International consultation by United States nurses: a descriptive study

Since the influence of United States Nursing; is far-reaching both geographically and ideologically, United States nurses are frequently asked to serve as consultants to other countries. This was an exploratory/descriptive study of United States nurses who have engaged in international consultation during the past 7 years. Two sets of data were used in the study. The first set consisted of the responses to a 12-page questionnaire which was completed by 93 informants, while the second set of data provided the content analysis of 25 interviews. Included in the data analysis were a demographic profile of the consultants, including the manner in which they had prepared for their international experience; reasons for engaging in international consultation; the nature of advice given in the areas of clinical practice, education, research, administration, attitudes and beliefs about what consultants can learn from and contribute to other countries; ways of adapting advice to make it culturally relevant and effective in its context; and problems encountered while consulting including discrepancies between consultant and client expectations and moral/ethical dilemmas. Identified from the data were conceptual components which could be used in developing a model program to prepare nurses for international consultation. Although specialization for international consultation was proposed at the master's level, suggestions were made for integration of concepts related to international health from the baccalaureate through the doctoral levels of education.

I I INTERNATIONAL CONSULTATION BY UNITED STATES NURSES: A DESCRIPTIVE STUDY by Margaret M. Andrews A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing The University of Utah December 1984 THE LTt\IVERSITY OF UTAH GRADCATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a dissertation submitted by Margaret M. Andrews This dissertation has been read by each member of the following supen'isory committee and by majority vote has been found to be satisfactory. September 7, 1984 ~. -y--gL---P_- ~------,-,*-(' Chairman: Peter C. Morley ~. I c<.-tk-- { ~. I "- ( . September 7. 1984 Patricia C. Albers September 7, 1984 Linda K. Amos September 7, 1984 S. Boyle September 7, 1984 THE V;\;I\'ERSITY OF VTAH OF GRADl"ATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Vtah: I have read the dissertation of Ma rga ret M. Andrews In ItS final form and have found that (I) its format. citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the SuperYis­ory Committee and is ready for submissio 0 the Graduate School. September 27, 1984 Dale Peter C. Morley Chairperson, Supervisory Committee Approved for the Major Department Linda K. Amos Chairman! Dean Approved for the Graduate Council ) Copyright © Margaret M. Andrews 1984 All Rights Reserved ABSTRACT Since the influence of United States nursing is far-reaching both geographically and ideologically, United States nurses are frequently asked to serve as consultants to other countries. This was an exploratory/descriptive study of United States nurses who have engaged in international consultation during the past 7 years. Two sets of data were used in the study. The first set consisted of the responses to a l2-page questionnaire which was com­pleted by 93 informants, while the second set of data provided the content analysis of 25 interviews. Included in the data analysis were a demographic profile of the consultants, including the manner in which they had prepared for their international experience; reasons for engaging in international consultation; the nature of advice given in the areas of clinical practice, education, research, administration, attitudes and beliefs about what consultants can learn from and contribute to other coun­tries; ways of adapting advice to make it culturally relevant and effective in its context; and problems encountered while consulting including discrepancies between consultant and client expectations and moral/ethical dilemmas. Identified from the data were conceptual components which could be used in developing a model program to prepare nurses for international consultation. Although specialization for international consultation was proposed at the master's level, suggestions were made for integration of concepts related to international health from the baccalaureate through the doctoral levels of education. v TABLE OF CONTENTS ABSTRACT Chapter 1. I NTRODUCTI ON Extent and Importance of the Problem . Purposes . . . . . . . . . Definition of Terms Background of the Problem .... Conceptual Framework . Research Questions . II. REVIEW OF LITERATURE. International Nursing Consultation ..... Cross-cultural Communication . III. METHODOLOGY Epistemological Considerations Development of Questionnaire ... Development of Interview Questions Methodological Strategies IV. DATA ANALYSIS Definition of International Consultation. Motivation for International Consultation Demographic Information ........ . Frequency of International Consultation . Preparation for International Consultation Nature of the Consultation. Clinical Practice .... . Nursing Education .... . Nursing Research ..... . Nursing Administration/Other The Client ......... . Economic Considerations .. Cultural Relevance and Effectiveness in Context Evaluation of the Consultation ........ . Page iv 1 1 2 3 5 8 14 16 16 33 38 42 42 44 47 51 53 54 56 68 77 79 90 91 93 96 97 98 109 115 129 Chapter Page Learning from Consultation: An International Exchange 145 Problems Encountered by Consultants . . . . . . 152 Discrepancies in Expectations of the Consultant and Client . . . . . . . . . . . . . . . . . . . 165 Ethical Aspects of International Consultation 168 Advice to Aspiring International Consultants 178 Limitations of the Study . . . . . . . . . . 179 Summary . . . . . . . . . . . . . . . . . . . 181 V. CONCEPTS IN THE ACADEMIC PREPARATION FOR INTERNATIONAL CONSULTATION . . . . . . . . . . . . . . . . . 184 International Nursing and Master1s Education Discussion ................. . VI. DISCUSSION AND RECOMMENDATIONS FOR FUTURE STUDY. Appendices A. QUESTIONNAIRE B. SAMPLE INTERVIEW QUESTIONS C. SURVEY FORM . . . . . D. INFORMED CONSENT FORM. SELECTED BIBLIOGRAPHY . . . vii 185 186 200 213 227 229 231 233 CHAPTER I INTRODUCTION Extent and Importance of the Problem According to Rowe (1975), there are approximately 22,000 United States nurses working abroad at any given time. This number does not include those who have international experiences through short-term consultation, educational exchange programs, research projects, or study/travel tours. The exact number of nurses partic-ipating in these activities is unknown. Opportunities for United States nurses to travel to other countries, however, are increasing in frequency each year. Although the population of the United States accounts for approximately 5% of the world population, 25% of the world's nurses are in the United States (Masson, 1984). The United States has a global reputation for its affluence, biomedical expertise, and tech­nological sophistication. Recognized as international pacesetters, United States nurses are frequently called upon to serve as interna­tional consultants. The influence of United States nurses is widespread both ideologically and geographically. Textbooks are translated and distributed worldwide while nursing theories developed in the United States are discussed and frequently adopted in schools of nursing throughout the world. United States nurses have organized hospitals, community health programs, and schools of nursing on every continent. The advice and opinions of United States nurses 2 are widely sought, highly respected, and influential forces in deter­mining the type of health care provided for people in many countries. Highly visible and mobile United States nurses are "highly valued commodities for import" (Masson, 1984, p. 4). For these and other reasons, United States nurses are frequently asked to provide international consultation. Invitations to consult are extended by both the More Developed Countries (MDCs) which will be used synony­mously with First World, industrialized countries, and by the Less Developed Countries (LOCs) which will be used synonymously with Third World, nonindustrialized countries. Although a significant number of United States nurses are active participants in international interactions which take place within sociocultural, economic, and political contexts different from this country, no research has been conducted which describes interna­tional consultation by United States nurses. Purposes The purposes of this study are to: 1. Identify the population of United States nurses who have done international consultation 2. Describe the educational, professional practice, and re­search background of consultants including the manner in which they prepared for international consultation 3. Describe the reasons why United States nurses choose to engage in international consultation 4. Describe the nature of the advice/consultation given by consultants to other countries 3 5. Describe the ways in which consultants adapted advice/ consultation to make it culturally relevant and effective in its context 6. Describe the attitudes and beliefs of United States nurse consultants regarding what they can contribute to and learn from people in other countries 7. Identify the conceptual components of an educational program to prepare nurses for international consultation 8. Identify problem areas for future research. Definition of Terms For the purpose of this study, the following operational definitions have been used: United States Nurse Consultant The term United States nurse consultant is defined as follows: 1. United States refers to any person who is a United States citizen. 2. Nurse refers to any person licensed in one or more of the 50 United States as a Registered Nurse (RN). 3. Consultant is defined by Webster (1979) as "one who gives professional or technical advice" (p. 244). The term consultant will be used throughout this paper to refer to United States 4 nurse consultants. Consultation Consultation, like love, is a general label for many varia­tions of relationship. The general definition of consultation assumes that (Blake & Mouton, 1976): 1. The consultation relationship is a voluntary relationship (i.e., neither consultant nor client is coerced or forced into the relationship): (a) between a professional helper (nurse) and a help-needing system or client (host country); (b) in which the consultant (nurse) is attempting to give help to the client (host country) in the solving of some current or potential problem; and (c) the relationship is perceived as temporary by both parties. 2. Also, the consultant is an "outsider" and marginal to the situation (i.e., is not a part of any hierarchical system in which the client is located). Cl i ent Client is being used in a broad sense to refer to the host country (as represented by some individual[s] or group[s]). The question "who is the client?" may appear to be an obvious or unimportant one, but in reality it is the most critical. When a consultant deals with the IIwrong" client, the consequence is, at best, unproductive, and at worst, destructive (Blake & Mouton, 1976). Relationship Relationship is defined as the basis of interaction mutually agreed upon by the consultant and the client. The client has 5 preconceived expectations as to what will be gained from the process of consultation and the consultant has a foundation for the contract. Contract Contract is used to specify the character of the consultant­client relationship. Contracts vary from explicit, formal agree-ments, either verbal or written, to intuitive-based informal under-standings. Among the types of contracts are those which are legally binding and those which are morally binding. For example, there is considerable difference in the nature of the contract between the volunteer affiliated with a church-related organization and the highly-paid consultant retained by an oil-rich Middle Eastern client. Host Country Host country refers to any nation other than the United States. Background of the Problem Nurse Consultants in the International Arena United States nurses become international consultants in a variety of ways. Some nurses are associated with international organizations (World Health Organization, International Council of Nurses, United Nations) or with United States government agencies (Peace Corps, Agency for International Development, Department of Health and Human Services). Some nurses are affiliated with colleges and universities or with private voluntary organizations (Project HOPE, CARE, MAP International). Many religious organizations and churches provide consultation to other countries. These religious groups are numerous, and they include the major Christian churches. Among those frequent advertisers in nursing journals are several profit-making organizations. These international placement agencies recruit nurses for long-term consultation (2 to 3 years), especially in the Middle East. Offering relatively high-paying 6 positions with many attractive fringe benefits, some nurses find them appealing. Organizations, such as Professional Seminar Consultants, Inc., recruit nurses to lead study/tours to a variety of countries. These are primarily short term in duration (4 to 8 weeks). Opportun-ities for United States nurses to serve as consultants to other countries are likely to continue and to increase in frequency. The reasons for this projected trend will be discussed in more detail in Chapter VI. Communication Channels for Consultation Consultation may be done at the initiative of the host country (client) or at the initiative of the United States IIsendingll organiza­tion. Consultation may occur through formal channels of official organizations with written, precise objectives and goals or it may occur less formally. Common in both the United States and the inter-national arena is networking among nurses. Informal, serendipitous contacts often occur during social gatherings at conferences and meetings of international organizations. Personal contacts may be more productive than responses to official requests for contracts and consultative services. The "old girl II or "men l s locker room" 7 networks are responsible for more consultation than is likely to be publicly acknowledged. In some cultures, official business cannot be conducted without extensive personal and social exchanges preced-ing it. Consultants need to be aware of unwritten IIrul es II whose violation may lead to misunderstanding, miscommunication, or exclusion from the international consultation arena. These will be addressed later in the study within the data analysis presentation. A Critical View of United States Nurse Consultants A cursory glance at the literature reveals that numerous allegations and criticisms have been made that consultants engage in the cultural imposition of a familiar biomedical and technological paradigm rather than consider the cultural values and beliefs of the host country. Most of our contributions ... have had the effect of widening the gulf between Western nursing theory and local nursing realities; for our focus is on the development of nursing as a profession more often than on meeting the nursing needs of the people, and more on transplanting our own theory and practice than on objectively assessing what we have to offer in the context of the local environment, culture, health needs, and resources. (Masson, 1981, p. 66) Similarly, the orientation and preparation for international nursing have been widely criticized. The