4
Status and Future Role of Academic Nursing in Clinical Research

Nurses with doctoral training are needed not only to train the nursing workforce but also to conduct research and oversee research training. Yet the number of doctorally trained nurses is insufficient to meet the demand in academic and clinical settings. The lack of doctorally trained nurses to serve as faculty is a significant constraint to training nurses for practice as well as for future faculty.

The challenges facing nurse-scientists are quite daunting. In academic and clinical institutions, there is a lack of nurse mentors with a career commitment to clinical research. The creation of research-intensive environments that foster the development of students is necessary to both attract nurses into research and support their development. Nurses interested in research who work in low-intensity research environments without adequate mentors or role models feel isolated and without the necessary support to begin a clinical research career (Reame, 2003).

THE ADVANCING AGE OF NURSING FACULTY

In 2000 nearly 6,000 qualified applicants were not admitted into nursing programs, despite the shortage of nurses. In more than a third of the cases the nonadmittance stemmed from a shortage of nursing faculty. In 2003, 11,000 applicants were turned away.1 In the next few years almost

1  

American Association of Colleges of Nursing at http://www.aacn.nche.edu. Date accessed November 22, 2004.



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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 4 Status and Future Role of Academic Nursing in Clinical Research Nurses with doctoral training are needed not only to train the nursing workforce but also to conduct research and oversee research training. Yet the number of doctorally trained nurses is insufficient to meet the demand in academic and clinical settings. The lack of doctorally trained nurses to serve as faculty is a significant constraint to training nurses for practice as well as for future faculty. The challenges facing nurse-scientists are quite daunting. In academic and clinical institutions, there is a lack of nurse mentors with a career commitment to clinical research. The creation of research-intensive environments that foster the development of students is necessary to both attract nurses into research and support their development. Nurses interested in research who work in low-intensity research environments without adequate mentors or role models feel isolated and without the necessary support to begin a clinical research career (Reame, 2003). THE ADVANCING AGE OF NURSING FACULTY In 2000 nearly 6,000 qualified applicants were not admitted into nursing programs, despite the shortage of nurses. In more than a third of the cases the nonadmittance stemmed from a shortage of nursing faculty. In 2003, 11,000 applicants were turned away.1 In the next few years almost 1   American Association of Colleges of Nursing at http://www.aacn.nche.edu. Date accessed November 22, 2004.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 34 percent of the nursing faculty is expected to retire, exacerbating the current situation. The maturing R.N. workforce is a product of two phenomena: (1) a shrinking pool of young nurses entering the R.N. population and (2) large cohorts of the R.N. population moving into their 50s and 60s (Spratley et al., 2000). The average age of nursing faculty members is over 50, most likely a function of the discipline’s conventional late entry to doctoral study. The advanced age of nursing Ph.D.s may stem from the norms of the profession, which encourages its members to acquire considerable professional experience before seeking research training (NRC, 2000). The average age of nurses upon completion of the doctorate is 46 years, well beyond that of other disciplines where the average age is 33 years. Those receiving National Research Service Award (NRSA) funds, which demand full-time study, are generally over 40 by the time they complete their studies (NRC, 2000). About 49 percent of all nurse-Ph.D. graduates enter the service sector rather than academia. The Nursing Pipeline There is an urgent need for enhanced recruitment of men and women into graduate and nursing education programs. In March 2000, R.N.s enrolled in formal education programs leading to a nursing or nursing-related degree represented only 6.7 percent of all the country’s R.N.s, or 180,765 of the 2,696,540 population (Spratley et al., 2000). Enrollees tended to be part-time students (76 percent) and to be employed full-time in nursing (72 percent). Of the 180,765 nurses pursuing formal education, about 53 percent were enrolled in programs leading to a baccalaureate degree, 36.4 percent in programs leading to a master’s degree, and less than 4 percent in doctoral programs. All baccalaureate programs in nursing education have built-in components: basic research methods, statistics, and research utilization. The overwhelming majority of master’s programs have a research obligation. Often this obligation takes the form of a requirement to carry out an evaluation study while receiving clinical experience or perhaps a requirement to do a secondary analysis of an existing clinical database. Doctoral training for nurses is by nature research intensive, just as it is in other disciplines. Many postdoctoral programs in nursing expect fellows to submit an individual grant proposal for external funding (e.g., NRSA) by the end of the fellowship period (McBride, 2003).

