American Nursing Scholars Abroad, Ayhan Aytekin Lash, Brigid Lusk, Madelyn A. Nelson

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1 Profession and Society American Nursing Scholars Abroad, Ayhan Aytekin Lash, Brigid Lusk, Madelyn A. Nelson Purpose: To explore the international activities of American nursing scholars from 1985 to 1995, as indicated by their international teaching, scholarship, and consultation. Methods: All faculty (N = 2,254) teaching in nursing doctoral programs in the United States were surveyed using an investigator-designed questionnaire. The professional characteristics of American nursing scholars who worked abroad and the dates, nature, and types of international activities they undertook were ascertained. From a total of 928 usable returns, 247 described international activity. Findings: Data indicated a three-fold increase in international activity from 1985 to 1995 in the three major areas investigated. Universities in Western Europe and Asia were the most frequent recipients of nursing scholarly activity. The scholars or representatives of the host institutions made approximately half the initial contacts. The international hosts or U.S. universities were the predominant providers of funding. Nurses most likely to participate in international scholarly activity were senior faculty who were full professors in doctoralgranting institutions, published in international journals, presented educational topics, and were recognized by peers through membership in honorary organizations. Conclusions: A substantial increase in international nursing scholarship occurred during the decade studied, particularly related to teaching. JOURNAL OF NURSING SCHOLARSHIP, 2000; 32:4, SIGMA THETA TAU INTERNATIONAL. [Key words: international nursing, international nursing scholars, consultation] * * * The nursing profession in any one country, including America, will never be able to mobilize its resources fully and to have the desired influence until nursing around the world is strengthened to the point where all nurses share a common competence (Christman, 1979, p. 66). During the last decade, emphasis on nursing science in the global community has escalated (Christman, 1979; Henry, 1998; Ketefian & Redman, 1997; Uhl, 1991). Henry (1998) delineated the types of efforts to be undertaken to actualize global exchange of nursing knowledge. Henry advised initiating educational programs that integrated philosophical foundations of health care in other countries. She further recommended initiating nursing inquiry that prepared nurses for leadership in international organizations such as the World Health Organization and the International Council of Nurses. Ketefian and Redman (1997) addressed the need to create globally relevant nursing theories, research, education, and practice. Despite these calls for globalization, the international activities of U.S. nurses have not been extensively investigated. As a scientific discipline, American nursing has progressed from hospital-based training to a scientifically based profession with substantive structure. This study was designed to explore whether American nurses have increased their activities in other countries. Documentation of the extent of U.S. nurses international activity may indicate the influence of American nursing globally and may strengthen nurses worldwide sense of communal understanding and endeavor. Background Significant numbers of American nursing scholars participate in international nursing (Andrews, 1985a; May & Meleis, 1987). Andrews (1988) regarded international nursing as a subspecialty within nursing. However, minimal research has been conducted to provide empirical support to these assertions. Even the number of U.S. nurses working abroad is uncertain. In 1975, Rowe estimated that 22,000 U.S. nurses were working abroad at any given time, and Baker, Weisman, and Piwoz (1984) said the number in 1984 Ayhan Aytekin Lash, RN, PhD, FAAN, Beta Omega, Associate Professor; Brigid Lusk, RN, PhD, Alpha Lambda & Beta Omega, Assistant Professor; both at School of Nursing; Madelyn A. Nelson, EdD, University Libraries; all at Northern Illinois University, DeKalb, IL. This study was partially supported by Sigma Theta Tau International and STTI Alpha Lambda and Beta Omega Chapters. The authors gratefully acknowledge the guidance of Beverly McElmurry, RN, EdD, FAAN, and the contributions of those who participated in the study. Correspondence to Dr. Lash, 648 Chippewa Drive, Naperville, IL alash@anet.com Accepted for publication: July 6, Journal of Nursing Scholarship Fourth Quarter

