Cross-cultural nursing research

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International Journal of Nursing Studies 46 (2009) 593–602 www.elsevier.com/ijns

Cross-cultural nursing research Riitta Suhonen a, Mikko Saarikoski b, Helena Leino-Kilpi c,* a

University of Turku, Department of Nursing Science/Health Care District of Forssa, Turku, Finland b University of Turku, Department of Nursing Science, Turku, Finland c University of Turku, Department of Nursing Science/Hospital District of Southwest Finland, 20014 Turku, Finland Received 16 May 2008; received in revised form 2 September 2008; accepted 6 September 2008

Abstract Background: International cross-cultural comparative nursing research is considered important for the advancement of nursing knowledge offering a global perspective for nursing. Although this is recognised in policy statements and quality standards, international comparative studies are rare in database citations. Objectives: To highlight the need for cross-cultural comparative research in nursing and to share some of the insights gained after conducting three international/cross-cultural comparative studies. These are: an examination of patients’ autonomy, privacy and informed consent in nursing interventions BIOMED 1998–2001, the ICProject International Patient Study 2002– 2006 and the Ethical Codes in Nursing (ECN) project 2003–2005. Results: There are three critical issues raised here for discussion from the international cross-cultural studies. These are: the planning and formulating of an international study, the conduct of cross-cultural research including the implementation of rigorous data collection and analysis and the reporting and implementing the results. Conclusion: International and cross-cultural nursing research is powerful tool for the improvement of clinical nursing practise, education and management and advancement of knowledge. Such studies should be carried out in order to improve European evidence based health care development in which the patients’ perspective plays an important part in the evaluation and benchmarking of services. # 2008 Elsevier Ltd. All rights reserved. Keywords: Cross-cultural research; International collaboration; Nursing

What this paper adds

What is already known about the topic?  International cross-cultural nursing research is considered important for the advancement of nursing knowledge and there is need for global perspective.  International multi-country comparative nursing studies are rare in database citations and reasons for this may include the philosophical, conceptual, methodological, operational and financial challenges met when conducting international studies. * Corresponding author. Tel.: +358 2 3338404; fax: +358 2 3338400. E-mail address: [email protected] (H. Leino-Kilpi).

 Gives reasons for a global approach to clinical nursing, nurse education, nursing science and research which can be divided into the following categories: (1) fundamentals of nursing practice, science and research, (2) the global nature of nursing care, (3) health care reforms, systems and organisations and (4) patients as health care customers.  Raises three critical issues from the international crosscultural studies based on the literature and three examples of an international collaborative multi-country studies. These are the planning and formulation of an international study, the conduct of cross-cultural research and the reporting and implementing cross-cultural results.

0020-7489/$ – see front matter # 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2008.09.006

