WORLD HEALTH A 2-Decade Appraisal of African Nursing Scholarship: 1986–2006 Oluyinka Adejumo, RN, MSc, Dlitt et Phil, RPN, RNE11 & Eucebious Lekalakala-Mokgele, RN, MCur, PhD, RM, RCN, RNE, RNA2 1 School of Nursing, University of the Western Cape, Cape Town, South Africa 2 School of Nursing, North West University, Potchefstroom, South Africa Key words Africa, nursing research, nursing scholarship, evidence-based practice Correspondence Dr. Eucebious Lekalakala-Mokgele, School of Nursing, North West University, Potchefstroom, South Africa. E-mail: sebi.LekalakalaMokgele@nwu.ac.za Accepted: November 1, 2008. doi: 10.1111/j.1547-5069.2009.01252.x Abstract Purpose: This paper is a description of a study about articles published about nursing in Africa from 1986 to 2006. Methods: An exhaustive database search of articles written by nurses or articles related to nursing in Africa was done. Access to the database was mainly via EBSCO (www.ebsco.com), which allowed searching seven electronic databases. These are major databases useful for finding and accessing articles in academic journals, repositories, and archives. Data were recorded on computer spreadsheets and analyzed using frequencies and percentages. Findings: A total of 1,860 indexed research studies were categorized and analysed for themes, content, source of publication, location, subject, scientific or nonscientific methods, nursing or non-nursing research, clinical or nonclinical nursing. A progressive increase of publications was noted. Regional variations were observed in the number of publications over the years with most from Southern Africa (67.3%) compared to West Africa (5.2%) and East Africa (3.3%). Common themes were nursing education (11.9%) HIV/AIDS (11.9%), community health care (16.1%), and professional nursing issues (10.3%). Single authorship (90.7%) outnumbered multiple authorship (9.3%), though research-based (50.5%) and nonresearch-based articles (49.5%) were almost evenly distributed. Conclusions and Recommendations: More emphasis will be required for research concerning clinical studies; and collaborations—particularly multinational and across regions of Africa—should be developed. Efforts should be intensified to continue to build research capacity among nurses. Clinical Relevance: Emphasis on African-based clinical studies which directly relate to patient care and culture can advance evidence-based practice in nursing with particular reference to African settings. Knowledge production and contributions to the body of knowledge in nursing from an African perspective has not often been a subject of analysis in nursing literature. Textbooks and journals in the nursing libraries of many schools of nursing and midwifery (SNM) in Africa are often from countries other than Africa. Books written for or by Africans are generally in short supply. Studies and journal articles in nursing that are focused on Africa or written by Africans have not been generally acknowledged as having any significant effect on the domain and practice of nursing. 64 Talking about evidence-based practice in nursing for Africa, one may be inclined to ask, “How much has Africa contributed to this or to nursing scholarship in general in the area of knowledge and practice of nursing?” No systematic studies of how much nurses in Africa have contributed or are contributing to nursing scholarship were found. Brink (1992) attempted a review of the status of nursing research, but this review was limited to South Africa. Tlou (1998), writing about research in Africa, laments the dearth of research studies concerning Africa but does not describe previous studies or contributions Journal of Nursing Scholarship, 2009; 41:1, 64–69. c 2009 Sigma Theta Tau International  Adejumo & Lekalakala-Mokgele made by African nurse scholars. There would be no way of knowing what contributions nurses in Africa are making to the body of nursing knowledge if we did not occasionally take stock of the activities of our nurses and midwives in this part of the world. Purpose The purpose of this study was to provide a systematic analysis of contributions to nursing scholarship from an African perspective and to acknowledge some of the contributions that authors from Africa have made to research and scholarship in nursing. The study was conducted to answer the following questions: r To what extent are Africans contributing to the emerging body of nursing knowledge in the world? r What are African nurses contributing to the nursing knowledge base? r Where do nurses from Africa publish? r What are the characteristics, including geographic, of African nurses who publish? r What are the most common topics and types of articles by African nurse authors? Definition of Term While the term “scholarship” may generally refer to personal studies for higher degrees, publications (e.g. articles, books, technical and research reports, case studies, policy developments), creative works, designs, patents, participation in and presentations at conferences, research projects, editorial works, intellectual leadership, and research partnerships, in this article the definition of “scholarship” is limited to published works or studies reported in journals of nursing or other health-related publications available on international electronic journal databases. Methods and Design Publications from 1986–2006 written by nurses or associated with nursing-related works were considered for inclusion in this study. The researchers used mainly multiple electronic database searches, combining key words such as nursing, nurse, Africa, or any of the countries in Africa appearing as part of the title, or author address in the article. Access to the databases was mainly via the NEXUS database system (http://stardata.nrf.ac.za/) with access to completed and ongoing research projects in South Africa and EBSCO (www.ebsco.com) via: Appraisal of African Nursing Scholarship 1 Academic Search Premier, with full text for nearly 4,500 journals, including more than 3,600 peerreviewed journals. 