienced nurses, may be low for several reasons: unwillingness to participate, minimal motivation, and improper training and education regarding waste disposal.28 Reasons for poor medical waste management in Dhaka City, Bangladesh, can be attributed to a lack of awareness, dearth of appropriate policy and laws, and apathy.29 In Iran and Tanzania, the staff’s unwillingness to participate, lack of motivation, and deficient training and education about green initiatives were reasons why waste management programs did not succeed.28
Researchers and environmental activists believe that resolution of these issues is possible. Activists believe that a key step in doing so is to raise hospital staff awareness because, as Chaerul et al state, “the performance of the waste segregation process depends on the knowledge of the hospital’s staff at the points of generation.”28. If nurses are to be accountable for waste disposal, it is imperative that they understand the waste life cycle, no matter where they are. When environmental awareness in developing countries is established, strong environmental controls and legislative policy are more likely to be enacted and higher standards regarded when considering the disposal of waste.31 Once government and hospital policies are introduced, refuse management projects can be categorized as such: source reduction, solid waste recycling and reuse, solid waste treatment, and solid waste incineration and disposal, according to Karamouz et al.32 Within these categories are the concepts of color-coded bins for different types of wastes and the implementation of multiuse, sterilized supplies.27,29,30 By joining the environmental sustainability bandwagon, US hospitals can hopefully become trendsetters for other countries to follow.
Specify the measures that exist to improve workplace health and safety practices
The ethical duty of a nurse to promote environmental health is one that persists not only in the hospital working environment but also in the community and world at large. As Dinkins and Sorrell13 note, this duty can take shape through educating patients and staff, performing research, and joining environmental health advocacy groups. Whether in the hospital or community, nurses can use the nursing process in education and policy efforts to promote “going green.”
Perhaps the most integral and basic education method for nurses is self-education, including continuing education. Environmental health nurse Ballard33 strongly encourages continuing education workshops on environmental health in the hospital setting. Nurses need to strongly advocate for required continuing education that includes basic information on environmental sustainability in the healthcare workplace. Basic information should address the environmental impact of hospitals, safe pharmaceutical disposal, PVC materials, recycling and energy conservation efforts, and those hospital committees that affect change. At the preventive level, nurses can advocate for this education to occur as part of new staff orientation and serially, with annual updates. Nurses and nurse educators could utilize the resources provided by the H2E, such as educational teleconferences, the technical assistance hotline, and the online waste priority planner, to enhance educational sessions.
As more nurses gain environmental health awareness, the shift must be from not only educating one’s self but also transferring this knowledge to allied healthcare staff. Nurses retain the duty of working with top hospital officials and key hospital stakeholders to improve the hospital’s environmental impact and create positive change. Nurses can use current literature to advocate for the environmental health, economic, political, and ethical incentives of going green. Sattler and Hall2 encourage nurses to demonstrate how “going green” remains a goal of The Joint Commission, the EPA, and the Institute of Medicine. As holistic practitioners, nurses must remain aware of the psychological phenomenon of unfreezing, moving, and refreezing in the change process. They must be prepared to educate staff about new “greening” practices and ways to become involved in these practices. As units introduce new, green products, environmentally aware nurses can provide needed education about their use and benefit.
In addition to advocating for integral environmental health education within the hospital, inpatient nurses can advocate for increased education in the community. Specifically, nurses can petition to the American Association of Colleges of Nursing to promote environmental health education as part of the core curriculum in nursing programs throughout the United States. Nurses could provide evidence that early education can prevent environmental health violations and introduce a passion for environmental health among the future nurses of America. The concepts of going green could be incorporated into all levels of nursing curricula, both in teaching and in practice, to promote increased environmental awareness. One such highly successful college-based environmental health program exists at the University of Maryland and has produced numerous environmental health nurse leaders and hospital-based greening programs.34 By writing petitions to state nursing boards, nurses can hopefully receive funding for continuing environmental health education. The H2E Web site provides a plethora of educational material to assist in implementing successful educational programs.
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Question 3
As a health care worker with managerial experience, you have been appointed as the most suitable candidate for for the post of health advisor, by a pharmaceutical company in Mumbai, India, that scources clinical trial contracts from abroad, especially the United States of America and western Europe. Because of its international operations, the work force of the company is also varied with employees from various countries around the world. As a manager, you are not only responsible for managing a section of the workforce; you are also responsible for the health and safety issues of the company’s workforce.
Analyze the responsibilities of organizations in improving work place health and safety.
All organizations employing five or more people must have a written Health and Safety Policy statement. The policy should cover all aspects of the organization and be relevant to all employees.
A Health and Safety Policy demonstrates how seriously an organization takes its health and safety responsibilities. A good policy will show how the organization protects those who could be affected by its activities. The policy should be of an appropriate length and relevance to the activities and size of the organization.