lIappropriatell preparation for nurses, including the consultant, encompasses a wide spectrum and ranges from: IInone is needed ll to nothing less than formal prepara­tion in transcultural nursing (Leininger, 1981). The previously discussed criticisms and suggestions for improvement of the consultant mayor may not be warranted. Critics 8 have proposed numerous interventions, prescriptions, and solutions to unnamed problems. Value-laden assumptions underlie each of the criticisms, yet no evidence has been provided to substantiate the charge that consultants are ethnocentric, biased, or poorly prepared. Even if these allegations could be documented, there remain more questions than answers. For example, does an ethnocentric consultant necessarily provide advice which is ineffective and inappropriate? Does the "best prepared" consultant necessarily provide the "best" advice? These questions are raised as examples, and are not intended to be exhaustive or all-inclusive. In summary, many "shoulds" and "oughts" have been proposed before any systematic description of the United States nurse consultant has been done. A more detailed discus­sion of the issues raised will follow in the literature review. conceptual Framework International consultation by United States nurses concerns itself with the process of sharing information, skills, and expertise with others. Consultants bring with them basic sets of attitudes, values, and beliefs to the encounter which influence the what, how, and why of the consultation. In the United States, nursing and other health care disci­plines are influenced by the values and assumptions of the prevailing biomedical paradigm, which is based upon the belief that the person is a manipulable object of science. Biomedicine and tech­nology are seen as holding the solution to all health problems. The underlying assumption is that if enough research is conducted in the 9 appropriate areas, it is possible to completely eradicate disease and illness. In this way, the World Health Organization (WHO) goal of "Health for all by the year 2000" is being approached by applying biomedical and technological solutions to all health problems through­out the world. Often exalted to positions of prominence, dominant paradigms are frequently given a higher status than warranted. At the present time, the biomedical paradigm enjoys much status in the world. Embraced by many less developed countries (LOCs) as being progressive and modern, the biomedical paradigm prevails even though this view is inconsistent with their cultural values and beliefs. This leads to a situation in which the dominant biomedical paradigm is sought as a panacea to problems for which it may be totally inappropriate and ineffective. Presenting the consultant with a serious dilemma is the discrepancy between the host country's often magico-religious or holistic paradigm and the biomedical paradigm. Consultants are forced to acknowledge their own world view and values, those of the host country to which they are consulting, and simultaneously to "fitll the system which best meets the needs expressed by the client. In some cases, consultants may need to consider "reverse ethnocentrism" in order to mesh the opposing and conflicting values and beliefs. Expected to participate in bringing about changes in the host country, consultants must do so as guests or visitors. Introducing different ideas and values, not only about health care and nursing, but about fundamental and deeply-rooted components of a culture such 10 as lifestyle, career expectations, male/female roles, and many others, the consultant engages in a complex process having unforseeable rami­fications. Regardless of conscious intention, consultants engage in cultural imposition of a familiar biomedical and technological paradigm rather than considering the cultural values and beliefs of the host country. International consultation is fundamentally a matter of overcoming ethnocentrism (limy way is best") and cultural paternalism ("I know what's best for you") while striving for cultural sensitivity ("I hear what you say you want; let's see how we can proceed ") . Without substantive evidence, consultants frequently have been accused of ethnocentrism. According to Porter (1972), ethnocentrism is "a tendency to view people unconsciously by using our own group and our own customs as the standard for all judgments " (p. 6). LeVine and Campbell (1972) state that an ethnocentric person "unre­flectively takes his own culture's values as objective reality and automatically uses them as the context within which he judges less familiar objects and events" (p. 1). At a more complex level is the ethnocentric attitude or outlook that regards those of other cultures as incorrect, inferior, or immoral. Ethnocentrism can prevent the nurse from accepting those of other cultures in a favor­able manner (Orque, Bloch, & Monrroy, 1983). The allegation ;s that ethnocentrism frequently underlies the consultation given by consult­ants, resulting in advice that is both inappropriate and ineffective. Believing that their own ideas are intrinsically good, and therefore, needed and desired, consultants may be unaware of opportunities to 11 learn from people in other countries, particularly when dealing with LDCs. Unfortunately, United States nurses often have assumed that what works in the United States will be equally beneficial and effec­tive in other cultural contexts. Advice and consultation frequently are given without a full understanding of the host country's values, needs, or resources. As a consequence, consultants have engaged in cultural paternalism and have failed to communicate or to contribute. The term "cultural sensitivity" necessarily addresses issues related to cross-cultural communication, language, assessment skills, and a knowledge and understanding of the client's culture, roles, norms, political and economic systems, historical background, religious beliefs, health values, health care delivery systems, and many other factors. Assuming that the goal of consultation is to effect change in the direction of improved health for the people of the host country, it is necessary for the nurse consultant to examine the factors which interfere with and enhance the process. Urged to transcend national and professional socialization, consultants have been admonished to become consciously aware of the United States values and beliefs which shape their world view. Consultants have been advised that nursing needs to be seen as inter­dependent with other sectors of the health care system, but within the context of the host country's sociocultural, economic, and political systems. Individual countries cannot be viewed as independent from each other, but as interrelated parts of a global 12 system (Bisch-Bryan, 1983). Assuming that the object of nursing is health, it is neces­sary to consider the meaning of this term to both the consultant and the client. The consultant's definition of health and perceptions of the role played in international consultation, will determine the nature of the consultation. Also of importance are the consultant's attitudes and beliefs about what can be learned from and contributed to people of other countries in terms of improved health. A wide variety of factors influence health beliefs and practices in any given culture including religious, socioeconomic, and political attitudes, values and practices. Although a conceptual framev-JOrk might be formulated in a variety of ways, Figure 1 summa­rizes the concepts of particular relevance in this study and identi­fies ways in which these concepts are interrelated. Problem Statement To date, no study has been conducted which describes or pro­files the international consultant. At the descriptive/exploratory level of inquiry, questions need to be asked such as: Who is the consultant? What has been the background (education, professional, practice, research consultation) of the consultant, including special preparation and orientation for the international consultation? Why has the United States nurse chosen to become involved in international consultation? What has been the nature and type of advice given by consultants? Who has been the client? Until such a description of "what is" has been identified, experimental, explanatory, and /;UTRE~ Politics • Economics. Family. Religion / Attltu{es •• VOI!es •• Beli~S / , \ HE Al T H-Ill NESS PARADIGMS Consultation UNITED STATES +++ + ++ ++ + HOST NURSE ....................... COUNTRY ComIRu n icotion language Symbols __ ...l 1li(---- Cultural Sensitivity 13 Figure 1. Interrelationship of key concepts in international consultation. predictive studies will lack the necessary data base from which to begin. Research Questions 1. What type of individual is currently engaging in inter­national consultation? 2. What is the demographic profile of the United States nurse consultant in the areas of: (a) Educational preparation and certification within nursing specialties? Nonnursing academic preparation? Special orientation/preparation prior 14 to international consultation? (b) Professional practice experiences including prior consultation in the United States and/ or abroad? (c) Research experience in the United States and/or abroad? (d) Linguistic competence, especially if consultation has been done in a non-English speaking country? 3. Why did the consultant choose to become involved in international consultation? Why was a particular agency and part of the world selected? 4. What was the nature of the advice/consultation given by the United States nurse consultant to the host country (client)? (a) Who was the host country? Under what auspices was the consultation arranged? Agency/Organization? (b) What were the economic aspects of the consultation? What items were included under the expenses? (c) Did the consultation have multidisciplinary components? (d) In what setting(s) did the consultation occur? (e) With whom from the host country did 15 most of the interactions occur? (f) To what extent was time a factor in the international consultation? (g) In what manner was the advice/consultation evaluated? By whom? 5. In what way was the advice/consultation adapted to make it culturally relevant and effective in its context? 6. What are the United States nurse consultant's attitudes and beliefs about the potential to contribute to and learn from other countries? 7. What are the problems associated with international consultation? 8. What are the conceptual components of an educational program which would prepare nurses for international consulta­tion? CHAPTER II REVIEW OF LITERATURE In an effort to focus the review of literature, international nursing, consultation, and cross-cultural communication have been selected as major topical areas for review. Due to the nature of the study, a wide variety of related disciplines interface with this research. The specific studies and their findings will be inter­woven throughout the data analysis and discussion chapters as appro­priate, rather than reported exhaustively in the literature review. International Nursing According to Hasson (1981), nursing is a "universal but culturally defined activityll (p. 84). Nursing may be a trade, an occupation, a vocation, or a profession, depending upon the prevail­ing attitudes and beliefs within a given country at a particular historical point. Nursing exists in every part of the world, but the definition and role of the nurse varies, as does the manner of preparation. Suggesting that nursing exists on three levels, Masson (1984) delineates the activities commonly performed by these three. Derived from the Latin nutrire, meaning to nourish, nursing's first level consists of that network of caring ways that constitutes one of the oldest and most universal of human activities which traditionally was 17 carried out by families or communities for their own members. Second, nursing is an occupation carried out by an individual having special-ized training or educational preparation. The International Council of Nurses (1983) defines this nurse as: ... a person who has completed a programme of basic nursing education and is qualified and authorized in his/her country to practice nursing ... The first level nurse is respon­sible for planning, providing, and evaluating nursing care in all settings for the promotion of health, prevention of ill­ness, care of the sick and rehabilitation, and functions as a member of the health team. In countries with more than one level of nursing personnel, the second level programme prepares the nurse ... to give nursing care in cooperation with and under the supervision of a first level nurse. (p. 3) Third, there is the IIprofessional ll nurse for whom nursing practice is characterized by academic rigor, the exercise of inde-pendent judgment, and personal accountability. Masson (1984) has 1 inked II professional ll with feminism IIbecause it is in the nature of nursing. II Out of this group comes a subgroup of nursing leaders who travel and collaborate frequently as representatives of their countries and their profession. Masson (1984) refers to these nurses as the lIinternational elite. 1I Since the terms IIprofessional ll and IIprofessionli appear not only in the literature review, but also in the words of informants throughout this study, a few brief remarks about these terms follow. Noting that there has been much disagreement over the use of the term profession, Freidson (1977) has examined the various definitions and considered their predictive ability. Professions may be viewed as ideologies, as self-employed occupations, or as monopolies which attempt to dominate part of the labor force. Definitions are not 18 mutually exclusive. Some may be related to one another while others are not (cf., Flexner, 1915). Freidson (1977) points out that commitment to occupation, fellow workers and work itself may vary with occupational organiza­tion, but it is likely to vary slightly with, and perhaps even independently of, education and skills. Dedication to service and to craftsmanship may be seen to have no simple and direct relationship to any of the other criteria of professionalization. For a term like "profession," used in so many ways, there cannot be sufficient con­sensus in usage and definition to make it possible to predict only one future. Rather, there can be many futures, each a function of the definition chosen. Without further elaboration, perhaps the only certainty is that the future of nursing as a profession will continue to be debated for many years to come, both by nurses and by others outside of the discipline (Aiken, 1982; Bullough & Bullough, 1977; Ellis & Hartley, 1980; Styles, 1982; White, 1983). In a broader sense, Goodman (1971) states that the inter­national nurse is involved in "health work which concerns more than one nation " (p. 3) and may perform the role of practitioner, educator, or consultant. For Hurley (1982), international nursing is "an extended, innovative, and specialized role involving a distinctive set of qualities and requirements that set it apart from traditional nursing" (p. 5). Meleis (1984a) suggests that international nursing is the framework through which some aspect of nursing is delivered, but in and of itself, is not a specialty. Arguing that every nurse plays a variety of roles, Meleis maintains that international nursing 19 should be viewed as a framework within which nurses utilize and apply their knowledge and expertise related to culture and health, culture and communication, culture and sex-role identity, coping with transi­tions, or international collaboration and negotiations. In an effort to determine whether or not nurses working abroad perceive international nursing to be a specialty, Henkle (1979) conducted a study of American nurses working overseas. Defin­ing international nursing as nursing which is done (a) for a period longer than 6 months in another country, (b) by an American nurse educated in the United States, and (c) under the sponsorship of an official agency or private contractor, Henkle (1979) limited the term to nursing carried out by Americans in another country. Although this study does not include nurses of other nationalities working in different countries, theoretically international nursing includes all nurses of all countries who are involved in international health work. Three research questions were posed: 1. Do American nurses working overseas need the same preparation as their counterparts in the United States? 