Global Nursing—a literature review in the field of education and practice

Abstract Aim To describe key findings of Global Nursing in empirical nursing studies. Design A literature review using descriptive data synthesis of peer‐reviewed articles in the field of nursing education and practice. Methods This review of Cinahl Complete, PubMed, PsycINFO and Scopus was undertaken using the search strategy “global nursing”. Independent title/abstract and full‐text screening was undertaken, identifying original articles written in English. Results A total of 472 titles and 170 abstracts were read through. Seventy‐three articles were included for full‐text review. Twenty published studies of Global Nursing with multiple research methodologies fulfilled the inclusion criteria. Findings were described with five categories. Global Nursing Arena, Global Nursing Working Environments, Global Nursing Workforce Management, Global Nursing Competencies and Global Nursing Networking were shown to be crucial when Global Nursing was addressed in the literature.


| BACKGROUND
Globalization is one of the most important driving forces in the new millennium. Together with urbanization and digitalization, it reshapes patterns of human existence and societies on a global scale. Although nursing to some extent has been a global profession, the expansion to global awareness clearly develops the patterns in nursing knowledge.
However, there have been few attempts to grasp and overview the consequences of globalization as it is addressed in scholarly knowledge. Researchers stress that nursing in the 21st century has many challenges due to the globalized world (Austin, 2001;Bradbury-Jones, 2009;Davidson, Meleis, Daly, & Douglas, 2003;Nardi & Gyurko, 2013;Silva, 2004). Furthermore, this global approach in nursing has been reported to correspond to the challenges of human vulnerability and equality. In addition, the strengthening of nursing discipline stands out, both in a local and Global Nursing scene (Bradbury-Jones, 2009;Davidson et al., 2003).
It has been stressed that the trend towards global justice or fairness as a deeper human rights issue is everyone's responsibility. Benatar, Daar, and Singer (2003) reported that a global agenda could include greater attention to duties, social justice and interdependence.
Globalization originally refers to the social and political collaboration of international organizations and people, to improve the quality of civil societies across the world (Crigger, 2008). High mobility, economic interdependence and electronic interconnectedness are positively addressed to globalization. To this date, the rapidly expanding global economy has failed to reduce poverty and improve health for all (cf. Benatar et al., 2003;Bradbury-Jones, 2009). From one published literature review the findings can be used by policy makers, researchers, clinicians and educators, to guide nursing professionals as Global Nursing provides a framework for better health worldwide (Wilson et al., 2016).
The nursing profession is changing and has gone through several modifications during the last decades (Nichols, Shaffer, & Porter, 2011;Silva, 2004). For that reason, nurses, individually and collectively, have the power and the social consciousness to influence basic social services and health care. Thus, nurses should conceive a broader global picture (Bradbury-Jones, 2009;Davidson et al., 2003;Silva, 2004). As global competencies must be mastered, a deconstruction of long held values, faculty knowledge, nursing policies, nursing education and research are highlighted as important factors (Bradbury-Jones, 2009;Crigger, 2008;Nardi & Gyurko, 2013;Parcells & Baernholth, 2014;Riner, 2011).
In an attempt to reconstruct nursing education, a critical reflection on Global Nursing practice is important and how it can be informed by enhanced political awareness. Furthermore, there have been few attempts to conceptualize Global Nursing to address the conclusive parts in the knowledge generated. Therefore, it is of vital importance to describe important aspects of Global Nursing. In addition, the focus in Global Nursing has often been from the perspective of cultural, ethnic and social differences or cultural diversity (cf. Leininger, 1997;Washburn, 1987;Wilson et al., 2016). To overcome this, nurses in clinical practice and nursing students in higher education are challenged to adopt a critical stance to such problematization and conceptualization in nursing. The aim of this study was to describe key findings of Global Nursing in empirical nursing studies.

| METHODS
A literature review using descriptive data synthesis of previous reported findings was used to conduct this investigation (cf. Evans, 2002;Kmet, Lee, & Cook, 2004).

