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CHAPTER VIII
Advancing Research in Nursing and
Getting Facts for Manpower Planning
The federal government traditionally has assisted the states,
universities, and industry in the support of research, in the
dissemination of its results, and in the provision of reliable, timely
information on matters of common concern. The committee's observations
and recommendations as to the import of these kinds of federal
activities for nursing services, nursing education, and nurse manpower
planning are set forth in this chapter.
Improving the Nation's Nursing Research Capacity
In the course of efforts to identify the types of nurses required
to fulfill specialized functions in the future, the committee
investigated the quantity and professional distribution of graduates
of higher education programs, as requested by Congress. The committee
heard testimony expressing deep concern about the current and future
level of nursing research to improve patient care. Data support the
contention that the nursing profession's capacity to undertake research
is hampered by insufficient support both for the education of qualified
researchers and for current work in research.
Of the 1.2 million employed nurses in 1980, fewer than 3,000 had a
doctoral degree, the generally accepted credential for advanced
research skillet The doctoral degree also is widely considered to
be a prerequisite for success in competing for research funds, yet less
than 6 percent of doctorally prepared nurses reported research as their
primary activity.
As described in Chapter V, there are 24 doctoral programs located
in nursing programs in 18 states. The limited number of programs
located in nursing departments that can attract nurses interested in
pursuing advanced education is only one part of the problem. An
additional disincentive for scientifically inclined nurses to commit
themselves to a career in nursing research is the paucity of funds
available to support it. Federal programs, such as the National
Research Service Awards and the former Nurse Scientist Training
Program that support predoctoral and postdoctoral fellowships, have
not provided a stable funding base for research training. Although
there are a number of sources of support for nursing research, none is
215
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216
large. From 1977 through 1981, for example, only $5 million was
earmarked annually for nursing research through the Division of
Nursing in the Health Resources and Services Administration (HRSA),
which principally is a nursing manpower unit of the Department of
Health and Human Services (DHHS). This dropped to $3.4 million in
1982. Nursing research is eligible to compete with other disciplines
for funds from the National Institute of Mental Health, National
Science Foundation, National Center for Health Services Research, and
other agencies. The amounts of awards for nursing-related research
under these programs are not known but are believed to be relatively
small. Nurse researchers suffer from various competitive
disadvantages, including the fact that nursing is not well represented
in peer review committees, and that the subject matter may not be of
prime interest to other reviewers.
The funding of research generally has long been considered an
appropriate federal government activity when its discoveries hold
promise of contributing to the general welfare and when private sources
of funding are likely to be inadequate. Nursing research, as all other
health care research, is conducted in order to contribute to the public
good. It is the nurse, for example, who will prove crucial to the
resolution of such clinical problems as complications associated with
prolonged bedrest, the control of nosocomial infections, and adherence
to treatment regimens (Appendix 8~. Solutions for these and similar
problems would inform nursing and other health care practice and could
lead to a reduction in the federal health care bill by lessening the
length of hospital stay, minimizing the need for additional treatment,
and preventing unnecessary or premature institutionalization in
long-term care facilities.
Elevating the Organizational
Base of Nursing Research
A substantial share of the health care dollar is expended on direct
nursing care, yet the professionals who deliver this care work without
the benefit of a strong organizational base to stimulate and support
scientific investigation in their field. The committee believes that
a center of nursing research is needed at a high level in the federal
government to be a focal point for promoting the growth of quality
nursing research. Such action would provide necessary leadership to
nursing research and expand the pool of experienced nurse researchers
who can become more competitive for general health care research
dollars. It would also promote closer interaction with other bases of
health care research.