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 Gives support and motivation for international collaborative studies in order to facilitate the understanding of the outcomes of nursing interventions in global terms so that nurses will be able to treat and care for patients of different cultures more effectively. 1. Introduction International cross-cultural nursing research is considered important for the advancement of nursing knowledge (ICN, 1999, 2006; Mapanga et al., 1999; WENR, 2001; Freshwater et al., 2006). This is recognised in policy statements and quality standards (e.g. Department of Health, 2001; ICN, 2004, 2005). The organisation of health and nursing care and nurse education are also influenced by international agendas and agreements (e.g. NHS, 2000; EC of the European Parliament and of the Council, 2002; European Union, 2004; OECD, 2004; European Commission, 2005; WHO, 2006). For example, the International Council of Nurses (ICN, 2007) stated that there is a need for research in areas which are meaningful to nurses’ daily practice, have health care practice implications and lead to improved outcomes for patients. Despite the need for a global perspective for nursing, international comparative nursing studies are rare in database citations (ChiangHanisko et al., 2006). The reasons for this may include the philosophical, conceptual, methodological, operational and financial challenges met when conducting international studies (Freshwater et al., 2006). Nursing research literature provides little information regarding the process and study protocols involved in international cross-cultural studies (e.g. Mapanga et al., 1999; Kearney et al., 2000; Chiang-Hanisko et al., 2006; Freshwater et al., 2006). To improve this the processes and issues arising from three examples of cross-cultural comparative nursing studies from the area of nursing ethics are discussed. These are: a project examining patients’ perceptions of autonomy, privacy and informed consent in nursing interventions (LeinoKilpi et al., 2002, 2003a,b; Schopp et al., 2003, 2004; Scott et al., 2003), the Individualised Care Project (ICProject) from patients’ point of view (Suhonen et al., 2008) and the Ethical codes in Nursing (ECN) project which explores nurses’ opinions of the content and function of the use of ethical codes (Heikkinen et al., 2006; Tadd et al., 2006). The patients’ autonomy, privacy and informed consent in nursing interventions study was funded by the European Commission BIOMED2 programme and conducted between 1998 and 2001. This empirical study focused on both patients and nursing professionals in five European countries, Finland, Germany, Greece, Spain and the UK (Scotland) and was co-ordinated by the University of Turku, Department of Nursing Science. The purpose of the project was to evaluate the realisation of autonomy, privacy and informed consent in surgical, maternity and long-term elderly patients (Leino-Kilpi et al., 2002, 2003b). More information about this is available in the web pages of

the project at: http://www.med.utu.fi/hoitotiede/tutkimus/ tutkimusprojektit/biomed/index.html. The ICProject International Patient Study (2002–2006), was an international comparative and correlation survey, carried out to explore the level of individualised care received in hospital from the orthopaedic and trauma patients’ perspective (Suhonen et al., 2008). It was part of a larger project which can be found at: http://www.med. utu.fi/hoitotiede/tutkimus/tutkimusprojektit/ic_project/ index.html. The aims of the ICProject International Patient study were: to provide a methodology and validate an instrument for the development of individualised nursing care and to describe and compare individualised care from the patients’ point of view in five countries, viz. Finland, Greece, Sweden, the United Kingdom and the USA. A total of 10 researchers were involved in the research group. The study was funded by four Finnish organisations. ECN was an international research project co-ordinated by the University of Maastricht during 2003–2005 (http:// www.zw.unimaas.nl/ecn/). The primary goal of the project was to contribute to discussions and policies harmonizing ethical standards for nursing practice and the nursing professions in Europe. This was done by identifying, clarifying and analyzing the moral values underlying ethical codes in nursing and by exploring their functions in nursing practice, education, and management. There were eight partners, from seven different countries responsible for carrying out this project. These were Belgium, Finland, Greece, Italy, the Netherlands, the United Kingdom and Poland. The programme was made possible by a grant from the European Union under the Fifth Framework Programme (Quality of Life and Management of Living Resources QL6G-2001-00945). The aim of this paper is twofold: to highlight the need for cross-cultural comparative research in nursing and to share some of the insights gained from literature and conducting three international/cross-cultural comparative studies.

2. The reasons for the need of international crosscultural research Nursing care is of global concern, and so it is important to examine the understanding of health and nursing care problems on an international basis (Im et al., 2004; Freshwater et al., 2006). Discussion about a global approach to clinical nursing, nurse education, nursing science and research can be divided into the following categories: (1) fundamentals of nursing practice, science and research, (2) the global nature of nursing care, (3) health care reforms, systems and organisations and (4) patients as health care customers (Table 1). 2.1. Fundamentals of nursing practice, science and research Nursing research should be directed towards improving the understanding of the outcomes of nursing interventions

