REVIEW ARTÍCULO DE REVISIÓN
Health literature authored by nurses within the LAC region: a cross-sectional study
Bibliografía sobre investigación en salud publicada por personal de enfermería en América Latina y el Caribe: un estudio transversal
Jasmine ParmarI; John HouseI; Silvia CassianiII; Ludovic ReveizI
IKnowledge Management, Bioethics and Research Office, Pan American Health Organization, Washington, D.C., United States of America. Send correspondence to: Ludovic Reveiz, firstname.lastname@example.org
IIHealth Systems and Services Department, Pan American Health Organization, Washington, D.C., United States of America
OBJECTIVE: To analyze current trends and directions in Latin America and Caribbean (LAC) nursing research and identify areas that need development.
METHODS: A search was conducted in PubMed and LILACS for studies published in English from 1 January 2008 to 26 June 2014 that met the inclusion criteria (health research conducted in the LAC region by authors with an explicit nursing affiliation working in a LAC country). Two reviewers assessed and extracted the data.
RESULTS: More than 4 000 references met the inclusion criteria and 1 343 of those were published in English during the search time period. Although the research originated from 17 different countries, most of it was produced by Brazil. The majority of the studies were from academic institutions (67%), 23.9% involved multi-institutional collaboration, and 5.4% involved multi-country collaboration. Almost all of the studies (98%) were applied research and had a descriptive (55%) or qualitative (30%) design. The most prevalent topic was nursing care (23.4%). Health systems and services were the least studied topics. /About 25% of the studies contained some reference to United Nations Millennium Development Goals.
CONCLUSIONS: The overwhelming majority of LAC countries rely on the scientific findings of a few leading countries in the region. Future directions should include the establishment of an agenda for the region and/or by country to define research priorities within the context of nursing practices. It is imperative for nurses to influence and conduct research in areas of policy and health systems and services given their important role in promoting, restoring, and maintaining health in individuals, and in helping to ensure universal access to health and universal health coverage.
Key words: Research; nursing research; health priorities; review literature as topic; Latin America; Caribbean Region.
OBJETIVO: Analizar las tendencias y orientaciones actuales de la investigación de enfermería en América Latina y el Caribe, y seleccionar las áreas que requieren un mayor desarrollo.
MÉTODOS: Se llevó a cabo en PubMed y LILACS una búsqueda de estudios publicados en inglés desde el 1 de enero del 2008 al 26 de junio del 2014 que reunieran los criterios de inclusión (investigación de salud realizada en América Latina y el Caribe por autores que tuvieran una afiliación explícita en el sector de enfermería y trabajaran en un país de esta región). Dos revisores evaluaron y extrajeron los datos.
RESULTADOS: Más de 4 000 documentos cumplieron los criterios de inclusión y, de estos, 1 343 se habían publicado en inglés durante el período seleccionado. Aunque la investigación procedía de 17 países diferentes, en su mayor parte era de producción brasileña. La mayoría de los estudios correspondían a instituciones académicas (67%), un 23,9% a colaboraciones multiinstitucionales y un 5,4% a colaboraciones entre diversos países. Casi todos los estudios (98%) eran de investigación aplicada y tenían un diseño descriptivo (55%) o cualitativo (30%). El tema más prevalente fue la atención de enfermería (23,4%). Los sistemas y servicios de salud fueron los temas menos estudiados. Cerca de 25% de los estudios contenían alguna referencia a los Objetivos de Desarrollo del Milenio de las Naciones Unidas.
CONCLUSIONES: La mayor parte de los países de América Latina y el Caribe depende de los hallazgos científicos de unos pocos países que lideran la región. Las orientaciones futuras deben incluir el establecimiento de un programa para la región o por países con objeto de definir las prioridades de investigación en el contexto de las prácticas de enfermería. Es indispensable que el personal de enfermería influya y oriente la investigación en las áreas de políticas y sistemas y servicios de salud, dado su importante función en la promoción, la recuperación y el mantenimiento de la salud de las personas, y en ayudar a garantizar el acceso y la cobertura universales en materia de salud.
Palabras clave: Investigación; investigación en enfermería; prioridades en salud; literatura de revisión como asunto; América Latina; Región del Caribe.
Scientific research in the Latin America and Caribbean (LAC) region has increased over the past decade (1, 2). However, this improved productivity has not been homogeneous across the region but has been concentrated in a few leading countries, namely Brazil and Mexico (3-7). This trend is well illustrated in nursing research, a field in which productivity has increased for the region overall but is by far most evident in Brazil, which publishes the vast majority of scientific studies but still has limited international visibility (8-12). Advancement of scientific nursing knowledge is limited in the LAC region due to significant barriers.
According to Malvárez & Castrillon, the primary barriers include 1) lack of education in scientific methodology, 2) lack of the English language skills that are required to publish in many high-impact international nursing journals, 3) low visibility of intellectual property, and 4) lack of access to scientific nursing journals (12). Because of these barriers, most nursing literature produced in the LAC region is disseminated in journals with limited international impact (10). Additional barriers include the need for policy and financing incentives for research, the low level of interdisciplinar-ity, the lack of graduate-level education among nurses and nursing institution affiliates, and the lack of a nursing research agenda for the region and within LAC countries (9-12).