Various organizational possibilities for a nursing research center
were considered. The structure of the nation's biomedical research
enterprise is currently under review. The committee believes this a
timely moment to add to this review considerations of the need for a
stronger locus for nursing research. Some committee members favored
the establishment of an institute of nursing research within the
National Institutes of Health (NIH). Others questioned the wisdom of
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217
adding new units to NIH. The committee considered alternative
proposals, such as having the director of bin appoint a broadly
representative expert task force to recommend priority areas for
investment in nursing research. Such a task force could also suggest
the appropriate organizational locus for such research and recommend
the level of funding. However, all agreed that the goal should be an
entity for nursing research at a level of scientific credibility that
would provide impetus toward the initiation, coordination, monitoring,
and dissemination of clinical and operational nursing research in
academic and other research centers throughout the United States.
Conclusion
Despite the fact that nurses represent the largest single group of
professionals in the provision of health services to the people of
this country, there is a remarkable dearth of research in nursing
practice. The lack~of adequate funding for research and the resulting
scarcity of talented nurse researchers have inhibited the development
of nursing investigation. The federal government's specific nursing
research initiative--in grants administered by a manpower unit in
DHHS--is not at a level of organizational visibility and scientific
prestige to encourage registered nurses to pursue careers principally
devoted to research of the direct applicability to patient care
problems that nurses confront. With adoption of the principles
underlying this recommendation, the committee would foresee a doubling
of the level of average 1977-1981 support over the next few years.
RECOMMENDATION 18
The federal government should establish an organizational entity
to place nursing research in the mainstream of scientific
investigation. An adequately funded focal point is needed at the
national level to foster research that informs nursing and other
health care practice and increases the potential for discovery and
application of various means to improve patient outcomes.
Comparative Competencies of Registered Nurses
With Different Educational Preparation
Other sections of this report have noted differences and
similarities in the career pathways of RNs who receive their
educational preparation in diploma, associate degree (AD), and
baccalaureate programs. Chapter IV called attention to the dearth of
reliable information showing the nature and extent of differences in
the performances of such RNs. Taken together with the lack of
systematic analysis of the various nursing education programs'
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218
curricula, the efforts of nurse educators and higher education
authorities to plan articulated programs for RNs working toward
baccalaureate degrees are handicapped. Lack of information about
knowledge and performance differentiation also handicaps nursing
service administrators who seek to place new graduates in positions
commensurate with their knowledge, skills, and capabilities for nursing
assessment, planning, judgment, and direct patient care. As discussed
in Chapter II, reports of nursing studies in many parts of the nation
indicate that state and private higher education authorities need such
information to assist them in decisions on how to allocate scarce
dollars among competing nursing education programs. Many such studies
have been constrained in making recommendations by uncertainties
concerning the most effective mix and allocation of nursing personnel.
The only national study to date that has provided empirical
evidence on the comparative performance of graduates of the three
types of programs that prepare for RN licensure is an analysis of the
scores of 64,761 candidates who took the standard national licensing
examination in 1977.* The candidates were graduates of approved
schools of nursing who took the examination for the first time. As
Table 32 shows, results for the graduates of baccalaureate degree, AD,
and diploma programs were analyzed separately according to their
scores in the five clinical areas of the examination: medical,
psychiatric, obstetric, surgical, and nursing of children. The mean
scores of the candidates from the three programs and the ranges of
these scores are displayed in Table 32. In psychiatric nursing,
baccalaureate candidates achieved higher mean scores; diploma
candidates achieved higher mean scores in the remaining areas.
The table also shows very wide ranges of candidates' scores within
each of the three categories of educational preparation. This suggests
that there may be considerable variability among the individual
programs within each major type, and in the capabilities of the
students they graduate.
Licensing examinations test only specific areas of knowledge
thought to be necessary to ensure that the public's health, safety,
and welfare will be protected. It can be reasonably argued that the
scores from such examinations may not reflect capacity to perform in
the less easily measured kinds of nursing competence that become
increasingly important in subsequent practice. For this, measures of
the comparative performance of practicing RNs are required.
