The United States is not alone in facing a period of significant healthcare reform. In reality, this is a global phenomenon. This article describes the use of bibliometric analysis to identify key features of the global literature on the nursing role in healthcare transformation. We describe our methods to critically examine indexed literature contained within the peer-reviewed database Scopus, and offer discussion, limitations and conclusions. Findings demonstrated that nursing scholarship in the field is not as voluminous as that of medicine. Nevertheless, our profession is active in contributing to the development of the science in this field of inquiry. Examining data from the perspective of multiple countries allowed consideration of similarities and differences in the scholarship focus.
Key Words: healthcare transformation, healthcare reform, bibliometric analysis, global, nursing scholarship
Healthcare transformation is not a new concept nor is it unique to the United States. Healthcare transformation is not a new concept nor is it unique to the United States. This is perhaps stating the obvious but something that we tend to forget. We see issues directly in front of us and all too often do not take time to raise our eyes above our immediate horizon. In a globally connected world, we contend that nurses can learn from each other if we are prepared to look beyond institutional, city, state, and also country borders. There are many ways to do this. We can read international literature. We can communicate with peers. We can visit or work in other countries.
The authors of this article take the first of these options, reading the literature, and consider published and indexed nursing literature as the basis of our analysis of healthcare transformation. We specifically contrast the United States with other country examples and also consider how our professional understanding of healthcare transformation in the context of nursing is similar and what ways it differs from other writings on the subject. To achieve this we utilize, bibliometrics, a technique that has been little used by nurses but can provide powerful insights into the collected literature on a topic (Benton & Alexander, 2016; Benton Cusack, Jabbour, & Penney, in press; Smith & Hazelton, 2011).
Any nurse familiar with evidence based practice will have heard about, read, or even conducted a systematic review of the literature. Systematic reviews could be characterized by the use of a photographic metaphor. Namely they are analogous to using a macro lens. They can capture a detailed, close up image of a tightly defined subject. The review looks at the precise structure of the content and enables the reader/viewer to see those well-researched and consistent parts of the topic in a predictable and consistent manner to support consolidated conclusions.
...bibliometric reviews offer a wide-angle lens view. Further elaborating this metaphor, areas of shadow or those that lack focus point to those parts of the science/topic that are less well understood. These often may be characterized by conflicting evidence and, as such, provide pointers to further inquiry. In contrast, bibliometric reviews offer a wide-angle lens view. They offer a different perspective that complements understanding of a topic. They provide a holistic view of the content, or a panorama. As such it is possible to see the contrasting elements of the scene, the way that component parts relate to one another, and how they develop over time. For these reasons, we selected this approach to gain a global, comparative, and evolving understanding of the topic of healthcare transformation.
The study aim was to conduct a bibliometric analysis of the published and indexed literature relating to the nursing contribution to healthcare transformation. To address this aim, we utilized a combination of descriptive, trend, co-word, and co-citation bibliometric analyses.
Bibliometrics is a method of analyzing published and indexed literature. Bibliometrics is a method of analyzing published and indexed literature. Data can be readily extracted from a number of sources; however, in terms of nursing literature, the Scopus database (Elsevier) has the most comprehensive coverage (De Groote & Raszewski, 2012).
The bibliometric analysis generated a range of metrics. Some metrics were relatively simple, such as raw counts of the number of articles on the topic of interest; the number of papers originating from a particular country; those published in a specific language; or the numbers of papers indexed year-on-year. However, more complex measures, such as co-word analysis, were also used. Co-word analysis helped to identify clusters of nouns and noun clauses that, due to similar locations within the text and associated proximity to each other, formed clusters that were then reviewed. In addition, it was also possible to look at the average year that any particular noun or noun clause was published and the extent that papers from which the word originated were cited. These type of metrics enable the evolution of concepts, their origins, and their influence on emergent thinking to be tracked over time.
