Abstract
This paper addresses the globalization of nursing especially as it pertains to nursing doctoral education. Its purpose is to consider the issues surrounding cross country doctoral education as identified by doctoral students and to suggest models and strategies that could be used to facilitate cross country doctoral education in light of the barriers identified by the doctoral students. This paper is based on published sources, conversations with doctoral students and personal observations. Nursing, in order to become globally relevant, should develop an independent body committed to cross country doctoral education. This body should be committed to increasing the accessibility and facilitating and organizing programs that provide opportunities for students and faculty to ascertain experiences abroad. Several models incorporated under a comprehensive strategy are suggested in this paper.

Paper presented at International Network for Doctoral Education in Nursing: Vision and Strategy for International Doctoral Education, June 17, 1997, University of British Colombia, Vancouver, Canada.

Introduction
There can be no question as to the virtual shrinking of our globe over the past several decades. As a result, peoples of all nations, cultures, and walks of life are being brought closer together in ways never before possible. It is rare that a day goes by that one doesn’t hear the words "global economy." Travel, communication, information exchange, and networking have all been almost unrecognizably transformed in the past fifty years. George Vidal, an American novelist, writes, "Thanks to modern technology, history now comes with a fast forward button." This commentary seems especially relevant as the year 2000 approaches and we will all witness the first days of a new millennium. Change is no longer becoming the constant but is the constant. As our world continues to evolve, we will again experience a continental drift. However, this time the drift will not involve the geography of rock and soil but the geography of the mind. The globe, as a result of change, will continue to shrink. Nursing, as a result of change, must begin to expand.

If we are to see these things come to pass, however, nurses will have to begin to think differently, speak differently, and act differently. In a recent article published by Drs. Ketefian and Redman (1997) on the development of nursing science in the global community, several notes of interest were made that I would like to highlight here. It was reported that there had been a 10% increase in international nursing students attending U.S. graduate programs in the past decade. The International Council of Nurses (ICN) now represents 110 national associations with a total of 1 million nurses. There are 110 schools worldwide offering doctoral degrees in nursing. Many U.S. nursing journals report on or have columns dedicated to international issues and several have international representatives on their review boards and many university libraries now subscribe to international journals. Ketefian and Redman go on to state, "...despite the increase in international activities, the nature of nursing theory, research, education, and practice has not changed appreciably to be globally relevant" (1997, p.11). I concur; and if nursing is to change, it must begin with its leaders.

As nurses venture into the global age it will be important that we set forth our vision and plan strategically. It is also important that our design follow our function or purpose. All of us are far too familiar with the program, project, or method that has clearly become an ends unto itself and ultimately contributes nothing to its stated purpose. So, as we together seek to discuss and develop models and strategies of collaboration across countries in doctoral education let us be persistent in rational, logical, and creative thought in which our purposes are clearly served by our strategies.

I would like first to outline for you the directions that nursing must begin to move in the education of its doctoral students. I would like, also, to persuade you to consider how it is that nursing can move in this direction. I will do this by first discussing why it is a necessity that we have strong, vision-oriented doctoral leadership for the discipline. Second, we will consider several issues identified by nursing doctoral students as being barriers to cross-country collaboration in nursing doctoral education. Thirdly, I’ll discuss five models that will potentiate the development of cross-country education. And fourth, I’ll consider several strategies that would aid in the implementation of the suggested models. Particularly, under strategies, I will discuss the forming of an independent body committed to the development, organization, and facilitation of cross-country collaboration in doctoral education.

Significance of Development of Strong Internationally-Oriented Leadership
If nursing is to emerge in the 21st century as a relevant and unique source of health care, it will be necessary and important that it develop leaders who will be agile in their adjustment to the rapid changes of the day. Nursing, in order to develop leaders who will successfully lead the discipline into the next century, will need to groom a new breed of doctorally trained nurses. Those nursing leaders must embrace the global community and develop a strong international network. In order for these changes to occur, it is the responsibility of those nurses who are now in the leadership positions to create an environment where this is possible for future generations. The vision must be projected and the pace set today so that we might be prepared for tomorrow.

