Reflexão ENHANCING NURSING KNOWLEDGE THROUGH DEMOCRATIC CROSS-NATIONAL COLLABORATION

Enhancing nursing knowledge requires the exchange of ideas worldwide through the collaboration of nurse scientists. Healthy partnerships abide by the values of collaboration, mutual trust, respect and dignity. However, a lack of information exists regarding the nature of cross-national academic partnerships in nursing. The purpose of this article is twofold: to explore democratic cross-national collaborations in nursing and to pose theoretically-based interventions to enhance future democratic collaborations crossnationally in nursing. While a review of the literature revealed some model nursing partnerships, nursing can benefit from having a better evidence based understanding of the topic. Theoretical formulations from education, philosophy and critical anthropology offer complementary lenses to aid in the analysis. The process can help nursing academics to think more critically about the issues and to delineate theory driven protocols for democratic cross-national collaboration with the ultimate aim of enhancing nursing knowledge. DESCRIPTORS: Nursing. Knowledge. Collaboration. Globalization. International aspects. MELHORAR O CONHECIMENTO DE ENFERMAGEM ATRAVÉS DA COLABORAÇÃO DEMOCRÁTICA ENTRE NAÇÕES RESUMO: Melhorar o conhecimento de enfermagem requer a troca de idéias em todo o mundo através da colaboração de cientistas enfermeira. Parcerias saudáveis respeitar os valores da colaboração, a confiança mútua, respeito e dignidade. No entanto, a falta de informação existente sobre a natureza da cruzada nacional parcerias acadêmicas em enfermagem. O objetivo deste artigo é duplo: para explorer democratic transnacional colaborações em enfermagem e para posar com base teórica, as intervenções para melhorar futuras colaborações democrática cruzada nacional em enfermagem. Enquanto uma revisão da literatura revelou algumas parcerias de enfermagem modelo, de enfermagem pode se beneficiar de ter uma melhor compreensão baseadas em evidências sobre o tema. Formulações teóricas da antropologia educação, filosofia e crítica oferecem lentes complementares para auxiliar na análise. O processo pode ajudar a acadêmicos de enfermagem para pensar mais criticamente sobre os problemas e delinear os protocolos teoria orientado para a colaboração entre países democráticos, com o objectivo último de melhorar o conhecimento de enfermagem. DESCRITORES: Enfermagem. Conhecimento. Colaboração. Globalização. Aspectos internacionais. MEJORAR LOS CONOCIMIENTOS DE ENFERMERÍA ATRAVÉS DA COLABORACION DEMOCRÁTICA ENTRE NACIONES RESUMEN: Mejorar los conocimientos de enfermería requiere el intercambio deideas en todo el mundo a través de la colaboración de científicos de enfermería. Asociaciones saludable cumplir con los valores de colaboración, la confianza mutua, respeto y dignidad. Sin embargo, la falta de información que existe sobre la naturaleza de la cruzada nacional de asociaciones académicas en la enfermería. El propósito de este artículo es doble: explorer democratic transnacional colaboraciones en enfermería y plantear teóricamente las intervenciones para mejorar futuras colaboraciones entre países democráticos en la enfermería. Mientras que una revision de la literatura reveló que algunas asociaciones de enfermería de modelo, de enfermería puede beneficiarse de tener una comprensión mejor evidencia basada en el tema. Formulaciones teóricas de la antropología la educación, la filosofía y la crítica ofrecen lentes complementarias para ayudar en el análisis. El proceso puede ayudar a los estudiantes de enfermería a pensar de manera más crítica sobre los problemas y para definer los protocolos de la teoría democratic impulsada por colaboración transnacional con el objetivo final de mejorar los conocimientos de enfermería DESCRIPTORES: Enfermería. Conocimento. Colaboración. Globalización. Aspectos internacionales. 592