Data Collection and Extraction
The four countries... were selected on the basis that there is a critical mass of papers relating to these countries. Data were extracted from Scopus as a comma separated value (CSV) file. A structured search of the database was conducted on the 5th of December 2016 using the following search terms [(Healthcare OR “Health Care” OR “Health System”) AND (Reform OR Redesign OR Transformation) AND (Nurse OR Nursing)]. Only papers written in English were downloaded as the analytical software cannot process articles in foreign languages. Five files in total were identified: one containing all articles relating to nursing and healthcare transformation and four specifically relating to four counties of interest. The four countries (Australia, Canada, United Kingdom [UK], and the United States of America) were selected on the basis that there is a critical mass of papers relating to these countries.
Bibliometric Mapping Software
Bibliographic maps using VOSviewer (Centre for Science and Technology Studies, 2017) were generated by uploading the CSV files into the specialized software relating to the total literature corpus and for each of the four countries. VOSviewer is a freeware package developed by Nees Jan van Eck and Ludo Waltman at the University of Leiden in the Netherlands that provides a range of support materials and guidance. VOS stands for visualization of similarities and is the basis upon which the package identifies similarities and differences in data. Specifically, this specialized software identifies commonly occurring in nouns and noun clauses from the titles, abstracts, and keywords of papers and generates cluster diagrams using a multi-dimensional scaling technique. In addition, the package can identify patterns relating to similarities in citation, journal authorship, countries of origin, and a range of other variables. Default settings for VOSviewer were used for the analysis (Van Eck & Waltman, 2014).
Basic descriptive statistics relating to the number of papers retrieved were noted. Scopus has a limit (2000 papers) on the number of articles that can be downloaded at one time. It was necessary to merge, and then clean several files into a single CSV file. This file was uploaded into the visual mapping VOSviewer software. Four subsets of papers were also identified and saved as CSV files, those relating to Australia, Canada, the United Kingdom, and the United States of America.
Reliability of Analysis
Having identified clusters of words, we then independently reviewed them and created a succinct descriptive title for each cluster and an operational description, both based on the various nouns and noun phrases generated. Once these were developed, we shared our initial work with each other and discussed the analyses until agreement on a single set of themes and narratives to describe the various clusters.
Results and the associated finding are presented together, as we believe this will help readers interpret results of the analysis by collocating the various figures and tables with associated discursive text. Findings consider healthcare transformation, as reported in the nursing literature, in the context of these themes: the overarching picture; country origins of the nursing literature; the nature of evolving scholarship; targeting publications; and considering and contrasting the scholarship focus.
The Overarching Picture
Our initial search revealed a significant number of indexed papers (N = 27,132) on the topic of healthcare transformation. Once duplicates; those written in a language other than English; and papers not relating to nursing had been removed, 7,923 papers remained. Figure 1 provides a graph of indexed papers by year. The majority of papers related to medicine, with the first paper published in 1948.
...while the Clinton proposed reforms did generate a modest increase in scholarship by nurses on the topic, the ACA did not generate the same level of response. The first nursing paper on healthcare transformation did not appear until 1969. Two United States policy initiatives have since caused a significant increase in scholarship on this subject, the proposed Clinton reforms in 1993 and the Patient Protection Affordable Care Act ([ACA], 2010) initiated by President Obama in 2008. However, as can be seen in Figure 1, the profession of nursing lags significantly behind that of medicine in contributions to the exploration of healthcare reform. It is interesting to note that while the Clinton proposed reforms did generate a modest increase in scholarship by nurses on the topic, the ACA did not generate the same level of response. This finding is disappointing since the profession of nursing has repeatedly demonstrated ability to increase access to care and provide innovative solutions to intractable problems (World Health Organization, 2013).
Figure 1. Summary of Indexed Papers by Year of Publication
Country Origins of the Nursing Literature
Using a multi-dimensional scaling technique, we used VOSviewer to place the countries of origin of various nursing papers on a two dimensional map. The size of the text and circles provided an indication of the number of papers originating from that country. Countries with the same color and close proximity to each other indicated use of the same bibliographic sources and contain commonality of content.
...nursing literature on the subject of healthcare transformation is dominated by the United States, United Kingdom, Canada, and Australia. The 10 strongest links between bibliographic content were indicated by the 10 lines linking the countries. Figure 2 clearly demonstrated that nursing literature on the subject of healthcare transformation is dominated by (in order) the United States, United Kingdom, Canada, and Australia. Scholars from these counties regularly look to each other’s work to further develop scholarship on this topic.