The world is changing and so must nursing
The obvious changes taking place will effect nursing in the areas of research, practice, and theory. Research focuses have changed and will continue to change. Good evidence of this is the move toward outcome - based research as the financing of health care has come under close scrutiny. Practice has changed and will continue to change as chronic addictions, lifestyle resultant diseases, and the reemergence of several infectious diseases have moved to the forefront of many developed countries’ health "problem lists." New theory will develop and old theory will change as new research is produced and practice focuses shift. The role of the doctorally prepared nurse is indispensable during these times of change. It will be he or she who will coordinate the evolution of these three areas in nursing.

Horded, knowledge is lifeless and without animation. Shared and exchanged, it becomes the ability to understand, to improve, and to change. This, in its essence, is the magic of collaboration. Doctoral education can be used to facilitate collaboration, this sharing of knowledge. Allowing nursing doctoral students the opportunity to partake in international experiences can only benefit the discipline of nursing. Doctoral training is a unique period in a scholars development and it is at this level of training that the development of knowledge is most flexible, creative, and productive. Things possible, probable, plausible and preferable can be explored and pursued in a way not viable at any other level. Exposing students to international training experiences during this potential-laden period will not only provide the immediate opportunity for the synergistic effect of shared knowledge, but will set a precedent in students minds that will follow them throughout the rest of their professional lives. An arena in which knowledge can be shared will lead to the development of true (shared) knowledge and consequently the development of a global discipline.

If nursing leadership fails to change with the world and reflect the society in which it exists and allow for the synergy of nursing knowledge through the creation of international forums for future nursing leaders, it will then also fail to meet its greater obligation to the health of societies. Doctorally prepared nurses, as coordinators of the science and the practice and therefore the art, must be at the forefront of these changes.

Issues in Collaboration Across Countries in Doctoral Education
In recent months I have taken the time to discuss with doctoral students at two different Korean universities what they perceive to be the barriers in cross country education (Kim, 1997). The issues identified can be summarized under four headings: finances, time investment, academic credit, and clinical emphasis. I think that the identified concerns, because of their universal nature, may be fairly representative of issues common to all doctoral nursing students involved in or wanting to be involved in collaboration across countries in doctoral education.

Finances
Often, the cost of international travel, room, board and tuition of the hosting university, far exceeds that which the student in doctoral training is able to afford. This becomes especially evident as students from less developed countries endeavor to train in countries more developed. Because of the highly prohibitive nature of cost and the decreasing number of dollars available from governments, scholarships, and grants (which often do not exist in many countries), it is necessary that ways are developed to decrease the cost of such experiences.

Several possible solutions are highlighted here, however, the employment of creative thinking could easily lead to many more. Every dollar often counts. This is a reality that many of us, blessed with financial freedom, need to be reminded of. First, the accommodations that are made for visiting students are, at times, in excess of what is required. A hotel room, when dormitory or guest housing will do, can be an unnecessary luxury. Provided that the student’s needs are met, there should be no shame on the part of the institution that chooses to house students in dormitories or in willing persons’ homes in order to defray costs. A benefit not often thought of is the opportunity for the student to build relationships with nationals, whether it be with a host family or the community that resides in a dormitory setting. The cultural experience is in turn enhanced and the student’s experience enriched. This rarely happens in the isolated hotel room setting.

A second area in which costs could be reduced is tuition. There is not much that can be said in the way of specifics due to high variation among institutions in budgetary matters. What can be said, however, is that a budget is reflective of our priorities. If nursing leadership and the future development of the discipline are made priority, it would follow that special allowances be set aside, even if it is small amounts, for the aiding of international doctoral students. At times, with ambition and thorough research, outside monies can be acquired to supplement tuition costs as well.

A third way that costs could be reduced is to hire the student into a research or graduate assistant position, if their stay is extended. Often, doctoral students traveling across borders for educational purposes are the cream of the crop and will benefit the nurse researcher or faculty member a great deal. This also enhances the students experience by not only reducing costs but by giving them an opportunity to be mentored and giving them another anchor in what is a completely new environment.

A fourth and final suggestion is the reduction in the amount of time actually necessary for the student to remain abroad. A decrease in length of stay will lead to reduced cost, which leads us to our next point.

