Advancing the Nation's Health Needs: NIH Research Training Programs (2005)

Research training in nursing prepares investigators who are a part of the larger health sciences workforce. Study questions are raised from the nursing perspective but contribute to knowledge in general. For scientists in the discipline of nursing, the ultimate intent of the knowledge generated through research is to provide information for guiding nursing practice; assessing the health care environment, enhancing patient, family, and community outcomes; and shaping health policy.

The science of nursing is characterized by three themes of inquiry that relate to the function of intact humans: (1) principles and laws that govern life processes, well-being, and optimum function during illness and health; (2) patterns of human behavior in interaction with the environment in critical life situations; and (3) processes by which positive changes in health status are affected.¹ Thus, within the health sciences, nursing studies integrate biobehavioral responses of humans. The science of nursing can also be classified as translational research because it advances clinical knowledge and has the directional aims of improved health care and human health status.² As stated in a classic policy paper, research for nursing focuses on ameliorating the consequences of disease, managing the symptoms of illnesses and treatments of disease, facilitating individuals and families coping or adapting to their disease, and dealing in large part with promoting healthy lifestyles for individuals of all ages and under different backgrounds and disease conditions.³ In addition, nursing research focuses on enhancing or redesigning the environment in which health care occurs in terms of the factors that influence patient, family, and community outcomes.

Focusing on ameliorating the consequences of illnesses or their treatment is the intent of many research programs conducted in nursing. For example, a new protocol for endotracheal suctioning has been tested and implemented in a number of hospital critical care units. Endotracheal suctioning is a frequently performed procedure that can have serious consequences if not done correctly. Another example in the area of symptom management is understanding the factors that influence common problems such as pain. In one study that focused on developing a longer-acting pain medication, investigators found that gender is a major factor in whether drugs are effective, with women responding well to seldom-used kappa-opioid drugs while men have little benefit from such drugs.

Another major area for research in nursing is facilitating individuals and families as they cope or adapt to long-term chronic disease. An excellent example of this area of study is a self-help program developed for Spanish-speaking people with arthritis. For many years, Hispanics with arthritis did not have many educational resources for how to cope with or adapt to their illness. Two investigators at Stanford University’s medical center have now developed and tested for effectiveness a self-management program with accompanying exercise and relaxation tapes. This self-help program is being considered for nationwide dissemination by the National Arthritis Foundation.

Research in nursing also has a strong focus on health promotion and risk reduction. The intent is to promote healthy lifestyles for individuals of all ages and backgrounds and with various disease conditions. One example is a school-based program now adapted by most North Carolina schools that is a tested health promotion program in exercise and diet for young children at risk for cardiovascular disease. The research results from this school-based intervention program are impressive; the young people’s total cholesterol levels and measurements of body fat were significantly reduced following the education and exercise interventions, and their fitness levels, physical activity, and knowledge about cardiovascular disease risk factors improved.⁴

Together, influencing, redesigning, and shaping the environment for patients, families, and communities is another major area of study in nursing. For example, over 80 studies have shown the influence of nursing surveillance and presence on positive patient outcomes.⁵ The shortage of nurses, a critical factor, in a health care environment has been demonstrated to increase patient mortality and morbidity.⁶ Other studies show the benefit of home visits by nurses in improving the health and quality of life of low-income mothers and children.⁷

Research in nursing is often referred to as “nursing science” or “nursing research,” which has led some to confuse it with the nursing profession. This terminology exists at the National Institutes of Health (NIH) in the name of the National Institute for Nursing Research (NINR); however, the funding from NINR supports scientific research relevant to the science of nursing, and the investigators may be nurses or nonnurses. Nursing science is a knowledge structure that is separate from the profession and clinical practice of nursing.⁸ Furthermore, the term “nurse-scientist” is not reserved for graduates of Ph.D. programs in nursing; it refers to any scientist conducting research in the disciplinary field of nursing. For example, highly trained nurses under the supervision of a principal investigator could conduct the bulk of the work in a clinical trial.