Material on healthcare transformation did originate from a wide range of countries and therefore represented a potentially rich source of ideas and/or opportunities for international collaboration. Countries located furthest away from the main cluster have significant differences from the rest such as in the middle of care delivery or in the dependence on migrant workers. Hence, further review of papers from Saudi Arabia, Jordan, the Czech Republic, Israel, Japan, or Singapore may provide new perspectives on the discourse taking place at the center of the map.
Figure 2. Countries Associated with the Nursing Discourse on Healthcare Transformation
The Nature of Evolving Scholarship
By conducting a co-citation analysis of the content of the papers identified, it was possible to track the evolution of different lines of inquiry. A co-citation analysis is a means of looking at the relatedness of papers based upon the frequency that two or more papers cited together.
Sometimes lines of inquiry develop in a linear fashion, as can be seen from the radiating spokes of authors and papers emerging from the central nexus (see Figure 3). These radiating spokes of scholarship indicated different lines of inquiry, such as in the case of the spoke that travels north east from the center material on the fiscal and economic issues whereas the spoke that travels southward focuses on theoretical and methodological perspectives. By exploring these different sources a more comprehensive understanding of the topic can be reached, for example by looking at how the various lines of inquiry relate to one another and also by looking for themes that are yet to be comprehensively explored.
Figure 3. Co-Citation Analysis of Authors and Their Work
Zooming on the central nexus or any part of Figure 3 offered us a more detailed understanding. Figure 4 illustrates how various sources related to one another. Additionally, although the nodes (authors and associated article titles) are scaled, a rank order listing of the most frequently cited work and the associated scholars can be exported (Table 1), which we also did to provide useful starting points for exploring the emergence of the most influential authors and their ideas.
Figure 4. Close-Up View of Co-Citation Analysis of Authors and Their Work
Identifying the location of the most cited scholars and the role that they have played both over time and in terms of geography supported new insights. For example, Starr (1982) has triggered and informed multiple lines of inquiry. Conversely, the publication by the United Kingdom Department of Health (1989), Working For Patients, was the third most cited paper, but has had a more isolated impact.
Table 1. Most-Cited Authors and Their Papers from Co-Citation Analysis
Most Cited Ranking
Author and Year of Publication
Title of Paper
The Social Transformation of American Medicine
Institutes of Medicine (2001)
Crossing the Quality Chasm: A new health system for the 21st century
Department of Health (1989)
Working For Patients
Error in Medicine
World Bank (1993)
World Development Report: Investing in Health
Another helpful way to look at the data was through the lens of the journals that frequently carry papers on a topic. Another helpful way to look at the data was through the lens of the journals that frequently carry papers on a topic. Figure 5 provides an illustration of this concept from our work. Knowing which journals most frequently publish such articles can help scholars keep up to date with new material and provide a target list of appropriate journals for publishable work. As noted in Figure 5, the journal Health Affairs was by far the most frequent source of papers about healthcare transformation. As a result, this is an example of a useful journal to consider for publications about this topic.
Figure 5. Mapping Journals Where Work of Healthcare Transformation Is Published
Considering and Contrasting the Scholarship Focus
To analyze the scholarship focus of the work, co-word analysis of the data was performed at an aggregate level (the entire literature) and at each of the four most prolific country levels (United States, United Kingdom. Australia, and Canada). We generated an associated visualization of the terms as a cluster analysis was performed and for each of the five sets of data. Figure 6 provides an illustration of the clusters from the UK data.
For clarification, image ovals were superimposed on the figure to identify the eight clusters of terms. It is important to note that some of these clusters overlap. These overlaps provided a reference to the source documents from which various terms were identified, such as Policy and Accountability; Care Delivery and Settings; and Aspects of Change and Desired Impact. We also zoomed into the image using the interactive feature of VOSviewer to achieve greater clarity in determining the focus of scholarship and the inter-relationships between the various concepts.