Time investment
Another problem encountered by students wishing to study internationally is the time commitment. Financial, emotional, family, and job constraints often exclude a student from an international experience because of the length of time required for the student to be away from his or her home. These obligations are real as we all know and need to be considered as we attempt to plan programmes of study for international students. Students suggested that more programmes designed around an intensive format be offered. Experiences that are specially tailored to "pack a lot" into a short amount of time can go a long way in reducing cost and personal strain. These experiences are often described as a "whirlwind experience" but highly effective for all involved.

Academic credit
Academic credit is another concern among the graduate students I spoke with. Credits earned at an overseas university are not always recognized by the student’s primary university of study. Not only does this reduce a student’s motivation to pursue international education, it fails to recognize work of academic merit on the part of the student. Further, the commitment is comprised of class-time and practical experience that has often been paid for by the student. There is a certain sense, when unrecognized, that a student’s work offers him or her no gratification either intellectually or emotionally. Although great personal benefit may have been gained, the time, money, and effort put into an international experience that is unrecognized by an academic institution may be difficult to justify. Recognition is a privilege that no scholar should be denied less they become discouraged or disillusioned.

An obvious issue is the transferability of an experience into credit and where exactly it should fit into a curriculum (Kim, Hahn, & Noh, 1996). Although the individual circumstances will vary considerably, there are several suggestions that should apply in most situations. The first and most obvious area is that in which the course(s) taken by a student are the general equivalent of a course required by the student’s primary university. This can often be ascertained by asking the student to secure a copy of the course syllabus and a transcript of the marks for the course. Where like or equivalent work has been done in an acceptable manner meritorious of recognition, there is little or no reason that a student should not be given credit equivalent to like courses at his or her primary university.

When the transfer is not as clear, such as in an intensive experience where classroom time is combined with discussion groups and practical experiences, there should still be an attempt on the part of both universities and institutions in some way to recognize the student for the work done. Often there is space in a university doctoral curriculum that is reserved for electives of the student’s choice in a certain area. This is a good place to credit an international experience because of the flexibility normally provided in elective selection. A way to document the student’s work is to simply ask them to submit a paper describing the experience and the ways in which it benefited them upon completion of their experience.

Clinical emphasis
A fourth concern of the doctoral students was the lack of clinical emphasis in exchange programs. As has been well documented in the literature, there exists a danger of creating or adding to an already existing gap between researchers/theorists and practitioners. The research-theory-practice cycle is crucial to the development of a practice discipline (Kim, Hahn, & Noh, 1996). Research answers questions, produces data, and generates information. Theory organizes, explains, and puts into relationships this data. Practice takes this organized data and applies it for the benefit of humans. Practice, in its intersection with real phenomena, produces new queries; sometimes secondary to the application of theory and research and other times in a spontaneous manner. These queries are then funneled back into research and the cycle continues. The doctorally trained nurse should be able to fluidly move from one context to another; developing, disseminating and practicing knowledge.

Nursing is a practice discipline, an applied science. It is essential that great pains be taken to avoid the intradisciplinary error of training researchers who have no link with practice. This is to divorce practice from discipline and applied from science. The suffering will not take place in nursing science nor will it occur in nursing practice. The great wound will be in nursing art, where theory and practice meet, research and application embrace and knowledge and care synergize to become that which we identify as "nursing."

Our commitment to the development of collaboration across countries in doctoral education and nursing leadership, in large, will be reflected in the effort put forth to develop and implement solutions to the above outlined barriers.

Models for Doctoral Collaboration of Doctoral Education
With these issues in mind, finances, time investment, academic credit, and clinical emphasis; I developed five models that will potentiate our efforts to progress in the development of cross-country doctoral education. These models are in no way exhaustive and should act as a stimulus for further thought on the part of individuals. The models are as follows: the intensive program, faculty exchange, the sharing of syllabi, student internships, and graduate student collaborative research.

Intensive programme
In this model students are the unit of exchange. In the summer of ‘95 I was part of an Intensive Psychiatric and Mental Health Nursing Programme at Oregon Health Sciences University School of Nursing. In this model two points were key. The first was the relatively short (approximately 2-4 weeks) format of the programme. The student is required to be away from their own responsibilities (family, school, work, etc.) for only a short amount of time. This minimizes not only financial strain but emotional as well. This requires that the hosting institution prepare a schedule that provides a well-balanced of experience that will benefit the student in a short amount of time. It is also important that the hosting institution have some idea of what it is the students(‘) objectives are so that an experience beneficial for the student can be tailored.