2. Are they involved in a unique type of nursing? 3. Do American nursing schools equip them with the education and skills needed to work outside the United States? Data were collected through a review of the literature, interviews with nurse administrators of four official nonprofit organizations, and from a questionnaire to 10 nurses with extensive international nursing experience. Questionnaires were also sent to 78 American nurses chosen at random who were working overseas. The 20 selection method allowed for the inclusion of nurses representing 25 countries in four major geographical regions. Reporting a 74% response rate to the questionnaires, Henkle (1979) found that 58% considered international nursing to be a specialty, 38% did not, and 4% were unsure. Despite these responses, nearly all of the respondents gave reasons why nursing overseas is significantly different from nursing in the United States. Four dimensions to this difference were reported: The first dimension relates to culture and setting; the second dimension deals with personal development of the nurse, including ability to function independently, confidently, and collaboratively as a member of the health team; the third dimension focuses on the nature of the problems encountered such as the means available for solution of problems, opportunities provided for the analysis of problems, and implementa­tion and intervention; and the fourth dimension focuses on the nature of nursing, including the status and respect for nurses. Other results of this study will be presented in the Data Analysis chapter, where the findings will be compared with the results of this study. In referring to specialization within nursing, Peplau (1965) states that at first, particular nurses move in a direction of special interest which presents as an immediate opportunity or need. Their focus becomes narrowed to one part of a larger field, thus allowing for greater depth in developing that part. Henkle (1979) elaborates the definition of "nursing specialty" as follows: 1. There is a unique body of knowledge and skills specific to a particular field. 2. This body of knowledge and skills is built upon a theoretical base. 3. This body of knowledge and skills can be identified and taught to professionals who possess a broad knowledge and skill base in nursing. 21 Given the dearth of information about international nursing as a bona fide specialty, it is assumed to be an emerging specialty within nursing. Perhaps the closest recognized specialty is that of "transcultural" or "cross-cultural" nursing (Branch & Paxton, 1976); Brink, 1976; Henderson & Primeaux, 1981; Leininger, 1970, 1978, 1981; Orque et al., 1983). Leininger (1981) defines transcultural nursing and compares it with international nursing as follows: Transcultural nursing is a formal area of study and prac­tice that focuses on a comparative analysis of cultures and subcultures with respect to diverse health-illness caring beliefs, values, and practices with the goal of generating scientific and humanistic culture-specific or culture­universal therapeutic nursing care practices (the term intercultural, cross-cultural, and international nursing are used interchangeably with transcultural nursing, even though international refers mainly to cultures that have become nations). Transcultural nursing focuses, not only on the study of the four federally defined cultures, but on all cultures and subcultures in the U.S. and throughout the world. (Leininger, 1981, p. 366) Preparation for International Nursing Although preparation for international nursing will be discussed in more detail in Chapter V, a cursory review of the literature follows. 22 The "appropriate" preparation for international nursing encompasses a wide spectrum and ranges from "none is needed" to nothing less than doctoral preparation. Several nurses with inter-national experience have attempted to identify characteristics necessary for success in the international arena. Henkle (1979) lists nine concepts which she believes can be taught to nurses so that they may be more effective and competent in the international setting: 1. Interrelatedness of culture and health 2. Health needs and priorities in developing countries 3. Cross-cultural communication 4. Problem-solving dimensions 5. Adaptability and flexibility in nursing care 6. International health issues 7. Counterpart system 8. Differing roles of nursing 9. Nursing independence. While some of these concepts are applicable to nursing as practiced in the United States, others require application of nursing knowledge and skills in an environment which is totally different socially, economically, politically, and culturally. Masson (1981) advises nurses to prepare carefully for appro-priate and effective practice in an international setting by: Developing a conscious awareness of self and the nursing profession; Gathering information about the country and culture in which they will be working, and organizing it in a meaning­ful way; Identifying those elements of nursing theory and practice which can be translated and transplanted into the new setting, those which must be transformed, and those which must be set aside altogether; Identifying and seeking to fill gaps in their own knowledge that become apparent in the new setting; and Slowly and deliberately deciding what they may have to contribute to nursing and health care in the new setting, and how this can be shared or accomplished most effectively. (p. 111) 23 In addition, Masson (1979) identifies personal qualities needed by the nurse entering the international setting: A minimum of 2 years of professional, general nursing experience; A formal or informal teaching experience; A working philosophy of nursing and the nurse's role within health care systems; The ability to establish productive interpersonal rela­tionships; The potential for adaptation to the local culture, lifestyle, and health care system; An aptitude for and commitment to learning the language (of the intended host country); An interest in and ability to solve problems within constraints of time, money, resources, and institutional factors. (p. 163) Range (1984) identifies skills and attitudes that certain government and private organizations look for in sending their staff members overseas. These include: Listening skills, including sensitivity to nonverbal cues; Careful observation; Patience, not always expecting "them" to do the adjust­ing; Flexibility, openness to change, and learning from others; Ability to take risks, try new things, development of "emotional muscle"; and Awareness of your own values and cultural assumptions; Sense of humor; Ability to identify cultural resources in the community; Recognition that feelings of frustration (or noncompli­ance on the part of patients) may be cultural in origin. (p. 63) Jaeger-Burns (1981) has identified specific requirements for 24 the nurse engaged in primary health care in the international setting: Basic health assessment skills and nursing diagnosis; Sensitivity to local beliefs and customs that bear on the problems of health; Includes involvement of health care recipients in problem solving process; Participation in health and environmental assessment at community and national level; Collaboration with traditional healers in training and the delivery of care; Development of procedures, equipment, and health systems that are affordable and promote self-reliance; Service as liaison between the primary health care system and other parts of the system; and Promotion of cooperation of individuals within the family and community in order to identify and meet their own specific health and environmental needs. (p. 46) While some of these suggestions have validity, it seems that others reflect the bias of the American writer. For example, "involvement of health care recipients in problem solving process" mayor may not be appropriate. The Chinese frequently prefer the decision making to be done by the provider of health care (Kleinman, 1980a). Likewise, it may be inappropriate for women or children to participate in decision making, but expected that the man will make all the deci-sions. Generalizations cannot be made without gathering additional data about the culture of the people involved. In March 1984, the National Council for International Health and the University of Utah College of Nursing co-sponsored a confer-ence entitled "Nursing Practice in a Kaleidoscope of Cultures. II Attended by over 100 nurses from across the country and several from other nations, this conference marked the beginning of a forum for the exchange of ideas by nurses having international experience. In a presentation at this conference, Dr. Afaf Ibrahim Meleis spoke to the issue of: "Education for International Nursing: The Ivory Tower or Trial and Error. II In her concluding comments, Dr. Meleis remarked that: International nursing is a field that requires the acqui-sition of certain affective and cognitive skills. a good deal of which could be achieved through organized education and some could be learned through trial and error. My position ... is to increase the former and decrease the latter. (Meleis, 1984a, p. 47) 25 Meleis proposes that a universal knowledge base could best be learned in the academic setting while the culture-specific knowledge could be learned within universities, in training agencies, or through sponsoring agencies (Meleis, 1984a). According to Harris and Moran (1979), culture-specific training is "designed to teach members of one culture ways of inter-acting effectively, with minimal interpersonal misunderstanding, in another culture (p. 147). Several techniques have been identified for dealing with culture-specific knowledge. These are based upon four models of training: 1. The intellectual model consists of lectures and read­ing about the host culture. It is assumed that exchange of information about another culture is effective preparation for living or working in that culture. 2. The area simulation model is based on the belief that an individual must be prepared and trained to enter a specific culture. It involves simulation of cultural experiences and practice in functioning in the new culture. 3. The self-awareness model is based on the assumption that understanding and accepting oneself is critical to understanding a person from another culture. 4. The cultural awareness model is based on the assump­tion that an individual IS effectiveness in intercultural communication can be improved by developing the individual IS self-awareness and in increasing the ability to recognize cultural influences in personal values, behaviors, and cognitions. (Harris & ~loran, 1979, p. 149) 26 Examples of strategies and programs based on these models are role playing, critical incidents, practice interviews, case study methods, and audiovisual media (Giovannini & Brownlee, 1982; Harris & Moran, 1979). In the nursing literature, specific content and approaches in teaching nurses skills for international nursing are areas lacking in the curricula of many schools. Ways of incorporat-ing international content on an elective basis have been implemented in a number of baccalaureate nursing programs while strategies for doing so have gained increasing attention (Amin, 1984; Baker & Mayer, 1982; Brink, 1972; Dirschel, 1981; Gagnon, 1983; Schenk, 1980). International Nursing: Past, Present, and Future In 1875, Linda Richards went to Japan under the auspices of the American Board of Missions, thus becoming the first United States nurse on record to engage in international nursing. With the crea-tion of the World Health Organization in 1948 and the proliferation of technical assistance programs in the LDCs, nurses became increas-ingly involved in international health. Since the beginning of the 1950s, the World Health Organization (WHO) has taken an active interest in nursing. Recognizing that the nurse is a key member of the health care team, WHO recognized that lack of and poor utiliza-tion of nursing personnel hinders the advancement of practically all health programs (Arnstein, 1953). In the report of the WHO Expert Committee on Nursing, it was recommended that fundamental research be conducted v/ith the assist-ance of social scientists to determine the health needs of various 27 societies and to suggest how nurses could best function to meet those needs; through direct care of the sick, health teaching, and partici­pation in primary prevention programs. The need to consider the IIwhole ll person with physical, social, psychological, and environmental needs rather than as a pathological "case ll was noted (Arnstein, 1953). At the WHO working conference on nursing education in 1952, it was suggested that the basic need in most countries is for nurses capable of providing total nursing care whether in the hospital or community setting. In those countries in which nursing was in its earliest stages, it was proposed that basic nursing education would include preparation for teaching, supervision, and public health care to the community. To further understand the international dimensions of nursing, the Ninth World Health Assembly of WHO, at which the technical discus­sions were devoted to nursing, arrived at five functions as being responsibilities of nurses in any country (WHO, 1979b). These included the giving of skilled nursing care according to the physical, psychological, and social needs of the patient in preventive and curative services and in any setting; the teaching and counseling, supervisory, and administrative duties of the nurse; and responsibili­ties as a member of the health team, acting as a liaison person and being involved in helping to plan and deliver needed health services to the community. During the 1950s and 1960s, the majority of countries expended their resources on hospitals and on the preparation of physicians and nurses to staff them. A gradual awareness developed in one country after another that the trend toward improved health which occurred was reaching a plateau or even reversing. During 28 the 1970s, WHO reviewed the many factors responsible for inhibiting the improvement of the health status of the world. The analysis indicated that some fundamental features could be identified for the failure of increased resources to the health sector to bring about the desired goal of improved health. One of the significant findings was that the rural poor who comprise the largest segment of the population were unable to utilize the curative, hospital-based services located in the urban areas. Of more importance, was the realization that the greatest need was for relatively simple preven­tive and promotive services that could be rendered in homes and at local communities and that these did not require highly trained health personnel and sophisticated equipment. Perhaps the most important conclusion was that these services required the active participation of the people themselves and that successful attain­ment of an integrated approach to health care required cooperation with personnel from other sectors such as agriculture, public works, education, and social welfare. These realizations led to what has been termed primary health care and culminated in the Alma-Ata Declaration of 1978 (WHO/UNICEF, 1978). At the International Conference on Primary Health Care, held jointly by the United Nations Children's Fund (UNICEF) and the WHO, delegates from 134 governments and representatives of 67 United Nations organizations agreed that primary health care was the key to attaining this goal: "If this approach is used throughout all member states, it will be the greatest influence of social policy in the attainment and maintenance of health throughout the world" (WHO/ UNICEF, 1978). Primary health care is more than a mere extension of basic health services. It has social and developmental dimensions which will influence the way in which the rest of the health system 29 functions. Health needs and approaches to solutions with primary health care evolve in direct response to the needs of populations "as identified and expressed by the people themselves, not politicians and physicians" (Skeet, 1982, p. 35). As primary health care became identified as being the strategy for achieving "Health for All by the Year 2000," a distinct change occurred in the way nursing was viewed within WHO and its American regional office--the Pan American Health Organization. Before Alma­Ata, priority had been given to producing sufficient manpower to provide institutionalized patients with safe nursing care. Programs were frequently directed toward the creation and strengthening of nursing education programs, many of which were replicas of United States models. More recently, however, official resolutions urge member governments of WHO to: . . . redirect education programs in order to strengthen the contribution of nursing to the enterprise of extending care services to the entire population ..