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 In general, students enter academic nursing programs to prepare themselves as clinicians, not researchers. Students and future clinical researchers often are not aware of the possibility of becoming clinical researchers, have incorrect assumptions about research, or believe that research would simply not be a good career match for them (Woods, 2003).2 Clinical Research as a Career One of the principal pushes in the nursing field is to encourage research as a career track; B.S.N.-Ph.D. and fast-track programs are the most common mechanisms. Development of an honors program at the B.S.N. level is a positive step toward this goal. A small number of institutions offer undergraduate and graduate education and postdoctoral training in an accelerated manner and provide mentoring throughout the education (McGivern, 2003). Nursing is a field populated largely by women; multiple relocations of families for graduate, postdoctoral, and finally permanent faculty positions may not be a possibility. Another problem in nursing is that the shortage is so great that every faculty member is expected to educate more people to replenish the workforce rather than build the science (McBride, 2003). PREPARING A DIVERSE AND REPRESENTATIVE CLINICAL RESEARCH WORKFORCE The scientific community should encourage children’s exposure to the nursing field as early as elementary and middle school to prepare a diverse and representative clinical research workforce. Graduates from baccalaureate, master’s, and doctoral programs in nursing demonstrate a lack of racial and ethnic diversity (see Table 4-1). A more representative workforce will require continuing and seamless opportunities to nurture interests in clinical research careers. There is a multiplicity of programs—some that involve children in grade school, some that engage middle schoolers, and some that work with high school and college students—but they are not always coordinated.3 Priority should be given to retaining, not just recruiting, a representative and diverse workforce. Changing the cultural demographics of nurse 2   Nancy Fugate Woods, R.N., Ph.D.,Workshop Presentation: 2003. 3   Ibid.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 TABLE 4-1 Race and Ethnicity of Graduates from Baccalaureate, Master’s, and Doctoral Programs in Nursing, 1999-2002   1999-2000 2000-2001 2001-2002 Number Percent Number Percent Number Percent Total baccalaureate enrollment (generic [basic] and R.N. to baccalaureate) White 26,063 81.2 24,405 79.5 25,031 78.5 Black or African American 3,125 9.7 3,241 10.6 3,448 10.8 Hispanic or Latino 1,383 4.3 1,559 5.1 1,696 5.3 Asian, Native Hawaiian, Other Pacific Islander 1,332 4.1 1,293 4.2 1,480 4.6 American Indian or Alaskan Native 210 0.7 192 0.6 227 0.7 Total 32,113   30,690   31,882   Total minority 6,050 8.8 6,285 20.5 6,851 21.5 Master’s enrollment White 8,117 86.3 7,781 83.7 7,306 83.0 Black or African American 565 6.0 696 7.5 690 7.8 Hispanic or Latino 275 2.9 366 3.9 349 4.0 Asian, Native Hawaiian, Other Pacific Islander 400 4.3 400 4.3 397 4.5 American Indian or Alaskan Native 52 0.6 58 0.6 61 0.7 Total 9,409   9,301   8,803   Total minority 1,292 13.7 1,520 16.3 1,497 17.0 Doctoral enrollment White 346 89.4 286 85.1 374 91.0 Black or African American 21 5.4 20 6.0 21 5.1 Hispanic or Latino 3 0.8 8 2.4 6 1.5 Asian, Native Hawaiian, Other Pacific Islander 16 4.1 19 5.7 10 2.4 American Indian or Alaskan Native 1 0.3 3 0.9 0 0.0 Total 387   336   411   Total minority 41 10.6 50 14.9 37 9.0   SOURCE: AACN (2002a ).