Research training for nurses, as for other biomedical and behavioral researchers, needs to occur within strong research-intensive universities and schools of nursing. Important characteristics of these training environments include an interdisciplinary cadre of researchers and a strong group of nursing research colleagues who are senior scientists in the sense of consistent extramural review and funding of their investigative programs and obvious productivity in terms of publications and presentations. These elements are essential to the environment required for excellence in research training.

The NINR has traditionally placed a greater emphasis on research training in relationship to the relative size of the institute’s budget than is evident with NIH in general. This is due to the current stage of development of nursing research and the need for greater numbers both as investigators and academic faculty. At least 8 percent of NINR funds go to research training, which is roughly twice the percentage invested by other institutes.⁹ This commitment has been consistent for a number of years. This committee’s Nursing Research Panel members commend the wisdom of this tradition and encourage its continuation.

This chapter focuses on the following two areas that are of major concern to the discipline: (1) changing the career trajectory of research training for nurse-scientists to include earlier and more rapid progression through the educational programs to and through doctoral and postdoctoral study as well as increasing the number of individuals seeking doctoral education and faculty roles, and (2) enhancing postdoctoral and career development opportunities in creative ways.

The following three major factors motivate the critical need to change the career trajectory for nurse-researchers: (1) enhancing the productivity of nurse-researchers to build strong, sustained research programs generating knowledge for nursing and health practice as well as shaping health policy; (2) responding to the shortage of nursing faculty and the advancing age of current nurse-investigators, and (3) emphasizing the need for strong research training of nurse-investigators in research-extensive and research-intensive universities with equally strong interdisciplinary research opportunities.

Nurse-scientists play a critical role in the conduct of research and the generation of new knowledge that can serve as the evidence base for practice and improvement of patient health outcomes. However, nurses delay entering Ph.D. programs. There is particular concern because of inherent limitations in the number of years of potential scientific productivity. Starting assistant professors in other scientific fields typically have a research career trajectory of 30 to 40 years in duration. The average age of an assistant professor in nursing is 50.2 years. Hinshaw reasons that for a faculty member who enters the nursing academic workforce at the age of 50 and retires at 65, this productive period will be only 15 years for developing research programs and contributing to science for nursing and health practice in general.¹⁰ Thus, nurse-investigators tend to have a short career span. This limitation severely constrains the growth of nursing research and thus knowledge for nursing practice.

The median time elapsed between entry into a master’s program to completion of a doctorate in nursing is approximately 15.9 years compared to 8.5 years in other disciplines.¹¹ In addition to having a long period of graduate training, the time has increased by 3 years since 1990, and there are no signs of the trend being reversed. Because there are many factors that reinforce the late entry of nurses into Ph.D. programs, there is a need to create incentives to change the career path. The challenge of promoting earlier entry into

science careers was discussed by this panel. Of several proposals considered, there was strong support for one that would encourage and support education trajectories with fewer interruptions. To facilitate this, there needs to be greater awareness of nursing as a scientific discipline. Once students enter undergraduate programs in nursing, those students with interests in science should be identified early and encouraged to consider doctoral education. Exposure to nurse-scientists during the undergraduate program would also entice students to consider research as a primary focus in nursing. A few programs of this type exist, such as the Early-Entry Option in the school of nursing at the University of Wisconsin, Madison. In this program highly talented undergraduates are moved directly into the Ph.D. program.

A “fast tracking” of undergraduates into doctoral programs also necessitates dispelling myths related to the need for clinical practice prior to graduate school entry. There is a need to evaluate the requirement of the master’s degree for individuals interested in an academic career with an emphasis on research. The lengthening of most master’s programs due to certification requirements for advanced-practice roles has resulted in two plus years for master’s program completion, which further delays entry into doctoral education.