2 was approximately 1,488. No more recent assessments were found in the literature. Furthermore, little is known about what these nurses were actually doing abroad. Baker, Weisman, and Piwoz (1984) surveyed 1,257 employers of U.S. health professionals, 23% of whom were nurses, working overseas. Approximately one-third of the nurses in Baker and associates study were in clinical practice, one-third were in public health, and the remainder were in areas such as administration and teaching. However, Baker and associates only minimally described the professional characteristics of these nurses. Wright and Korniewicz (1997) assessed programs or activities that supported international aspects of nursing education. They surveyed a sample of participants at 110 U.S. schools of nursing and 5 Latin American schools of nursing, with a questionnaire that included an assessment of international health projects of faculty. Thirty-four U.S. schools of nursing offered international projects in which faculty participated. These projects were primarily concerned with educational and service activities, but minimal further information was reported. Review of the literature revealed one detailed study, reported by Andrews (1985a; 1986) and Andrews and Fargotstein (1986), of nurses international activities. Andrews surveyed the international consulting activities of a purposive sample of 93 American nurses and conducted 25 interviews with nurses who had international consulting experience. Participants were recruited via requests to 50 U.S. universities and 50 U.S. agencies known to have nurses with international experience (Andrews, 1986). Additional participants were obtained through informal networking. The results showed that consultants provided assistance in the areas of practice (98%), education (90%), research (45%), and administration (39%). These nurses went abroad for visits ranging from 1 day to 3.5 years. Andrews (1986) reported that 89% had master s degrees, and 55% of the total sample had both master s and doctoral degrees. According to this study, the greatest participation was in the Middle East, East Asia, and Latin America. The consultants reported most frequent interactions with directors of nursing in hospitals (37%), university deans (37%), chief nurses (34%), and faculty (33%). Ben-David (1992) wrote that throughout educational history, the French, German, English, and American systems have served as centers and models for world higher education. Ben-David documented that these four educational systems became centers of learning because they developed a high degree of scientific excellence over time. He showed how this scientific excellence provided these four educational systems with high levels of selfsufficiency as indicated by their scholars writing textbooks, presenting high-level course content which drew international students, and conducting breakthrough research with use of local primary sources. Another index of self-sufficiency identified by Ben-David was the ability to train local and international scholars to advanced levels in the fields of science and scholarship. Ben- David argued that the success of the American educational system, together with its achievements in research after World War II, encouraged scholars in many other countries to imitate the American model. Furthermore, Ben-David asserted that education for the professions (the PhD in practice fields) was one of the most distinct, and by far the most influential, of innovations of American higher education. Consistent with Ben-David s (1992) analysis of the most influential world educational systems, the nursing profession in the United States has become globally influential. With everincreasing frequency American nursing scholars are now being asked to share their professional nursing knowledge and expertise internationally. Writing about the need for international research, Meleis (1989) said that American nurses constitute the largest pool of health care professionals who receive invitations to work abroad. The international influence of American nursing is also evident in the interest of international students who wish to pursue graduate nursing education in the United States. Colling and Liu (1995) reported an increase in the number of international students enrolled in U.S. graduate nursing programs over the past decade. However, the number of international graduate students in American nursing schools is artificially low because of the frequent requirement of nursing licensure for admission. Uhl (1991) said this requirement is an obstacle to admission of international nursing students to American graduate schools. Therefore, the number of graduate students enrolled in American universities cannot be used, as in other disciplines, as a proxy measure of the international influence of American nursing higher education. Mooneyhan, McElmurry, Sofranko, and Campos (1986) reported that schools of nursing with larger numbers of faculty and schools with graduate programs were more likely to have faculty involved in international activity compared to smaller schools and schools without graduate programs. The purpose of this exploratory study was to assess the international activities of American nurse scholars in greater depth. The specific research questions were: (a) What were the extent and nature of U.S. nursing scholarship abroad from with scholarship defined as international teaching, research, consultation and service? (b) What was the ranking of countries by number of visits by U.S. nursing scholars? (c) What was the ranking of nursing schools according to internationally active faculty? and (d) What were the demographic and professional characteristics of internationally active U.S. nursing scholars? Methods Sample Names of all nursing faculty (N = 2,254) from the 62 U.S. nursing schools with doctoral programs were identified through lists provided by the deans and by searching on institutional Web pages. A response of 1,010 (50%) was obtained from the 2,009 faculty who were successfully contacted. Of these, 82 either refused to participate or the response was unusable. Nine hundred and twenty-eight usable questionnaires were returned. The rationale for including only doctoral degree-granting institutions was based on the cost-effectiveness of the study and the focus on scholarship. Also, previous research showed that faculty in larger, graduate degree-granting institutions had 416 Fourth Quarter 2000 Journal of Nursing Scholarship

3 greater international involvement than did faculty at smaller or nongraduate degree-granting institutions (Mooneyhan et al., 1986). Furthermore, internationally active nurse scholars are likely to have graduate degrees (Andrews, 1985b). Of the 928 usable responses, 247 (27%) were from scholars with international experience. Of these, 239 (97%) were women and 149 (60%) were married. With respect to faculty rank, the largest group, 107 (43%), were full professors, 86 (35.1%) were associate professors, and the remaining were primarily assistant professors. In regard to citizenship, 227 (94.6%) identified themselves as citizens born in the US, 11 were naturalized citizens, and two were noncitizens. Nursing scholars with and without international experience (n = 247 and n = 681 respectively) were similar with regard to demographic variables, such as marital status and number of children, except that more of those with international experience were full professors (χ 2 p =.00). Instrument Career attainment research (Cole & Cole, 1973) has indicated that productivity in publication, quality ranking of workplace, professorial rank, and professional recognition were among factors associated with a positive career trajectory. Lash (1992) demonstrated the association of these variables with the career attainment of graduates of doctoral programs in nursing. These findings influenced design of the instrument American Nursing Scholars Abroad, The 17-item instrument included three sections: professional background, international activity, and demographics. Professional background was measured to assess its relationship to international activity. Questions related to faculty rank, institution, length of nursing career, area of specialization, scholarly productivity, and evidence of professional recognition were included in this section. Professional recognition was measured as awards received, membership in professional and honorary organizations, and service on editorial boards. The international activity section indicated the date and length of experiences, countries visited, name and location of host organization, means of initial contact, sponsoring organization, and the nature of the work, such as research, teaching, consultation, or service. Demographic variables included sex, marital status, number of children, country of birth, and languages spoken. Hayter s (1984) productivity ranking of nursing programs was used to discern any relationship between institutional quality and international activity by the program s faculty. Although Hayter s ranking is old, it was chosen for two reasons. First, it was current in 1985, the start of the period studied, and second, Hayter assessed institutional productivity through journal publications rather than by less scholarly variables such as program cost or the subjective appraisal of deans. The questionnaire was assessed for content validity by seven nurse researchers with extensive international experience. Their recommendations about validity, clarity, and ease of completion were incorporated as appropriate. Because only factual information about professional activities was sought, no attempt was made to establish reliability, such as through test-retest procedures. Procedures Approval for the study was obtained from the university s institutional review board. All colleges of nursing with doctoral programs were mailed packets containing envelopes individually addressed to each faculty member. The envelopes contained the questionnaire and a cover letter describing the purpose of the study, the rights of the respondent, and the confidentiality of the information. Return of the questionnaire indicated consent to participate in the study. Reminder postcards were mailed 2 weeks after the