Figure 6. Visualization of Co-Word Analysis of UK Data
The entire nursing literature on healthcare transformation, especially redesign and reform, is extremely rich and complex. The entire nursing literature on healthcare transformation, especially redesign and reform, is extremely rich and complex. Appropriate labels and short descriptive definitions have been generated and are summarized in Table 2 (literature for all countries) and Table 3 (literature by country). In each data set, a degree of overlap and interaction occurred, indicating some co-dependence between various clusters. To comprehend relationships between clusters it was necessary to zoom in to the map to identify the granularity of how terms associated within one cluster were located in proximity to other clusters of terms. Looking at the original sources of the nouns and noun clauses offered further information on the context and usage of the term.
Examination of data specifically relating to the United States, the United Kingdom, Australia and Canada revealed more nuanced findings. These findings suggested the more specific concerns addressed by policy change in these countries. Even with country specific concerns identified, there were some overlaps of clusters, both between the aggregated analysis and the individual country results and sometimes between country data. On occasion, different aspects of the same core concept was found, such as those relating to maternal and child health that occurred across several sets.
...access; financing and the affordability of healthcare; and quality and outcomes feature significantly. Importantly, but perhaps not surprisingly, access; financing and the affordability of healthcare; and quality and outcomes feature significantly. For anyone familiar with the literature on the ACA (ACA, 2010), these three areas were often discussed and/or referred to as the ‘triple aim’ but this triad of terms is far from new. Benton (1994), in his examination of the United Kingdom’s National Health Service reforms, highlighted tensions between various stakeholders (e.g., purchasers, providers, patients, and the population) when considering the necessary balance between access, cost, and quality. Dialogue on this triumvirate of terms can be found in the literature from many countries.
The setting or location of care, particularly in terms of primary care and the promotion of health and wellbeing, was also a major theme... The setting or location of care, particularly in terms of primary care and the promotion of health and wellbeing, was also a major theme across the various datasets. A number of health conditions and users groups was also found. Chronic diseases, such as diabetes, mental health problems and services for the elderly or children, were all featured across multiple maps.
Table 2. Cluster Data Summary/Reflection for All Literature
All Literature (N = 7, 923)
Focus and Dimensions of Reform
This was a large and expansive cluster and provided the basic focus and dimensions of reform. Concepts of care setting; different types of practitioners; outcomes, quality and performance; and change, transformation and redesign processes, all were featured extensively and formed the bedrock of the entire map.
Health Policy, Efficiency, & Effectiveness
The second cluster of terms was almost as large and complex as the first. Various noun and noun clauses overlaid terms found in the first cluster, indicating a great deal of interaction and co-dependence. This was not surprising as these terms related extensively to policy making; legislation at state, federal and global levels; and associated concepts of efficiency, effectiveness and universal access or coverage.
Healthcare Financing and Equitable Access
The third cluster contained information on different types of financing mechanisms and how equitable access, particularly to rural communities, could be assured.
The fourth cluster focused on a specific set terms relating to the reform and provision of mental health and substance abuse services.
This cluster highlighted a wide range of factors associated with the educational reform required to underpin healthcare redesign. Modes of educational delivery; curriculum; competence; faculty; and academic and clinical experience were all terms present in this cluster.
Maternal Care Access, Coverage, and Affordability
This cluster of terms was located in close proximity to cluster 3 but considered the issue from the perspective of the specific client group of maternity services. Factors such as access, coverage, and affordability featured prominently for this group.
A number of terms associated with the measurement of performance were found in this cluster. Some terms were specific to certain conditions (e.g., glycemic control) whilst others were more general (e.g., length of stay, resource use, mortality).
Financial Reform and Payment
A range of factors associated with financial reform (e.g., payment structures, incentives, expenditures, premiums) were all found in this cluster.
This cluster recognized the need to address the increasing numbers of older people, the need for a preventive approach, and the increasing incidence and challenges of dementia.
Organizational Level Nursing Contribution
The final cluster consisted of a range of terms that related to the organizational level of executive contribution that nursing can bring to the agenda of healthcare reform.
Table 3. Cluster Data Summary/Reflection for Literature by Country
United States (N = 3,488)
United Kingdom (N = 696)
Affordability and Healthcare Financing: This was the most dominant focus of attention related to healthcare financing and affordability, perhaps due to the lack of total coverage and costs of healthcare in the United States.