The second key was the variety of experience. As mentioned earlier it is imperative that doctoral students, as future leaders, be trained in the areas of research, theory and practice. This would mean that a portion of the students experience be given to research, ideally mentored by an nurse researcher, and a portion be given to practice, preferably in the area of the student’s focus/specialty.

Since this time the Oregon Health Sciences University (OHSU) has established a fee structure for visiting scholars. Cost is calculated according to a range of length of stay (e.g. 2-5 days = $, 1-5 weeks = $, etc.). OHSU has also developed a set of services that are offered to visiting scholars including airport pickup, housing or dormitory location services, visa preparation, campus orientation, and other information of importance to students living abroad. OHSU is not unique in developing visiting scholar programs, indeed many schools have, and I commend those. Yet many barriers, as mentioned earlier, still exist. Further, there exists no method or unity of action among universities, institutions, or nursing in general. It is largely many independent bodies functioning independently, unawares of each other’s activity. There is no strategy, no common vision or goal. Such action will not cohesively move nursing, as a profession and a discipline, into a globally relevant position for the 21st century.

An alternate model would be to simply match students according to course need. In other words, a student would indicate the class(es) needed and would be matched with the appropriate institution based on this need. It would then be the hosting institution’s responsibility to identify clinical and mentored research experiences within the students realm of interest. This model could also be employed in the internship model.

Faculty exchange
A second model involves the exchange of faculty to teach intensive courses at the doctoral level. Faculty would be invited by universities in other countries to teach courses to doctoral students on selected topics. Again, the pattern of addressing theory, research, and practice should be adhered to. This model requires minimum displacement of individuals and will, as a result, reduce cost. Both this model and the intensive programme model should merit academic credit for the student. Again, many universities have embarked upon such programs and with great success. However, as explained earlier, this has been without any sense of cohesiveness or unity in the discipline.

Sharing syllabi
A third model is the sharing of syllabi. This model, to my knowledge, is yet unexplored as a method for the exchange of knowledge in doctoral programmes. Syllabi can be virtual treasure chests of information. A host of invaluable material is contained within a syllabus including course structure, reading material, lecture topics, related readings and course requirements. This material reveals a particular institution’s or individual’s conceptualization of topics or subjects which can then be compared with like courses at other universities. This comparing and contrasting process will inevitably enrich cooperating universities’ curricula and may even spawn new classes or approaches.

Internships
A fourth model that could be employed would be the use of doctoral students in positions which did not involve academic courses per se (Kim, 1994). For example, I am currently involved in a joint UNDP and Ministry of Science and Technology demonstration project. We are using a community-based intervention model to rehabilitate chronic psychiatric patients. This work is the first of its kind in Korea and has received much notice. Part of my responsibility as national project director is to see that reports are filed to the appropriate organizations and that knowledge is disseminated. Both of these tasks require excellent English writing and speaking skills. I have published in English and it should be obvious that I speak it - I hope! - however, time does not allow me to compile the necessary reports and publications myself. Many Korean students do speak and write English, but it is very difficult to find a student who is able to do both at the level required for this work.

Through a series of connections I was able to contact an American doctoral student who was able to come to Seoul for the summer and aid me in my writing responsibilities. This contact was made at an international conference held in Padau, Italy this past spring. The match turned out to be an excellent one as the student was interested in both writing and nursing at the international level. The student is currently in Seoul and has had excellent opportunities to be exposed to nursing in Korea, broaden his network, and gain more of a global perspective on health care.

I share this story to demonstrate two points. First, it seems obvious that the coincidence involved in this particular scenario is not our typical experience. If we were to develop a body committed to linking doctoral students with international training opportunities, it could make what was coincidence here a regular occurrence. Second, I want to ground this idea of developing a body committed to cross country doctoral education in reality to avoid the perception of this as being pie in the sky. There are indeed doctoral students interested in international training whether it be in course work, research, or practice. And there are also those universities, organizations, institutions and agencies interested in hosting international students for various reasons. The project that is going to be suggested in this talk is merely a means of bringing these parties together in an efficient manner under one body that could serve to purposefully direct the development of nursing as a globally relevant discipline.

