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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 a) so To - - C) o to U] Ct o - o So on C: o o - u t - x a) h in al al h ~4 ~ O AN U o h C) O h C) En ~ C) C) Cal O at ~ ~ h - U' Z Cal be m~ ~ .,1 ., ~ on ~ h h cD 3 zip ~ C) - h U U ~ 0 So O Z O .o ~ h .- C) U) ~ ~ ~ C: PI ~ Cal ~ C) . - a,1 Ce h a Z P~ C~ cn O U h ~ .,' Z C) O ~ ~0 O ~ S~ E~ r4 oo oo O O oO 1 1 O I_ oO - 1 1 O oO C~ CO oO . oo U~ oo ~ cr. 1 1 O O ~O~ ee U^` O U~ C~C ~C~ OO 0000 0000 11 11 00 0000 U~ e ~U~ 1 r~ 11 11 OO OO ~D - 00 O U~ O 0 00 11 11 ~o ~ c ~t- .- ~c~ oc ~ ~u ~u~ oo5\ ~ - ~ o ~u~ O u ~cd 1 ~.- ~ a) ~ ~ ~ <) h ~/ O ~ C) ~ 0 ~ ~ ~ co a) 0 ,= ~a ~ o o a 0 e h 00 o h o CO U h ..' . o 0 1 U~ ~ O C~ h ~0 I C~ cr o 3 O :~: ~ ~rl CO h E~ ~ ~ O a) t h O . .,1 h 5; . - 0, C`. CO o - ..o C' C~ CO

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220 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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224 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 /