• strengthen the preparation of teaching staff, in aspects of community health. (Pan American Health Organization, 1984, p. 23) In expressing his opinion of nursing and its present and potential contribution to international health, Dr. Halfdan Mahler, Director-General of the World Health Organization, wrote: If those who are now called nurses, or will be so called in the future, are willing to confront the formidable challenges implicit in primary health care, and to acknowl­edge primary health care as the medium for achieving an acceptable level of health for all people in the foreseeable future, then the world does, indeed, need nurses. (t~ahler, 1978, p. 3) In the nursing literature, the term primary health care is used in reference to a variety of concepts. Aware of the confusion of terms, the International Council of Nurses (ICN) has accepted 30 the definition as it is defined in the Alma-Ata Declaration of 1978: Primary health care is essential to health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at costs that the community and country can afford. It forms an integral part both of the country's health system, of which it is the nucleus, and of the overall social and economic development of the community. (WHO, 1978, p. 2) In accepting this definition, ICN views primary health care as a concept of health care "and an approach to providing care (Krebs, 1983). It is important to note that the definition of primary health has a strong sense of prevention which includes immunizations, lifestyle-related issues, and environmental factors such as clean air and water. In a cursory review of the literature, it is apparent that nurses have responded to the challenge of primary health care by developing viable programs which hopefully will make "health for all" a possibility in the near future (Colliere, 1980; de la Cuesta, 1982; Ha, 1982; Jato, 1982; Jinadu, 1980; Minnett, 1980; Mpeta, 1982; Reid, 1982; Seivwright, 1981a; Smith, 1981). In an effort to identify those issues which nurses from 31 countries around the world believe to be important, a review of articles published during the past 5 years in the International Nursing Review and in the International Journal of Nursing Studies was undertaken as a means of determining areas of concern to nurses in other countries. These two journals were chosen for a systematic literature review because they are the most widely used by nurses in various countries to exchange ideas on issues and problems relevant to international nursing. As the official journal of the Interna­tional Council of Nurses (ICN), the International Nursing Review frequently contains policy statements by ICN, as well as articles concerning specific problems of concern to nurses globally. Related to the nurse's role in promoting primary health care were articles about the "expanded" role of nurses in pediatric and family nurse practitioner roles (Morrow & Amoako, 1980; Ojo, 1980; Tulloch, 1980). Among the nursing education issues internationally were articles about curriculum development (Gliguie-Djokotoe, 1982; Meleis, 1979; Mooneyhan, 1979; Ogundeyin, 1982), continuing education appropriate textbooks (Jato, Mounlom, Colgate & Carriere, 1979). The formation of a professional image among nursing students (Ichilov, 1980) and other professional/role issues were the subject in several other articles (Grayson, 1983; Huntington & Shores, 1983; McCloskey, 1981; Rhodes, 1980; White, 1983). Using the nursing process for evaluating the quality of nursing care (Hegyvary, 1979) was considered important by nurses in some countries. Given that one of the purposes of ICN is the socioeconomic advancement of nurses internationally, it is not surprising that a 32 number of articles dealt with socioeconomic and political change in both the LOCs and in the MOCs. Several of these articles consider the role of the professional association in bringing about socio­economic and political change within their respective nations (Akita, Agbleze, Samarasinghe, Quaison & Quartey, 1979; Marshall-Burnett, 1981; Morrow, 1982; Padarath, 1982; Quinn, 1979; Rowsell, 1982; Rydho 1m, 1982). Since children under 15 years of age comprise over half of the population in the LOCs, it is not an unexpected finding that many articles dealt with maternal-child and pediatric nursing problems (Beaton, 1983; Buchan, 1979; Haydee & Coelhe, 1980; Malgarinou, 1979; Munoz, Agasso, Persico, & Riso, 1979; Okunade, 1980; Osei­Boateng, 1979; Williams, 1980; Yamanishi, 1979). Reflecting the prob­lems associated with lldevelopment" faced by the MDCs were clinical topics related to nursing care of the elderly (Goldstone & Roberts, 1980) and death and dying (Qvarnstrom, 1979). Administrative problems related to ward organization (van Eindhoven, 1979) and availability of medications in hospitals (Leke, 1982) were considered as was the use of unskilled assistants in hospitals for cost-effective delivery of care (Inoue,1983). Although many of the previously cited articles were reports of research studies conducted in various countries, research strategies were also the subject of articles (Abdel-Al, 1982; Davitz, 1979). Finally, the executive director of the ICN wrote an article about the migration of nurses across national boundaries (Logan, 1980). Written in response to the WHO study on physician 33 and nurse migration (Mejia, Pizurka, & Royston, 1979), the thesis of the article was that the ramifications for nursing internationally were minimal; however, national nurses' associations were encour­aged by lCN to cooperate with the governments of those countries affected in order to assist in the resolution of the problem. The next area to be reviewed is the literature on consultation, including international consultation, by nurses. Consultation A concept to be interwoven throughout this paper, consulta­tion, will be reviewed in the literature in a cursory manner. Many disciplines borrow principles related to consultation from one another, and nursing is among those disciplines. Adapting the definition of Blake and Mouton (1976), inter­national consultation was defined in Chapter I as a voluntary rela­tionship between a professional helper (nurse) and a help-needing system or client (host country) in which the nurse attempts to help in the solution of a problem. Furthermore, the relationship is perceived to be temporary by both parties and the consultant is an "outsider" (i.e., not a part of any hierarchical system in which the client is located). Most references on consultation have focused their attention on business organizations in the private, profit-making sector (Argyris, 1970, 1973; Argyris & Schon, 1978; Beckhart & Harris, 1977; Bell & Hadler, 1979; Bennis, 1979; Dalton, Lawrence, & Greiner, 1970; Fuchs, 1975; Gellerman, 1968; Hunt, 1977; Leavitt, 1978; Lippitt & 34 Lippitt, 1978; Schein, 1965, 1969; Steele, 1975). In addition, the human service delivery systems both in the public and private sectors have become concerns of consultants. Consultation has a long tradition in the healing arts, especially the area of mental health. In his book on mental health consultation, Caplan (1970) restricts the use of the term consulta­tion to the process of collaboration between two professional persons: the consultant, typically the specialist, and the consultee who requests the consultant's help in solving a problem which is seen as being within the consultant's area of specialized competence (Goodstein, 1978). Increased interest in consultation across cultural and national boundaries has become a trend in recent years. The interest generally focuses on multinational corporations, national businesses with an eye on the international market, and human services agencies (Guttman, 1976; Lippitt & Hoopes, 1978; UNIDO, 1972; Walsh, 1973). Consultation and Nursing Consultation is an integral part of nursing and has its historical origins firmly rooted in Nightingale's consultation during the Crimean War. This is the first documented instance in which nursing expertise was called upon. The consultation dealt with improvement of wound healing among the injured soldiers, a goal which the surgeons had been unsuccessful in meeting. It is interesting to note that from its earliest history, nurses had a consultative role and that physicians were the recipients of their consultation. 35 Nightingale's consultation resulted in improved sanitary conditions for the British troops and in a significantly reduced rate of infec­tion following traumatic amputations in the field hospitals. In more recent times, nurses have become increasingly more active in consultation as clinical specialization within nursing developed and as nursing has gained recognition as a profession. Consultation reported in the nursing literature cuts across clinical specialty areas and involves nursing practice, education, research, and administration in the United States and abroad (Beaton, 1983; Clark, 1983; Lancaster & Lancaster, 1982; Levenstein, 1979; Miller, 1983; Norris, 1972; Oda, 1982; Pati, 1980; Sedgewick, 1972; Termini, 1981). The Consultant Role Nursing consultants assume multiple roles (Beaton, 1983; Pati, 1980; Sedgewick, 1973; von Schilling, 1982). Seldom in the consultation process will one mode of role behavior be sufficient, because most consultation problems are too complex to be resolved by a single type of intervention strategy. Although there is a shading and blending of a variety of roles in most consultation situations, the roles which consultants assume can be categorized according to the predominant behavioral characteristics underlying enactment of the role. Lippitt and Lippitt (1978) posit a descriptive model of consultant role behavior along a directive-nondirective continuum. In assuming a directive role, the consultant is in command and assumes responsibility for problem-solving activity. When the 36 consultant is nondirective, the responsibility for problem solving is shared with the client. In the latter case, the consultant is more a facilitator than a director. The particular role of the consultant is dependent upon a number of factors. According to Lippitt and Lippitt (1978), the consultant role is determined by three considerations: the consultee, the situation, and the client. Sedgewick (1973) states that it is the consultee's problem-solving ability that determines the appro­priate consultant role. When the solution to a problem is important and the consultee lacks the necessary skills to resolve it, and is unlikely to acquire these skills in the future, then it is appro­priate for the consultant to function in the role of expert by prescribing the actions deemed necessary for the solution of the problem. When the consultee has the necessary skills and potential to solve a problem, and the goal is to improve the client's problem­solving ability, then the consultant functions in a process-oriented manner (Miller, 1983; Termini, 1981). According to Pati (1980), the appropriate consultant role is dictated by the needs inherent in the consultation situation. For example, the role of the consultant may be analytic when it is important to diagnose areas of organizational difficulty, facilitative when a change agent is needed to promote understanding and acceptance of new ideas and practices, or educative when improvement or introduction of educational or training programs is required (Beaton, 1983; Clark, 1983; Frazier & Styles, 1982; Miller, 1983; Oda, 1982; Pati, 1980; Sedgewick, 1973; Termini, 1981). 37 Consultants have differing levels of ability to assume multiple roles. Personal limitations can and should be one of the determining factors in deciding upon the appropriate consultant role. However, Blake and Mouton (1976) warn against consultant preferences being the only determining factor in making the decision. Rather, an effort should be made by the consultant to make a diagnosis of the requirements necessary for helping the client's situation, which can be realistically meshed with the consultant's personality and style of consulting (Goodstein, 1978). Consultation and International Nursing Although many journal articles acknowledge the assistance of international consultants in the development of their programs, only two are concerned with the role of the nurse consultant. In describ-ing the consultant role in multidisciplinary team development, von Schilling (1982) identifies the stages in group development followed by individuals from various health care disciplines. These stages are typical of the dynamics found in small groups regardless of the cultural setting. Using the World Health Organization's risk strategy approach, Beaton (1983) proposes a conceptual framework for developing culture-specific programs in maternal-infant health. Suggested consultant role behaviors are articulated with this approach as are the various phases of program development at a project in Juarez, Mexico, which the author uses as a model for nursing consultation. 