Graduate student collaborative research
Yonge, Skillen and Henderson (1996) in a recent article make a strong argument for collaborative research by students at the graduate level. The article presents both a model and rationale for the implementation of collaborative research by graduate students. Although their model was originally designed for students whose primary university of study was the same, I would like to expand the model to include students working collaboratively from different universities and across national borders.

Yonge et al. (1996) have defined "student collaborative research" as, "the intentional act of equitably working together under an approved agreement by two or more graduate students for the purpose of a thesis, project, or other specified outcome" (p. 365). The trends in healthcare today toward cross-disciplinary cooperation and multi-disciplinary research bring to bear the need for collaborative minded scholars in nursing. It follows that training for nurses should reflect the needs of the discipline and society in which they serve. The benefits of engaging such a model may exceed those of producing solo research as students learn to collaborate, recognize others’ strengths and weaknesses, and value collective thought as well as benefiting from personal accountability to a co-researcher. These are the qualities that the researchers of the future need to possess to be successful in the healthcare environment.

Building on this model, graduate student researchers involved in exchange programs or internships could, as well, develop joint research or thesis projects. For instance, a Canadian nursing doctoral student interested in carrying out research on the effects of reminiscence theory in the elderly could be linked with a Korean doctoral student with like interests. The research plan and proposal could be developed by both students in their respective locations through electronic mail, fax and other modern modes of communication. The data collection could be done during an internship in which the Canadian student spent a semester in Korea. A major benefit to data collection in Korea, and many other foreign countries, is that the populations are readily accessible and often very willing. There does not exist the bureaucracy of red tape that is often necessary for a researcher to wade through as they attempt to gain approval from several review boards. Data could be analyzed, interpreted, and written up during a visit of the Korean student to Canada. A venture of this scope holds great promise for the development of doctorally trained nursing leaders who are globally conscience and committed to the betterment of a species versus a race or ethnic group. This is not to mention the many other benefits that would be reaped, such as second language skills (a requirement that has unfortunately fallen out of most doctoral curriculums), development of a global network and exposure to other cultures, to name a few.

Strategies
As has already been mentioned, many of these models or pieces of these models are currently being practiced by institutions around the world. However, as also mentioned earlier, these efforts are not coordinated in any united attempt to advance the nursing profession into the global setting. It would seem rational and possible to begin to think about establishing a body or organization specifically responsible for the development, organization and facilitation of cross-country collaboration in doctoral education. Any or all of the models mentioned above could be implemented through such a body. It would bring into concert not only the desires of doctoral students and institutions but a discipline; a discipline often typified by its lack of unity and coherence.

Strategies important in the above mentioned plans will include at least three important areas and likely many more. First, such a body would ideally be linked with an organization larger than itself able to provide regulatory governance, consultant services, start-up monies and operating space. The Association of the American Colleges of Nursing (AACN), because of its regulatory role in graduate nursing education, seems to be an obvious choice.

Second, the development of a database would be necessary in any of the models established. In the first and fourth model discussed, the intensive and internship programmes, a database would be the most valuable. Interested universities, institutions and organizations would be added to the database and referenced in three areas -theory, concept, and issue. Particularly, participating bodies would be referenced for those areas in which they excel.

For instance, University X has been carrying out in-depth research in the area of spinal injury rehabilitation. Roy's Systems Theory has been the organizing framework used for most of the research. Coping, crisis intervention, skin care, and prevention are all areas that have been researched at this University. University X is recognized as a leader in this area and is affiliated with a regional hospital that has developed a unique program specifically designed for the care and rehabilitation of spinal cord injury patients. In the database, this institution would be referenced in the three areas, theory, concepts, and issue. Under theory, University X would be listed as Roy or Systems. In the area of concept, listings such as coping, crisis intervention, skin care in bed bound patients, and accident prevention might be included. The issue designation would be spinal cord injury.