Care Delivery Roles and Settings: Care setting, different types of practitioners, and approaches to measure and evaluate these concepts all were featured in this cluster.
Australia (N = 258)
Canada (N = 301)
Leadership and Workplace: Various aspects of leadership and workplace transformation were captured by this cluster. Some of these aspects, such as communication, the environment, leadership, and relationships are central components of creating a positive practice environment (International Council of Nurses, 2007).
Policy Drivers: This cluster contained a large and diverse group of policy drivers (e.g., globalization, chronic disease, demographics and changing disease burden).
Firstly, as noted earlier all papers not in English were excluded from this analysis (N = 1,314 in total; 354 Spanish, 275 French, and 261 Portuguese papers, respectively). Thus, important and different concepts may have been lost, thereby limiting our understanding of the nursing contribution to healthcare transformation. Secondly, although Scopus does provide comprehensive coverage of a great deal of peer-reviewed literature, important concepts and contributions may have been missed due to non-inclusions of grey literature (papers from authors/organizations published external to traditional academic publishers). Thirdly, some peer reviewed journals (e.g., Health Affairs) have historically published specially focused editions of the journal. Such a focus may have distorted the results of an analysis designed to determine journals from which a particular topic may most frequently originate.
We have demonstrated that bibliometrics can provide a wide range of valuable insights regarding the published literature on healthcare transformation. While nursing scholarship in the field in not as voluminous as that of medicine, our profession is nevertheless active in contributing to the development of the science in this field of inquiry. Examining similarities and dissimilarities in data from the perspective of multiple countries further allowed us to both determine countries that show leadership in scholarly contributions to healthcare transformation, and also those that may be able to help us better understand significant differences.
It is clear that major healthcare reforms... do have an impact on both the content and volume of scholarship. It is clear that major healthcare reforms, such as the UK’s Working for Patients (Department of Health, 1989), the proposed Clinton reforms, and ACA in the United States, do have an impact on both the content and volume of scholarship. It is clear that many authors build upon previous work and restrict their citations to a small number of core papers. This, coupled with the apparent lack of co-citation of work across more than the four core countries identified by our analysis (US, UK, Canada, and Australia), suggests an opportunity for nurse scholars to interact more widely and as a result gain new perspectives on their work.
Continued scholarly analysis of healthcare transformation, at both the individual country and global levels, is important to provide credible information related to many aspects of policymaking, including formation and implementation. Dissemination of findings can better inform all stakeholders involved in health reform.
David C. Benton PhD, RGN, FRCN, FAAN
Dr Benton, who hails originally from Scotland, has over thirty five years of experience in a wide range of leadership positions, including Executive Director of Nursing at a health authority in London; a senior civil servant in Northern and Yorkshire Region; Chief Executive of a nurse regulatory body in Scotland, Executive Nurse Director of a university trust health system; Chief Executive Officer of the International Council of Nurses and is the current Chief Executive Officer of the National Council of State Boards of Nursing. A qualified general and mental health nurse, his MPhil research focused on the application of computer assisted learning to post-basic nurse education. He gained his PhD Summa Cum Laude from the University of Complutense, Madrid, Spain, for his work on researching an international comparative analysis of the regulation of nursing practice. Benton, over the past thirty-five years, has published nearly 200 articles and book chapters in relation to research, practice, education, leadership, policy and regulation. He is the recipient of several awards and honors and is particularly proud of being awarded the inaugural Nursing Standard Leadership award in 1993. He has Fellowships of the Florence Nightingale Foundation, the Royal College of Nursing and the American Academy of Nursing.
Deborah E. Trautman, PhD, RN, FAAN
Dr. Trautman has held clinical and administrative leadership positions at the University of Pittsburgh Medical Center and the Johns Hopkins Medical Institutions prior to being appointed as President and Chief Executive Officer of the American Association of Colleges of Nursing. Trautman, has authored and coauthored publications on health policy, intimate partner violence, pain management, clinical competency, change management, cardiopulmonary bypass, the use of music in the emergency department, and consolidating emergency services. She received a B.S.N. from West Virginia Wesleyan College, an M.S.N. with emphasis on education and administration from the University of Pittsburgh, and a Ph.D. in health policy from the University of Maryland's Department of Public Policy. She is a 2007/2008 Robert Wood Johnson Health Policy Fellow and worked for the Honorable Nancy Pelosi, Speaker of the House, United States House of Representatives.