INTRODUCTION
The importance of democratic cross-national collaboration in academic nursing cannot be overstated.While much has been written about the need to partner in a globalized world, little research exists on the topic of egalitarian and democratic collaboration cross-nationally in nursing.The purpose of this reflective article is: 1) to explore the topic of democratic cross-national collaboration in nursing and 2) to pose theoreticalbased interventions to enhance future democratic collaboration cross-nationally in nursing.
Sound nursing education and research endeavors are essential to high quality nursing care and to the continued development of a scientific base for nursing practice.Producing a sufficient supply of nurses (nurse educators, researchers and practitioners) adequately prepared to offer evidence-based, expert nursing care is vital to the advancement of the discipline.Enhancing nursing knowledge through democratic cross-national collaboration offers the possibility of productive exchanges of new ideas, formulations, theories and methods.Twenty-first century technological innovations allow increased communication worldwide and relatively easy access to nurses cross-nationally using the internet, blogs, online databases and social networks.
For nurses to build collaborative working environments on an international platform where democratic knowledge exchange can flourish requires the establishment of democratic collaborative relationships that are based on egalitarianism, mutual trust, respect and dignity.It also requires time, funding and precedent so that good examples of international collaborations can be replicated and become commonplace and routine.Innovative cross-national research and theoretical study also require expert analysts and scholars to conduct the work.Human nature and the propensity for misunderstandings as a result of power dynamics, embedded stereotypes and preconceived ideas can pose formidable obstacles to carrying out effective and meaningful international projects.Cultural and language barriers add to the difficulty of conducting successful collaborations across nations and once misunderstandings are imbedded, oftentimes, they are hard to reverse.Lastly, political economic dimensions in the development of modern nursing greatly influence how international nursing collaborations and partnerships evolve.
While academics in some disciplines have collaborated internationally for many decades, for example in the sciences such as physics, chemistry and mathematics, [1][2] international partnerships in nursing among academic peers are a relatively recent phenomenon.Formal nursing science is handicapped by the fact that, on the one hand, nursing has a history of domination by medicine and on the other hand, it is bound by the political economics of institutions and bureaucracies where education and practice are carried out.Moreover, historically, the evolution of modern nursing occurred primarily from the global north to the global south, from the first world to the second and third worlds, and from the core to the periphery.This one-sided flow of ideas posed and continues to pose an inevitable evolutionary paradox in which nursing as a profession has not yet fully emerged despite the active development of basic and applied nursing science innovations in a number of peripheral and semi-peripheral nations, e.g.Brazil. 3istorically, the pattern of nursing knowledge transfer from core to periphery (global north to global south) inevitably set up a dynamic where knowledge generated in the core was disseminated (for good or for bad) to the periphery and semiperiphery.Two assumptions ensued from this: one assumption was that knowledge generated in the core was superior, and the other assumption is that the periphery was either incapable or unwilling to generate its own knowledge.The authors of this paper jettison both assumptions and maintain the strong position that scientific knowledge production and dissemination are products of imbedded power and social class relationships, hegemony and domination.As such, they are linked inextricably to the political economy of the global world system.

N U R S I N G L I T E R A T U R E O N CROSS-NATIONAL DEMOCRATIC COLLABORATION
Opportunities for international nursing collaborations exist in international health organizations, volunteer organizations, religious organizations and missions (e.g.Operation Smile, UNICEF), educational travel organizations (e.g. Ambassador People to People), university sponsored learning abroad programs, and research training exchanges to name a few.While these projects can offer extraordinary opportunities for nursing participants and serve as the groundwork for enduring exchanges, they can also pose ethical concerns and perpetuate cultural stereotypes (labeling), patriarchal patterns and other misunderstandings.
Enhancing nursing knowledge through democratic cross-national...[6][7][8][9][10][11] DeSantis 5 urged the field of academic nursing to adopt a critical perspective that would focus on the social, political and economic causes of world health problems.In terms of nursing exchanges, Uhl 12 saw North American nursing focusing on the "export model" of cultural exchanges and on what North Americans could teach others, rather than on what North Americas could learn from others.Holleran 8 cautioned nursing not to engage in what she termed "nursing imperialism" which happens when North American nursing consultants take on a paternalistic view of the country they visit.Using ethnography, Thorne 10 studied Canadian expatriate nurses who held an "international perspective" of the world.Interestingly, she found that after periods abroad and upon their return to Canada, the nurses had difficulty adapting to Canadian society.What these "internationalized" expatriate nurses perceived as a culture of material excess, individual self-interest, and an absence of global responsibility in Canada lent, in part, to their dissatisfaction upon re-entry.
Wright, Godue, Manfredi and Korniewicz 11 surveyed university schools of nursing on their international health curricula and found that while many focused on components of "international nursing", few focused on the broader and more complex topic of "international health.":35 Given this body of work, one might expect the contemporary North American nursing literature to have further expanded the critical trajectory.However, the focus of recent literature on international nursing is largely uncritical.It centers largely on international collaboration; [13][14] on global health concepts and issues; [15][16][17] and on global nursing partnerships [18][19][20][21] without concern for the egalitarian values of mutual trust, respect and dignity.Indeed, in this era of globalization, while more international nursing practice and education exchanges exist today than ever before and while more formal international academic and clinical nursing partnerships have been created, little attention is being given in the North American nursing literature to issues of social class, power and dominance, to the structural nature of the international partnerships themselves, or to the vehicles of knowledge transfer and exchange.Similarly, ways to enhance democratic partnerships in nursing cross-nationally are not viewed as a particularly current problem.
Additionally, while North American nursing has focused considerable attention over the last two decades on diversity and on nurses attaining a level of cultural competence, it is unclear how much nursing as a whole has benefited from diversity education.For example, a study of English speaking nurse educators from the UK, USA and Australia teaching nursing in Eastern Asia revealed multiple areas of misunderstanding and conflicts in values and expectations. 22An analysis of the experience of these Western expatriate nursing educators showed that language barriers presented one level of concern, while a lack of preparation by the nurse educators in cross-cultural knowledge for East Asian society posed another level of concern.Because exploitation and issues of dominance and cultural hegemony are often beyond the scope of competence for members of such organizational exchanges, partners on both sides of the exchange may emerge with different understandings and possible misconceptions of the experience.
With this said, some articles described healthy nursing partnerships and worthy collaborative relationships, [23][24] as well as formal and important international nursing alliances such as the International Academic Nursing Alliance sponsored by Sigma Theta Tau International, 25 the Global Network of WHO Collaborating Centres (WHOCCs) for Nursing and Midwifery Development sponsored by the World Health Organization 26 and others not mentioned here.
Indeed, while some successful and model international academic partnerships exist, nursing can still benefit from a careful exploration of the topic and an analysis of theoretical-based interventions that may enhance the democratic nature of the cross-national collaborations.To do this, the authors drew on three theories described in the following section.