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 clinical researchers will require seeking initiatives that lead to both the graduation and retention of minority students (Nugent et al., 2004). One way to achieve this goal is by building learning communities of mentors who are working clinical scientists and students who represent all levels of the university curricula, bridging the disciplinary boundaries. According to the National Learning Communities Project, “In higher education, curricular learning communities are classes that are linked or clustered during an academic term, often around an interdisciplinary theme, and enroll a common cohort of students. A variety of approaches are used to build these learning communities, with all intended to restructure the students’ time, credit, and learning experiences to build community among students, between students and their teachers, and among faculty members and disciplines.”4 Nurse educators are valuing diversity and cultural competence with the growing diversity of the American population (Christman, 1998). Retaining a representative and diverse workforce can also be achieved by helping students find meaning in the work of clinical researchers. Students can understand what a study or particular health problem may mean to them personally, to their culture, or to their ethnic group. Students can see the relevance of the issue to them and to their community and can understand who will benefit from the work. Nurses can create some learning opportunities that help students address these questions as part of their training (Woods, 2003). NATIONAL INSTITUTE OF NURSING RESEARCH The National Institute of Nursing Research (NINR), established in 1985 as the National Center for Nursing Research at the National Institutes of Health (NIH), provides funds for training nurse-researchers and sets a national nursing research agenda. The National Institute of Nursing Research5 devotes about 8 percent of its budget to training, which is more than twice the average across NIH. NINR’s budget support for training reflects a commitment to developing the next generation of researchers. 4   National Learning Communities Project at http://www.pewundergradforum.org/project%20washington%20center.html. Date accessed December 6, 2004. See also http://learningcommons.evergreen.edu/02_nlcp_entry.asp. Date accessed November 16, 2004. 5   National Institute of Nursing Research at http://www.nih.gov/ninr/index.html. Date accessed November 16, 2004.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 In terms of success across NIH, schools of nursing, with few exceptions, are funded by all NIH institutes and centers. The NINR collaborates with other institutes and centers in many areas of shared interest, including joint funding of research project grants and requests for applications (RFAs). Collaboration extends to other agencies within the Department of Health and Human Services and beyond, including the Health Resources and Services Administration, Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention. As part of the NIH roadmap initiative, NINR created five expert panels to look at the future needs of nursing research. NINR’s scientific goals for 2000-2004 are to (1) identify and support research opportunities that will achieve scientific distinction and produce significant contributions to health; (2) identify and support future areas of opportunity to advance research on high-quality, cost-effective care and to contribute to the scientific base for nursing practice; (3) communicate and disseminate research findings resulting from NINR-funded research; and (4) enhance the development of nurse-researchers through training and career development opportunities. The NINR supports the research training of about 200 predoctoral students and about 70 postdoctoral fellows a year. In FY 2004 about 2,420 trainees were participating in T32 training grants in schools of nursing across the United States.6 The NINR supports developmental centers and institutional training awards, as well as 10 P30 grants, 8 of which focus on health disparities in minority populations. Approximately 20 percent of the NINR budget is directed toward research and training that has specific objectives related to minority health and the broader area of health disparities. NINR collaborates with historically black colleges and universities, especially those few that provide nursing education. In the broader area of health disparities NINR plans to undertake the following in the future: (1) the institute will continue to provide links between NINR-funded investigators and minority researchers who are interested in participating in large multicenter studies; (2) specific RFAs will be issued to target minority researchers and infrastructure development to support research on health disparities; and (3) the Research Supplement for Underrepresented Minority (RSUM) mechanism will continue to target minority students and faculty early in their nursing 6   CRISP database at http://crisp.cit.nih.gov. Date accessed October 19, 2004.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 careers to stimulate their interest in research. In addition to the developmental centers and institutional training awards, the NINR intramural program offers an intensive summer genetics institute. The institute also has developed online information for junior investigators preparing to launch their independent careers. The NINR and the National Center for Minority Health and Health Disparities are funding exploratory centers across the country called Nursing Partnership Centers on Health Disparities (P20). These 17 centers encompass traditionally black colleges and universities and institutions serving Hispanic and American Indian students. The centers have a two-pronged approach: (1) to boost the numbers of minority researchers and (2) to improve the quality of minority health research itself. To achieve these goals, they are funding pilot studies to entice people to enter a research career track. FUTURE NEEDS AT THE INTERFACE OF NURSING AND CLINICAL RESEARCH For the new paradigms in clinical research training, interdisciplinary exposure is the foundation for team science; for example, the Human Genome Project has already altered the future landscape of nursing—the underlying genetic foundation is known for diagnosis and the treatment of disease, affecting all of medicine and nursing (Horner et al., 2004). Nursing science is beginning to utilize genetic principles in research design and methodologies. Collaboration among nursing researchers and researchers in related disciplines is important for successful integration of genetic concepts into nursing science. In order to participate in the knowledge becoming available about the connections between genetics, health, and nursing, nurses must grasp genetic concepts (Williams et al., 2004). One study, which examined several surveys, found a near absence of genetics curricula in nursing schools. To address the lack of genetics contents in nursing curricula, the Genetics Program for Nursing Faculty (GPNF) was created, and it led to the formulation of a Genetics Curriculum Checklist to consolidate genetics material into curricula (Hetteberg and Prows, 2004). Challenges also lay ahead in dealing with the nursing shortage. One workshop participant finds that a high percentage of the students who enter his clinical research administration program are nurses who either are tired of the patient care component of nursing or have left the profession for something different. The retention of nurses is an issue related to the