In addition, the average number of years registered in a doctoral program is longer for nursing than for other fields. On average, it takes 8.3 years for nursing Ph.D. students to complete their degrees compared to 6.8 years for all research program doctoral students.¹² This is due in part to the fact that the majority of doctoral nursing students are part-time students. As of 2002, there were 81 research-focused doctoral programs in nursing with a total of 3,168 enrollees; 55 percent of enrollees were part-time students. This accounts for the low percentage of graduates; 12.8 percent of enrollees graduate each year.¹³

Nursing developed both its Ph.D. and its D.N.Sc.¹⁴ programs to build on the master’s degree in nursing as well as to accommodate breaks between degrees for clinical practice. Early reliance on the master’s degree is understandable in that it was nursing’s highest degree for many years before the establishment of a significant number of research doctoral programs. As doctoral programs were developed, they built on the master’s content, which at the time was predominantly research and theory focused. Over time the master’s programs have changed to become primarily preparation for advanced clinical practice, yet nursing continues to require the master’s degree for entry into doctoral study in most programs. Currently, very few doctoral programs in nursing admit baccalaureate graduates directly into the program, and for those that do, the master’s degree is usually required as a progression step. This requirement for entry into the Ph.D. program makes the group of advanced nurse-practitioners, rather than baccalaureate students, the major pool from which applicants are recruited into research. This is problematic in that this practitioner pool has the same demographic characteristics as the profession and thus is older in average age and more limited in diversity compared to applicants for science Ph.D. programs in general. Incorporation of the clinical/professional content from the master’s degree as foundational to the Ph.D. in nursing also encourages faculty to recruit and teach only nurses. Currently there are only a few doctorate programs in nursing that admit nonnurses.

Even though there are other fields that require a master’s degree as a requirement for earning the professional research doctorate, such as the M.P.H. for the Dr.P.H., the master’s degree has a completely different meaning relative to the science Ph.D. degree. The master’s degree is usually awarded as a “consolation prize” for students who are unable to complete the requirements for the science Ph.D. By making the master’s degree a requirement for its Ph.D. program, nursing has created confusion as to the meaning of the degree outside the nursing profession.

In considering strategies for increasing the number and length of productive research years for scientists in nursing, it is important to distinguish between the educational needs and goals of nursing as a practice profession that requires practitioners with clinical expertise from nursing as an academic discipline and science that requires independent researchers and scientists to build the body of knowledge.¹⁵ To improve the productivity and research focus of the Ph.D. in nursing, doctoral programs need to be reengineered to admit directly from baccalaureate programs, to admit nonnurses, to decrease the number of years from high school to Ph.D. graduation, and to expand the interdisciplinary scope of the program and the research. The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new nonresearch clinical doctorate, similar to the M.D. and Pharm.D. in medicine and pharmacy, respectively. The concept of a nonresearch clinical doctorate in nursing is controversial, but some programs of this type exist.

Nursing should be encouraged to reengineer some of its doctorate programs to exclusively meet the goal of producing scientists and researchers who are the most capable in terms of skills and projected career life, to meet the needs of nursing as a science and for the development of its research-based disciplinary knowledge. Doctorate programs currently require core coursework in theoretical systems, philosophy of science, qualitative and quantitative methods, and statistical/data analysis techniques. What is different from other science degrees is the amount of advanced practice usually required prior to the doctoral program. Some educational

depth in a clinical area or in practice is important for the study of clinical questions, but how much is the issue.

There is no clear research career trajectory evident among scientists in nursing today. The common thread is that they entered their doctoral programs later than most other scientists and have not benefited from postdoctoral education. This is because most nurses enter doctoral programs following receipt of the clinical master’s degree, also often with many years of clinical experience, and their primary socialization has been as practitioners. As such, they bring with them rich experiences that may help shape the focus of their inquiry. However, they also carry with them enormous burdens relating to their readiness for entering rigorous science training, their interest in continuing training following their predoctoral experience, and their long-term capacity for developing a research career. In addition, when nurses complete their doctoral training, most move directly into an academic career. There they frequently encounter settings in which the demands for teaching and lack of pervasive research programs, socialization, and further mentoring make continuing progress as a scientist difficult.

There is evidence to suggest that a successful career in science is the result of a number of key factors across the life span. These factors include inspiration and “connection” to science and the field; involvement in the enterprise of discovery and science; knowledge, skill, and leadership development; opportunities for coaching, role modeling, and mentoring; a scientific community with peer engagement, assessment, support, and critique; an intensive research environment; and adequate support for research in all of its phases. With these factors in mind, each stage of nursing from precollege, undergraduate, predoctoral, and postdoctoral to the career scientist can build strategies to enhance the career path.