initial mailing and a second questionnaire was sent to nonrespondents. After data entry, before data analysis, the list of participants names with matching code numbers was destroyed. Duration of visits was entered in days. The few scholars whose visits extended over several years received a credit of one visit extending 365 days for every year of their stay. Relationships among the study variables were examined using correlational analysis, t-tests, analysis of variance, and path analysis. The schools with the most international experience and countries utilizing the most consultation were ranked, and the most frequent types of scholarship and specialties were identified. Institutions with internationally active faculty were compared with Hayter s (1984) productivity ranking of nursing schools. Results Extent of International Scholarly Activity Nearly a threefold increase in international activity by the respondents occurred between the years of , from 58 visits in 1985 to 148 visits in 1995, a 155% increase (Figure 1). During the decade, the 247 faculty had a total of 805 international experiences. Faculty from Oregon Health Sciences University made a total of 55 international visits, followed by faculty from the universities of Kentucky and Pennsylvania (40 visits each) and the University of Michigan (35 visits). The number of visits per faculty ranged from 1 to 28 (M 3.2, SD 3.74). The distribution of the internationally active respondents ranged from 1 to 13 faculty members per university, with Oregon Health Sciences University having the highest number followed by the University of Maryland at Baltimore and the University of Michigan. The average number of days spent Number of visits Year of Visit Figure 1. International visits per year. Journal of Nursing Scholarship Fourth Quarter

4 abroad over the decade was 74, with a range of 1 to 365 days per each year abroad. Consistent with these findings was an increase in the number of schools with international scholars, from 17 in 1985 to 37 in 1995, also a notable 117% increase. Initial Contact For the first visit, the visiting scholar initiated contact with an international site in 62 (30%) cases, and host institutions initiated contact in 60 (29%) cases. Colleagues abroad were responsible for contacting the scholar for the first international visit in 26 (13%) cases, while the scholar s home institution initiated 22 (11%) visits. A slight trend was noted from first to ensuing visits, in that the host institutions were more likely to initiate contact with the scholar on subsequent visits. For example, fifth international visits, made by 46 scholars, showed a slight increase in host-initiated contact (n = 16, 34.8% by host, and n = 14, 30.4% by scholar), and for the 14 nurse scholars who made a 10th visit, 50% of the visits were following contact initiated by the host institution. Types of International Work Experiences The most commonly identified area of international activity was teaching, followed by consultation and research. As Figure 2 shows, 242 scholars marked teaching, 219 marked consultation, and 206 marked research as their major activities. Topics of teaching included research designs and measurement issues, nursing theory development, bioethics, chronic illness care, pediatric pain management, cancer care, and community health nursing. Areas of research conducted included quality of life studies, replication of family dynamics studies such as family violence, instrument development and testing, health promotion, and HIV prevalence. Areas of consultation included curriculum development for undergraduate and graduate programs (most common), implementation of the clinical specialist role, grant writing, and research implementation. Other activities included program and faculty development for local nursing schools and personal study. Direct patient care was the activity reported by 32 scholars. For each year of the decade, teaching remained the most frequent activity. Thus, in the global market, the dissemination of nursing knowledge by U.S. scholars through teaching appeared to be the area in highest demand, assuming that reported activity indicates demand. Moreover, a substantial growth of teaching occurred in 1994 and 1995, with an almost threefold total increase in the amount of teaching undertaken, from 17 in 1985 to 42 in Locations of International Activity U.S. nursing scholars in this study visited a total of 109 countries throughout the world. These countries ranged in geographic location from South Africa, at the southern tip of the African continent, to Norway, Europe s most northerly point, and in size from China to the islands of Micronesia. The countries of Western Europe, followed by those in Asia, were the most frequent destinations (Figure 3). The countries most frequently visited were the United Kingdom (86), China (50), Canada (49), Japan (45), and Australia (39). Host Organizations and Sources of Funding The