| Sample
An extensive four-part search strategy was employed to identify relevant studies in the field of nursing education and practice. Research studies focusing on topics concerning Global Nursing were selected.
Moreover, review criteria were established by three of the four authors to include articles of primary research or secondary data analysis.
Each phase of the data collection was carried out using six inclusion criteria described in Table 1. Initially, a literature search based on the first inclusion criteria started the process. In accordance with criteria 2-6, the literature search was performed in databases: Cinahl Complete, PubMed, PsycINFO and Scopus. No date restrictions were applied. The use of the database PsycINFO was decided to include an interdisciplinary database with focus on psychology, behaviour and social science related to nursing.
In the four databases, studies were excluded if they were critic comments, conference reports, historical discussions, meeting abstracts, opinion pieces or studies focused on globalization issues other than nursing. Moreover, review articles and non-scientific publications were eliminated and only articles published in peer-reviewed scientific journals were accepted. Some of the articles were not available with reasonable resources; they were therefore omitted. In addition, disagreements were resolved by consensus between the three authors (cf. Whittemore, 2005;Whittemore & Knafl, 2005).
A first search in databases was conducted in PubMed using the term "global nurse" or "global nursing" in title/abstract. The progression of the review process is shown in Figure 1. The PubMed search generated 191 articles for potential inclusion. Then, publications were tentatively selected by title. After title and abstract review, 137 were retained. After exclusion, in total, 54 articles were included for fulltext reading (n = 54) after this first search. Next, a second search in databases was applied in PsycINFO using the term "global nurs*". The PsycINFO search produced 59 articles for potential inclusion. Title review, abstract review and elimination of duplications yielded 13 additional articles from PsycINFO. Eight were included for full-text reading. Then, a third search in databases was conducted in Scopus using the term "global nurs*" and generated 167 articles for potential inclusion. Title review, abstract review and elimination of duplications yielded 11 additional articles from Scopus for full-text reading.
Consequently, a fourth keyword search in databases was carried out in Cinahl Complete using the term "global nurs*" as a keyword (n = 55).
All 55 articles were rejected after title review, abstract review and elimination of duplications.
Finally, after searches in four databases, a total of 472 titles were read through. After reviewing 170 abstracts, 73 articles were included for full-text review (Figure 1). In the following phase, data collection and article approval were carried out on the basis of the valid content of the full-text articles.
The appreciation and evaluation of the selected articles (n = 73) were carried out using a checklist described in Table 2. This checklist was created and modified by three of the authors on the basis of available literature. The used checklist (Table 2) was outlined according to Kmet et al. (2004). It was expanded with some components (sections 1-5) and a few components were modified (sections 10) or excluded. Ten specific evaluation sections were included in the checklist and each of these sections consisted of evaluation criteria ( Table 2).
Studies that accumulated "Yes" in 9 or 10 specific evaluation sections were accepted for the next phase. After the evaluation, 53 articles were rejected based on invalid content. Disagreements were resolved by consensus between three of the authors. Totally, after careful appreciation and evaluation of the full-text research articles, 20 empirical studies between January 2003 -October 2015 were accepted and included for the findings part of this review (Table 3).

| Data analysis
The studies were analysed using descriptive data synthesis according to Evans (2002). The studies were read repeatedly by two authors, separately, to gain a sense of the Global Nursing issues presented in the data as a whole. Furthermore, the content of the data was divided by choosing a unit of analysis. In the reading, attention was paid to both the details of accounts and to what each study described. Then, the key components were collected from each study and listed. After F I G U R E 1 Flow chart of the review process for search and inclusion this listing of key components, they were also discussed together by the two authors. Furthermore, the process of identifying common areas continued. Differences and similarities were compared during this process. Similar key components were categorized into subcategories. The subcategories in turn constituted five overall explanatory categories (Table 4).

| FINDINGS
Global Nursing was first and foremost published in Western journals, mostly represented by the United Kingdom (UK) and the United States (USA). Both educational and practice settings were presented and the participants were nursing students, nurses with varying educational levels and faculty members.  Table 5.

| Global Nursing Working Environments
In the articles, Global Nursing practice in dynamic working environments was influenced by predictors such as encouragement in the work place; an organizational culture that values diversity and an inclusive social atmosphere (Garner et al., 2008;Gerrish & Griffith, 2003;Harrowing et al., 2010;Havens et al., 2013;Kim et al., 2006;Toren et al., 2012;Tourangeau et al., 2014;Weng et al., 2015). Nurse professionals' equal opportunities for professional practice, use of competence and collaboration in academic and practice contexts were described as essential in supportive environments (Garner et al., 2008;Gerrish & Griffith, 2003;Harrowing et al., 2010;Wros et al., 2004). T A B L E 2 Checklist with evaluation sections

Evaluation sections
Yes No

Is the type of approach empirical?
The type of approach is empirical study.
There is no description about the type of approach. The type of approach is not empirical.