The development of future scientists begins very early in the educational experiences of young people. These include education in school but also beyond. This begins with exposing students interested in nursing at the precollege level to both the profession and nursing science. Undergraduate development of scientists moves individuals from a more general interest in and connection to science to actually beginning to embark on a career in science. The context should be designed to support both the acquisition of a solid academic foundation for further study, a clear notion of pathways for becoming a scientist, and educational experiences that move the student into actual conduct of research. Predoctoral training should begin before the doctoral student starts a course of study. The student’s program should assure a very strong match between the research interests of the student and the capacity of the program and faculty. Programs should be fundamentally grounded in a commitment to and processes that support the development of scientists. The postdoctoral phase is the point at which one’s own science career should begin to take hold and the intrinsic rewards of science and discovery drive the work of the postdoctoral fellow. Ultimately, the career scientist is at the stage of developing and maintaining his/her program of research. For academic scientists this is the point at which mentoree becomes mentor and teacher, based on the program of research. It is also the point at which the scientist should become an active member of the academic community.

It has been well established that there is both a current shortage and a projected continued shortage of nursing faculty, especially those who are scientists and researchers. At this time, approximately 50 percent of faculty that teach in nursing baccalaureate programs are doctorally prepared. This represents a marked increase from the late 1970s, when only 15 percent were. This 50 percent level was achieved in 1999 but has not increased since then despite a large increase in the number of doctoral degree programs available to nurses during the same time period (e.g., in 2002 there were 81 research-focused programs). Two factors that likely contribute to this stalemate are (1) the relatively constant number of doctoral degrees earned each year, despite the increase in the number of programs, as shown in Table 6-1, and (2) the older age of graduates, as evidenced by an increase in the average age of assistant professors from 45 to 49.6 years for the period 1996 to 1999. In 2002 the average age of doctorally prepared faculty was 53.3, compared to 50.2 in 1999 and 2000.¹⁶ These statistics suggest that the doctorally prepared faculty is aging, and because the percentage of faculty members with doctorates is not increasing, it does not appear that younger replacements are being put in place. Thus, this older group of doctorally prepared faculty members in nursing is likely to retire from the academic workforce over the next few years, leaving nursing programs with too few faculty members to conduct research and educate the next generation of scientists.

The need to dramatically increase, even double, the number of nurse-scientists is acute, especially at earlier points in their careers. A recent Special Survey of Vacant Faculty Positions conducted by the American Association of Colleges of Nursing indicated that 59.8 percent of the vacancies require an earned doctoral degree.¹⁷ Training opportunities are available, including predoctoral and postdoctoral fellowship programs offered primarily by the NINR. The number of applicants for these awards has remained relatively stable over time, consistent with the flat doctoral graduation rate for nursing. It is important to provide research training incentives that increase the number of nurses selecting a research career and at a much earlier point in their professional development.

Strong, research-intensive environments are critical in both the general universities and the schools of nursing for doctoral, postdoctoral, and career development preparation. Such environments provide the experience of being immersed in scientific inquiry with mentors and the intellectual cohort of investigators required for the preparation of nurse-researchers. Research-intensive environments also promote crucial interdisciplinary research opportunities. Nursing research confronts complex questions. Thus it needs to involve multiple perspectives and bodies of interdisciplinary expertise.

To date, scientific training for nurses and others committed to nursing research has utilized a variety of National Research Service Awards (NRSAs) and Career Development K awards. These research training awards are funded by the NINR. The individual predoctoral awards (F31) have been slowly increasing, with very limited numbers of individual postdoctoral awards (F32) evident. The NRSA institutional awards (T32) have grown considerably over time, with 43 such awards made between 1986 and 2002 and 27 operational in 2003. Within the T32s, 65 postdoctoral trainees and 93 predoctoral awards were anticipated for 2003. For the individual NRSA awards there were five postdoctoral awards (F32) and 100 predoctoral awards (F31) for 2003 (see Figure 6-1).

The level of scientific productivity differs among the NRSA mechanisms for the individuals and institutions funded by the NINR. Analysis of the funding record for successfully acquiring either research (R) or career (K) development awards later in the career shows a pattern similar to that of the total NIH research training programs. NINR trainees and fellows funded on individual NRSAs are more apt to successfully acquire R and K awards (see Table 6-2) at a later date.