2 CINAHL and Pre-CINAHL, with over 1,000,000 records that are an authoritative resource for nursing and allied health professionals, students, educators, and researchers; 2,857 journals in the fields of nursing and allied health are indexed. 3 The Educational Resource Information Center (ERIC), with more than 2,200 digests, along with references for additional information, and citations and abstracts from over 1,000 educational and education-related journals. 4 Health Source’s consumer and nursing academic editions, with a rich collection of consumer health information indexed from nearly 850 journals. The academic edition includes nearly 550 scholarly full-text journals from many medical disciplines. 5 MasterFILE Premier, with a multidisciplinary database providing full text for more than 1,730 general reference publications with full-text information dating back to 1975; MasterFILE Premier also includes nearly 500 full-text reference books, 84,774 biographies, and over 100,000 primary-source documents. 6 MEDLINE, with authoritative information on medicine, nursing, dentistry, the healthcare system, preclinical sciences, and more, using Medical Subject Headings (MeSH) for searching citations from over 4,800 current biomedical and nursing journals. 7 PsycINFO, from the American Psychological Association (APA), with nearly 2.3 million citations and summaries of scholarly journal articles, book chapters, books, and dissertations, in psychology and related disciplines, with over 2,100 periodicals—some dating back to the 1800s. Boolean searches were used to find published works that combined nursing or nurse and Africa or any of the countries in Africa in the journal name, author, abstract, or full content fields. Journals considered for inclusion had to be nursing or nursing and health-related publications. The initial search yielded over 4,000 published articles that were later reduced to 1,860, based on the chosen criteria. We believe many more publications might have been found, particularly because African locations were not always cited, but the final sample of 1,860 publications was deemed adequate for our analysis. Data Collection and Analysis The collected data and the analysis were based mainly on published journal articles. A decision was made not to include books or chapter titles because these were not 65 Appraisal of African Nursing Scholarship always readily available from the electronic databases. Articles retrieved were identified by title, author, journal, and journal location (Africa or outside Africa). Further classifications were made regarding whether the articles were published by single or multiple authors, the subject (topic) of publication, and whether the article was in a research- or nonresearch-based publication. Research-based articles were further analysed for methodologic perspective i.e., whether qualitative, quantitative, or mixed research. Additional information considered was source of the data–whether client- or health professional-based. Raw data were entered on Excel spreadsheets for analysis, with frequencies and percentages used for the grouped data. Findings from the analysis were converted to graphs and figures. Adejumo & Lekalakala-Mokgele What do Nurses in Africa Publish? The content of each article was reviewed and analysed for subject or focus, and was categorised as research-based or nonresearch-based. The published articles were almost evenly divided between research- and nonresearch-based, 939 (50.51%) and 921 (49.49%) respectively. Subject or Focus of Articles The subject or focus of articles covered a wide range of topics between 1986 and 2006 (see Figure 2). A heavy emphasis was on HIV/AIDS (n=221, 11.9%), nursing education-related issues (n=221,11.9%), community health nursing or primary health care (n=299,16.1%), and issues concerning professionalism in nursing (n=192, 10.3%). Figure 2 shows the steady growth in these areas. Findings Publication growth 1986–2006 Supporting evidence was found that publications originating from nurses in Africa grew steadily from 1986 to 2006 (see Figure 1). A strong surge was observed toward the late 1990s that might have coincided with more conscious efforts of nurses in Africa to contribute articles about research and nursing practice. Figure 1. Number of articles by year of publication 1986–2006. 