While previously published literature reviews have investigated bibliometric indicators of nursing research in the region, few have assessed the characteristics of the reviewed studies in detail. The objective of this review was to 1) analyze current trends and directions in LAC nursing research and 2) identify areas that need development.
MATERIALS AND METHODS
A systematic search was conducted in PubMed and LILACS, using the National Library of Medicine (NLM) Medical Subject Heading (MeSH) and text term "Nurse" (or variations thereof) (Annex 1) in the affiliation field. Specific filters were used for various countries. The inclusion criteria were studies that 1) involved health research, 2) were conducted in the LAC region, and 3) were carried out by authors with an explicit nursing affiliation working in a LAC country. More than 4 000 references met the inclusion criteria. The review was limited to the 1 343 studies published in English between 1 January 2008 and 26 June 2014. Duplicate articles were excluded.
Study selection and data extraction
Data extraction and quality control (consistency with the inclusion criteria) were conducted independently by two investigators: one carried out study selection and data extraction and the other checked for consistency. Discrepancies were resolved by consensus or through consultation with a third reviewer.
The extracted data were entered into a spreadsheet under predefined categories. Each included article was reviewed in detail and classified by 1) study type (basic research, applied research, or experimental development) and design (systematic review, guideline, observational analytic study, descriptive study, experimental study, quasi-experimental study, qualitative study, or "other");1 2) research location (academic institution and/or hospital/primary care facility); and 3) predefined primary topic (child health, health systems, nursing care, nursing education, noncommunica-ble diseases (NCDs), infectious diseases, maternal/women's health, and "other"). Each article was assessed for 1) coverage of study topics pertaining to nursing students and 2) reference to United Nations Millennium Development Goals (MDGs) (13).
A descriptive analysis was carried out for all evaluated articles. Data obtained were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, Illinois, United States).
More than 4 000 references were identified with the search terms. The majority of articles (63.5%) were retrieved from LILACS alone, with the remainder accessed either from PubMed alone or from both databases. Based on the inclusion criteria, the selected time period, and the English-language filter, a final sample of 1 343 articles originating from 17 countries in the LAC region was reviewed. Article characteristics were assessed in detail to gain an understanding of the scope of nursing literature produced in the region.
Distribution of nursing graduate programs and studies conducted by nurses/nursing institution affiliates at academic institution and/or hospital/ primary care facilities across the region are shown in Table 1. The majority of studies conducted by nurses/nursing institution affiliates took place in Brazil, with a limited amount carried out in Argentina, Chile, Colombia, Cuba, Mexico, and Peru. Studies conducted by nurses/nursing institution affiliates working in the remaining 10 countries were scarce. The largest percentage of studies were conducted solely at academic institutions (67.0%), followed by those conducted at both academic institutions and hospitals/primary care facilities (31.0%), and hospitals/primary care facilities alone (1.0%) (not shown). Less than a quarter of the studies demonstrated collaboration with other institutions (23.9%) and countries (5.4%), and almost all studies were applied research (98%) (not shown). Further examination determined that most of the studies were descriptive (55%) or qualitative (30%) (Figure 1). The dominant themes extracted from the articles are listed in Table 2. The most prevalent topic was nursing care (23.4%). Other recurrent topics included child health (15.8%), NCDs (14.3%), and nursing education (12.2%). Miscellaneous topics, such as the role of nursing in surgical procedures, quality of life, and palliative care, were categorized as "other" (14.3%).
Themes related to health systems, infectious disease, and maternal/women's health were the least studied. A total of 11.3% of the studies included content about nursing students (not shown). About 25% of the articles included some reference (explicit or implicit) to MDGs (Table 3). MDG 4 ("Reduce child mortality") was the most frequently mentioned (8.7%), followed by MDG 8 ("Develop a global partnership for development") (5.7%), MDG 6 ("Combat HIV/AIDS, malaria, and other diseases") (5.1%), MDG 5 ("Improve maternal health") (4.2%), and MDG 3 ("Promote gender equality and empower women") (1.8%).
This literature review aimed to provide a snapshot of the emerging landscape of scientific literature produced by nurses and affiliates of nursing institutions in the LAC region. Despite the increase in scientific research conducted by this group for the region overall, many challenges remain in advancing nursing research in most LAC countries (11, 14-17). One important barrier to increasing this type of research in most LAC countries is the lack of educational opportunities for nurses. The impressive amount of research performed by nurses and nursing institution affiliates in Brazil identified in this review may be attributed to the large number of academic institutions offering nursing education at the undergraduate level and the graduate level (master's and doctoral degrees). Brazil is known to have the highest volume of nursing graduate training programs per capita in the LAC region (11, 18). In other countries across the region, opportunities for nursing graduate study are much more limited. Bueno-Robles et al. found that only eight countries in the region had any PhD programs in nursing in 2010 (Argentina, 1; Brazil, 15; Colombia, 2; Chile, 2; Cuba, 1; Mexico, 1; Peru, 1; and Venezuela, 1) (18). This disparity could be a factor in the widespread disproportion in nursing-related research across countries found in this review. Based on the sample reported here, no research was produced by nurses and nursing institution affiliates in close to 50% of LAC countries (Antigua and Barbuda, the Bahamas, Barbados, Belize, Dominica, the Dominican Republic, El Salvador, Grenada, Guatemala, Guyana, Haiti, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname, and Trinidad and Tobago). Similar results were found in an analysis of nursing research in Latin America (1988-1998) in which the authors demonstrated that Brazil produced 68% of all presentations at the biannual Pan American Colloquia (17). Efforts have been made to improve research capacity in low- and middle-income countries in more recent decades (19), but based on the literature review reported here, the disparity remains.