R. Suhonen et al. / International Journal of Nursing Studies 46 (2009) 593–602 Table 1 Reasons for international approach on nursing and research. Fundamentals and the global nature of nursing practice, science and research Lack of knowledge about the interventions of patient care delivery The universal philosophy and nature of nursing Globalisation, travel and increasing mobility The basic concepts of nursing science share global meaning and interests Global interest in nursing research for the investigation of the outcomes of nursing interventions Issues for the global development of clinical nursing care To find out about the cultural variations in basic concepts in nursing practice The applicability of research evidence about specific nursing phenomena Health care reforms, systems and organisations The need for improvement in the processes and outcomes of care Restructuring and harmonisation of health care systems and education in the European Union Demand for the flexible use of the healthcare workforce and shortages in the health care workforce Patients Similar age profile of the population in European countries Patients’ expectancy of transparency about the performance and quality of care services Differences across countries in care outcomes from the patients’ perspective

to ensure the quality of nursing care so fundamental to patients (Hinshaw, 2000; ICNE, 2003; Niven and Scott, 2003; ICN, 2005). This is especially important because one of the most acute deficits in nursing knowledge is a lack of insight into the day-to-day activities, judgements, decisions and interventions of staff nurses at the cutting edge of patient care delivery (Niven and Scott, 2003). We also have little understanding of how, or indeed whether, staff nurses identify or articulate these activities, judgements, decisions and interventions using a moral dimension rooted in respect for the needs and perceptions of the individual patient (Niven and Scott, 2003). 2.2. The global nature of nursing care The increase in inter-European travel and the facility for European citizens to be treated throughout the European Union (EU) means that health care professionals need to have the competence to treat patients, of different cultures, in a culturally sensitive manner (e.g. Jones et al., 2004). Issues related to ethical questions in nursing may be of universal interest but some ethical phenomena accepted in a democratic country may be inappropriate in a country where the concept of individual rights does not exist (Lutze´n, 1997). Similarly although nursing has many universal core elements individual foci of nursing research may have different connotations in different cultures and be perceived differ-

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ently by health care professionals (Im et al., 2004; Gopal et al., 2005; Chiang-Hanisko et al., 2006). Therefore, as the domestic nursing knowledge base expands, the research evidence needs to be examined to assess whether it is applicable internationally. Nurses in different countries do not work in isolation but in teams and in different contexts. It is therefore important for practitioners and researchers to be able to perceive themselves in the context of global developments (Freshwater et al., 2006). Because of the universal nature of nursing, international comparative studies may facilitate this change in perception by identifying issues for international development working to harmonise care delivery and patient outcomes. Expanding a research project from a national to an international level certainly involves new practical considerations (Chiang-Hanisko et al., 2006) posing challenges to the promotion of international scholarly efforts in nursing in Western countries. 2.3. Health care reforms, systems and organisations Health care and hospital systems have undertaken similar restructuring interventions in the developed countries (European Union, 2004; OECD, 2004; Network for Future Regional Health Care, 2006) particularly ones aimed at reducing labour costs through work redesign (WHO, 1996; Lankshear et al., 2005; Camerino et al., 2006). For example, in addition to regulations and directives from the EU there are verdicts from the European Court of Justice that facilitate inter-European harmonisation including health care (EC of the European Parliament and of the Council, 2002). A move towards a more flexible international healthcare workforce (Norman, 2007) and increasing mobility of health professionals (European Union, 2004) increases the need for an international examination of health care systems. The nursing profession throughout Europe currently experiences differing educational structures and practices. Professional and student mobility is low and it is difficult for nurses to transfer their education and expertise in an appropriate manner across the EU or on wider areas (TENN, 2003; Marrow, 2006). In Europe, there is ongoing collaborative work, which contributes to the integration of nurse education. European Commission (2005) has started to define minimum standards for the content and duration of basic nurse education in countries including the EU. Such integration has been given strategic importance through national directives, national curricula, which order the organisation of clinical education at national level. This integration process needs research as well, which is focused on these emerging nursing educational systems and must be international. Only a few cross-cultural studies have been undertaken in this field (French et al., 1996; Lusk et al., 2001; Saarikoski et al., 2007). Population trends, such as aging, show similar trends in European countries (e.g. OECD, 2004; Network for Future Regional Health Care, 2006; WHO, 2006). Although the number of nursing professionals employed in the different

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European countries varies widely (WHO, 2006; EUROSTAT: http://epp.eurostat.ec.europa.eu; OECD: http:// www.oecd.org/statsportal) the age profile of nurses internationally shows that many nurses will retire in the near future. In some countries this may lead to local nurse shortages encouraging the migration of nurses across countries (WHO, 2006).

comes (e.g. Clarke and Aiken, 2006; Seago et al., 2006). More research is needed to analyse these differences to find explanations that can be used to improve clinical care.