greatest percentage (40%) of the scholars visits were hosted by universities abroad (Figure 4). Hospitals, governments, and nursing organizations of the countries visited also regularly acted as hosts. Other local organizations hosted a total of 8% of the scholars visits. The finding that universities were the most common host organization indicates the scholarly nature of these international visits. Very few of the visits (1%) were funded by the scholars themselves. Local universities were responsible for 18% of the funding for the visits. They were followed by U.S. universities (15%) and foundations (10%) in frequency of providing funding. The United Nations funded 9% of the visits, which compares well with the funding provided by U.S. foundations. Characteristics of International Scholars Internationally active scholars collectively belonged to 21 nursing organizations. The largest membership was in Sigma Theta Tau International (n = 202), followed by the American Nurses Association (n = 179), the American Academy of Nursing (AAN) (n = 91), the National League for Nursing (n = 43), and the American Association of Critical Care Nurses (n = 25). In regard to language skills, Teaching Consultation Research Workshop Extended presentation Direct care Program development Study Tour Faculty development Other Service Technical assistance Religious E. Europe 7% Africa 7% Australia 6% N. America 8% C. & S. America 11% Middle East 5% Caribbean 2% W. Europe 32% Asia 22% Figure 2. Types of international work experiences. Figure 3. Areas of international activity by percentage of visits. 418 Fourth Quarter 2000 Journal of Nursing Scholarship

5 Nursing organizations abroad- 3% U.S. university sites abroad - 3% U.N. - 3% U.S. organizations - 3% Religious organizations- 4% Governments abroad- 5% Hospitals abroad- 6% Organizations abroad- 8% Other- 10% Figure 4. Hosting organizations by proportion of visits. internationally active scholars spoke a combined total of 31 languages. Spanish was the most common second language (n = 52), followed by French (n = 33). In addition, 53 nurse scholars spoke three languages and 12 spoke four languages. In evaluating the quality ranking of the schools, using Hayter s (1984) faculty productivity ranking, the majority (n = 134, 54%) of the internationally active scholars worked in those schools included in Hayter s ranking. Factors Associated with International Activity The following variables related to scholarly productivity of the respondents showed a significant correlation with international activity: nursing education presentations (r =.28, p =.00), articles in international journals (r =.18, p =.01), research articles (r =.14, p =.03), and writing books or monographs (r =.14, p =.05). Serving as a manuscript reviewer for professional journals also showed a positive correlation (r =.15, p =.03) with international activity. Further analysis of the factors that influenced professional activity showed that the number of international experiences was influenced by professorial rank; that is, the higher the rank, the more the international activity (F = 9.9, p = 00). In regard to the influence of recognition, membership in professional associations was the only factor significantly associated with international activity: Members of the AAN (r =.19, p =.00; t = 3.02, p =.00) had a significantly higher mean number of international scholarly visits. The mean number of visits by members of the AAN (n = 91) was 4.25, but it was 3.2 for the remainder. Nurse scholars who were naturalized citizens (n = 11, M = 5.91, p =.05) had a significantly higher mean number of visits than did those respondents born in the U.S. (n = 227). However, the small number of naturalized citizens in the sample limits the generalizability of this finding. Discussion Universities abroad- 40% No host identified - 16% In this study, the nurse scholar most likely to participate in international scholarly activity was a full professor who was located in a doctoral degree-granting institution, published in international journals, presented educational topics, and was recognized by peers through membership in honorary organizations. That teaching is the scholarly activity most frequently undertaken is evidence of global dissemination of nursing knowledge by these respondents. Through their willingness to host, and sometimes fund, visits by U.S. nursing scholars, universities abroad indicated an interest in U.S. nursing knowledge and educational expertise. Furthermore, the predominance of university funding, both foreign and domestic, showed the scholarly interest in these visits. In this respect, U.S. nursing scholarship appears to have gained international recognition. The findings that English-speaking countries collectively received the highest number of visits may indicate that issues of language, perceived safety, similarity of culture, and ease of travel are important in the international activities of