Intensive and Critical Care Nursing (2010) 26, 61—63

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EDITORIAL

Challenges and rewards in multi-national research

KEYWORDSResearch;International;Multi-cultural

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Introduction

The recent Declaration of Vienna launched by the EuropeanSociety of Intensive Care Medicine (Moreno et al., 2009)emphasises the global nature of disease yet the increas-ingly uneven distribution of resources. Over the past decade,studies have identified variation across European countriesin physician values and practices (Vincent, 1999), resusci-tation directives (Cook et al., 2001) end of life practices(Sprung et al., 2008) and nurse involvement in end-of-lifedecision-making (Benbenishty et al., 2006). Increase in theuse of internet and e-mail for data collection has made inter-national studies much easier to conduct, for example theEPIC study examining the prevalence of nosocomial infectionwas supported by 1417 ICUs across Europe (Vincent et al.,1997) and the ETHICUS study examining end of life practicesacross Europe included data from 37 units in 17 countries(Benbenishty et al., 2006).

There are a number of key issues to consider whenembarking on research in more than one country; this guesteditorial introduces a new series to be published in Intensiveand Critical Care Nursing over the next 12 months. Duringthe series papers will address: methodological and practicalconsiderations when conducting research in different coun-tries, international variation in practices such as sedationand adapting research tools for use in different countries.These issues are important for those undertaking, or apply-ing findings from, international research.

Whilst multi-national studies are common in critical care

medicine, they are much less well developed in critical carenursing. Review of all papers published in ICCN over a 1-yearperiod revealed that, whilst three papers had authors frommore than one country, none of the research studies hadbeen conducted in more than one country. Across all issues

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0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2009.12.004

or the year, authors came from 16 countries, providing aistinctly more international flavor to the journal than wasvident a decade earlier.

hy conduct multi-national research?

ulti-national studies can be conducted for a number ofeasons, for example, to compare casemix or outcomesetween countries (Jones et al., 2007a; Kause et al., 2004;artin and Mathisen, 2005); to test an intervention in differ-nt countries or increase patient recruitment (Finfer et al.,004) and to develop international consensus for the man-gement of disease processes (Cheatham et al., 2007). Inome international studies there is no attempt to distinguishetween responses provided by participants in differentountries (Sprung et al., 2007; Latour et al., 2009) whereasn others the inter-country differences are the focus of dataresentation (Benbenishty et al., 2006; Sprung et al., 2003,008).

A review of multi-center and multi-national research col-aborations revealed common characteristics to be: a spiritf cohesion, motivation to achieve shared research goals andecognition that such a collaboration is ‘more than the sumf its parts’ (Cook et al., 2002).

ultural differences

nternational research can highlight differences in

atient/family preferences. For example two studiesxplored preferences of intensive care (ICU) family mem-ers for shared decision-making; a study conducted with89 patients in 6 ICUs in Canada found that 81% of familiesould like a shared decision-making model (Heyland et al.,

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003) whilst a study conducted with 357 patients in 78 ICUsn France found a much lower rate of 47% requirement forhared decision-making (Azoulay et al., 2004). Caution mustlways be exercised when comparing studies conducted byifferent groups of researchers, in different countries; it isot clear from the Heyland and Azoulay papers whether theame definition of shared decision-making was used in thewo countries. Sampling methods may also have generatedifferent findings.

Differences in culturally accepted practice can also beeen in clinical guidelines. For example, guidelines for phys-cal restraint differ in the United Kingdom (UK) and thenited States (US); the US guidelines recommend physicalestraint use in preference to chemical restraint (sedation)Maccioli et al., 2003) whilst UK guidelines recommend usef sedation rather than physical restraint (Bray et al., 2004).orrespondence following publication of studies can alsoighlight cultural differences, for example, the discussionenerated by a paper by Jones et al. (2007a) regardingactors potentially contributing to post traumatic stress dis-rder following intensive care (see correspondence fromapadia, 2007; Jones et al., 2007b). The social status ofursing practice and nursing education can also have a con-iderable impact on development of multi-national researchtudies since support of such activities vary greatly.

he impact of geography on ICU outcomes

unsch et al. (2007) suggest that a number of country-pecific factors such as critical care resources, diseaseatterns and cultural practices, should be taken intoccount when interpreting findings from internationalesearch. Vincent and Brimioulle (2001) remind us thathe north—south Europe gradient in ICU outcome is largelyxplained by smaller ICUs in southern Europe treating sickeratients (Vincent et al., 1997) hence applying the samentry criteria for pan-Europe studies will tend to resultn higher mortality rates in southern European countriesVincent and Brimioulle, 2001).