2.4. Patients as health care customers

There are many reasons why it is important to move a project from a smaller, similar subject and nationally based study to an international cross-cultural study. Five are mentioned here. Firstly, the researcher may need to find out whether a topic has a multi-cultural relevance or is restricted to a specific culture (Im et al., 2004; Gopal et al., 2005; Chiang-Hanisko et al., 2006). Secondly, the researcher may wish to construct a wider theoretical framework or theory focusing on a typical nursing phenomenon or concept using empirical data (e.g. Meleis, 2007). Thirdly, the researcher may wish to increase the published information on the topic using comparative multi-cultural empirical research (Im et al., 2004; Freshwater et al., 2006). Fourthly, the researcher aims to increase scientific knowledge to develop specific nursing interventions and methods based on research evidence (Hinshaw, 2000). Finally, the researcher may want to create an international research career. Whatever the reasons, when moving from a national to an international study it will entail moving from smallscale projects usually led by lone researchers, to large-scale, multi-centre, team-led, thematic programmes of research. This poses opportunities and challenges. However, review of the literature does little to provide information regarding the process involved in multinational collaboration (Mapanga et al., 1999; Kearney et al., 2000) or methodological considerations (Chiang-Hanisko et al., 2006). The current literature points out the importance of international collaborative studies (e.g. Freshwater et al., 2006) and problems and challenges for cross-cultural studies (e.g. Kearney et al., 2000; Chiang-Hanisko et al., 2006; Freshwater et al., 2006; Borg et al., 2008). However, it rarely gives concrete methods or tools for conducting such research. Three critical issues are raised from nursing literature and the international cross-cultural studies based on the above examples. These are: (1) the planning and formulation of an international study (e.g. Kearney et al., 2000; ChiangHanisko et al., 2006), (2) the conduct of cross-cultural research (e.g. Mapanga et al., 1999; Chiang-Hanisko et al., 2006; Borg et al., 2008), and (3) the reporting and implementing cross-cultural results (e.g. Mapanga et al., 1999; COPE, 2003; ICMJE, 2007).

Patients also expect greater transparency about the performance and quality of care services (EC of the European Parliament and of the Council, 2002; OECD, 2004). A growing body of research and political contention suggests the need for improvement in the processes and outcomes of care that include patient involvement within current health care systems (NHS, 2000; OECD, 2004; ICN, 2006). Therefore, studies on patients’ perceptions of the quality of care they receive are of importance. This presents a challenge, especially to international nursing research, because these patient perceptions are influenced by the culture, health beliefs and the practices of health care professionals and is different in different countries (Gerrish, 2000; Im et al., 2004; Weiner, 2004). 2.5. International cross-cultural studies in nursing International comparative and cross-cultural studies are needed to address common problems in health care and such research is therefore a powerful tool in the development of international harmonisation in nursing (Mapanga et al., 1999; Rolfe et al., 2004). International qualitative studies are more common than quantitative comparative studies and typically focus on health professionals’ perspectives (e.g. Lauri et al., 1999, 2001; Jones et al., 2004; Lankshear et al., 2005; Heikkinen et al., 2006; Tadd et al., 2006) or quality outcomes (e.g. Jensdottir et al., 2003). Only a few of these comparative cross-cultural studies research health care interventions from the patients’ perspective, for example, in the MEDLINE database (e.g. Ali et al., 1993; Leino-Kilpi et al., 2002, 2003a,b; Jensen, 2003; Scott et al., 2003; Davis and Bush, 2003; Schopp et al., 2003, 2004; Va¨limaki et al., 2004; Gopal et al., 2005; Larsson et al., 2005; Borg et al., 2008). Within these few studies there are some between-country differences in health care outcomes (e.g. WHO, 1996; Davis and Bush, 2003; Leino-Kilpi et al., 2003a,b; Scott et al., 2003; Larsson et al., 2005). These differences might be explained by the intensity of treatment, technical quality of care, the organisation and co-ordination of care, and also influences outside the health system (OECD, 2004), such as culture and patient characteristics. Some of the differences in patients’ perceptions may also be due to the different ways and levels of patient involvement in care or a failure to tailor care to each patient sufficiently (Suhonen et al., 2008). Health systems can do more to meet the expectations and preferences of patients (OECD, 2004) and so have a greater impact on patient out-