66 Methodologic Paradigms Adopted by the Nurse Researchers Research-based articles (n=939, 50.5%) were categorised for methodologic orientation. Of the 939 research-based articles, 664 (70.7%) were quantitative studies, 237 (25.2%) were qualitative, and the remaining 38 (4.1%) were mixed-method studies. Adejumo & Lekalakala-Mokgele Appraisal of African Nursing Scholarship < 45 AH C h ild H e a lt h CH N 40 CIPN C o m m u n ic a b le d is C rit ica l C a re 35 DD EBP E th ic s 30 G e ro n to H is to ric a l H I V /A I D S 25 HSR In f e ct io n Managem ent 20 M e n t a l H e a lth NE O HN 15 O n co O p h th a l O ra l-H e a lt h 10 P e rio p e ra tiv e P HC R e g u la t o ry 5 R e p ro d u c tiv e h e a lt h RM TC N 0 06 20 05 04 20 20 03 02 20 20 01 00 20 99 20 19 98 97 19 96 19 19 95 94 19 19 93 92 19 91 19 19 90 89 19 88 19 87 19 19 19 86 T ra u m a W o m e n H e a lt h W o u n d C a re Figure 2. Year-specific trends and focus of publication. AH = adolescent health; CHN = community health nursing; CIPN = current issues in professional nursing; DD = death and dying; EBP = evidence-based practice; HSR = health system research; NE = nursing education; OHN = occupational health nursing; PHC = primary health care; RM= research methodology; TCN = transcultural nursing. Where do African Authors Publish? Analysis was done concerning location of the journals where articles by African authors were published. Slightly more publications (n=980,52.67%) were retrieved from African-based journals, compared to 880 (47.33%) retrieved from non-African-based journals (difference not statistically significant, p>0.05). It was noted, however, that more of the research-based articles were published by African-based journals than by the non-African-based journals. Researching Clients or Health Professionals Of the 939 research-based articles, 603 (64.3%) were conducted on health professionals; and only 336 (35.75%) included source data from patients or clients. Location of Publishing Nurses? More than two-thirds (n=1,252 or 67.3%) of the published works came from nurses in Southern Africa, particularly South Africa, while nurses from West and East African regions contributed about 8.5% (n=158) of the total number of retrieved works. Nurses from South Africa alone contributed about 64% of the published works that were analysed (see Figure 2). The institutional affiliations of the authors indicated that most of the authors were associated with universities or nursing colleges, with fewer than 1% not indicating an educational institution affiliation. Indicators of Collaboration Immediate indicators of collaboration or working together can mostly be discerned by the number of authors associated with a publication. A total of 1,687 (90.7%) of the 1,860 analysed articles were written by one author, while only 173 (9.3%) were by more than one author. Discussion The analyses indicated that significant contributions had been made toward nursing scholarship in Africa. African and non-African journals were utilised almost evenly; this might indicate over-reliance on foreign journals, showing the need for nurses in Africa to develop their own journals. The fact that topics such as nursing education, current issues in professional nursing, and community and primary health care were dominant in 67 Appraisal of African Nursing Scholarship Adejumo & Lekalakala-Mokgele Figure 3. Location of authors of retrieved works by region. works published between 1986 and 2006 were even more dominant in works published between 2000 and 2006 has implications for evidence-based practice. Fewer studies should be conducted on healthcare professionals and more on consumers of healthcare services. Evidence of effectiveness of care is more likely to be obtained from observations of clients compared to observations of nurses and other healthcare providers. Emerging trends in joint authorship are indications of collaboration, but more publications are from single than from multiple authors. Collaboration is important in strengthening research and practice. Burns and Grove (2005) indicate that educators, researchers, and practitioners should collaborate on applying a variety of strategies to increase evidence-based practice in nursing. Collaboration among researchers and clinicians is seen as an important requirement for successful application of research findings (Funk, Champagne, Tornquist, & Wiese, 1995). Regions are disproportionately represented in the published works, because over 60% of all published works are from Southern Africa, which is probably an indication of the level of nursing and midwifery development in South Africa and the fact that most internationally indexed journals of nursing and midwifery in Africa are published in South Africa. The publication growth trend observed probably correlates with the demand by the South African Ministry of Education in its new National Plan for Higher Education in South Africa, which encourages higher education institutions in South Africa to give 68 a high priority to increasing research output (Ministry of Education, 2001). The regional distribution of the published works shows where nursing education has been longstanding: South Africa, Nigeria, Ghana, and a few East African countries. The number of publications has also been affected by the presence of nursing journals in the countries associated with better publication records. Curationis, Health SA Gesondheid, Nursing Update, and Africa Journal of Nursing and Midwifery are published in South Africa, West African Journal of Nursing is published in Nigeria (West Africa), and the East African Journal of Nursing is published in East Africa. Even