Maureen Swick, RN, MSN, PhD, NEA-BC
Dr. Swick’s background includes 30 years of experience in healthcare, including staff nursing, clinical nurse specialist, middle management, Chief Nursing Officer, Chief Operating Officer, System Chief Nurse Executive and currently serving as Chief Executive Officer for the American Organization of Nurse Executives representing over 9800 nurse leaders both nationally and globally. Swick served as AONE’s 2015 President-elect and 2016 President. Dr. Swick also represented nursing on the 2012-2014 AHA Board of Trustees. Prior to becoming AONE’s CEO, Swick served as Senior Vice President, CNE for Inova which is the largest not for profit health care system located in northern Virginia. During her time at Inova, Swick led the redesign of Inova’s care delivery model which was highlighted in the 2014 Advisory Board’s Nurse Executive leadership sessions. The design of this new model utilized AONE’s work on the nurse of the future and the IOM’s report on the Future of Nursing. She holds a BSN from Monmouth University, an MSN from Columbia University and a PhD from Kennedy Western University.
Benton, D. (1994) NHS counter culture. Nursing Standard, 8(19), 48-50.
Benton, D. & Alexander, M. (2016) The Journal of Nursing Regulation at Age 6: A Bibliographic Analysis. Journal of Nursing Regulation. 7(2), 5-8. doi:10.1016/S2155-8256(16)31072-9
Benton, D., Cusack, L., Jabbour, R., & Penney, C. (In Press). A exploration of nursing’s scope of practice. International Nursing Review
Centre for Science and Technology Studies. Leiden University. (2017). VOSviewer. Visualizing scientific landscapes. Retrieved from http://www.vosviewer.com/
Department of Health. (1989). Working for patients. Cmnd 555. HMSO. London, United Kingdom.
De Groote, S.L. & Raszewski, R. (2012) Coverage of Google scholar, scopus and web of science: A case study of the h-index in nursing. Nursing Outlook, 60(6), 391–400. doi:10.1016/j.outlook.2012.04.007
Institutes of Medicine. (2001). Crossing the quality chasm: A new health system for the 21stcentury. Washington, DC: Institutes of Medicine.
International Council of Nurses. (2007). Positive practice environments: Quality workplaces = quality patient care. Geneva: International Council of Nurses. Retrieved from http://www.icn.ch/images/stories/documents/publications/ind/indkit2007.pdf
Leape, L.L. (1994). Error in medicine. JAMA, 272(23), 1851-1857.
Patient Protection and Affordable Care Act (PPACA) Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319. (2010). Retrieved at www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Smith, D. M., & Hazelton, M. (2011) Bibliometric awareness in nursing scholarship: Can we afford to ignore it any longer? Nursing and Health Sciences. 13:4, 384-387. doi:10.1111/inr.12337
Starr, P. (1982). The social transformation of American medicine. New York, NY:Basic Books, Inc.
Van Eck, N.J. & Waltman, L. (2014) Visualizing bibliometric networks. In Y. Ding, R. Rousseau, & D. Wolfman, (Eds.), Measuring Scholarly Impact (pp. 285-320). Cham, Switzerland:Springer International Publishing.
World Bank. (1993.) World development report: Investing in health. Washington, DC:World Bank Group.
World Bank. (2013). Twenty years of health system reform in Brazil: An assessment of the sistema unico de saude. Washington, DC: The World Bank Group. Retrieved from: http://documents.worldbank.org/curated/en/909701468020377135/pdf/786820PUB0EPI10Box0377351B00PUBLIC0.pdf
World Health Organization. (2013). Interprofessional collaborative practice in primary health care: Nursing and midwifery perspectives. Geneva:World Health Organization. Retrieved from http://www.who.int/hrh/resources/IPE_SixCaseStudies.pdf?ua=1