The difference is sizable, with predoctoral awards being 17 percent of the individual awards (F31) and 5 percent of the T32 predoctoral positions. The pattern is similar with a greater difference for the postdoctoral fellows—38 percent for the F32 and 18 percent of the T32 positions. However, productivity in terms of publications shows the opposite pattern (see Figure 6-2).

The 2 years 1997 and 1999 illustrate a consistent pattern of higher publications for trainees and fellows on the T32 awards. In 1997 and 1999, 158 and 154 publications resulted from trainees and fellows on the institutional T32 awards versus 66 and 23, respectively, for doctoral students holding the individual F awards.

Both institutional and individual research training awards under the NRSA program should continue. The individual awards build strong scientific capability and independence when working with a research-active mentor. With the T32 institutional awards, the cadre of strong senior researchers

FIGURE 6-1 Training positions at the postdoctoral and predoctoral levels.

SOURCE: National Institute for Nursing Research Budget Office.

forming a scientific community is valuable in terms of mentoring and publications. The individual predoctoral awards (F31) can be used for a variable length of study. The NINR/NIH is encouraged to allocate three to four years per award in order to support full-time, consistent progression for research training.

The lower productivity of trainers and fellows, who have been funded on the institutional NRSAs (T32) and later obtain R01 and K awards, is of concern. The research training offered through T32 mechanisms needs to be strengthened in the following manner:

• T32 awards should be placed in research-intensive universities with strong interdisciplinary opportunities and

FIGURE 6-2 Publications, T32 versus non-T32.

SOURCE: Outcome analysis by National Institute for Nursing Research at NIH.

research funding, and research interdisciplinary activities should be a critical aspect of the initial NRSA application and annual reports.

• The T32 awards should be allocated only to schools with research-intensive environments, including a cadre of senior investigators with extramurally funded research or research track records and research infrastructures that support research and research training.

• The application process for T32 positions as predoctoral trainees or postdoctoral fellows should be more formalized, with specific proposals submitted in relationship to their research and the match with faculty at the institution made explicit.

• Trainees and fellows on a T32 award position should provide evidence of the interdisciplinary strength that is part of their program of study.

• Criteria for selection of T32 fellows and trainees should be based on a consistent, full-time plan for research training and long-term potential for contribution to science and nursing.

• The monitoring and tracking of trainees and fellows should be formalized, with changes in research plans or mentor(s) filed as part of the annual report.

A small but growing cadre of nurse-investigators is supported in their research development by K awards. In addition to the awards from NINR, other institutes and centers also support nursing research through the K mechanisms, since elements of nursing research are intrinsic to other fields. These awards are usually awarded to nurse-scientists in their early or midcareer stages when they are shifting the substantive or methodological focus of their research. NINR has primarily used the following four types of career awards: K01, Mentored Research Scientist Development Award; Minority K01, Mentored Research Scientist Development Award for Minority Investigators; K22, Career Transition Award, and K23, Mentored Patient-Oriented Research Career Development Award; and K24, Mid-Career Investigator Award in Patient-Oriented Research.¹⁸

These awards could be important in advancing both career development and science development. Unfortunately, there is limited information regarding the outcomes of these awards, including successful research grants and publications by awardees.

In summary, three major factors influence the recommendation to change the research training career trajectory pattern for nurse-scientists: the need to enhance the productivity of each investigator’s study for nursing practice and for shaping health policy; increasing the numbers of nurse-investigators to respond to the investigator and faculty shortage; and emphasizing the need for research training within strong research-intensive environments.

Recommendation 6-1: The committee recommends that a new T32 program be established that focuses on rapid progression into research careers. Criteria might include predoctoral trainees who are within 8 years of high school graduation, not requiring a master’s degree before commencing with a Ph.D., and postdoctoral trainees who are within 2 years of their Ph.D.

This new program would produce strong research personnel and lengthen the research careers of the trainees. These grants should be placed in research-intensive universities with strong interdisciplinary opportunities and research funding, including a cadre of well-established senior investigators.