Year of publication
Year of publication is described.
There is no year of publication described.

Year of data collection
Year of data collection is described.
There is no year of data collection described.

Country for data collection
Country for data collection is described.
There is no country for data collection described.
5. Objective: Is global nursing a part of the reported aim of the study?
There is a clear description of Global Nursing in the objective.
The objective is not mentioned or the objective does not relate to Global Nursing.
6. Context (education or nursing professionals) for the study clear?
A description about the context is clearly defined and suited for the research.
There is no description about the context. 7. Recruitment strategy described, relevant and justified?
The study group is described accurately as is the reason why the group concerned was chosen.
There is hardly enough information about the study group.
8. Data collection methods clearly described and systematic?
Data collection is described accurately. There is hardly enough information about the data collection.
9. Results and conclusions reported in sufficient detail?
The research questions are described.
There is no description of global nursing in the results part.

Ethics described?
The ethical issues of the research are widely stated, inclusive acquisition of anonymity, research approval and contraction of informed consent.
There is no mention or insufficient mention of ethical issues or weaknesses.

| Global Nursing Workforce Management
Managing changes in gender, class and generational issues were described as essential when facilitating the Global Nursing practice (Brunetto et al., 2012;Havens et 1993,1994,1998  Challenges in management were related to class, gender and power hierarchies, which negatively affected nurses' perspectives on work (Brunetto et al., 2012;Gerrish & Griffith, 2003;Kim et al., 2006;Tourangeau et al., 2014;Zhou et al., 2011). For example, female nurse migration could perpetuate elements of patriarchy (Wros et al., 2004).
Accordingly, nurses' professional power with respect to diagnostic and prognostic disclosure has been negatively affected by hierarchies.

| Global Nursing Competencies
The development of global competencies was explained as one of the great opportunities the nursing profession is facing in the future (Garner et al., 2009;Kim et al., 2006;Wieck, 2003). In the studies, these competencies were closely linked to global leadership. It was also stated that global leaders have knowledge about political operations, politically charged environments and their role in international nursing organizations (Garner et al., 2009;Kim et al., 2006 models, allocated creative projects, and skilled nursing faculty was presented in the studies (Garner et al., 2009;Gutierrez et al., 2012;Kim et al., 2006;Meum et al., 2013;Tourangeau et al., 2014). In addition, education could teach students to apply leadership theories, co-constructing global standards, collaborative activities in nursing research and an active use of nursing values or nursing ethics (Gutierrez et al., 2012;Meum et al., 2013;Wieck, 2003). Broadened perspectives of global competencies and effective leadership skills were noted by Garner et al. (2009) who stated that "The students gained awareness of Global Nursing issues (advocacy), presented research on topics of interest (activism) and contributed to a continuing education workshop based on their experiences (professional accountability)" (p. 105).
In the studies, there were descriptions of challenges with regard to global competencies (Ortiga, 2014;Walton-Roberts, 2012;Zinsli & Smythe, 2009). This could, for example, be lack of equal recognition of knowledge in the field of nursing, inability to demonstrate nurse autonomy and negative connotations ascribed to nurses' professional competence (Ortiga, 2014;Zinsli & Smythe, 2009). Challenges in terms of inequalities were further described by Ortiga (2014), when nurse educators outside the Western world are forced to negotiate an overloaded curriculum, due to the influx of aspiring migrants into nursing programmes. Differences were also indicated for international disaster and emergency nurses, when their growth in global competence was diminished due to personal danger and overwhelming needs (Zinsli & Smythe, 2009).