3. Critical issues in the process of an international cross-cultural study

3.1. The planning and formulation of an international study Planning an international study typically involves two phases: (1) forming a research group and (2) developing the research plan.

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3.1.1. Forming an international research group Research priorities outlined in many countries and regions of the world show some similar interests (Hinshaw, 2000) and so, providing it is approached with care, there are usually opportunities to form international research groups. Research groups have a larger knowledge base than individual researchers providing opportunities and challenges. There is the opportunity to use the knowledge and skill base of the whole research team and the challenge of welding a team together whose members are from different cultural and social backgrounds and who may have a diversity of opinions and ways of working (Freshwater et al., 2006). The primary initiative for conducting international crosscultural research usually comes from one researcher who is focusing on a specific topic either alone or with a domestic research group (Mapanga et al., 1999; Chiang-Hanisko et al., 2006). A research group may be formed in different ways meeting the needs of the individuals and the work to be done. Sometimes the research group may be formed based on previous experiences of collaborative research projects. If so the researchers may share a similar knowledge base, interests and methodological skills. At other times the number of nurse researchers may be expanding unevenly in a subject area. In this situation collaboration is a means of bringing together researchers with similar research interest to share ideas filling in the gaps of the expertise of lone researchers whilst addressing research issues of common concern. International collaboration may start by chance, for example when permission is asked to use a copyrighted research instrument. Getting to know researchers personally may also help to form a research group. Some researchers actively seek out individuals with specific experience to form a talented and multi-skilled research group. For example, in the BIOMED2 project, because the origin of ethical concepts, such as autonomy, appeared first in ancient Greek culture Greece was included in the international study. The Finnish legislation on Patients’ rights, the very first in this area, also provided important insights that could be used beneficially in this project. Researchers may also find future partners in published national and international research reports. Finally, international research collaboration may develop more formally in organisations, such as the European Academy of Nursing Science (EANS) (http://www.european-academy-of-nursing-science.com/), the Workgroup of European Nurse Researchers (WENR) (http://www.wenr.org/) or the International Network for Doctoral Education in Nursing (INDEN) (http://www.umich.edu/inden/about/aims.html). Funding authorities may demand internationally conducted research and an international research team as a precondition of obtaining funding. Participating in these international networks such as EANS and WENR both enables and facilitates collaboration in research. Being part of these groups also seems to increase the commitment of the research team to the research protocol, which needs to be strictly followed in order to ensure the comparability of the results derived.