Geography also appears to influence other factors suchs end of life practices and nursing roles:

(a) Information on end of life practices in Brazil is reportedas ‘scarce’ because of legal concerns (fear of pros-ecution) (Soares et al., 2007); rates of limiting lifesustaining treatments are reported to be lower in Brazil(Kipper et al., 2005) and Argentina (Althabe et al., 2003)than in Europe (Sprung et al., 2003) or north America(Prendergast et al., 1998).

b) Benbenishty et al. (2006) found a significant relation-ship between European region and nurse involvement indecision-making. Respect between professional groupsand attitudes towards patients and family may also influ-ence quality indicators in different countries.

As Zimmerman et al. (2001) remind us, these comparisons

ake on a political edge when those making decisions are notamiliar with differences between countries and do not takento account limitations to international comparison. Thempact of economic factors on education and modernisationf the different health systems may also be an important

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actor when considering differences in ICU outcomes acrossountries.

thical considerations in multi-nationalesearch

here are a number of principles underpinning conduct ofethically sound’ research (for example, informed consent,onfidentiality, beneficence/non-maleficence and justice).manuel et al. (2004) propose eight principles that shoulde followed when conducting multi-national research, par-icularly with developing countries, to minimise risk ofxploitation:

. Collaborative partnership.

. Social value.

. Scientific validity.

. Fair selection of study population.

. Favourable risk-benefit ratio.

. Independent review.

. Informed consent.

. Respect for recruited participants and study communi-ties.

Discussion between research team members regardinghese principles during study design can illuminate (andesolve) differing expectations, for example in recruitmentractices or data collection techniques. Burns et al. (2009)ighlight different approaches to gaining informed consentor the inclusion of patients in research studies, with ‘waivero consent’ available in Scotland, Belgium, Germany, Francend the Netherlands but not permitted in Poland, Portu-al, Italy or Denmark (Burns et al., 2009). It is importanto ensure that ‘fair selection of study participants’ andinformed consent’ are carefully considered when the studyequires a certain standard of education or language ability.ll efforts should be made to ensure the study is under-tood by all potential participants and that study exclusion isot (deliberately or naively) based on language or educationbility.

A further ethical principle less frequently debateds whether the research is scientifically sound; indeedhe role of ethics committees in making these judg-ents is oft-debated. It is considered unethical to

ecruit patients/family members/colleagues to participaten research that is not scientifically sound. Hence the impor-ance of following strict principles for translation of researchnstruments and ensuring that data collection processes areoth valid and reliable.

Collaborating in multi-national nursing studies provides aositive learning experience for all involved. Where can onend research partners? The nursing and allied health pro-essional (AHP) section of the European Society of Intensiveare Medicine (ESICM) is one of the avenues one can exploreo join or initiate a multi-national study. For the investiga-ors, these studies provide opportunities to learn about theesearch process in different countries, as well as compar-

ng nursing practices and discovering how culture influencesveryday practice. Although much effort is required and fre-uently little monetary compensation is offered, the benefitf collaboration in a team project leads to cohesive part-erships that out-last the project. Whilst the requirement

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to converse in a common language (usually English) can bea barrier, involvement in collaborative multi-national stud-ies provides an ideal opportunity to build confidence andto bring problems noted above to the attention of otherresearchers.

References

Althabe M, Cardigni G, Vassallo JC, Allende D, Berrueta M, Coder-matz M, et al. Dying in the intensive care unit: collaborativemulticenter study about forgoing life-sustaining treatment inArgentine pediatric intensive care units. Pediatr Crit Care Med2003;4:164—9.

Azoulay E, Pochard F, Chevret S, Adrie C, Annane D, Bleichner G, etal. Half the family members of intensive care unit patients donot want to share in the decision-making process: a study in 78French intensive care units. Crit Care Med 2004;32:1832—8.

Benbenishty J, Ganz FD, Lippert A, Bulow H-H, Wennberg E, Hender-son B, et al. Nurse involvement in end-of-life decision making:the ETHICUS study. Intens Care Med 2006;32:129—32.

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Ruth Endacotta,b,∗a Critical Care Nursing, University of Plymouth, UK

b La Trobe University, Melbourne, AustraliaJulie Benbenishty1

Hadassah Hebrew University Medical Center, Generalntensive Care Unit, PO Box 12000, 91120 Jerusalem, Israel

Myriam Seha2

Spital Maennedorf, Asylstr 8708 Maennedorf,Switzerland

∗ Corresponding author at: Faculty of Health, Centre Court,Drake Circus, Plymouth PL4 8AA, UK.

Tel.: +44 1752 587488; fax: +44 1752 586748.E-mail addresses: ruth.endacott@plymouth.ac.uk,

endacottsinoz@hotmail.com (R. Endacott),JULIE@hadassah.org.il (J. Benbenishty),m.seha@spitalmaennedorf.ch (M. Seha)

1 Tel.: +972 2 6778060; fax: +972 2 6430349.2 Tel.: +41 44 922 20 60; fax: +41 44 922 20 67.