*The national licensing examination for licensure of RNs, known as the
State Board Test Pool Examination (SBTPE), evolved in the l950s and
has been periodically revised. The latest version was introduced in
July 1982. The examination is currently conducted under the auspices
of the National Council of State Boards of Nursing. Scoring is
standardized, but until 1982 each state determined its own minimum
passing score. As of 1982, there are no longer separate scores for
different parts of the test; a single score is provided.
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219
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Nurse researchers have conducted a great many small-scale studies,
of ten as doc Coral dissertat ions, to examine various aspec ts of
possible differences among graduates of the three types of programs.
These studies have used varying approaches: surveys of head nurses,
supervisors, and nursing services directors; HNs ' responses to
simulated clinical situat ions, such as portrayed ire film sequences;
recollected "critical incidents"; and, in one case, direct observation
of 29 RN subjects. A review of such research, conducted under a
contract with the Division of Nursing, reported that the number of
studies that found statistically significant differences in nursing
practice related to nursing education have been limited. Results from
some studies were conflicting; results from others found no overall
effect. 2 The reviewers conclude that study limitations could have
inf luenc ed the re suit s .
As in any other type of soc ial sc fence research that seeks to
associate causal factors with outcomes, formidable problems of method
are encountered in attempts to explicate the dif ferences in practice
among RNs educated in the three types of programs. In this case, they
include (1) def ining the particular knowledge, skills, and attributes
of nursing to be tested, ~ 2) assigning weights to them that are
reasonably related to patient outcomes, (3) identifying objective
performance measures that will be reliable in the many settings where
nursing care is provided, (4) obtaining random samples of subjects in
suff icient numbers to allow for quality differences among individual
nursing educat ion programs of the same general type and for
differences in the length of the graduates ~ work experience,
~ 5) assuring an adequate response rate in surveys, and (6) getting
from personnel records the kinds of data required for an analysis.
Many studies of nursing performance have recognized these problems
but have been limited in the ability to deal with them. No investment
at the level of resources required for large-scale empirical studies
has yet been made.
Several efforts currently under way should facilitate the efforts
of researchers by alleviating some problems of study methods. For
example, the New York External Degree program, described in Chapter
IV, in the course of formulating in detail the performance expected of
the candidates for its examination, has taken major steps in defining
the differences in the particular competencies expected of AD and
baccalaureate candidates, and has designed objective measures for
their testing. The Orange County-Long Beach Consortium for education
mobility has def ined competencies for testing that also extend to
graduates of practical nurse programs. Several other large-scale
efforts, including those of the Southern Regional Education Board's
Nursing Curriculum Project, are under way to define differences in
expec ted c ompetenc e.
Hospital personnel records usually do not include information
the RNs they
about the educational background of the RNs they employ in a manner
that permits systematic performance comparisons. Here, too, changes
may be coming to increase study feasibility. For example, the
Intermountain Health Care Corporation, a nonprofit multihospital
system in Utah, will by early 1983 have a reporting system in place
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221
from all of its 22 member hospitals that will indicate the highest
educational preparation of each RN staff member in conjunction with
position held and length of experience.
Conclusion
Several different pathways in nursing education lead to
eligibility for initial licensure as an RN. The opinions of nurse
educators, nursing service administrators, and nurse employers differ
on the outcomes of these different educational paths, and more
fundamentally on the competencies that should be expected and
utilized, both in the short and long term.
As with most other kinds of postsecondary education, there is
little empirical evidence on the performance differences of the
graduates of these different types of nursing education programs
according to established measurable criteria of knowledge, skills,
attitudes, and range of competence. This lack creates problems for
nurse educators planning curricula to encourage educational
advancement, for nursing service administrators trying to utilize RNs
and LPNs most efficiently, and for the various organized groups within
nursing who are seeking to establish new levels of licensure or to
maintain the current ones. Most important, perhaps, the current lack
of clear objectives and performance measures seriously handicaps the
efforts of higher education bodies and state university systems
attempting to allocate resources for nursing education in ways that
will best match the demand for nurses with different kinds of
competencies.