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In the preparation of an international research project the research team may be faced with differences in personal culture, academic approaches and preferred methodologies along with experiences of different health care systems and care processes in each host country (OECD, 2004). Therefore the research group needs to include both experienced and novice researchers who will learn about the issues involved. 3.1.2. Developing the research plan An initial, clearly written, research plan is an effective tool for obtaining researchers’ interest and obtaining the preliminary commitment to co-operative research (Mapanga et al., 1999). As the work develops it is important to involve all the partners in the updating and clarification of the research plan. This will help to ensure the full and even development of cultural aspects, relevancy, methodology, possible instrumentation, funding needs and concrete study protocols necessary to obtain useful data from each country. For example, in the BIOMED2 project, the planning of the project included a long and thorough discussion about the definition of the term nursing intervention. At the conclusion of this the research team agreed that nursing interventions were focused on concrete nursing activities, such as helping patients with nutrition, hygiene, elimination and medication. This was important because this definition facilitated the same quantitative analysis of methods and outcomes in each participating country. However it is important to recognise that nursing interventions throughout the EU may include different activities requiring the analysis of practice at a national level (Hinshaw, 2000). Also, the many educational establishments and methods of teaching and learning at different levels of education provide for the variety of ways nursing interventions are discussed and carried out. 3.2. Conducting and implementing cross-cultural research Four issues are important in conducting and implementing cross-cultural research: (1) the translation of the instrument into different languages, (2) project management and quality control, (3) obtaining ethical approval and permission to conduct the study, and (4) implementing rigorous data collection and analysis. 3.2.1. The translation of the instrument into different languages The philosophical and conceptual appropriateness of a research instrument that has been conceptualised and operationalised in only one country needs to be analysed in detail as the wording may have different connotations in the other participating countries (Borg et al., 2008). In conducting cross-cultural research, the main critical problems that the research team will inevitably encounter are the methodological challenges related to translating the research instrument into the language of the participants and the cultural

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validation of the instrument into the context in which the study will be conducted. There are a variety of methods for ensuring the semantic, cultural, content, technical and criterion equivalence of the research instruments for crosscultural research and pilot studies (e.g. Hilton and Skrutkowski, 2002; Beck et al., 2003; Maneesriwongul and Dixon, 2004). 3.2.2. Project management and quality control An international comparative study needs well-organised protocols, leadership, management and co-ordination to ensure success. There are some practical considerations, such as differences in intensity of working and approach to research activities, time zones and the availability of resources that need to be taken into account. Typically, the lack of research funding/resources has complicated collaborative international multi-site studies. However, regular meetings throughout the study in a shared language are a necessity (Freshwater et al., 2006). A good management plan is needed to implement the whole project, including information on meetings, co-operation and dissemination of information regarding the study conduct (Mapanga et al., 1999; Freshwater et al., 2006). Web pages are a good way of informing public audience about the study. Additionally, all agreements, plans and memorandums should be electronically documented and sent to all partners in a timely fashion. Most advanced communication system for an international research group is a virtual learning environment (e.g. Blackboard, WebCT, etc.). It enables effective co-operation in the editing of common documents and offers a possibility for the discussions of the research group. In the best case it can decrease the need of face-to-face meetings. This kind of closed digital space acts a safe and well-organised file archive for all documents of the study. Most of all trust and confidence among research team members is needed. Each researcher involved in the study has shared responsibilities which require the ability to cooperate (Mapanga et al., 1999). In addition each researcher must conduct their own national research as part of their individual responsibilities. Some partners may have extra specific team responsibilities based on their own specific knowledge or expertise for example lead authorship. Methodological issues such as the use of instrumentation and the skilful management of the study protocols are important in conducting cross-cultural comparative studies. To ensure comparability, the timing of the questionnaire, the completion and return the questionnaires should be the same. There are some between-country differences, for example how the sample can be accessed and how many patients are willing to complete the questionnaire that challenges comparability. During the ICProject, for example, it was noted that the response rates in Finnish studies are generally high compared to USA studies which report much lower response rates. The conduct of an international research project requires a team with knowledge about research policy (e.g. ICN,

