IN CONSIDERING the call for articles for this edition, the authors discussed how best to address the nursing profession's growing participation on the world stage as we move from a single, country-based view to a supranational and global perspective. Both authors have held posts in a number of countries and have undertaken consultancy and other work in all of the World Health Organization's regions. However, rather than producing a critical reflection of our personal experiences, we decided to turn to a more quantifiable, robust, reliable, and valid approach to the identification and illumination of issues that currently confront contemporary nurse leaders. To do this, we have focused on unearthing how nursing has contributed to the scholarship surrounding trade in services. We hope that by examining this topic and extrapolating from the already published, peer-reviewed literature on work that addresses bilateral, regional, or multilateral agreements and their associated connection to trade in services, we can provide a benchmark against which future progress can be measured.
TRADE IN SERVICES, GATS
Events and actions taken in one part of the world can quickly spread and influence daily lives on the other side of the planet. Since the earliest days of the first explorers and traders, barriers between peoples have been eroding. In today's world, we are increasingly likely to have professional connections in multiple countries and to gather information and insights from colleagues who live in different time zones and work in environments significantly unlike our own.1 Furthermore, not only have improvements in transportation reduced the time it takes to travel physically from one place to another, but as Bill Gates has noted, “the Internet is becoming the town square for the global village of tomorrow.”2 It therefore seems timely to assess whether nurse leaders are adequately engaged in contributing to the scholarship that will shape the environs our successors will inherit. One way to do this is by examining the corpus of literature relating to trade in services and mutual recognition. Health care delivery is, according to the World Trade Organization, part of the 12 broad categories of service described by the 1995 General Agreement on Trade and Services (GATS).3 Also, particularly relevant to the increasingly mobile nursing profession, are the 4 modes of supply that are used, in part, to codify the specific commitments that a country makes in articulating its trade activity (Figure 1). Whether it is the service itself, the person delivering the service, or the person receiving the service, the 4 modes of supply can be used to clearly describe the way trade in that service is delivered.
To provide a benchmark that documents the current state, a reliable, valid, and robust means of measuring how nurses are engaged in these processes is needed. For this article, bibliometrics are used to map key dimensions as well as the focus of scholarship published and indexed on this topic. Based on this work, the authors postulate opportunities for nurses to contribute to this agenda at the supranational level. Supranational is defined as working across any combination of 2 or more countries where trade in services is taking place via one or more of the modes of supply.
WHAT IS BIBLIOMETRICS?
Bibliometrics is a technique used in the informational sciences to map the structure of scholarship within a particular domain or originating from a specific source such as a journal, institution, or individual/groups of scholars.4 , 5 With the advent of powerful computers that can retrieve, manipulate, and display large quantities of data, the use of bibliometrics has become increasingly common across a wide range of disciplines. A number of texts are readily available, which can provide a comprehensive description of the broad span of analytical and visualization techniques that can be used to explore scholarship in the domain of interest.4 , 5 Only the techniques used in this study are described in this article.
AIM AND METHODS
The purpose of the study here was to conduct a comparative bibliometric analysis of the scholarship landscape of nursing relative to medicine to postulate the opportunities for nurses to contribute to the policy dialogue at the supranational level. To conduct a bibliometric analysis, there are a number of sources that can be searched to identify scholarship on the subject of trade in services. However, from a nursing content perspective, the most comprehensive source is Scopus (Elsevier), so this was the database of choice. A structured search of the database was conducted, using the following terms and associated logical operators: “Trade in Services” OR “GATS” OR “MRA” OR “Bilateral Agreement” OR “General Agreement on Trade in Services” OR “Mutual Recognition Agreement” OR “Health Tourism” OR “NAFTA” OR “ASEAN” OR “MERCOSUR” OR “CARICOM.” Subsequent to conducting the search, article titles were reviewed to exclude any that did not relate to the topic of interest.
Data extraction and analysis
Data relating to the frequency of articles published per year up until the end of 2017 (the last complete year for which data were available) were downloaded, so a simple line graph and key features could be determined. Data for all articles, both those classified as relating to medicine and those relating to nursing, were extracted as comma-separated value files.
In addition, full bibliometric data relating to the identified content for both medicine and nursing were downloaded, ready for importing into the specialized program capable of analyzing and visualizing the structure of scholarship. These 2 datasets were then examined to compare and contrast the similarities and differences between the scholarship in the medical and nursing domains. VOSviewer, developed by researchers Van Eck and Waltman6 at the University of Leiden Centre for Science and Technology Studies, was utilized for this examination. VOSviewer uses a multidimensional scaling technique to identify and map the underlying scholarship structure through the visualization of similarities. The package enables researchers to examine a wide range of variables of interest. In this case, the study was deployed with 2 analytical techniques. The first was co-occurrence analysis, generating clusters of potentially related terms providing a means of identifying general themes based on the variable of interest. For this study, the variable of interest was the keyword(s) associated with each article. The second analytical approach was bibliometric coupling that uses citations to identify 2 authors who both cite a third. Such couplings are likely to indicate that all 3 articles share a common topic of interest.