RECOMMENDATION 19
Federal and private funds should support research that will
provide scientifically valid measurements of the knowledge and
performance c~mpetencies of nurses with various levels and types
of educational preparation and experience.
Evaluation of Promising Management Approaches
In its review of the literature and in testimony heard, the
committee noted numerous descriptions of management initiatives that
individual institutions have successfully implemented to attract
nurses, improve their retention, and employ them productively. There
is little, however, to indicate widespread application of some
promising innovations, or to characterize the determinants of success.
Thus, i-or an individual institution seeking to cope with its own turn-
over or productivity problem, the-e are no adequate guides on how to
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222
choose from the growing number of strategies and adapt them to specific
circumstances. Although many of these measures may have produced posi-
tive results in one place or another, they often required major organi-
zational and financial investments and may not be appropriate for all
institutions.
In this respect, the accomplishments of the National Commission on
Nursing are important, for they provide evidence that major components
of the hospital industry--hospital associations, administrators, and
trustees--can work effectively with leadership of the nursing and
medical professions to identify the causes and solutions of problems
in the organization and delivery of nursing care. There is a need to
continue the process begun by the commission of identifying nursing
management innovations and assessing their applicability at national,
regional, and local levels. An example of a statewide approach can be
found in the type of organization recommended recently by the Statewide
Health Coordinating Council of Michigan (SHCC), which recommended the
creation of a joint commission of employers and employees "to serve as
a clearinghouse for information, to develop some common understanding,
to make consulting services available, and to make reports to the SHCC
and others."3
To expand that type of activity quickly to other areas of the
country, the committee believes that federal participation is required.
Support is needed for rigorous evaluations of demonstrations and of
naturally occurring experiments to reveal the costs, relative risks,
benefits, and prerequisites that need to be considered in undertaking
various management strategies. The dissemination of results from such
evaluations under federal auspices could provide an incentive for
further communication and collaborative action among the various
national and local groups that affect nursing manpower and education
policy. It is believed that such activities will attract other
sources of support in the private sector to carry out an ongoing
effort.
Conclusion
Managers attempting to solve problems in the delivery and
organization of nursing services often lack critical assessment of
others' experience with innovative solutions.
Although individual health care institutions often develop
interesting approaches for maintaining the desirability of careers in
nursing, there is, nonetheless, a dearth of systematic information on
their wider applicability. The committee would like to see the
hospital and nursing home industry and the professions of nursing and
medicine develop a concerted effort to continue the work begun by the
National Commission on Nursing. We believe that the federal government
can stimulate innovation by disseminating information, by according
national recognition to model solutions, and by supporting more
rigorous evaluation than is likely to be undertaken by the industry
itself. The focus of federal attention on these areas of research
should draw the interest of other sources of support in the private
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223
sector. The federal investment in such research could be repaid many
times through savings in health care expenditures resulting from
improved efficiency in the management and use of nursing resources.
RECOMMENDATION 20
As national and regional forums identify promising approaches to
problems in the organization and delivery of nursing services,
there will be a need for wider experimentation, demonstration, and
evaluation. The federal government, in conjunction with private
sector organizations, should participate in the critical assessment
of new ideas and the broad dissemination of research results.
Information to Monitor Supply and Demand
To conduct the monitoring necessary to anticipate future nursing
surpluses or shortages, and thus to plan appropriately, federal and
state government policymakers, nursing service employers, and the
nursing profession all need adequate and timely information. Their
efforts can only be useful to the extent that their baseline data are
current and complete.
The U.S. Census Bureau, the Bureau of Labor Statistics, and the
National Center for Health Statistics all provide essential background
against which to examine the significance of data about the supply of
nurses. The information generated by the American Hospital Association
(AMA) in its annual surveys by hospitals and by the National League for
Nursing (NLN) in its annual surveys of nursing education programs also
constitutes essential components for nursing education planning. The
inventories of RNs and LPNs, conducted periodically by the American
Nurses' Association (ANA), and the regular publication of the ANA fact
book are other invaluable sources of data. The sample surveys of RNs
and subsequent analyses made by the DHHS Bureau of Health Professions
are of major importance.* Nevertheless, there are many gaps in
necessary data and unrealized possibilities for filling them.