38 Cross-cultural Communication In a general sense, every behavioral interaction can be described as an exchange of communication. Communication is the complex process that carries the learned and shared cultural meanings and interpretations. Intercultural or cross-cultural communication is the exchange among people of different cultural backgrounds. Cross-cultural communication serves as a guide for action in situa­tions of an unfamiliar cultural nature (Brislin & Pedersen, 1976; Hall & Whyte, 1976). Watzlawick and Beavin (1967) distinguish three aspects of human communication: syntactics, semantics, and pragmatics. Syntactics refers to the relationship of signs to each other (i.e., the message structure), while semantics examines the relations of signs to their referents or symbolic meanings. Pragmatics investi­gates the relations of signs to their users (i.e., the interpreta­tions). These components are consistent with the symbolic inter­actionist orientation. Symbolic interactionism refers to "human interaction mediated by the use of symbols, by interpretation, or by ascertaining the meaning of one another's action" (Blumer, 1962, p. 180). As such, it is a process of learned experiences (Blumer, 1962; Cooley, 1964; Mead, 1934; Turner, 1962). Rose (1962) summarizes symbolic inter­actionism with basic assumptions and propositions as follows: (a) the human person lives in both a symbolic environment as well as a physical environment; (b) through symbols, a person can evoke similar meanings and values in oneself and in others; (c) many meanings and values can be learned through communication of symbols and prescribed ways of action; (d) the symbols used are complex, multiple clusters, not found in isolated segments; (e) individuals ascribe meaning to themselves, objects, actions, and phenomena from 39 what has been learned; (f) since society is a network of interacting individuals from which the learned meanings and values are taught to individuals, society precedes any existing individual; (g) the individual learns through socialization from the society of inter­acting individuals which comprise reality; (h) meanings and values are not forgotten, only modified and refined. While recognizing the contribution of symbolic interactionism to an increased understanding of cross-cultural communication, this is not an uncritical endorsement of symbolic interactionism. It may be argued that symbolic interactionism extracts the individual from the universe and allows for learning which is divorced from its cultural context. The following criticisms by Brittan (1973) have been taken from Meltzer, Petras, and Reynolds (1975): Interactionism places an over-emphasis on self­consciousness as it ignores or de-emphasizes both the unconscious and the emotive factors as they influence the interactive process. Symbolic interactionism diminishes the influence of psychological factors in the person such as human needs, motives, intentions, and aspirations by treating them as mere derivations and/or expressions of socially defined categories. In an obsession with meaning, the interactionist perspective on the social world is often viewed as a mere adjunct to symbolic analysis. As a result, both social change and social structure are lightly treated. In considering the implications of the fragmentation of self, multiple identities are seen as being merely the lI unfortunate and dysfunctional end-products of a fragmented system of relationships.1I In undertaking a relativistic analysis of social interac­tion, that which is "transient, episodic and fleeting," often received more emphasis than is warranted. Since interactions espouse a metaphysic meaning, there is a danger that a fetish will be made out of everyday life. (pp. 84-85) Although fluency in the language of the host country is the ideal way to begin communicating with people of another culture, 40 understanding of symbols, gestures, and other modes of communication likewise facilitate communication. In itself, proficiency in a language is not necessarily proficiency in cultural knowledge. Knowing culture-specific gestures, symbols, and meanings saves creative energy that may be wasted in mending the damage that results from miscommunication (Meleis, 1984b). Americans have been characterized as "abrupt, time-oriented, to-the-point, with a functional, rational approach to power and authority" (Schaaf, 1981, p. 85). More often than not, gestures are culture-specific in their meaning. For example, the American V-sign for peace or the A-okay sign used by astronauts may not only be culturally insensitive, but obscene in certain cultures (Range, 1984). As a faculty member at the School for International Training of The Experiment in International Living, Brattleboro, Vermont, Range (1984) laments the lack of communication among professional disciplines in sharing what has been learned about cross-cultural communication. I have been working with cross-cultural psychiatrists, social workers, clinic receptionists, medical anthropolo­gists, refugee workers, transcultural nurses, cross-cultural counselors, foreign students, advisors, intercultural trainers, international medical students, etc. etc. I see each group struggling to build up its own information base, its own jargon, its own approaches, with rarely an awareness of what is being done in other fields. I am struck by the separation, compartmentalization, the recreating of the wheel by group after group. This separation, this linear approach is extremely Western in origin ..• we need a more synchron­istic approach in our thinking, our research, and our practice of cross-cultural health care. Nurses, because of their more wholistic approach to patient care are in a special position to bring about this synchronistic team effort. (Range, 1984, pp. 64-65) Range further advises that the energy of nurses should be directed toward "building bridges, into linking professional groups, into sharing different approaches and knowledge" (Range, 1984, p. 65). Since much elaboration will occur in the data analysis 41 chapter, only this brief introduction to cross-cultural communication has been provided at this time. CHAPTER III METHODOLOGY Two methodological approaches to the research problem were used for this study. A quantitative approach was taken with the majority of responses sought on questionnaires (see Appendix A) which were mailed to 200 potential informants. The questionnaires consisted predominantly of multiple-choice options which provided data according to the preconceived categories of the researcher. A qualitative approach was used for several sections on the questionnaire in which informants were asked to write short answers to specific questions. These data were analyzed using content analysis (Holsti, 1968; Spradley, 1979, 1980). Qualitative data were gathered from 25 informants who were interviewed using an open-ended interview approach (see Appendix 8). Demographic data were collected on those interviewed (see Appendix A). Multiple methodologies are advantageous because the strengths of both quantitative and qualitative methods can be achieved while the weaknesses and limitations of each are minimized. Epistemological Considerations Interpretive and explanatory modes of understanding each possess a different epistemology. These differences do not preclude their necessity nor their complementarity. Explanatory understanding 43 is grounded in the empirical. Interpretive understanding requires other ways of knowing such as the personal component, including intuition and mysticism, esthetics, and ethics (which at times can be exp 1 ana tory) . Interpretation presupposes the understanding of linguistic meaning. According to Keat and Urry (1982), hermeneutics is central to interpretation while Reason and Rowan (1981) further argue that: "All understanding is hermeneutical, taking place, to a very large extent determined by, our finite existence in time, history and culture" (p. 132). Hermeneutic understanding in interpretive social science cannot be applied from the outside. The assumption is that the interpreter "knows" to some degree the phenomena sought to be understood. Reason and Rowan (1981) identify four cannons of hermeneutic understanding: 1. Autonomy of the subject 2. Interpretation of the phenomena which is maximally reason­able in human terms 3. Historical connectedness (i.e., the interpreter achieves the greatest possible familiarity with the phenomena) and 4. The hermeneutic circle. By autonomy of the subject is meant that the interpreter does not project preconceived attributes onto the phenomena under study. Meaning must be derived from the phenomena itself. To provide inter­pretation which is maximally reasonable, it is necessary that the interpreter explore, identify and relate the historical roots of the 44 phenomena. Achieving the greatest possible familiarity with the phenomena involves a twofold task. First, the interpreter must have experiential knowledge in which to root the interpretation. Second, the meaning of the phenomena must be related to the interpreter's own situation. Nothing can be interpreted apart from one's own personal history. Finally, the dialectical process of the hermeneutic circle must be utilized: Understanding ... consists of circular and spiral relationships between whole and parts, between what is known and what is unknown, between the phenomena itself and its wider context, between the knower and the known. (Reason & Rowan, 1981, p. 135) In trying to identify the grounds on which explanatory and interpretive modes of understanding are different, one is led to dialectical thinking because contradiction and change are inherent. Here are opposites (explanatory and interpretive) which are found within each other, which demand each other, and which display a unity. In the words of Keat and Urry (1982), this dialectical thinking is summarized: "Interpretation of meanings is partly perceptual and perception is partly interpretive" (p. 240). Development of Questionnaire A questionnaire was developed which addressed each of the research questions. The major areas in which information was sought included preparation for international consultation, the nature of the advice given, attitudes and beliefs about the perceived contribu­tion of United States nurses to international health, and demographic 45 information about the consultant (see Appendix A). Questionnaire response format included multiple-choice, item-ranking, and short open-response questions. In measuring attitudes and beliefs about selected international health issues, a Likert scale was used (Nunnally, 1978; Shaw, 1967). Tuckman (1968) identified an important benefit to using a Likert scale. "This scale is used to register the extent of agreement or disagreement with a particular statement of an attitude, belief, or judgment" (p. 157). Herbst (1968) contended that an attitudinal study can be met with some degree of confidence. "Attitudes and disposition arise from the thoughtful appraisal of experience, and indicate our conscious and personal acceptance of a way of life" (p. 18) . A concern in utilizing a Likert scale was detailed by Kerlinger and Kaya (1959): Generally speaking, the logical validity stage of measuring attitudes has usually been an a priori stage. The investigator tries to determine the nature of the variable he seeks to measure. In most cases, determina­tion boils down to his and other people's judgments. If it is at all possible, he will then use empirical or predictive validity to check on his original variable postulation and its measurement. And while he may attain a high degree of predictive validity, he may still know little about the real nature of "reality" of the vari­able( s) he is measuring. (pp. 21-22) An open-response format was chosen for questions regarding preparation for international consultation, areas in which interna-tional sharing is beneficial to both consultant and client. Three advantages to open-response questionnaire formats are: 1. Respondents are given the opportunity to express their feelings to researchers. 2. Responses may help researchers identify unanticipated variables or situations that would not have been possible with closed-response questionnaires. 3. Open-response questions allow for a wider range of answers to questions. More data become available for analysis (Henerson & Morris, 1978). Assistance in preparing the response format was sought from pertinent literature, similar research, and several professional reviewers. Consideration was given to responses that would lend themselves to desired data analysis. -----', 46 Petry (1976) analyzed the reasons given by nonrespondents for failure to complete questionnaire surveys. Among the most common reasons he identified were: 1. Questionnaire too long 2. Too complex 3. Lack of questionnaire focus 4. Sender seeking unimportant information 5. Sensitive information 6. No stamped return envelope 7. Too many subject areas 8. Timing (received during a busy period). Petry's findings were taken into consideration while preparing survey instruments used in this study. 47 Development of Interview Questions Given that the purpose of interviewing as a research method­ology is to find out "what is in and on someone else's mind" (Patton, 1980, p. 196), it was one of the methodologies chosen for this study. In one of the first systematic discussions of interviewing methods, Bingham and Moore (1924) describe the interview as "a conversation with a purpose." The purpose of open-ended interviewing is not to project the interviewer's preconceived categories for organizing the world onto the interviewee, but rather to access the perspectives of the person being interviewed. Interviews are con­ducted to find out from the person those things that cannot be observed directly. The issue is not whether observational data is more desirable, valid, or meaningful than self-report data. The significant issue is rather, that the researcher cannot observe everything, such as feelings, thoughts, and intentions. In addition, experiences that took place at some previous point in time cannot be retrieved, except in part, those which may have been recorded (taped, photographed, or videotaped). The researcher cannot observe how people have organized their world and the meanings they attach to events and situations. In summary, the purpose of interviewing is to enter into another person's perspective. The assumption is made that the person's perspective is meaningful, knowable, and capable of being made explicit. There are three basic approaches to collecting qualitative data through open-ended interviews. The three approaches involve 48 different types of preparation, conceptualization, and instrumenta-tion. Each approach has its strengths and weaknesses, and each serves a different purpose. The three types are: 1. The informal conversational interview 2. The general interview guide approach 3. The standardized, open-ended interview. The differences among these three approaches to the design of the interview is the extent to which interview questions are determined and standardized before the actual interview occurs. Each of the three types of interviews has its own characteristics, strengths, and weaknesses. The common characteristic of all three qualitative approaches to interviewing is that the persons being interviewed respond in their own words to express their own personal perspectives. The interviewer does not supply or predetermine the phrases or categories that respondents use to express themselves. The fundamental prin­ciple of qualitative interviewing is to provide a framework within which respondents can express their own understandings in their own terms. An interview guide approach was used with 5 informants to develop a standardized open-ended interview instrument which was then used for an additional 20 interviews. The interview guide consisted of a list of questions and issues that were explored in the course of the interview. An inter­view guide was prepared in order to make certain that essentially the same information was obtained from all informants by covering the 49 same material. Issues related to protection of rights of subjects and informed consent are sun~arized in Appendix C. Interviews were tape recorded to increase accuracy. The interview guide provided topics and subject areas within which