HOW THEORY CAN HELP INFORM DEMOCRATIC COLLABORATION
Broad theory from outside the discipline of nursing may provide insight into the intricacies of democratic partnerships and help to pose meaningful suggestions for ways to enhance future democratic cross-national collaborations in nursing.The authors of this article use theoretical formulations from education, philosophy and critical anthropology to aid in the analysis. 27,29,31

Freire's Critical Pedagogy
Brazilian educator Paulo Freire's Critical Pedagogy emerged out of the fertile socio-political economic environment in Brazil pre-1964.It called for students and teachers, as well as education administrators and planners to recognize authoritarianism in education and to reframe a consciousness of freedom vis-à-vis pedagogical styles. 27His theoretical work as well as his social activism is as vital and essential today as it was in the mid 20 th century.
:15 We know through Freire that education is "a political as well as a moral practice."Nursing also can be considered a political as well as a moral practice.Using Freire's perspective, a critical pedagogy of nursing could evolve if nursing education were to focus more on critical thinking and expanding boundaries and less on memorization and acquisition of content.Furthermore, academic nursing research would be better positioned if it followed Freire's challenge to use research methodologies and designs that engage populations in identifying the direction of research needs.In doing so, nurse scientists could create innovative, meaningful research agendas which could seek to expand disciplinary boundaries.By giving itself permission to engage in what Freire calls a "culture of questioning" rather than a "culture of oppression", nursing would be in a better position to expand cross-national relationships in a two-way exchange between the south and the north.
Engaging in critical pedagogy and research is important today precisely because nursing is a relatively new science in the process of developing an exciting theoretical and evidence base.Nursing education and research can use Freire's framework to help to explore the forces that have shaped its consciousness.:15 From this point of departure significant and egalitarian crossnational collaborations can progress in nursing.

Nussbaum's philosophy of multiculturalism
To help to develop democratic and collaborative cross-national initiatives, nurses can begin by seeking to understand the dynamics of paternalism, chauvinism and ethnocentrism.North American philosopher Martha Nussbaum, in an attempt to analyze multiculturalism, discussed two vices chauvinism and romanticism in her book Cultivating Humanity. 29Both vices undermine authentic partnerships and threaten the development of collaborative relationships that are based on trust, respect, egalitarianism and mutual understanding.The vice of descriptive chauvinism occurs when we meet people from other cultures whose actions appear strange to us and thus, to normalize their behavior, we recreate them in our own image to make them seem less strange.:1118 In making others familiar and exactly like us, (when they are not) decreases our ability to understand differences and to negotiate novel ways of thinking and being.The second vice descriptive romanticism occurs when, in considering the same strange or foreign behavior, we romanticize it and consider it exotic.:123 By engaging in descriptive romanticism we see others as exotic, but nothing else, and in doing so we deprive ourselves of genuinely knowing the other.
Both vices described by Nussbaum (descriptive chauvinism and descriptive romanticism) fail to allow us to authentically comprehend diversity in human society.Refusing to engage in both descriptive chauvinism and descriptive romanticism frees us to understand human responses to diversity more genuinely.This could help nurse scientists and academics to collaborate more genuinely in a multicultural world, to understand and transcend bigotry and prejudice, and to confront paternalistic reactions such as chauvinism and romanticism in cross-national collaborations.In the end, Nussbaum supports multiculturalism and the preservation of liberal arts components at the university level.If nursing were to follow Nussbaum's principles, it would extend beyond local affiliations and nurses could become what she calls citizens of the world. 30