| Global Nursing Networking
Global strategies were explained to build stronger international bodies (Kim et al., 2006;Swenson et al., 2005). Garner et al. (2009) also stated that global networking is promoted by global strategies and could be further developed in joint creative projects. In these projects, it was important to discuss activities for global networking (Garner et al., 2009;Kim et al., 2006;Swenson et al., 2005). It was also stated that the understanding of the impact of politics on healthcare provision and how it affects global networking could broaden the global perspectives (Garner et al., 2009;Harrowing et al., 2010;Ortiga, 2014;Walton-Roberts, 2012;Zinsli & Smythe, 2009). Furthermore, growth in leadership competencies and an increased sense of both professional and personal nursing community was described as essential (Garner et al., 2009;Kim et al., 2006;Weng et al., 2015).
In the studies, it was stated that political differences in global networking are challenging. In some Global Nursing contexts, political disparities still exist, for example, international nurse migration has not been addressed (Ortiga, 2014;Walton-Roberts, 2012;Wros et al., 2004;Zinsli & Smythe, 2009). According to Ortiga (2014), many countries bear the burden of nursing employability and nations lower down the chain supply labour to wealthier countries, "Nurse educators expressed wanting their students to be resourceful and quick on their feet, given the lack of proper facilities in many local hospitals. Yet, as schools became focused on producing nurses for export, the educators faced the dilemma of teaching students how to practice 'first world' nursing in a 'third world' context" (p. 67).

| DISCUSSION
The aim of this study was to describe key findings of Global Nursing in empirical nursing studies. The findings are described in five categories.
The Global Nursing Arena category showed that the focus has shifted from an interest in education and values to a focus on how a nursing faculty can adopt sustainable strategies to engage in Global Nursing leadership (cf. Garner, et al., 2008). Therefore, we suggest that education for nurses has to contain broadened fundamental knowledge and awareness of dominant areas such as economics, demographics, politics and social constitutions. Our interpretation is that technological developments and policy changes during recent decades have increased the meaning and implication of Global Nursing in both nursing education and practice. The debate has matured considerably and become more extensive over time.
In the Global Nursing Working Environments category, discrepancies in work environments due to globalization might transform evidence-based nursing practice or research to support inequalities in the global village (cf. Harrowing et al., 2010). Our concern is that global care chains demonstrate the south to north migration of nurses and this global movement reinforces inequities. Migration is structured by the power hierarchies embodied in class, ethnicity, gender, nationality and race especially in the era of Global Nursing shortage (cf. England, 2015;Xu, 2015). Widding Isaksen (2012) described how the Norwegian welfare state is becoming a global employer and global nurse recruitment generates transnational spaces of care. Furthermore, international nurse recruitment is not a win-win situation and the idealized image of social justice and gender equality needs to be critically examined. We suggest that power hierarchies and global justice or fairness as a deeper human right need to be discussed in practical contexts in nursing education. By training nurses to discover stereotypical behaviour, hidden prejudices and normative structures, nursing education has the opportunity to explain how to counteract inequities.
Consequently, it is important that the use of suitable solutions follows local contexts in nursing practice and research.
The consequences of power hierarchies in healthcare systems cause differences in nursing, a loss of identity for nurses and a risk for deskilling in the profession (cf. Toren et al., 2012;Widding Isaksen, 2012). Gender and class are often constituted as "otherness".
Moreover, identity such as the Self is relative and changing compared with the Other (Eriksson-Baaz, 2005). Said (1978) argued that Western societies have used their hegemonic position of interpretation to antagonize those who are non-Western. Throughout colonial history, there have been descriptions of qualities such as the Other; to be childish, irrational and depraved in contrast to the Self which has been ascribed with qualities as rational, mature, virtues and normal (Eriksson-Baaz, 2005;Said, 1978). White Western culture, historically and still today, has monopolized science, knowledge, clinical practice and health-promoting models. Anderson et al. (2009) claimed that it is our lack of concern about the social disadvantage of "others" at local, national and global levels that leads to serious health disparities.
Furthermore, social justice is highlighted as being of importance for nurses. Our interpretation is that these cases have to be further investigated. Education can prevent inequalities by training nurses to make conscious choices in nursing activities when power hierarchies occur in healthcare systems.
The Global Nursing Workforce Management category highlighted transformational leadership, growth in the nursing profession, nurse innovation behaviour and high mobility. However, nurse migration and the export of nurses create business and profits for many countries, organizations and agencies (cf. Zhou et al., 2011). This raises the question of how inequality in nurse migration has become a moral problem. England (2015) concluded that analyses of linkages between globalization, migration and care are essential. In countries with nurse export, there is a lack of healthcare professionals, which in turn results in a lack of health care, an economic imbalance and vulnerability among people (cf. Kaelin, 2011). Accordingly, in developing countries, nurse recruitment hinders people in their ability to make use of their po- Global Nursing Competencies have shifted in focus to engagement in a global leadership and professional activism (cf. Garner et al., 2009). Based on the findings, we stress that nursing education provides a great opportunity to promote global competencies and explain diminishing aspects important for the nursing profession in nursing practice. Furthermore, a mission is to prepare students to train global awareness by actions and reflection on their experiences. According to our findings, we recommend an ethical framework and nursing actions as useful tools in the efforts to reduce inequities and inequalities in Global Nursing practice (cf. Grootjans & Newman, 2013;Gutierrez et al., 2012;Meum et al., 2013;Wieck, 2003).
Global Nursing Networking explained strategies that could be helpful and used to further develop joint creative projects (cf. Garner et al., 2009;Kim et al., 2006;Swenson et al., 2005). Moreover, global leadership was described as being of vital importance. One solution for change in nursing challenges is proposed by Nardi and Gyurko (2013). shown. This is a question of concern as the concept of a global representation might also be connected to values that have their origin in colonialism. We stress the importance of postcolonial awareness in nursing when dealing with matters of globalization. Postcolonialism has been described as the response to the marginalization of Western cultures' values and norms (cf. Said, 1978;Shakib, 2011).
This is a concern as the Western context needs to undergo a series of changes to tackle its colonial past even in nursing. We would like to add that this is a critical aspect in advocating for a global agenda in nursing.