The literature search identified that scholarship on the issues associated with trade in services is growing rapidly across a wide range of disciplines. While the first article on the topic appeared in 1919, it was not until 1965 that the first article encompassing medicine appeared. Nursing started to contribute to scholarship in the field in 1974. While interest in trade in services by the medical profession has expanded considerably (with 1213 articles being identified), nursing's contribution to the topic is still quite minimal, with only 101 articles retrieved (Figure 2). The inserted graph with a range of 0 to 250 articles illustrates that nursing's work on the topic is relatively new and has only hit double figures in the past decade.
By conducting a co-occurrence analysis of the keywords used to codify the various articles in both the nursing and medical scholarship spaces, it is possible to identify the general thematic content being addressed (Figures 3 and 4). While there are similarities between the 2 disciplines in terms of content, there are a number of differences worthy of further exploration.
To assist in the exploration of the similarities and differences, the Table details the general themes and associated narrative description.
Scrutiny of the content of the co-occurrence plots for both nursing and medicine reveals that the nursing material is more practically orientated toward specific care groups such as child health, or related to the quality and safety of products in specific industries, namely pharmaceuticals or food. In addition, there seems to be more of a regional trade focus within the nursing scholarship, with regional interest in food safety in the European Union, MERCOSUR, and ASEAN; content relating to health care systems and public health in NAFTA countries; and health access and equity in the United Kingdom. Medical scholarship is more policy oriented, less focused upon specific trade agreements, and more attuned to high-level concepts such as justice, economics, and population health.
By conducting a bibliographic coupling analysis, it is possible to obtain an indication of the degree of programmatic scholarship taking place. Articles that cite the same work are indicative of emergent domains of study and programs of research. In the case of nursing, with the exception of work by Benton et al,7 Thompson et al,8 and Yagi,9 who look at the issues associated with nurse and faculty mobility and their relationship to trade in services, the literature is yet to coalesce on specific topics. The situation for medicine demonstrates a much more evolved situation. Multiple authors are engaged in a complex network of cited work (see Figure 5). In this case, various aspects of the Trans Pacific Partnership focusing on pharmaceuticals, food, public health, and the sustainable development goals are explored.
The nursing profession is inadequately engaged in scholarship relating to trade in services. To this point, nursing's contribution, in general, tends to be operationally focused, regionally based, and oriented toward Mode 4: Mobility of the Profession (see Figure 3). Medicine, on the other hand, is engaged in higher order conceptual and policy issues and how they relate to major global trade agreements. This is not an unexpected finding, since commentary on the inadequacy of nursing's engagement in policy debates is well documented.10 , 11 Furthermore, the proliferation of the DNP programs and the stagnation of PhD scholars in nursing,12 along with the fact that postgraduate education, although significantly on the increase, is a relatively recent phenomenon.10 While entities such as the International Council of Nurses13 , 14 advocate for nursing to have a voice at the policy table, nurse scholars must increase their output and their level of engagement on issues such as trade agreements and wide-ranging health and social policy topics to be viewed as credible contributors. Although there are examples of nurses engaging in multidisciplinary policy activity,15 , 16 these are far from the norm. Greater engagement would be a positive step in demonstrating the added value of nursing contributions to global policy dialogue. This would increase the likelihood that nurses would secure seats at the policy table.
With the advent of increased health tour-ism,17 ongoing nurse mobility,18 and the wide range of opportunities provided for nurses through the pursuit of the sustainable development goals,19 , 20 nurses have unprecedented opportunities to develop and hone their skills, actively contribute their voices to the policy agenda, and fill the void in scholarship in this important and growing policy arena. Entities such as the World Health Organization frequently post opportunities on the world wide web for volunteers to engage in the highest levels of policy making. However, far too often, these calls for input go unanswered by appropriately experienced nurses. This is a missed opportunity, and one that the profession must rectify. Fortunately, much of the nursing scholarship activity currently being conducted is focused on regional trade group-based topics. This can be viewed as a strength, especially if nurses working on common topics connect with one another. This would potentially increase robust evidence, build momentum, and provide opportunities for peer support. This may prove challenging because even the most senior nurses holding high-level policy roles are often poorly connected internationally.21 However, it is possible—through action learning-based leadership development, e-mail follow-up, and mentoring—to rapidly grow, strengthen, and sustain transnational networks of policy-active nurses.21 , 22
The authors of this study based their analysis on data drawn from a single bibliometric source. While other sources could have been used, such as PubMed or Web of Science, such an approach would have exacerbated the difference between nursing and medicine, as both of these additional sources have a higher percentage of medical as opposed to nursing coverage.
Bibliographic analysis is a useful tool for providing a high-level snapshot of the nursing scholarship relating to trade in services. While nursing is increasing its scholarly output, it is lagging considerably behind the medical community. With the impetus of initiatives such as Nursing Now,21 opportunities exist to increase the policy contribution of nurses in today's ever more connected supranational environment. Interventions that can strengthen nurse policy networks have been shown to be effective.22–24 However, if quantum rather than incremental progress is to be made, more scholarship on policy-oriented topics is needed. An increased output of PhD-prepared nurses is essential. Collaboration in multidisciplinary policy teams must become the norm, so nurses can demonstrate their unique and essential contribution to addressing the many and complex challenges that health systems now face. This article provides insight into the current state of engagement and offers a baseline from which progress can be measured relating to the profession's impact on health systems reform, presence at policy tables, and ultimately nurses' contribution to global health and well-being.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
bibliometrics; GATS; mobility; trade in services