nurse scholars. Moreover, citizens of these affluent countries may be more capable of providing funding. Therefore, creating funding resources for global exchange may be a vehicle for greater dissemination of nursing knowledge. This research provides documentation of the range of activities of American nursing scholars and geographical breadth of scholarly visits between The findings did not indicate the pervasiveness of U.S. international activity claimed by some authors. Only 247 (27%) of the 928 responding scholars reported international scholarly activity during the decade. Thus a majority, 73%, of the scholars who responded reported no international activity. In addition, a response bias may have occurred so that persons with international experiences were more likely to respond, further limiting these findings. However, those participants who were internationally active during the decade did so extensively, some making repeated visits, and mostly in the areas of teaching, consultation, and research. Conclusions The investigation of international activity in this study provided comparative historical data that indicated significant trends. However, this study was limited in its inclusion of only nurse scholars teaching in doctoral programs. Thus, international activity outside doctoral programs and universities was not investigated. Moreover, the findings are limited by the fact that only 50% of the 2,009 faculty contacted returned the questionnaires. In addition, those who were internationally active during the decade but were no longer at the universities contacted were inadvertently excluded from the study. The detailed nature of the questionnaire and the need to recall events as far back as 10 years also limit the generalizability of findings. Because the researchers (two of whom received their nursing education abroad) are particularly cognizant of scholarship emanating from other countries, continuation of this study to understand the nature of that scholarship is highly recommended. JNS Journal of Nursing Scholarship Fourth Quarter

6 References Andrews, M.M. (1985a). U.S. nurse consultants in the international marketplace. Journal of Professional Nursing, 1, 189. Andrews, M.M. (1985b). International consultation by United States nurses. International Nursing Review, 32(2), Andrews, M.M. (1986). U.S. nurse consultants in the international marketplace. International Nursing Review, 33(2), 50-55, 60. Andrews, M.M. (1988). Educational preparation for international nursing. Journal of Professional Nursing, 4, Andrews, M.M., & Fargotstein, B.P. (1986). International nursing consultation: A perspective on ethical issues. Journal of Professional Nursing, 2, Baker, T.D., Weisman, C., & Piwoz, E. (1984). United States health professionals in international health work. American Journal of Public Health, 74, Ben-David, J. (1992). Centers of learning: Britain, France, Germany, United States. New Brunswick, NJ: Transaction. Christman, L. (1979, October). Center of excellence in nursing-the conceptual model. Proceedings of Rush-Presbyterian-St. Luke s Medical Center, Chicago. Cole, J.R., & Cole, S. (1973). Social stratification in science. Chicago: University of Chicago Press. Colling, J.C., & Liu, Y.C. (1995). International nurses experiences seeking graduate education in the United States. Journal of Nursing Education, 34(4), Hayter, J. (1984). Institutional sources of articles published in 13 nursing journals, Nursing Research, 33, Henry, B. (1998). Globalization, nursing philosophy, and nursing science. Image: Journal of Nursing Scholarship, 30, 302. Ketefian, S., & Redman, R.W. (1997). Nursing science in the global community. Image: Journal of Nursing Scholarship, 29, Lash, A.A. (1992). Determinants of career attainments of doctorates in nursing. Nursing Research, 41(4), May, K.M., & Meleis, A.I. (1987). International nursing guidelines for core content. Nurse Educator, 40(5), Meleis, A.I. (1989). International research: A need or luxury? Nursing Outlook, 37(3), Mooneyhan, E.L., McElmurry, B.J., Sofranko, M.S., & Campos, A.B. (1986). International dimensions of nursing and health care in baccalaureate and higher degree nursing programs in the United States. Journal of Professional Nursing, 2(2), Rowe, E.L. (1975). The knowledge of American nurses serving in Ethiopia, Nigeria, and Liberia concerning the etiology and treatment of typhoid, typhus, and malaria. Unpublished doctoral dissertation, Boston University, Boston. Uhl, J.E. (1991). Globalization and nursing partnership. Journal of Professional Nursing, 7(1), 2-3. Wright, M.G.M., & Korniewicz, D.M. (1997). Study of international health activities at schools of nursing in the United States and some schools in Latin America and the Caribbean. Human Resources Development Publication Series #4. Pan American Health Organization. Washington, DC: World Health Organization. G R E E N S B O R O 420 Fourth Quarter 2000 Journal of Nursing Scholarship