| Methodological considerations
The data collection and data analysis in this review will be critically discussed based on various parts linked to trustworthiness (cp. Sandelowski, 1993;Rolfe, 2006). Credibility involves aspects such as how to source articles, how to select key components and how well the explanatory categories cover the data. Careful considerations have been taken when planning and working with the appraisal of each phase in the review process.
The appraisal was based on inclusion and exclusion criteria in the search strategy. Subjective reading and evaluation with the modified checklist with evaluation sections related to Kmet et al. (2004). For the studies with qualitative methods, the appraisal process for each study included has been taken into account through an investigation of the reflexivity of the researcher, the participants and the description of context. For the surveys included, the appraisal process has been taken into account through an investigation of validity and reliability of sample, data collection, analysis methods, setting and participants, to enhance the understanding of the findings in this evaluation.
Transferability refers to the extent to which findings can be transferred to other settings. The number of organizations taking part in the study, where they are based and the number of participants involved have carefully been described to get sufficient contextual information about the studies included. Accordingly, the data collection methods that were employed and the time period over which the data were collected, has been reported. However, it is up to the reader to decide whether it is possible to transfer outcomes to other contexts.
Dependability of the data analysis was ensured by showing the procedure of coding and formulating the explanatory categories according to Evans (2002). In this review, the two authors who conducted the analysis reflected on and discussed the content and categorization models. To address the dependability issue, the processes in the study have been reported in detail and include the researcher design and how it was carried out. For this review, only the term Global Nursing in the field of nursing was accepted in the search and research literature. Other related terms were excluded due to the large amount of material and the intention to obtain a clear description with respect to the Global Nursing phenomenon. In addition, some research articles had to be excluded due to non-availability or translation problems from the original language into English. Consequently, these aforementioned issues might limit the search and cause selection bias.
Confirmability is the investigator's comparable concern to objectivity.
In this review, a detailed methodological description allows the reader to determine how far the data and constructs emerging from it may be accepted.

| CONCLUSION
This literature review emphasized that nursing education provides a great opportunity to promote global relationships through global networking. Global Nursing offers wider awareness in nursing knowledge and contributes to a nursing profession equipped for today's challenges and global work with inequalities.