the interviewer was free to explore, probe, and ask questions that would elucidate and illuminate various aspects of international nursing consultation. The inter­viewer remained free to build a conversation with particular subject areas, to word questions spontaneously, and to establish a conversa­tional style, yet the focus was narrowed to international consulta­tion. The advantage of the interview guide was that it ensured that limited interview time was used carefully. The interview guide promoted systematic and comprehensive interviewing by delimiting the issues discussed in the interview. The guide kept the interaction focused, but allowed individual perspectives and experiences to emerge. The interview guideline provided a framework within which the interviewer developed questions, sequenced those questions, and made decisions about which information to pursue in greater depth. The interviewer normally adhered to the predetermined subjects and avoided areas not within the framework of the interview guide, the researcher asked each informant if there were any topics not addressed which might be helpful in elucidating aspects of international nursing consultation. Suggestions from informants were incorporated into subsequent interviews as appropriate. Since this topic has not been studied before, the researcher relied upon the expertise and judg­ment of the 5 informants to develop and refine the standardized, 50 open-ended interview instrument. In the standardized open-ended approach, the interview questions were written out in advance exactly as they were asked during the interview (see Appendix B). The basic purpose of the standardized open-ended interview was to minimize interviewer effects by asking the same questions of each respondent. The interview was systematic and familiar for each person interviewed. The advantages of using standardized, open-ended interviews are that: 1. The exact instrument used is available for inspection and/or replication purposes 2. Variation among interviewers can be minimized when a number of different interviewers are used 3. The interview is highly focused so that interviewee time is used carefully. A major consideration in choosing the standardized, open­ended interview approach was related to economical, practical, and logistical considerations. Since the informants were spread geographically across the country, an effort was made to conduct interviews while the informants were gathered centrally, such as attending a conference or meeting. In using the standardized, open-ended interview, data con­sisted of the informants' own words, including insights and reflec­tions upon the questions, but the exact questions asked were prede­termined. The weakness of this approach is that it does not permit the interviewer to pursue topics or issues that were not anticipated 51 when the interview instrument was written. In an effort to minimize this limitation, the final question allowed the informant to provide information which was believed to be relevant, but which was not asked. Methodological Strategies This study was conducted in four stages. Phase I. Identification of target Population A preliminary survey was conducted to locate informants from the target population of United States nurses who have engaged in international consultation. Survey forms (see Appendix D) were mailed to 50 universities and 50 agencies known to have nurses with international experience. The purpose of the survey was to locate nurses having international nursing backgrounds and from among those nurses to identify the subset who have served as international consultants. From among the 226 returns, approximately 100 indicated that they had been international consultants. An additional 100 were identified through informal networking making approximately 200 potential informants for this study. An effort was made to contact nurses who had done international con-sultation under the auspices of a cross-section of organizations including private voluntary, church-related, private proprietary, and government agencies. In using a purposive sampling method, it was intended that the target population might be more readily identified. Phast II. Administration of Questionnaire Two hundred (see Appendix A) questionnaires were mailed to those informants identified during Phase I. A follow-up letter and another questionnaire were mailed to those who had not responded after a 2-month period of time. Phase III. Interviews with Panel ~f Experts and Refinement of Interview Instrument Having identified key informants from the target population of nurse consultants through the mail survey, 5 informants having 52 much experience in international consultation were interviewed using an interview guide approach in order to pilot test the interview questions. Questions were changed and added as appropriate. Phase IV. Conduction of Standardized Interviews Based upon the data obtained from the five interviews in Phase III, 20 key informants were interviewed using a standardized, open-ended interview (see Appendix B). Interviews were tape recorded to enhance the accuracy of the data. Rights of Human Subjects In order to safeguard the rights of informants, the Univer­s'ity of Utah Guidelines for Preparation of Proposals Involving Human Subjects were followed. The Institutional Review Board approved the study prior to data collection. CHAPTER IV DATA ANALYSIS As noted in Chapter III, two sets of data have been used in this study. The first set consists of responses to a questionnaire which provided predominantly quantitative data, but also some qualitative information as obtained from short responses to open­ended questions. Ninety-three informants completed the 12-page questionnaires. The second set of data consisted of the content analysis of 25 interviews with informants who had engaged in inter­national consultation within the past 7 years. In using two methodological approaches and thereby generating two data sets, the purpose is to better understand the entire phenomena of international consultation. Since both the question­naire and the interview instruments are available for replication, findings from the two data sets will be referred to jointly as "results" throughout this chapter. A brief overview of the questionnaire analysis will be discussed first. Overall, the response rate for the questionnaires was 65%. Although 200 questionnaires were mailed, only 153 were actually considered eligible for inclusion in the study. Excluded were 47 who failed to meet the study criteria for the following reasons: 1. Not United States citizens (1) 2. Not nurses (3) although they are on the faculty of schools of nursing 3. Had worked abroad but had not done consultation (32). Refusing to participate in the study was one Private Voluntary Organization (PVO) whose director stated in a letter: "Nurses do not consult, they just work." Three nurses in the study had, in fact, consulted for this PVO, but were contacted directly rather than through the agency office. Definition of International Consultation In Chapter I, an operational definition of international consultation was offered. Here the purpose is to elaborate upon that definition using the informants' own words. 54 For the purpose of this study, a phenomenological approach to the term international consultation was taken. If the informants perceived themselves to be international informants, then this percep-tion was accepted as true. Recognizing that there would be different definitions, the researcher asked each informant to define the term. Responses given were consistent with the definition set forth initially. Among the definitions given were those focusing on the process of consultation and on the content of the consultation, or both. The majority of responses dealt with the content of the consultation with emphasis on the "specific area of expertise" which the consultant brought to the consultation interaction. Examples of responses in which the definition focused on the process include the following: International consultation is: Sitting down and talking to someone and helping under­stand their goals, their desires ... and just helping them work out a plan .... Listening and facilitating the client's abilities to meet their own needs .... Dialoguing with others, hearing their concerns and issues. The majority of consultants, however, felt that the content provided was an important component. Examples of responses in which the content was primarily of concern are as follows: Providing expert counsel in a specific area with no consideration of the needs of the host country. Assisting others to solve problems and sharing knowledge of the specialized area with others .... . . . offering a view about alternate approaches to issues based on a sound knowledge of the problem and of the field . . • . imparting expertise so that it is relevant to the recipients. The mutual exchange of ideas was important to some in their definition: . any activity in which information has been exchanged so that both consultant and recipient go away with a broader base. Providing a service in a reciprocal [way] to benefit or advance a projected goal .... Effecting change was significant in some definitions: Deliberating or considering, especially information related to change processes and the focus of change ... and offering a view about alternate approaches .... Bringing about change by helping the client to mobilize internal or external sources to deal with problems .... 55 While the majority of informants defined international con­sultation as previously described, several added the component of service to the definition: A consultant is a teacher, a practitioner, an advisor, a "doer" and a friend. Consultation, especially in underdeveloped countries often means getting involved and doing things ... being a role mode. The service aspect may be related to the traditional orientation of nurses as members of a practice discipline. Having defined international consultation from the inform­antis perspective, an effort will be made to understand the motiva-tion for engaging in consultation as described by the informants themselves. Motivation for International Consultation Before discussing the findings, it is necessary to intro- 56 duce this section with an operational definition of the term motiva­tion. While recognizing the scholarly research on human motiva-tion conducted by social and behavioral scientists, the term is being used in this study as follows. Motivation refers to those factors which cause a person to act in a particular way. It also refers to those reasons, expressed from the perception of the individual, as explanations for certain behaviors. Also included are the incentives responsible for movement or action. In this sense, motivation is not intended to convey any level of measurement, but rather to describe those things which incite people to act in a particular way. These 57 categories are suggested in light of the informant's emphasis and are not mutually exclusive. The emphasis is that of the respondent. As indicated in Table 1, the motivation for becoming an international consultant may be classified into six categories: 1. Enjoyment of people from other cultures 2. Opportunity to travel 3. Moral convictions 4. Religious beliefs 5. Financial rewards Table 1 Reported Motivation for Engaging in International Consultation Reason Enjoy people of other cultures Opportunity to travel Moral convictions Religious beliefs F"inancial rewards Other: (ii = 92) Cross-cultural exchange of ideas Professional commitment Personal invitation Service N 72 60 30 14 13 17 12 10 9 % 78 55 28 13 12 19 13 11 10 58 6. Other. ,Among the "otherll category on the questionnaire, several subcategor­ies were identified: 1. Cross-cultural exchange of ideas 2. Professional commitment 3. Personal invitation/personal growth 4. Desire to serve. Data obtained from the questionnaire were corroborated by interview data. In addition, these findings are consistent with those of Baker, Weisman, and Piwoz (1984) who conducted a survey of United States health workers engaged in international health. Reported motivational factors in their study included: "idealism, opportunities for adventure, research opportunities, chances for learning about new cultures, and, in a few cases, higher earnings" (p. 440). Enjoyment of People from Other Cultures Stating that enjoyment of people from other cultures was a strong motivating factor, informants made the following remarks: I just loved meeting people from other countries. I loved working with other people. Basically 11m curious about other people. I like to meet people. Consulting was more than just a chance to travel, but really a way to get to know people in another country and to live there. , 5 59 Opportunity to Travel While attempting to avoid cliches about international travel opportunities, the world has indeed become smaller. It is possible to travel to virtually anywhere in the world within a reasonable period of time. Mass communication networks bring remote parts of the world into our living rooms while magazines entice with attrac-tive and reasonably priced tours of almost everywhere. Having traveled abroad once, most Americans express the desire to see, hear, and experience even more of the world. When the opportunity to travel is combined with certain personality characteristics such as low tolerance for boredom, international consultation emerges as an attractive option for nurses. Given the chance to travel with "all expenses paid,1I the individual usually needs to examine the reasons IIwhy not" more carefully than the "whys.1I Some of the con-straints on international consultation are discussed in the section on problems encountered by consultants. The majority of informants, however, reported that the opportunity to travel was a motivating factor: Once you become a part of the world community, you want to continue to explore it. I love to travel. I have a low boring point. bored very quickly if I stay in a routine job probably a personality characteristic. I get . that's I grew up in a small farming community ... and I wanted to see the world. I wanted to meet exciting peop 1 e • . . I have always thought that I would like to travel and see other parts of the world. This was an opportunity to do it with all expenses paid. 60 Moral Convictions Although it might be argued that moral convictions evolved from religious proclivities, informants reported a distinction between motivation due to moral convictions and those having origins in their religious beliefs. I was a kid of the '60s and I grew up with Kennedy as President There was this kind of feeling that you should do things for other people and get involved. I also loved the idea of getting to travel and see other countries. Nursing was the perfect opportunity to blend this. It was the Kennedy era and it was just the "in" thing for people to do then .