*The ANA initiated inventories of RN and LPN supply in 1949 and 1967,
respectively. Following these original inventories, others were
conducted during the 1950s and 1960s. Most recently, inventories of
RNs were conducted in 1S77 and of LPNs in 1974. Because of their
large cost, inventories have been largely replaced by sample surveys
relying on statistical sampling methods to reduce cost and yet yield
reliable supply estimates. The DHHS Division of Nursing (BRA) funded
RN sample surveys conducted in 1977 by the ANA and in 1980 by Research
Triangle Institute. Surveys of nurses in public health departments
are also conducted from time to time.
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The recent national projections from the Vector model, published
in the DHHS 1982 Third Report to Congress, had to rely on baseline
information on the supply of nurses from a 1977 survey and population
projections made in 1978.4 Accurate national data on numbers and
distribution of LPNs, in total and by work setting, have been unavail-
able since the ANA inventory in 1974. Many essential data collection
activities, such as sample surveys of nurses, on which this and other
studies have relied, are conducted only sporadically. Since 1977, no
detailed information has been available about the nation's nursing
homes, the characteristics of their patients, or their staffing.
The NLN makes important contributions to national supply estimates
by collecting annual nursing school admission, enrollment, and
graduation data. However, it does not collect data on the cost and
financing of nursing education. In the coming years of increasing
fiscal constraints, it will be particularly important for policymakers
concerned with the supply of nurses to have current information on
nursing students' educational costs and their sources of financial
support. The National League for Nursing collects data on tuition and
fees, but there are no comparable data on students' other out-of-pocket
education expenses, nor on their living expenses. No current data are
available on the amounts of funds from various sources--state, federal,
and private--that nursing students use to meet their education costs.
Periodic surveys of nursing students in undergraduate and graduate
education programs, analogous to those conducted in other health
professions, will become very valuable to state and federal
policymakers in the future on such issues as
· whether nursing education is more or less costly for students
than other education programs
· whether nursing students are more likely than other students to
be self-supporting
· how heavily nursing students rely on general federal student
aid, state student aid, and other sources, as well as on their own
earnings
· how important the availability of financial assistance is to
their choice of nursing education and their choices among specific
programs.
The annual surveys of hospitals conducted by the AHA have provided
data about hospital nursing service staffs (RNs, LPNs, and aides)
since 1953. However, their data collection efforts have not been
focused on nursing service cost and revenue generation.
Although detailed data about the curricula of individual nursing
education programs are collected during the course of accreditation
reviews and are available in catalogs, the information has not been
assembled in a form that permits comparative analysis.
State boards of nurse kc ensure keep current counts of RNs and LPNs
who hold licenses in their state. This information is important for
state projections. However, it cannot now be used to provide aggregate
national supply estimates because many nurses hold licenses in several
states, and there is no system for unduplicating the count. The state
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225
boards of nurse licensure also gather detailed information about all
nursing programs in their jurisdictions. This information could
provide a rich source of information for state nursing education
planning, but is largely untapped. If it were collected in a
standardized manner, individual states could use it to compare their
experiences with others.
The committee, having identified these current gaps in information,
also stresses the necessity for the federal government, the states, and
the professional associations to continue their current data collection
and analysis activities. The short-run costs of data collection and
analysis can prevent poorly planned long-run investments in nursing
education that result in too large or too small a supply of nurses.
The federal government has a proved ability to coordinate data
collection efforts on national nursing supply and requirements with
the nursing profession, nursing service employers, and state
agencies. It is in a unique position to do so. The government also
has proved its technical capacity in designing the collection and
analysis of timely, unduplicated, and accurate national nursing data.
The nursing profession, employer groups, and state agencies collect
data for different purposes and according to different definitions.
