Conducting international nursing research requires an overarching commitment to caring in the context of the local culture. Globally, respect for persons, beneficence, and justice are the foundation for responsible community engagement in the research process. This aligns with the ICN's Code of Ethics for Nurses, which states that the universal mandates for nursing practice, and therefore, nursing research, are respect for human rights—the right to life and choice, to dignity, and to be treated with respect. Practically, this requires that APRNs follow the ethical mandates of the professional practice of nursing as they plan and conduct research. Furthermore, all nurse researchers are expected to know the rules and regulations governing human subjects research where the study will be conducted. Yearly, the U.S. Department of Health and Human Services' (DHHS's) Office for Human Research Protections provides an updated international compilation of human research standards ( index.html) and the DHHS's Office of Research Integrity provides a primer on the responsible conduct of research ( In short, all researchers should know international as well as local professional codes, government regulations, and institutional polices.

All research codes and policies address the issue of informed consent. However, specific cultural factors, such as decision-making processes and issues of literacy, need to be addressed in the research process (Krogstad et al., 2010). In areas where there is a tradition of communal decision making, community leaders may need to be engaged before potential participants are asked to consent. Also, where there is low literacy and consent is obtained verbally, the researcher must recognize the risk of inconsistent information being shared. To minimize the risk of uninformed consent, an adaptation of teach back can be employed whereby the participant's level of understanding is evaluated before consent is confirmed (Krogstad et al., 2010).

Often, APRNs may be planning to conduct research as they are providing clinical care. This sets up special concerns. Four particular issues have been identified (Laman, Pomat, Siba, & Betuela, 2013). They include the risk of putting a priority on accomplishing the research activity over patient care, confusing the patient's expectation for clinical care with his or her participation consent, setting up inappropriate inducements, and providing one-time clinical services that are not sustainable by the host area. According to international nursing ethical standards, patient care must always take precedence over research. As well, local ethics committees can provide important perspectives to minimize patient confusion, counterproposals for what may be considered inappropriate inducements, and partnership with the researcher to work toward creating sustainable clinical services. Overall, nurses engaged in conducting international research must think globally about gaining new scientific knowledge but act wisely at the local level, always moving in accordance with nursing's consistent commitment to ethical practice.


The global nursing shortage of both professional nurses providing care and of nursing faculty creates an environment where the pooling of professional resources is critical (Appiagyei et al, 2014; Bell, Rominski, Bam, Donkor, & Lori, 2013; Nardi & Gyurko, 2013). Nursing providers and faculty are increasingly able to come together to increase the capacity and quality of professional nurses through educational consultation. Technology use, communication that makes the world small, various iterations of distance education, and the ease and improvement of global transportation may profoundly change the landscape of APRN education globally. Currently, most examples of U.S. participation in APRN or other health care education and consultation has involved face-to-face work, with students coming to the United States or U.S. faculty going to the host country. The selection of clinical sites for APRNs requires particular vigilance—some distance programs expect students to come to the United States for this part of the program, work out experiences at U.S. facilities outside the United States (e.g., military bases, embassies), or scrupulously review the preceptor. One APRN involved in a long-term educational commitment is described in the sidebar.

Box 6.1 Kiwi Conversion: One NP's Educational Experience

In 2008, a good friend contacted me regarding an opportunity to teach with her at the Center for Postgraduate Nursing Studies for the University of Otago. They were looking for a senior lecturer for adult health and pharmacology. I was teaching these courses for Clemson University's graduate nursing program for several years along with working full time as a family nurse practitioner. It had been my dream to work and teach internationally. To my surprise, in November 2008, I arrived in Christ-church, New Zealand to begin a career adventure.

Transfer of Registered Nurse licensure was accomplished prior to leaving for New Zealand. However, my nurse practitioner certification did not transfer as ANCC or AANP certification exams are not recognized by the Nursing Council of New Zealand. You must have a minimum of four years of experience and a clinical master's degree, create a portfolio, and pass a panel assessment for nurse practitioner competency (Nursing Council of New Zealand, 2014).

A learning curve both in spelling, health care systems, and nursing ensued. I came from private practice to a public and private health system where health care is a basic human right, not a privilege. A baccalaureate is required for registered nurses with opportunity for specialty certification. Nurse practitioners are expert nurses in specific areas with advanced knowledge and skills, who work independently and in collaboration with other health care professionals (Nursing Council of New Zealand, 2014). To obtain the qualifications for application for nurse practitioner status, I needed an advanced nursing practice position. In the United States, nurse practitioner positions are everywhere—in the newspapers, employment agencies, private practice, and health care institutions. I needed an advanced practice position that would enable me to gain the necessary experience. The director of University of Otago Center for Post Graduate Nursing Studies, Dr. Beverley Burrell, interceded, and I started working for Canterbury University's Student Health Center as a provider once a week. I am grateful and thankful for the support and guidance provided by the staff. In addition, I worked with a nurse practitioner in private practice and a family physician, both of whom provided letters of support. Portfolio development is both an aggravation and enriching experience. It requires you to fully evaluate your practice and qualifications for advanced practice nursing. In February 2011,1 successfully passed panel assessment achieving primary care nurse practitioner certification.

The students were bright, creative, highly motivated, and involved with their community. It was a pleasure to teach and mentor such individuals. On September 4,2010, a 7.1 earthquake struck Christchurch, New Zealand, followedby multiple aftershocks. In February 2011, amore devastating earthquake occurred, killing 185 people. Many of the institutions and individuals I loved were no longer standing or left for safer venues. Although I was safe, after much soul searching, I returned in 2012 and currently work with an Arizona Native American tribal community as a primary care nurse practitioner. Last week, I received an e-mail from two students who recently achieved primary care nurse practitioner certification, making me very happy. I remain active with the Advanced Practice Nursing Network of the International Council of Nurses and plan to work abroad again at the first opportunity.

—Patricia Maybee

Educational consultation can fall into roughly three categories of professional focus.

• Individuals: At this level, education consultation occurs within the context of medical brigades.

• Communities: Education consultation at this level can occur within the context of medical brigades but also within broader regional or national population health consultation similar to train-the-trainer scenarios (Lasater, Upvall, Nielsen, Prak, & Ptachcinski, 2012).

• Professional: Consultation regarding education at this level provides professional infrastructure enrichment, support, or capacity building. Areas for consultation include academic preparation and professional development (Kemp & Tindiweegi, 2001).

This professional consultation can occur in a country where a small group of visiting providers come to receive specialized training/experiences or can occur when a visiting professional can come into a country to provide training or program development. Both areas hold great promise for expanding capacity and quality, yet both raise concerns. Visiting con-suiters who leave their home for individualized or small group training may not use the training or may not return to their home country at all (Sherwood & Liu, 2005). Visiting single consultants may provide train-the-trainer types of experiences within the host country, but they may do so through a cultural lens that is not the same as the host consulter (Palmer & Heaston, 2009).

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