•. helping people overseas to enjoy the same standard of health that we had in the U.S. I read in Time magazine about the way the [Southeast Asians] were being slaughtered. It was like another holocaust and I could never understand how six million Jews could be killed while the world watched and did not know about it. Why didn't more people do something? I thought: "Here's my chance to do something. Shut up or put up." Religious Beliefs Often affiliated with church-related sending agencies, some informants cited strong religious convictions as their primary moti­vation (cf., Lavery, 1984; Thiessen, 1984). Since my earliest childhood, I wanted to be a medical missionary and felt a tug to be involved when I grew up. During my final months of nurses' training, I met a young doctor who was planning to go abroad. He was a second generation missionary. To make a long story short, we were married. Our lives have been dedicated to medical missionary service throughout our 21 years of marriage. My Christian commitment makes me want to give to others. My church calls individuals to serve in particular ways. I was called as a health missionary to [the Pacific Islands]. Financial Rewards Although there was a wide range of responses about the financial rewards of international consultation, those who con-sulted to the oil-rich Middle East reported exceptionally high salaries and attractive fringe benefits (Baker et al., 1984). The salary range ... was between $70,000 and $100,000 ... so it was really worth your while. At that point in time, you could have 75% of it tax free ... Besides the salary, the benefits were great ... furnished housing in an American compound, car and driver, plenty of vacation time to travel allover the world if you wanted to ... and lots of attractive benefits. I wanted to work internationally but couldn't find positions doing what I wanted to do at a decent salary. The ones that paid well were those in administration or management of some sort. The PVOs [private voluntary organizations] don't pay hardly anything, so consultation positions were all that was left. You're almost pushed into consultant work if you want to survive financially. It was like a free vacation. I was getting paid my regular salary anyway. When my [boss] asked "Would you like to go to [X country] for 6 weeks with all expenses paid? II naturally I said, "Sure. When do I leave?" Other 61 Cross-cultural exchange of ideas. The cross-cultural exchange of ideas was given as another reason for engaging in international consultation and is perhaps related to the basic human need for new experience. I just wanted to share with people in another culture. I wanted to learn about different health problems and traditions ... to find out how other countries deal with problems. I wanted to be exposed to different nursing education systems. 62 Professional commitment. Expressing an interest in advancing nursing globally, several informants offered professional commitment as a reason for their interest in international consultation. Although the term "professional" is defined in a variety of ways, a phenomenological approach is being taken in this study. Therefore, the informants I use of the word has been presented in this section (cf., White, 1983). I have this dream to further nursing research worldwide. The challenge of problem-solving in a different cultural setting ••. of helping nurses in other countries ... I find that exciting because my job is about solving problems. I wanted to share my professional knowledge and exper­tise, but didn't want to preach. As a child, I had an aunt who was a missionary. I wanted to give something to people, but didn't want to do it with that heavy-handed religious influence. Personal invitation. Related to informal networking, several informants indicated that they had been contacted by the client, an intermediary of the client, or former employer who knew their areas of expertise. The administrator of the hospital had been recruited by [a country in the Middle East] and was asked to bring his own team. He picked people he knew he could work well with. I worked with him before and he knew that I was good at my job and that he could work with me. A former student in the master's program at the univer­sity where I teach now holds a high ministry position and asked me to come and consult. I happened to sit next to this person on an airplane who turned out to be [a highly placed administrator] with [an international health organization]. We just got to talking about international health and other things. At the end of the flight, she told me to submit an application to her organization, so I did. That's how a lot of things have happened in my life ... just being in the right place at the right time. It's just luck. 63 Desire to serve. Given that some informants included a service dimension in their definitions of international consultation, it is not surprising to find that the desire to serve was part of their motivation. I didn't choose [consultation] at first, but when I got there [Central America] and saw so many problems that needed answers, I realized there was a need for consultation. Basically, I think it was just a gut need to want to be the person to lay the hands on ... I would love to be the person to ... deliver the food ... the food on my plate. They always say "People are starving in Africa." Okay, so send them my pork chop. This was a chance to take it and deliver it in person. Motivation for Choosing Agency and Region Before discussing the motivation for choosing a particular sending agency, a brief overview of the types of agencies with which informants affiliated will be presented. As summarized on Table 2, the agencies sponsoring the consultants were as follows: 46% United States sponsorship which included government agencies (26%), private proprietary organizations (15%), universities (13%), and church­related organizations (9%); 28% host country sponsorship; 23% international agency sponsorship; 11% international church organiza-tions; and 7% joint sponsorship. In addition to understanding the motivation underlying the decision to engage in international consultation, an effort was made to understand why consultants chose a particular sending agency and a specific region of the world. Motivation for choosing a specific agency may be classified as: 64 1. Philosophy of the sending agency 2. Advertising/recruitment efforts by sending agency 3. Relationships with someone affiliated with sending agency. Motivation for going to a particular geographic region may be classified as: 1. Political stability of the host country 2. Personal reasons 3. Matching of host country needs with the expertise of the consultant. Philosophy of the sending agency. The philosophy of the sending agency was identified as being an important factor: Table 2 Type of Agency Sponsoring International Consultation (Ji = 93) Type of Agency United States sponsorship: Government Private voluntary organization Private proprietary organization University Church-related organization Host country sponsorship International agency International church organization Joint sponsorship N 42 23 19 13 12 8 28 21 10 6 0' 10 46 26 21 15 13 9 30 23 11 7 My husband and I wanted it to be a religious affiliation. I did not want the religious setting and it seemed like the easiest way to do it at the time, so I worked for [a government agency]. It's important to know the philosophy of the organiza­tion you consult with. Do they believe in working with the people of the country? Or do they just want to impose some American model? Advertising/recruitment by the sending agency. Indicating that the sending agencies themselves had done a successful job at recruitment, several informants related that they had seen journal or television advertisements about the sending agency. There was a lot of publicity on television, in journals, allover the place. The position was advertised in [a newsletter] sent to all employees [of a particular church-related hospital]. 65 Relationship with another person affiliated with the agency. Personal contacts and informal networking (cf., C. Kleinman, 1980; Welch, 1980) were responsible for the particular agency with which some consultants affiliated. To a large extent, some of the inter-actions with others could be described as serendipitous. I just happened to develop a friendship with another nurse who had worked for [a particular private voluntary organization]. In talking with her about her experiences, it reminded me that that was something I had always wanted to do. I submitted a formal application, interviewed for a position, and was offered a job. I have worked with many organizations worldwide [govern­ment, PVOs, universities] which have afforded me lots of contacts. When contracts come up, people remember who I am and call. So that's how I have networked. It's because I have been overseas for 11 years and because of the con­tacts I've had with many people. Inspired by the enthusiasm of a clergyman on furlough from his mission in South America, one consultant described how she came to decide upon a particular, church-related agency: He was an extremely dynamic and exciting man ... My husband and I decided to spend a month [in South America] travelling and staying with missionaries. There was just something about the life and being in a foreign country that spoke to the young adolescent in me ... After visit­ing, they [church-related agency] contacted us directly and offered jobs to both my husband and me. 66 Reasons given for choosing a particular geographic region or country included the following: Political stability of the country. Describing the reason for declining a consulting position in a country fighting a civil war, one informant indicated that she felt she should accept the next "reasonable offer" presented by the agency. Concerned that she would not be offered another opportunity by the sending agency if she consistently turned down their offers, the informant subsequently accepted a position in Central Asia. I was originally offered a position in [Southeast Asia] in the early 1970s and I didn't take that one. I had a hard time with my family ... after my family's input and my own thinking about it, I decided not to accept the position. After describing an international service position in a war zone/refugee camp, an informant stated: I desired a more stable environment such as Africa promised. Personal/emotional motivations. The category personal/ emotional refers to those motivations in which the pursuit of an intimate relationship with a significant other person was offered as a reason. Although there are only two informants in this category, their reasons for choosing a particular geographical region are of interest. I went partly for the relationship I developed with a guy [working with a private voluntary organization] and partly to learn more. This [African country] looked like a nice place to do it and it turned out it was. I originally wanted to go to Africa. The reason I ended up in South America was that my boyfriend at the time very much disapproved of me going into [a government agency]. We had been dating for 4 years and weren't really going anywhere. He expected me to sit home and wait for him ... so I decided that I wasn't going to sit and wait for that. He was in [Central America] ... so I decided to go to South America. I didn't know any Spanish but [South American] was closer to [Central America] than Africa was. I figured that we could visit sometime. I was originally assigned to [a particular South American country] but that project was cancelled at the last minute. On a two-week notice, the [agency] said, II We II , do you want to go to [a country in South America]?" I had to look up on the map and see where it was. I said, "Sure . II I was ready to go. Matching host country needs with expertise of consultant. Stating that they did not have a preference for a particular geographic region, several consultants were given assignments according to the needs of the host country. Included in the match­ing of expertise is the informant's ability to speak the language of the host country. An effort is made to match personnel with a particular country based upon language skills and familiarity with the culture of the country. The background of the personnel are considered with much care. They [a certain PVO] were recruiting for a specific position for which I had the appropriate background [nursing education]. In summary, the informants offered a variety of reasons for engaging in international consultation including the enjoyment of 67 people from other cultures, opportunity to travel, moral convictions, religious beliefs, financial rewards, and a variety of "other" reasons such as the cross-cultural exchange of ideas, professional commitment, personal invitation, and service. Also discussed were the motivations for choosing a particular sending agency and for consulting in a given geographic location. Demographic Information 68 Demographic data were obtained from the questionnaires and from subjects who were also interviewed. Since 11 of the subjects completed questionnaires and were interviewed, the total sample size is 104. When the ~ is less than 104, missing data are responsible. Included in the demographic data are educational background, professional nursing experience, age, sex, minority status, citizen­ship, professional activities such as publishing, presentations at professional meetings, holding of offices in professional organiza­tions, and the number of times served as an international consultant. Educational Background Table 3 provides an overview of the educational backgrounds of the informants. Of the 104 informants, 81% had baccalaureate degrees in nursing, 43% diplomas in nursing, 2% associate degrees, and, 11% baccalaureate degrees in nonnursing fields as their basic educational background. Table 4 shows that 89% were master's pre­pared with 31% prepared in community health, 20% in medical surgical nursing, 14% in mental health/psychiatric nursing, 11% in education, 9% in pediatric nursing, 14% in maternal-child nursing and 1% in gerontological nursing. Sixty-nine percent held master's degrees in nursing, 10% held master of science degrees in nonnursing fields, Table 3 Basic Educational Background (Ji = 104) Program Baccalaureate Diploma Associate Other nonnursing baccalaureate Table 4 N 84 45 2 11 Master1s Educational Background Area Degree type (~ = 106): Master of Science (nursing) Master of Public Health Master of Science (nonnursing) Master of Arts Nursing specialty area (Ji = 81): Community health Medical-surgical Mental health/psychiatric Ma terna l-chil d Nursing education Pediatrics Gerontological N 69 17 10 6 26 16 11 11 9 7 1 69 % 81 43 2 11 % 72 18 10 6 31 20 14 14 11 9 1 70 primarily in education, 17% held a Master of Public Health (MPH) degree, and 6% held a Master of Arts degree. Twelve percent had two master's degrees, generally in nursing and in another field. Summarized in Table 5 are the type and area of specializa­tion of those informants having doctorates. Fifty-five percent held doctoral degrees. Seventy-five percent of the doctoral degrees were Ph.D.s (Doctor of Philosophy), 12% D.N.S. (Doctor of Nursing Science), Tab 1 e 5 Doctoral Educational Background Area N % Degree type (Ii = 57): Ph.D. 43 75 D.N.S. 7 12 Ed. D. 5 9 Other 2 4 Field (Ii = 55): Education 18 33 Nursing 12 22 Educational psychology 8 15 Anthropology 2 4 Sociology 2 4 Other 16 24 71 5% Doctor of Education (Ed.D.), and 4% other. The fields of special-ization include education, nursing, and a wide variety of other disciplines. These findings are in marked contrast to the distribution of educational preparation of United States nurses as reported by the American Nurses l Association (ANA, 1983). Based upon 1980, data, the highest earned credential for nurses was reported as follows: diploma 52%, associate degree 20%, baccalaureate degree 23%, and master1s or doctoral degrees 5%, thus demonstrating that the inform-ants in this study have educational preparation which exceeds that which would be expected of nurses in general. Since consultants presumably have specific clinical expertise, informants were asked about certification in specialty areas. As summarized in Table 6, 30% indicated they were certified, as compared with 1.3% of all United States nurses (ANA, 1983). Nineteen percent indicated certification as nurse-midwives, 