though many published works were already being produced by nurses in Africa, Segrott, McIvor, and Green (2006) point out the continued lack of research capacity among nurse researchers in general and low levels of funding available to them. Many nurses who had been involved in conducting research claimed that they did research not because they were interested in research, but because it was a requirement (Ofi, Sowunmi, Edet, & Anarado, 2008). Another claim was that nurses were assigned the responsibility to assist researchers in other health-related disciplines, or they just viewed research as the task of university staff and academics (DuPlessis & Human, 2007). According to Brink (1998), nurses were not prepared to conduct research before the mid-1920s and members of other disciplines conducted much of the early nursing research. This might be related to the undermining of nurses’ ability to conduct research of high Adejumo & Lekalakala-Mokgele quality and to the fact that nurses in general are inexperienced in generating their own research funds and in writing scientifically competitive proposals for funding. Appraisal of African Nursing Scholarship challenges faced by nurse researchers in Africa, the period 1986–2006 provides us with evidence that nurses in Africa have contributed and continue to contribute nursing knowledge by means of publications in regional as well as international journals. Limitations of the Study The initial search yielded over 4,000 published articles that were later decreased to 1,860, based on the inclusion criteria. Only articles that were indexed in the available databases were accessed, which indicates that articles not accessible from the listed electronic databases were not taken into consideration. If other relevant works existed, it would have made this study more comprehensive had they been included in the analysis. Nevertheless, the data that were accessed were deemed to provide a good indication of the present state of nursing scholarship in Africa. The use of the NEXUS database system might also have tilted the balance regarding the number of articles retrieved in favour of South Africa, because no such system existed for other countries in Africa. Clinical Resources r A system which promotes r r dissemination of research findings, research networking, and research capacity development in South Africa: www. nexusdb.com/-35 A research journal of the Democratic Nursing Organisation of South Africa: www.denosa.or.za/ Curationis.htm-11k Health SA Gesondheid is an accredited interdisciplinary health research journal that contributes to the development of science : www.uj.ac.za/ healthsa/-23k References Conclusions and Recommendations Based on the findings in this study, it could be concluded that clinical studies were few and far between. Collaboration, particularly multinational and across regions of Africa, was inadequate. While obvious that nurses must continue to conduct research and make the products of such scholastic endeavours available, a major factor that will drive this is the research capacity of nurses themselves and the availability of funding support for such initiatives. We therefore recommended that efforts be intensified to continue to build research capacity among nurses. Also educational programmes to produce nurses must be focused on developing nurses who will be interested in doing clinical research. African nurses must develop our own nursing and midwifery journals. We must learn to tell our own stories rather than letting other people tell our stories for us. Efforts have been made by leaders of higher education programs in nursing in Southern Africa to develop qualifications for nursing research at the master’s level. Intentions of developers of such programs were to develop a core of nurse researchers for nursing in Africa. We recommend that other nursing educational institutions adopt this approach for developing research capacity among nurses in other parts of Africa. Despite the Brink, H.I. (1992). The status of nursing research in the Republic of South Africa: Past and present perspectives. Curationis, 15(4), 28–31. Brink, H.I. (1998). Fundamentals of research methodology for health care professionals. Cape Town, South Africa: Juta. Burns, N., & Grove, S.K. (2005). The practice of nursing research. Conduct, critique and utilization (5th ed.). Philadelphia: Elsevier Saunders. DuPlessis, E., & Human, S. (2007). Exploring a strategy to promote nurses’ health research contribution. Health SA, 12(4), 36–52. Funk, S.G., Champagne, M.T., Tornquist, E.M., & Wiese, A. (1995). Administrators’ views on barriers to research utilization. Applied Nursing Research, 8(1), 44–49. Ministry of Education. (2001). National plan for higher education in South Africa. Pretoria, South Africa: Author. Ofi, B., Sowunmi, L., Edet, D., & Anarado, N. (2008). Professional nurses’ opinion on research and research utilization for promoting quality nursing care in selected teaching hospital in Nigeria. International Journal of Nursing Practice, 14, 243–255. Segrott, J., McIvor, M., & Green, B. (2006). Challenges and strategies in developing nursing research capacity: A review of the literature. International Journal of Nursing Studies, 43, 637–651. Tlou, S.D. (1998). Nursing research in Africa. International Nursing Review, 45(1), 20. 69