Once a database of this nature was developed, students could be matched with programs best suited to their interests whether it be issue, theory, or concept based. This type of system could be used to facilitate the work of any of the four above mentioned models. It is a simple design but would be powerful in its ability to quickly and accurately match students with their areas of interest. Once forms were developed it would only be a matter of having interested institutions/organizations fill in the form with the necessary information and return it to the organizing body. Information regarding the availability of such a service could be disseminated through international organizations such as ICN or the WHOCC for Nursing as well as personal networks.

Third, I would be remiss if I did not address the use of the Internet as a strategy to facilitate cross-country collaboration in doctoral education. The collection of the data mentioned earlier needed to establish a database could easily be done through an electronic format. The system could be designed in such a way that the relayed information would be automatically entered into an already existing database. The database could then be made available to anyone through a Web page. Links could be established to a participating institution’s Web page or e-mail address allowing individuals and institutions to contact each other directly. This would largely reduce the need of a "middle man" or liaison between institution and individual.

Fourth, the issue of financing could be addressed in several ways. Organizations/institutions interested in being site providers could pay a small annual membership fee. This would serve to offset the costs of overhead (paper, copies, mailings, data entry, etc.) Whatever organization the body was actually linked with, the AACN for instance, could also contribute a small amount whether this be through the sharing of space, resources or through simply providing a minimal cost annual budget. A third source that could be explored would be the private and public sectors. It is not unlikely that monies could be found to fund such an operation in the way of small grants or gifts. Regardless of the source, it is likely that a demonstration project of this sorts, well-planned, smartly (deftly) networked and given to a small group of ambitious people committed to seeing the project through, could be financed with little difficulty.

Conclusion
In conclusion, there is no debate as to the need for nursing to evolve in synchrony with society. Since leaders set the pace, it is important that we focus on developing leaders who will be globally minded and dedicated to a world vision for nursing. In the nursing profession, nurse doctorates are the leaders. Therefore, we must be dedicated to providing opportunities for our future leaders to develop as such. The issues of finances, time, academic credit, and well-rounded experiences that include study in theory, research, and practice must be creatively and aggressively addressed by the current leaders in nursing.

Today, five models and strategies to implement those models have been presented to you. What will our next steps be? As I mentioned during my introduction, it is my sincere desire that this talk act as stimulus for conversation and thought during the group discussion following this talk. However, all our "talk" will be for nought if action does not arise out of it. The formation of a workgroup established to brainstorm and explore different venues for collaboration across countries in doctoral education would be an ideal first step.

To return to Ketefian and Redman (1997), they state, "In 1997 we are at a critical juncture for American nursing science. Given the global society in which we live, nursing science now faces the challenge of moving to its next phase of development, which we call ‘becoming globally relevant’" (p.15). They go on to make several suggestions for accomplishing this, two of which are pertinent to today’s topic: (1) provide opportunities for doctoral students to develop nursing research internships abroad, and (2) integrate collaborative international research in the ongoing work of scientists in leading nursing institutions throughout the world. Although these comments are made in application to American nursing, I believe that they can be expanded to include the nursing discipline globally. If indeed, providing opportunities for doctoral students to study abroad and integrating collaborative international research in nursing institutions worldwide will serve to make nursing more "globally relevant", and I believe they will, then the suggestions and recommendations made in this paper are viable ideas that can contribute to our global relevancy. May we as nurses look ahead to the future and consider our role.

References
Ketefian, S., & Redman, R. (1997). Nursing science in the global community. Image, 29 (1), 11-15.

Kim, S. (in press). Barriers and strategies of international collaboration in nursing doctoral program. Journal of Nursing Science.

Kim, S. (1994). Educational reform in nursing. Proceedings of Annual Conference, Korean Academy of Nursing, 1-7.

Kim, S., Hahn, Y., & Noh, C. (1996). Relationship between professional self-concept and attitudes toward nursing specialization of clinical nurses. Korean Journal of Mental Health & Psychiatric Nursing, 5 (2), 5-17.

Strategies for clinical nursing development: Break through the nursing education. (1996). Proceeding of SNA's Jubilee Symposium, Seoul Nurses Association.

Yonge, O., Skillen, L.D., & Henderson, D. (1996). Collaborative research by graduate students. Image, 28 (4), 365-367.