Thus, in the absence of major federal guidance and federal financial
support, they often are unable to provide unduplicated, accurate, and
timely data needed for estimating present conditions as well as for
projecting nurse requirements and supply.
Although the committee believes that the federal government should
continue to take the lead in coordinating and supporting national
nursing data collection efforts, it assumes that the important
contributions of other organizations in obtaining these data will
continue. Professional associations can provide technical assistance
in the development of new kinds of professionally relevant data
collection instruments and can solicit the support of the profession
in new data collection efforts. Nursing service employers can provide
similar assistance, in addition to financial support; they would be
particularly benefited by adequate estimates of future nursing supply
geared to future demand. Employers also can promote the collection of
nursing service cost and revenue data in a uniform manner. If state
licensing agencies standardized and expanded their licensing files, a
large proportion of needed data could be obtained through the annual
or biennial license application and renewal process. State education
agencies could promote the collection of both public and private
nursing program data, including detailed program cost and financing
data.
Conclusion
In order to maintain the necessary capability for monitoring the
future balance between the nation's supply of and demand (or its
perceived needs) for both RNs and LPNs, officials responsible for
planning and decision making in state and federal governments depend
on continuing streams of reliable national information from many
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226
sources. Some is collected periodically, some occasionally. Same is
badly outdated, as in the case of survey information concerning LPNs.
Data collection and analysis require the continued support of the
federal and state governments and of professional associations to
assure adequate financing of necessary studies. The collection of new
data to yield information not now available requires some rearrangement
of priorities within available funding, rather than infusions of new
funds. In the course of this study, we have identified serious gaps in
such areas as costs and financing sources for nursing education,
nursing education curricula, the supply and distribution of LPNs, and
the staffing of nursing homes.
The federal government, in cooperation with the nursing profession,
nursing organizations, health care institutions, and state governments,
should continue to provide leadership in nurse manpower data collection
in order to maintain and improve definitional conformity, to provide a
sense of priorities, and to minimize duplicative efforts.
The total appropriation for DHHS-HRA program management in FY 1982,
of which nursing data collection activities constituted only a part,
was approximately $9.5 million. By recent reorganization, the amounts
for this function will now be included in the HRSA budget. Cost-
benefit assessments on the value of data collection and
. ~, . . .
analysis are
cut to generalize; individual projects must be judged on their
merits. Short-run investments in information can often avoid much
costlier misallocation of program funds over the longer run. The
committee's recommendation is intended to reflect its concern for
maintaining appropriation support for program management, data
collection, and analysis at a level comparable to the value of the
1982 appropriations for these programs.
RECOMMENDATION 21
To ensure that federal and state policymakers have the information
they need for future nurse manpower decisions, the federal
government should continue to support the collection and analysis
of compatible, unduplicated and timely data on national nursing
supply, education, and practice, with special attention to filling
identified deficits in currently available information.
>
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227
RE ESSENCES ANT) NOTES
1 . Health Re sources Admini strat ion. The reg istered nurse populat ion,
an overview. From national sample survey of registered nurses,
November, 1980 (Report No. 82-5, revised June 1982) . Hyattsville,
Md.: Health Resources Administration, 1982, Table 3, p. 11.
Dennis, L. C., and Janken, J.K. The relationship between nursing
education and performance: A critical_review (DHEW Publication
No . BRA- 79-38) . Washington, D. C.:
Off ice, 1979, p. 36.
3. Michigan Statewide Health Coordinating Council.
state health plan 1983-1987 (Vol.
=
U.S. Government Printing
Proposed Michigan
Health personnel) . Lansing,
Mich.: Michigan Office of Health and Medical Af fairs, 1982, p. 77.
4. Secretary of Health and Human Services. Third report to the
Congress, February 17, 1982:
Hyattsville, Md.
Nurse Training Ac t of 1975.
Health Resources Administration, 1982.
l
/
Representative terms from entire chapter:
nursing education