The occupational health nurse’s traditional role of evaluating occupational hazards is uniquely difficult in the pharmaceutical industry due to the continuous discovery of new compounds. Awareness of new chemicals and knowledge about their hazards are essential. The authors address these specific challenges as well as nurses’ changing roles in industry.
Pharmaceutical employers have a vested interest in maintaining worker health & safety. Because their products are intimately tied to the health care community, employers in this industry need to excel in worker safety and the systems that ensure worker and environmental protection. The benefits are clear. Employees who believe that their employer cares for their health & safety and the environment are more likely to be a positive advocate for the company and its products. As in any manufacturing setting, worker health and safety is enhanced by engaging employees in solutions to workplace health & safety issues, proactive management response, and reasoned infrastructure investments. A well-designed, comprehensive Environmental Health and Safety (EHS) program can also help address community concerns that can develop from pharmaceutical industry activities.
Exponent is well versed in the dynamics of health & safety within industry and specifically the dynamics unique to the pharmaceutical industry; both in the US and internationally. For example, consulting personnel have directed EHS organizations within the Pharma industry, participated at both State and National levels setting occupation exposure limits, performed epidemiological and risk assessment studies on pharmaceuticals, assessed facilities for the causation of exposures and contamination, and participated in the design of new facilities. Further, Exponent can directly support employers with: a.) Pre-exposure third party risk assessments of facilities, system audits, and efficacy of EHS management systems and practices; b.) Product containment and facility alarm systems; c.) Post exposure root cause analysis, containment, decontamination, and clearance; d.) Change management in the Pharma workplace; e.) Education, communication, and assessment of community concerns regarding environmental impacts and worker health and safety issues; f.) Long-term epidemiological studies; g.) Management, toxicological assessment, and review of new compounds and intermediates.
From R&D, to manufacturing, pharmaceutical management should expect their EHS program to maintain employee and community exposures as low as reasonably achievable and reap the benefits of improved employee morale, positive community and media perceptions, and minimization of the costs associated with unexpected events.
Review approaches to the management of diversity in healthcare settings.
Diversity management programs combine Equal Employment Opportunity and Affirmative Action with internal organizational initiatives such as diversity sensitivity training. These diversity management policies and initiatives may be interpreted and enacted in various ways. This exploratory study was designed to investigate how managers interpreted the meaning of diversity management and enacted EEO/AA laws and diversity initiatives in a hospital in the process of evaluating its diversity programming. Using a grounded theory approach, in-depth interviews with clinical and non-clinical managers were conducted. Several themes emerged, including professional differences in the legal and social understanding of diversity, the nature of managerial uncertainty, and the significance of formal and informal resources when managing diversity. Compare organizational approaches to ensuring positive policies of work place diversity.
Looks at the relationship between changes in the business world and managing diversity. Suggests the adoption of a balanced scorecard approach, to integrate diversity into business strategy and operational activities.
The report examines the theory and practice, to conclude that good diversity management does indeed add value. But it is not a quick-fix – organizations have to invest time and effort. There are warnings against paying lip-service to diversity – especially ignoring the organizational contexts and circumstances in making progress on diversity issues.
Employers can be active, proactive or reactive in relation to how they deal with diversity. Proactive employers make forward-looking decisions to employ diverse groups for reasons of business advantage. Active employers seek to engage in best practice when faced with the issue; while reactive employers seek to comply with the provisions of the law.
Legislation on anti-discrimination specifies the grounds upon which discrimination is banned. These grounds vary from country to country, but they typically include gender, race, disability, age, sexual orientation and religion. Diversity management programmes may focus on any of these issues but even in the case where legislation is a driver, it is rare to find programmes that focus on all of them.
National and EU level definitions of the areas to be covered by diversity emphasize the range of issues that are covered by the legislation. This comprehensive listing of issues reflects a broad concept of diversity that is apparently not reflected in the kinds of concepts used by companies in their diversity management programmes. In companies, DM tends to deal with one or two issues simultaneously (e.g. nationality, ethnicity), even though companies may have relevant programmes in other areas (e.g. older workers, disabled people). The concept (or perhaps the organisation) of DM used by companies is more limited than that implied by legislation.
Approaches to diversity management vary. Companies develop DM programmes for a range of reasons. Some companies are active in their approach, i.e. they tend to introduce DM in order to comply with legislation. Others are reactive – they introduce DM programmes in response to circumstance, e.g. when job applicants come from different ethnic backgrounds. Other companies are more proactive, i.e. they seek to take business advantage of the opportunities offered by a diverse workforce.
Role of legislation is complex. Legislation in the area appears to play a complex role in promoting diversity management programmes. In the public sector, legislation is more likely to act as a major driver, while in the private sector, companies may have other drivers operating, though compliance with legislation appears to be a useful additional benefit of DM programmes.
Depth of diversity management varies. Many DM programmes operate primarily through recruitment practices. There is a