2005), scientific inquiry and methodology who are able to work together to solve problems creatively (e.g. Im et al., 2004; Freshwater et al., 2006). As a team, good access to information and experience of the conduct of an international comparative study is very important. Within the international research team there needs to be some recognition of the wide variation in the different domestic nursing research agendas (Hinshaw, 2000; El-Ansari et al., 2007) and research priorities (Hinshaw, 2000). Individual team members also need to be flexible, have a willingness to understand other cultures and have the mutual respect of all the partners. 3.2.3. Obtaining ethical approval and permission to conduct the study Ethical principles of research ethics are universal (e.g. Beauchamp and Childress, 2001; Directive of the European Parliament and of the Council, 2001; European Group on Ethics in Science and New Technologies, 2008; European Union, 2008; World Medical Association, 2004). However, there are different protocols in different European countries for the conduct of an ethical evaluation of a study proposal culminating in obtaining ethical approval (e.g. Hearnshaw, 2004; Rikkert et al., 2005). The recruitment of patients, the right to informed consent and domestic rules of access for sampling are different and difficult in some countries. These differences in access to study subjects and different protocols need to be clarified and taken into account, especially in terms of timing, before data collection commences. For example, in the BIOMED2 project the time taken to obtain ethical approval and permission to collect the data varied from 2 weeks (Germany) to 6 months in the UK, Scotland. In the ICProject ethical approval, required from an ethical committee, was needed in Finland, Greece, the UK and the USA but not in Sweden, where the hospital advisory board evaluated and accepted the study plan. In addition, permission to conduct the individual national studies was obtained from organisations and clinics in each country according to individual national standards. The time it took to access study sites varied from 1 to 6 months. Within ethical approval there are also individual national practices with regard to obtaining informed consent from study subjects. In the ICProject it was discovered that in some countries oral informed consent to conduct a questionnaire survey may suffice, e.g. Finland, Greece and Sweden. In other countries written permission is required, for example the UK. Because of issues like this, although a standard research protocol for each phase of the ICProject was written, the conduct of each phase had slight variances due to the cultural variations, relevancy and context issues. 3.2.4. Implementing rigorous data collection and analysis Conduct within an international study requires rationality and rigour in decision-making regarding the issues that the researchers face in acting out the research protocol exactly as

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planned. However, conducting research in a culturally sensitive manner may mean that a particular aspect is not suitable in all countries. For example, in the ICProject, the USA sample was small due to the short lengths of hospital stay and patients’ unwillingness to participate in the study by completing the questionnaires in hospital before leaving home. To help make decisions about what to do in such situations a responsible researcher in each participating country and a responsible person on each of the national study sites must be available. This may facilitate the completion of data collection ensuring an adequate response rate. Web-based survey offers a flexible and cost-effective data-collecting option. It has some unbeatable profits compared to a traditional paper-pencil questionnaire survey method (Duffy, 2002; Ahern, 2005). When the data accumulates to the server it is possible to follow up the increase of the sample by the joining countries at real time. Using web-based questionnaire it is also possible to avoid a lot of manual work as saving the data. Limitations of this method links to the ICT infrastructure of the joining organisations. Also the target population may cause limitations (for example in a case of elderly). Depending on the design of the study a web-based survey can be carried out using open (non-identified) web page link or using an e-mail address identified questionnaires (Hewson et al., 2003; Ahern, 2005). The web-based questionnaire is very suitable in the situations where the target population is consisting of nurses, nurse teachers or nursing students and in the studies in which large sample is needed. A specific analysis plan, drawn up with the help of research team members with statistical expertise, is needed to ensure good data management and analysis. Even though statistical programs are the same in different countries, different coding, data handling and data matrixes might cause difficulties if analysed in each country and aggregated later. Therefore, the coding and analysis of data should be conducted in one place enabling team decisions about the data, quality assurance and the avoidance of data management errors. Coding data from questionnaires in one place also reveals how the questionnaire was interpreted in each country. This should be exact and not dependant on language specifically. However, in some international studies national level data analysis might be conducted in each participating country. This way of working makes narrative analysis comparisons between countries rather difficult, because the data is closely connected to the context. 3.3. Reporting and implementing the results Reporting international comparative study results follows the basic principles of publication ethics (e.g. COPE, 2003; ICMJE, 2007) and good scientific practice of research (Beauchamp and Childress, 2001; European Union, 2008; European Group on Ethics in Science and New Technologies, 2008). However, the publishing of large international