16% as family nurse Table 6 Certifications of Consultants (li = 31) Area Midwifery Adult/family nurse practitioner Pediatric nurse practitioner Other N 6 5 3 17 % 19 16 10 55 72 practitioners, 10% as pediatric nurse practitioners, and 55% in other areas, some of which included licensure and certifications in countries to which they consulted. Professional Experience Table 7 summarizes the professional practice background of informants. In examining the data, it was found that the number of years spent in practice ranged from 2 to 43 years with a mean of 23 years. Since the mean (23 years) and median (22.3 years) are close Years 5 or less 6-10 11-15 16-20 21-25 26-30 31-35 36-40 More than 40 Table 7 Total Number of Years Employed in Nursing (l! = 98) N 1 9 17 17 14 20 7 10 3 x = 23.0; SD = 9.7; range = 2-43; median = 22.3. % 1 9 18 18 14 20 7 10 3 73 in value, extremes at the low (2 years) and the high (43 years) ends of the continuum have not significantly skewed the findings. As summarized in Table 8, specialty areas identified by informants in order of prevalence were: 74% nursing education, 54% medical surgical nursing, 38% community health nursing, 31% nursing administration, 27% pediatric nursing, 27% mental health/psychiatric nursing, 24% nursing research, 22% maternal-child/obstetric nursing, 14% critical care nursing, 12% geriatric nursing, and 11% primary Speci a lty Area Nursing education Medical-surgical Community health Table 8 Proportion of Total Sample in Each Nursing Specialty (l'! = 105) N 78 58 40 Nursing administration 33 Pediatric 28 Psychiatric/mental health 28 Research 25 Materna l-chil d 23 Critical care 16 Geri atri c 13 Primary care 12 % 74 55 38 31 27 27 24 22 14 12 11 74 care nursing. All specialties were represented. The relatively high proportion with experience in education, administration, and research is consistent with the educational background of the informants. Professional Activities Table 9 presents an overview of the professional activities of informants. In an effort to determine professional activity of the consultants, data were gathered on the publication activities, participation in professional organizations, and research endeavors of informants. Findings indicate that informants have been active professionally in those areas surveyed, a finding which is consistent with the high percentage of master's and doctorally prepared nurses, many of whom hold positions of leadership in the United States and abroad. Sample Characteristics: Age Sex, and Ethnicity As shown in Table 10, the median age is in the 41 to 46 category, while the majority (96%) are female. These findings reflect demographic profiles of United States nurses in general for gender, but the median age is slightly higher than the national median of 36.3 years (ANA, 1983). Nine percent of the informants identified themselves as being members of an ethnic minority group, slightly higher than the 7.2% nationally (ANA, 1983). Among those who indicated a minority affiliation, 2% were black, 6% Asian American, and 6% nonspecified minority affiliation. Table 9 Professional Activities of Consultants (Ji = 104) Acti vit i es Journal pub 1 i cat ions: None 1-5 6-10 11-15 16-20 Over 20 X= 1. 9a SO = 1. 7 Books/monographs/chapters: None 1-3 4-6 7-10 Over 10 X = O.6b SO = 0.8 Speeches at professional meetings: (Past 5 years) None 1-3 4-6 7-10 11-20 Over 20 X = 2.8c SO = 1.8 Participation in research projects: None 1-3 4-6 7-10 Over 10 X = 1.9d SO = 1.3 N 20 33 19 7 6 16 52 36 5 2 1 13 18 14 16 9 30 10 36 27 8 19 75 % 20 33 19 7 6 16 54 38 5 2 1 13 18 14 16 9 30 10 36 27 8 19 76 Table 9 (Continued) Activities N % Professional offices held (past 5 years): None 33 33 1-3 42 42 4-6 17 17 7-10 3 3 Over 10 LIe 5 5 X = SD = 1. 0 aCorresponds to falling between 1-5 and 6-10 categories. bCorresponds to fall ing between none and 1-3 categories. cCorresponds to falling between 4-6 and 7-10 categories. dCorresponds to falling between 1-3 and 4-6 categories. eCorresponds to falling between 1-3 and 4-6 categories. Characteristic Age 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 Over 60 Sex Male Female Ethni ci ty White Black x = 5.8* Asian American Hispanic Other Table 10 Sample Characteristics SO = 1. 9 N 2 9 21 14 21 15 11 10 4 100 91 2 6 6 *Corresponds to falling between 41-45 and 46-50 years categories. Frequency of International Consultation 77 % 2 9 20 14 20 15 11 10 4 96 86 2 6 6 Table 11 summarizes the number of times that informants con-sulted internationally. Recognizing that there could be differences among those who have consulted only once, many times, and full-time, the frequencies were as follows. Thirty-one percent of the respond-ents consulted once, 45% two to five times, 6% six to ten times, 11% more than ten times, and 8% indicated that international consultation 78 Times served Table 11 Times Served as International Consultant (~ = 100) N % Once 31 31 2-5 Times 45 45 6-10 Times 6 6 More than 10 Times 11 11 Full-Time Job 8 Note. -X = 2.2 a ; SD = 1.2. aCorresponds to falling between once and 2-5 times. was their full-time position. The statistical analyses of data related to the frequency of consultation and perceived benefit to the client demonstrated no statistically significant results. Using Kendall IS Tau and Spearman rho correlations, there was no statistical significance between the frequency of international consultation and the perceived benefit to the client. As shown on Table 11, the informants were divided into three groups: those who consulted once, more than once, and full-time. Chi-square was used to determine any significant differences among 8 the groups according to the nature of the advice given. The results were not significant at the £ < .01 level for those who had consulted in the areas of nursing practice, education, or research. 79 Significance at the Q < .01 level was found when the nature of advice was in the administration/other category. The significance lies in the fact that all but 1 of the informants who consulted full-time gave advice in the administration/other area. This finding is consistent with the demographic data on the informants. It is reasonable to expect consultants to have administrative experience and to be recruited for this expertise. This was especially true for consultants to the Middle Eastern countries. With a lambda of .08, the predictive ability generated from these results is low. A larger sample size would be needed to enhance the confidence as a predictor (see Table 12). Preparation for International Consultation Summarized on Table 13 are the various ways in which informants indicated they had prepared for their consulting experi-ence. In examining the preparation by informants for international consultation, responses ranged from "none is necessary" to a wide variety of practical and academic suggestions for preparation. Reading about the culture, geography, and climate (96%) were the most common ways in which informants prepared. Eighty-five percent indicated that they read about the sociopolitical situation, while 82% read about the health care system of the country. Other types of preparation included talking with other Americans who had visited or lived in the host country (79%), studying about the religious practices (71%), and talking with nationals of the country currently living in the United States (50%). Table 12 Distribution of Administrative/Other Advice According to Times Served 80 Administrative consulting Yes Times served ern (W % Once (28) (7) 25.0 More than once (53) (21) 39.6 F u 11 -time ( 8 ) (7) 87.5 Note. Chi-square (2 df) = 10.2; Q < .01; Lambda = .08. Table 13 Preconsulting Preparations by International Consultants (Ii = 12) Preparati on Read about country Read about culture Read about sociopolitical situation Read about health-care system Talked with Americans who were there Read about religious practices Talked with nationals living in U.S. Insufficient time to prepare No preparation necessary N 88 88 78 75 73 65 46 19 6 No (W 0' 70 (21) 75.0 (32) 60.4 (1) 12.5 % 96 96 85 82 79 71 50 21 7 81 Table 14 summarizes language studies done in preparation for consultation. Although the majority of informants emphasized the importance of studying the language when consulting to non-English speaking countries, only 38% of those completing the questionnaires indicated that they had done language studies prior to consulting. Among those who had studied a language, a median period of 11.8 weeks was spent. The median is reported because the mean (17.9) was inflated by extreme values. Obviously there are differences of opinion between those who are short-term consultants and those who are long-term consultants. Realistically, the short-term consultant is less willing to invest a great deal of time in learning the language unless frequent return visits are planned. Often learning simple greetings is all that can be mastered and this is frequently done as a goodwill gesture not as a serious effort to gain an understanding of the language or the people. The long-term consultant who intends to live in the country for several years has much more reason to take the time needed to learn the language of the host country, if there is a single language. Many African countries have hundreds of different languages spoken within their boundaries, with English or French often being used by the nationals themselves to communicate with people of other tribes within their own boundaries. Some languages are extremely complicated and difficult to learn, even with many years of intense study. Others are learned more easily by English-speaking persons. In addition to the informant's own interests and motivation Studied language Table 14 Language Studies (! = 52) How long studied language (weeks)a: 1-4 5-8 9-12 13-16 17-20 21-24 More than 24 N 35 4 5 8 2 1 3 2 aBased on 25 who responded, medianb is used because the mean (17.9) was inflated by extreme values (range of 1 week to 3 years). bMedian = 11.8; range = 1-96. 82 % 38 16 20 32 8 4 12 8 to learn the language, external pressures are sometimes exerted. For example, certain sending agencies require that the consultant speak the language. Several PVOs provide opportunities for language study before giving the consultant a particular assignment. In some cases, the assignment may depend upon the consultant's ability to master the language. When the sending agency has a language competency expectation, opportunities are usually provided for the consultant to prepare. The sending agency arranged for private tutoring for a full year ... for any number of hours that the tutor and person felt were advantageous. 83 Henkle (1979) indicated that 63% of her respondents (~ = 78) identified language as a problem while 75% felt that other communica-tion difficulties had resulted from differences in culture. In reporting the study results, Henkle says that: Both verbal and nonverbal communication should be stressed. The ability to learn another language is one of the most important skills of the international nurse. The ability to communicate nonverbally in a warm manner is also needed and techniques for such communication can be taught. (p. 171) Many others concur that failure to master the language of the host country (client) is a serious threat to successful cross-cultural communication (Giovannini & Brownlee, 1983; Hall & White, 1976; Harris & Moran, 1979; Hurley, 1982; Lindholm, 1974; Masson, 1981; Meleis, 1984b; Range, 1984; Schaff, 1981; Thiessen, 1984; Watzlawick & Beavin, 1967). Many informants cited their own educational back-ground, including their basic nursing preparation as ways in which they believed they became ready to consult. Knowledge of the content area in which consultation is expected by the client was identified as being significant (cf., Henkle, 1979; Hurley, 1982); I spent many hours going over my notes and making sure I knew my stuff. Hours go into preparing for a consultation. I updated everything, making sure that what I had was current. Other informants emphasized the importance of practical experience as being the best preparation. You can have all the education in the world, but experi­ence makes all the difference. Get some experience yourself for 2 to 3 years where you are totally immersed in a setting before you try to consult. Experts will pop in and out and people will be very gracious. We tell them what we think they want to hear but it often is far from reality. I don't think there is a substitute for some hands-on, long-term experience. One informant hesitated briefly before offering her opinion on preparation and then said, I really don't know if you could prepare anybody for it. It's something to experience and live through. Viewed as being extremely valuable were nurse practitioner 84 skills. Since the role of nurses in many LDCs includes the diagnosis and treatment of diseases, those having practitioner skills are particularly well-prepared to deal with the daily problems confront­ing nurses, especially in rural areas (cf., Henkle, 1979; Hurley, 1982). While assessment of clients is important to United States nurses, it has an added significance for nurses in many other parts of the world where the nurse may be the sole provider of health care. Of particular value are skills as a family nurse practitioner, pediatric nurse practitioner, and nurse-midwife (Morrow & Amoako, 1980; Ojo, 1980; Tulloch, 1980). In the words of one informant, liMen don't come that much and it's mostly women and children that come and need help." Over 50% of the population is less than 15 years of age in most LDCs (WHO, 1981), so the consultant must be knowledgeable in areas affecting the majority of people. Personal attributes of the consultant and attitudes about oneself and the people of the host country were identified as relevant and appropriate preparation. You need to be very flexible and able to tolerate a lot of ambiguity ... to be very patient and not expect change to occur rapidly. My own personal background was the best preparation. In consulting to [a Middle Eastern country] the prohibitions against smoking and alcohol were not too much different than what I knew from my own religious upbringing. Also, my prior experiences--and they were many--as a consultant in the U.S. prepared me well for what I was expected to do. I didn't have much trouble transferring the principles to another country. These findings are consistent with others who have studied 85 international nursing and found that personal qualities of the nurse are significant for success (cf., Henkle, 1979; Hurley, 1982; Jaeger-Burns, 1981; Masson, 1981; Meleis, 1984b; Range, 1984). Although 48% of the informants indicated that no formal orientation was offered prior to consulting, many of those inter­viewed believed that it was an integral part of preparation for the consultation (cf., Henkle, 1979; Hurley, 1982; Masson, 1979, 1981; Range, 1984). When picking an organization, pick one that is going to support you, especially for first timers. Pick one that will give a proper orientation. Attend some type of preparatory program that would include the transcultural issues and treating tropical diseases. The effectiveness of the orientation program in meeting the perceived needs of the consultant was described in a variety of ways, often depending upon the length of the program. As presented in Table 15, 48% reported that no formal orientation was offered. Among the 35% Table 15 Formal Orientation for International Consultation Oi = 92) Attended formal orientation Length of formal orientation (weeks)a: 1 or less 2 3 4 5 6 7 8 More than 8 No formal orientation offered aBased on 22 responses. N 32 8 2 1 3 3 5 44 bMedian = 3.5; r