Challenges and rewards in multi-national research
Article Outline
- Introduction
- Why conduct multi-national research?
- Cultural differences
- The impact of geography on ICU outcomes
- Ethical considerations in multi-national research
- References
- Copyright
Keywords: Research, International, Multi-cultural
Introduction
The recent Declaration of Vienna launched by the European Society of Intensive Care Medicine (Moreno et al., 2009) emphasises the global nature of disease yet the increasingly uneven distribution of resources. Over the past decade, studies have identified variation across European countries in physician values and practices (Vincent, 1999), resuscitation directives (Cook et al., 2001) end of life practices (Sprung et al., 2008) and nurse involvement in end-of-life decision-making (Benbenishty et al., 2006). Increase in the use of internet and e-mail for data collection has made international studies much easier to conduct, for example the EPIC study examining the prevalence of nosocomial infection was supported by 1417 ICUs across Europe (Vincent et al., 1997) and the ETHICUS study examining end of life practices across Europe included data from 37 units in 17 countries (Benbenishty et al., 2006).
There are a number of key issues to consider when embarking on research in more than one country; this guest editorial introduces a new series to be published in Intensive and Critical Care Nursing over the next 12 months. During the series papers will address: methodological and practical considerations when conducting research in different countries, international variation in practices such as sedation and adapting research tools for use in different countries. These issues are important for those undertaking, or applying findings from, international research.
Whilst multi-national studies are common in critical care medicine, they are much less well developed in critical care nursing. Review of all papers published in ICCN over a 1-year period revealed that, whilst three papers had authors from more than one country, none of the research studies had been conducted in more than one country. Across all issues for the year, authors came from 16 countries, providing a distinctly more international flavor to the journal than was evident a decade earlier.
Why conduct multi-national research?
Multi-national studies can be conducted for a number of reasons, for example, to compare casemix or outcomes between countries (Jones et al., 2007a, Kause et al., 2004, Martin and Mathisen, 2005); to test an intervention in different countries or increase patient recruitment (Finfer et al., 2004) and to develop international consensus for the management of disease processes (Cheatham et al., 2007). In some international studies there is no attempt to distinguish between responses provided by participants in different countries (Sprung et al., 2007, Latour et al., 2009) whereas in others the inter-country differences are the focus of data presentation (Benbenishty et al., 2006, Sprung et al., 2003, Sprung et al., 2008).
A review of multi-center and multi-national research collaborations revealed common characteristics to be: a spirit of cohesion, motivation to achieve shared research goals and recognition that such a collaboration is ‘more than the sum of its parts’ (Cook et al., 2002).
Cultural differences
International research can highlight differences in patient/family preferences. For example two studies explored preferences of intensive care (ICU) family members for shared decision-making; a study conducted with 789 patients in 6 ICUs in Canada found that 81% of families would like a shared decision-making model (Heyland et al., 2003) whilst a study conducted with 357 patients in 78 ICUs in France found a much lower rate of 47% requirement for shared decision-making (Azoulay et al., 2004). Caution must always be exercised when comparing studies conducted by different groups of researchers, in different countries; it is not clear from the Heyland and Azoulay papers whether the same definition of shared decision-making was used in the two countries. Sampling methods may also have generated different findings.
Differences in culturally accepted practice can also be seen in clinical guidelines. For example, guidelines for physical restraint differ in the United Kingdom (UK) and the United States (US); the US guidelines recommend physical restraint use in preference to chemical restraint (sedation) (Maccioli et al., 2003) whilst UK guidelines recommend use of sedation rather than physical restraint (Bray et al., 2004). Correspondence following publication of studies can also highlight cultural differences, for example, the discussion generated by a paper by Jones et al. (2007a) regarding factors potentially contributing to post traumatic stress disorder following intensive care (see correspondence from Kapadia, 2007, Jones et al., 2007b). The social status of nursing practice and nursing education can also have a considerable impact on development of multi-national research studies since support of such activities vary greatly.
The impact of geography on ICU outcomes
Wunsch et al. (2007) suggest that a number of country-specific factors such as critical care resources, disease patterns and cultural practices, should be taken into account when interpreting findings from international research. Vincent and Brimioulle (2001) remind us that the north–south Europe gradient in ICU outcome is largely explained by smaller ICUs in southern Europe treating sicker patients (Vincent et al., 1997) hence applying the same entry criteria for pan-Europe studies will tend to result in higher mortality rates in southern European countries (Vincent and Brimioulle, 2001).
Geography also appears to influence other factors such as end of life practices and nursing roles:
As Zimmerman et al. (2001) remind us, these comparisons take on a political edge when those making decisions are not familiar with differences between countries and do not take into account limitations to international comparison. The impact of economic factors on education and modernisation of the different health systems may also be an important factor when considering differences in ICU outcomes across countries.
Ethical considerations in multi-national research
There are a number of principles underpinning conduct of ‘ethically sound’ research (for example, informed consent, confidentiality, beneficence/non-maleficence and justice). Emanuel et al. (2004) propose eight principles that should be followed when conducting multi-national research, particularly with developing countries, to minimise risk of exploitation:
Discussion between research team members regarding these principles during study design can illuminate (and resolve) differing expectations, for example in recruitment practices or data collection techniques. Burns et al. (2009) highlight different approaches to gaining informed consent for the inclusion of patients in research studies, with ‘waiver to consent’ available in Scotland, Belgium, Germany, France and the Netherlands but not permitted in Poland, Portugal, Italy or Denmark (Burns et al., 2009). It is important to ensure that ‘fair selection of study participants’ and ‘informed consent’ are carefully considered when the study requires a certain standard of education or language ability. All efforts should be made to ensure the study is understood by all potential participants and that study exclusion is not (deliberately or naively) based on language or education ability.
A further ethical principle less frequently debated is whether the research is scientifically sound; indeed the role of ethics committees in making these judgments is oft-debated. It is considered unethical to recruit patients/family members/colleagues to participate in research that is not scientifically sound. Hence the importance of following strict principles for translation of research instruments and ensuring that data collection processes are both valid and reliable.
Collaborating in multi-national nursing studies provides a positive learning experience for all involved. Where can one find research partners? The nursing and allied health professional (AHP) section of the European Society of Intensive Care Medicine (ESICM) is one of the avenues one can explore to join or initiate a multi-national study. For the investigators, these studies provide opportunities to learn about the research process in different countries, as well as comparing nursing practices and discovering how culture influences everyday practice. Although much effort is required and frequently little monetary compensation is offered, the benefit of collaboration in a team project leads to cohesive partnerships that out-last the project. Whilst the requirement to converse in a common language (usually English) can be a barrier, involvement in collaborative multi-national studies provides an ideal opportunity to build confidence and to bring problems noted above to the attention of other researchers.
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PII: S0964-3397(09)00114-1
doi:10.1016/j.iccn.2009.12.004
© 2009 Elsevier Ltd. All rights reserved.