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cross-cultural research includes some specific issues that need to be taken into account: (1) reporting comparative results from the study, (2) reporting national results in different languages based on the sub-data of a multi-site study, (3) avoiding duplicate publication and replication and finally (4) authorship. The aim of the cross-cultural studies is to compare results from different countries. However, there may be differences in the context and organisation of care, such as the length of hospitalisation, outcomes of care, and differences in care processes and protocols that reflect different hospital systems (Mapanga et al., 1999; Chiang-Hanisko et al., 2006). These differences may have an effect on patients’ perceptions which in turn reflect their responses to the research questions. In addition, while examining health professionals’ views, differences in education, roles, work environment and duties may be a threat to the comparability of the findings. Therefore any report, of the analysis of the context, organisation and background must be argued using international health care statistics, e.g. EUROSTAT (http://epp.eurostat.ec.europa.eu), or recognised existing descriptions of a country’s specialities such as WHO (http://www.who.int/whosis/en/) or OECD (http://www.oecd.org/statsportal). Detailed information about the study conduct is needed for a justification of the validity and comparability of results. Therefore, the manuscript should include the necessary information about the different backgrounds, contexts, nursing staff and health care systems of participating countries. This information will help in the interpretation of the results finding out, for example whether differences are due to internal or external factors such as cultures, nursing practices, the different care delivery processes, roles of healthcare personnel or the different nature of patients in different countries (Suhonen et al., 2008). National level results are important in developing evidence based clinical nursing care. Some of the papers may be written in different languages, and this can partly help to avoid repetition. However, a good scientific practice in conducting research is to obtain written permission from the editorial offices of the chosen international journals to report results using the national data, the sub-data in the larger study. Redundant publication occurs when two or more papers, without full cross-referencing, share the same hypothesis, data, discussion points, or conclusions (COPE, 2003; ICMJE, 2007). Re-publication of a paper in another language may be acceptable, provided that there is full and prominent disclosure of its original source at the time of submission. A good practice is to negotiate with the editor of the intended journal for submission about how to do this using part, or parts, of the larger study. Although attempts have been made to define authorship there is no universally agreed definition (COPE, 2003; ICMJE, 2007). As a minimum, authors should take responsibility for a particular section of the study. The award of authorship should be a balance of intellectual contributions

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to the conception, design, analysis and writing of the study against routine work such as the collection of data. In international projects, there is need to develop a publication plan including information on who are the responsible authors, first author and co-authors, the goal and purpose of each paper, the scope and data, the schedule and the target journals for paper submission.

Ethical approval None declared.

Conflict of interest None declared.

4. Conclusion Internationally and cross-culturally conducted nursing research is a powerful tool which can be used to improve clinical nursing practise, education and management. However, there is a lack of published evidence of international comparative studies. There are many reasons why conducting international cross-cultural studies is important. Perhaps the most important of these is to improve European evidence based health care development in which the patients’ perspective plays an important part in the evaluation and benchmarking of services. In this way the outcomes of nursing interventions will be further understood in global terms so that nurses will be able to treat and care for patients of different cultures more effectively. However, while started intensively, there is also need for multidisciplinary research (Hallberg, 2006). The three examples of international cross-cultural research discussed demonstrate some of the important considerations when bringing an international research team together. The issues discussed were concerned with the research instrument, project management and the publication plan. It is important to make sure that the instruments used to collect data from many countries are translated carefully so that the data obtained can be aggregated with confidence. Similarly good project management that provides clear divisions of responsibility and takes into account the different requirements of ethical approval and data collection in different countries is required. Finally the careful and early development of a publication plan which prevents duplication of the work is useful to make sure the research produces maximum benefit for nursing practice. This type of collaborative work is important for its scientific merit and as a social process. Collaboration may foster long-term professional relationships and friendships as well as increasing the awareness of different cultures. In this co-operation, junior researchers may learn important issues about scientific activity, such as practice in the use of research protocols and the development of nursing philosophy, whilst sharing experiences and pushing back the boundaries of nursing knowledge.

Funding None declared.

Acknowledgement We wish to thank Norman Rickard, BSc (Hons), MSc RN, for his help with the English language.

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