Singer and baer critical medical anthropology
The overarching framework of critical political economy and the subfield of what Singer and Baer 31 call Critical Medical Anthropology (CMA) offers a sharp analytical lens to examine nursing science and education.The theory provides a means of analyzing how the broad macro-level political, economic, socio-cultural and historical dimensions shape the narrow micro-level and everyday circumstances of nursing practice and education.Also, it allows analysts to trace the dialectical social relations inherent in health care systems generally and in nursing specifically while considering how the political economy perpetuates or reproduces contradictions inherent in health care systems themselves.It does this by paying attention and applying a critical lens to the inconsistencies linked to power relations, to agency, and to social class.Critical medical anthropologists maintain that cultural relativism "teaches us respect for other ways of being and knowing, as well as humility about our approaches to worldly knowledge". 31ollaboration and advocacy among nurses from different countries is one vehicle for sharing essential new information and innovations.However, how to promote the sharing of knowledge generated in specific contexts is an identified need.The generation of new knowledge in local contexts is one way to enhance the knowledge base of the discipline.While merit exists in sharing theories and philosophies cross-nationally, the authors of this paper maintain that theory generation is inherently bound to the place and to the unique political economic and socio-cultural phenomena of local environs. 32ver the last several decades economic globalization and neoliberal economic reforms have changed the face of health care as well as nursing education and practice.For neoliberalism to be successful, profit margins must be large.A flexible and compliant labor force characterized by nursing migration, part time work, temporary work contracts and weak labor unions are necessary for a strong private sector to succeed at the expense of acquiring vibrant new insights into nursing theory.
The theory of critical medical anthropology can assist nursing in analyzing nursing as a form of social labor cross-nationally, as well as the global exercise of power and the structural components of inequality in social relations, the increasing push to privatize health care internationally, nursing wage compression and work intensification cross-nationally.

SUMMARY
While egalitarian and democratic collaboration in academic nursing cross-nationally is essential to the evolution of the discipline, little research exists on the topic.The authors have explored the topic of democratic collaboration in nursing and reviewed several models to help inform theoretical-based interventions that can be used to enhance future democratic collaboration cross-nationally in nursing.The complementary theoretical formulations of educator Paulo Freire, philosopher Martha Nussbaum and critical medical anthropologists Singer and Baer were used to frame the conceptual basis and analysis for this paper.The models can help nursing academics to think more critically about the issues and to delineate theory driven protocols for collaborative and democratic partnerships based on egalitarianism, trust, respect and dignity.

FINAL CONSIDERATIONS
Nurses constitute the largest group of health care providers worldwide and provide an immeasurable benefit to the health and welfare of individuals and communities everywhere. 33In this era of globalization nursing academics and scientists learning from each other across nations through democratic, collaborative partnerships can expand nursing knowledge in unimaginable ways and open even more possibilities for rich innovation and the democratic enhancement of knowledge.
Factors like the level of education for nurses, the requirements for licensure of nurses, and the scope of nursing practice as well as numerous problems connected to clinical nursing practice have been fraught with paradoxes and challenges and are topics of concern that could be studied by cross-national teams rather than by single-country teams.In this way, groups of scholars working in democratic collaborative partnerships could use local expertise and understandings to consistently expand the knowledge base of the discipline and science of nursing.
First, those who understand that nursing is a political as well as a moral practice 27 can benefit from a better understanding of political economic factors that influence and shape power relations relevant to the institutions they are a part of.Second, by following Nussbaum's call to become citizens of the world 29 nurses can more genuinely understand other forms of knowledge and cultural traditions.Third, by putting the principles of critical medical anthropology into action and by using a broad interpretation of cultural relativism to frame one's understanding of "other ways of being and knowing" nursing can create and sustain more effective democratic collaborations and partnerships.To reaffirm the theoretical stances taken by critical medical anthropologists, 31 learning from everyone in multiple contexts "teaches us respect for other ways of being and knowing, as well as humility about our approaches to worldly knowledge".In sum, implementing the theoretically driven considerations put forth in this article can help scholars generate democratic collaborations cross-nationally with the intention of truly enhancing nursing knowledge.