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 nursing shortage, and clinical research is a tremendous draw, bringing nurses who have left back into the profession. Another workshop participant added that even when nurses become coordinators of clinical research activities, they are perceived as having left the nursing field. Instead, clinical research needs to be seen as a part of the range of what constitutes nursing. Much of what must be done to engage people in a study, keep them enrolled, and work with them over time involves the basic skills that are part of nursing education and preparation. The percentage of nurses who do not stay in clinical nursing for longer than two years is very high. Retention is as critical an issue as recruitment into the field. This workshop participant also observed that although there is a worldwide nursing shortage, some Asian entrants come into American doctoral programs because they are attracted to the American model of nursing education. The Asian entrants want to develop research-intensive programs, and many of them, depending on their country and the year, have full-time funding from their governments. Indeed, in a given year the strongest applicants to nursing programs have been from other countries, because they have had government funding to support full-time study. American-born individuals have not had the same kinds of resource options for doctoral study. Moreover, international students, particularly for graduate studies, do not necessarily remain in the United States; many of them come with the expectation that the support is contingent on returning to their country for at least two years. The proportion of foreign-born nurses has grown steadily since 1998, topping 14 percent in 2003 (Brush et al., 2004). The nursing field wants the best and the brightest undergraduate students at the top institutions to consider nursing as a possibility. It can be quite challenging to make this appeal, especially in cultures where nursing is not considered a status profession and especially at a time when many other barriers for women (particularly minority women) are falling, thereby providing new options that might be more appealing from a cultural and social standpoint.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 BOX 4-1 Summary Nursing’s Clinical Research Workforce Only 0.6 percent of R.N.s are doctorally prepared. Between 1993 and 2002 the number of new doctorates fluctuated annually between 360 (1999) and 472 (2002). In 1999-2000 the mean number of years registered in doctoral programs was 8.3 for nursing graduates compared with 6.8 years for all doctoral awardees. The median time elapsed between entry into any graduate program to completion of the doctorate in nursing was almost twice that of other fields—15.9 years versus 8.5 years. The greatest nursing workforce shortage is the shortage of nursing faculty. Increasing the Numbers of Women and Minorities Requires an interdisciplinary approach, because there are fields with more women and minorities that already value clinical research and an emphasis on the “lived experience” with its appreciation of participatory action (e.g., nursing, social work, psychology). Requires a multidisciplinary approach, because the translation of new knowledge into clinical practice and health decision making involves team or consortium building around complex problems and across institutions and sectors. Evaluating Existing Training Efforts Assess the extent to which existing NIH-funded research centers are interdisciplinary and sector spanning in their training efforts (e.g., composition of advisory boards and mentors, shared courses, infrastructure supports). Catalog the clinical research outcomes expected of trainees at institutions with institutional research training grants, starting with the presentation of results to clinical agencies where data are collected. Identify the best practices of institutions that have successfully recruited and graduated minorities. Addressing Health Disparities Although NINR is already focusing strongly on addressing health disparities, its success should be evaluated.

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 Collaborate with the National Center on Minority Health and Health Disparities (NCMHD) to develop partnership center awards to both minority-serving and research-intensive schools of nursing. Addressing the Nursing Faculty Shortage Take steps to address the expected retirement over the next four to seven years of about 34 percent of nursing faculty. Extend the recruitment of future clinical researchers to grade school and middle school sites so that children have a vision of possibilities (e.g., Kids into Health Careers, U.S. Public Health Service) before they make choices about courses in middle school that track them. Discuss research, teaching, and clinical practice as different options for physicians, psychologists, nurses, pharmacists, dentists, and social workers. Fund continuing, seamless opportunities to nurture interest in clinical research careers (clinical and research emphases) beginning with field experiences for middle school students and continuing throughout high school and college. Identify and train mentors to work with young people interested in health careers and help mentors to understand clinical research career options (include school counselors). Retaining a Representative and Diverse Workforce for Clinical Research Help students to find meaning in the work of a clinical researcher: What does the study or research area mean to them personally? Within their cultural, ethnic group? Is the problem one that matters in their community? Who will benefit from their work? Create learning opportunities that address these questions. Education of Future Clinical Researchers Expose students to interdisciplinary efforts so that they better understand complementary team members (e.g., Health Sciences Interprofessional Clinical Education Program at the University of Washington).

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Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 Have students collaborate as members of teams while learning—clinical projects, research projects. Broaden students’ exposure beyond a single discipline (e.g., see Sung et al., 2003). Caution students about achieving depth in a field of study at the expense of awareness of possible connections beyond the disciplinary gaze (e.g., connecting the molecular to the organismic level). Alert students to the likely emergence of new disciplines (e.g., computational biology, biomedical informatics). Resources for Educating Clinical Researchers T32 awards are often confined to a single discipline; they may not be broad enough to accommodate interdisciplinary clinical research. K30 awards—clinical research training—can support interdisciplinary training, but they are not usually structured specifically to emphasize the experiences and skill sets for research collaboration (e.g., the University of Washington Clinical Research Training Program is inclusive of physicians and other healthcare professionals). New Paradigms in Clinical Research Training Interdisciplinary exposure as a foundation for team science. Building research networks (e.g., cross-institutional partnerships between academic health centers and less research-intensive universities, medical centers, primary care practices). Creative fellowship models with multisite study options for place-bound researchers, including online support.