In addition to the lack of graduate nursing programs in many LAC countries, deficits in second-language proficiency may contribute to the disparity in nursing research output across the region. Many of the journals indexed in PubMed are international journals that publish in English. Therefore, the low number of publications found in this review for some countries could be associated with the lack of writing skills in English. In a recent study, Squires & Beltran-Sanchez highlighted the lack of English language skills among many Spanish-speaking nurses in the region (20). The inability to publish scientific literature in English reduces international visibility. Increasing educational opportunities for nurses and nursing institution affiliates to improve English skills would prove beneficial, especially among those that express an interest in working at an international level.
Broadening the spectrum of research studies conducted in the LAC region could also improve nursing research output. This review found a strong presence of descriptive and qualitative studies. While observational studies are helpful in providing overviews of health research issues, other types of studies (clinical trials, particularly randomized control trials and cohort studies) are needed to test the effectiveness of clinical interventions and provide robust scientific evidence. Support and encouragement of basic science/experimental research could also help stimulate innovation within the scope of nursing. Most of the studies analyzed in the review reported here originated from academic settings; only about one-third were from hospitals or primary care facilities. This may be due in part to a lack of mechanisms for developing and funding research about health systems and services.
Nursing care was the dominant topic in studies from 12 of the 17 LAC countries that produced nursing research that fit the review criteria. This outcome is not surprising, given the role of nursing in regional health care. Other frequently researched themes found in the review included (in descending order) NCDs, child health, infectious diseases, and maternal/women's health-all of which have a strong connection to the MDGs. In the "other" category of research themes found in this study, geriatric health (including dependence on caregivers, frailty, and palliative care) was also prominent, due to the strong presence of nurses in geriatric general care.
Research on health systems and services was one of the least studied topics found in this review. This area of research, particularly health systems, needs to be strengthened in the LAC region. It is imperative for nurses to influence and conduct research in areas of policy and health systems and services due to their important role in promoting, restoring, and maintaining health in individuals, and in helping to ensure universal access to health and universal health coverage (21). Improvements are needed to build a strong framework to increase the research potential of nurses region-wide, especially in countries with a low level of output in this area.
Multi-institutional partnership in health research helps provide a stronger foundation for research efficacy and is thus a desirable model that is becoming more common worldwide. Based on the sample of studies reported here, only a few countries in the region (Brazil, Chile, and Colombia) had a notable level of multi-institutional collaboration in their research (approximately 19% of their total studies were collaborative). The multi-institutional research model includes collaboration among researchers in government, academic, and clinical settings. Collaboration allows researchers to develop strong, intellectually diverse research teams and provides them with access to greater economic resources, which can lead to higher research productivity. The establishment of nursing research agendas to guide and determine research priorities at the local and national level and region-wide, based on international policies and goals, could also improve output (13, 22, 23).
Strengths and weaknesses
One major strength and unique feature of this literature review was the fact that it examined the content of the included studies, in detail, as well as the bibliometric indicators for nursing-related research. Another strength was the use of PubMed and LILACS, the most representative databases in the region, for literature search and retrieval. Weaknesses of this review included the fact that it only included studies that 1) contained nursing-related terminology in the author affiliation(s) and 2) were published in English. Both of these limitations contributed to the exclusion of a number of articles. Future studies of scientific nursing research should explore studies reported in journals publishing in languages other than English.
While the visibility of scientific literature authored by nurses or nursing institution affiliates has increased in certain parts of the LAC region, little is known about the efficacy and quality of the research that was conducted. Most LAC countries rely on the scientific findings of a few countries in the region for this type of research. The bulk of the research produced in the LAC region is from Brazil, due to the plethora of academic institutions in that country offering graduate nursing education. A strong educational framework is needed to create graduate training opportunities for nurses that provide them with the skills to conduct research and teach future generations of nursing professionals. Additional efforts should be made to encourage and assist countries with low output in this area of research to publish more scientific literature in English by providing economic resources and international collaborative support. Future directions should include the establishment of local, national, and regional agendas to define research priorities within the context of nursing practices in each respective area. It is imperative that nurses influence and conduct research in health systems and services and related areas of policy given their important role in patient care and in helping to ensure universal access to health and universal health coverage.
Conflicts of interest. None.
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Manuscript received on 2 December 2014. Revised version
accepted for publication on 24 March 2015.
1 Categories were based on Frascati Manual criteria (standards of conduct for R&D surveys and data collection developed by the Organisation for Economic Co-operation and Development).