Careers in Clinical Research: Obstacles and Opportunities (1994)

Nurses who conduct clinical research share commonalities and differences with professionals in other health-related disciplines who are engaged in research. Advances in science, health crises such as AIDS, changes in health care delivery, and population changes over the past few decades have yielded opportunities for clinical research that nurses need to improve health care delivery and the health of the American public. Nevertheless, the limited number of nurses with the doctoral training needed to conduct clinical research and oversee research training, the erosion of federal funding for research and research training, and the frequent lack of administrative and financial incentives to pursue research rather than more financially rewarding administrative or other positions in the clinical and private sector mitigate against the pursuit of careers in clinical research.

Although the focus of nursing research has shifted over more than a century, its roots were formed in clinical practice and remain in clinical practice. Nursing research dates to the mid-1800s and the work of Florence Nightingale on the impact of nursing care on morbidity and mortality of soldiers during the Crimean War. From the turn of the century through the 1940s, nursing research focused on nursing education. Much of the preparation of nurses during that period was oriented toward providing an apprentice service rather than what most would consider an education. With World War II, the unprecedented demand for nurses shifted the focus of research to the supply and demand for nurses, the hospital

environment, and the status of staff nurses. A variety of converging forces resulted in an escalation in nursing research in the 1950s. This included an increase in the number of nurses with advanced educational degrees and the availability of many master's programs that required a thesis, the establishment of the nursing research grants and fellowship programs of the Division of Nursing of the Public Health Service, establishment of the American Nurses' Foundation to foster research, and the establishment of the professional journal Nursing Research (Polit and Hungler, 1978; Wilson, 1985). In the 1960s the focus was on theoretical bases for nursing practice, along with a continuing attention to students and nursing education. From the 1970s to the present the focus of research in nursing has been on the improvement of patient care. Establishment of the National Center for Nursing Research at the National Institutes of Health (NIH) in 1985 not only fostered these efforts but also, by establishing a national nursing research agenda, served to draw the research efforts of nurses into priority areas.

In nursing research, training is well developed from the undergraduate level, through the postdoctoral level, and through midcareer development. Nurses currently holding doctorates may have been prepared for clinical research through a nursing doctoral program or a doctoral program in a related discipline such as one in the biological, social, or behavioral sciences. The pool of doctorate-prepared nurses capable of pursuing careers in clinical research is on the increase. The number of such individuals, however, is insufficient to meet the current demand in academic and clinical settings where research and research training are conducted. In addition, the frequent lack of administrative and undervaluing of support of clinical research, combined with the availability of lucrative administrative, clinical, and consultative positions, reduces the number of individuals drawn to and retained in clinical research.

There are numerous opportunities for clinical research in nursing. Nursing research focuses on major public health issues with the purpose of providing accurate and reliable information that will improve nursing practice. The ultimate goal is to promote health and ameliorate disease for the American public. The critical issue is the need to accelerate the conduct and support of nursing research and research training to more effectively attack public health concerns.

Nursing research involves the study of the human biological and psychological responses to health and illness across the life span. Nursing research does not focus on disease or the treatment of disease but rather on individuals' and families' responses to the disease and subsequent treatments. There is a strong orientation toward health promotion and disease prevention and

enhancing individuals' and families' independence in health and illness. Taking a holistic perspective, nursing research generates knowledge about:

• health promotion and disease prevention across the life span,

• therapeutic actions to mitigate the effects of illness and treatment,

• optimal functioning in chronic illness,

• special and physical environments that influence health and illness,

• innovative and efficient systems for enhancing quality care and desired individual and family outcomes,

• maximal independence in health and disease, and

• emphasis on vulnerable populations.

A strong interdisciplinary focus is evident and encouraged for nursing research and research training. Given the complexity of clinical nursing research concerns and questions, synthesis of knowledge from across many disciplines is required in the quest to generate new information for nursing practice.

The scope of nursing research opportunities is broad. To focus resources in several critical public health areas, the nursing research community as well as the Advisory Council and staff of the National Center for Nursing Research have identified a National Nursing Research Agenda consisting of seven priorities. These are staged in a three-step framework that allows for refinement of the priorities and implementation with targeted resources. The priorities include:

• Stage I

  • Low birthweight: mothers and infants

  • HIV infection: prevention and care

• Stage II

  • Long-term care for older adults

  • Symptom assessment and management of acute pain in adults

  • Nursing information: support for patient care

• Stage III

  • Health promotion for children and adolescents

  • Technology dependency across the life span

In addition to the identified priorities, much research has arisen from the science evolving from the current nursing research base. These include:

• symptom management of clinical conditions secondary to illness and treatment,

• women's midlife health issues,

• health promotion and disease prevention (community and environmental issues),

• biobehavioral interface issues with increased biological studies,

• clinical bioethics concerns,

• health promotion within chronic illnesses for vulnerable populations (older persons, individuals at high risk for a specific illness, children, and so forth),

• rural health problems,

• innovative practice systems to enhance desired individual and family outcomes,

• nurse-sensitive patient outcomes and cost factors, and

• culturally sensitive interventions.

These are only samples of the current opportunities for nursing research; many others could be cited or will evolve over time.

Several barriers inhibit the growth of nursing research and impede the ability of nurses to take full advantage of the numerous research opportunities. These include the following:

• In several of the areas of research opportunities, there are a limited number of individuals with the clinical and research training required to investigate crucial areas, for example, biobehavioral interface, clinical bioethical issues, and symptom management with biologically based problems.

• The opportunities and the need to attack critical public health problems are growing more rapidly than the resources available for clinical nursing research and research training. Although this reflects a ''fighting success" phenomenon, the lack of resources limits the profession's ability to respond fully to important health problems.

• Well-established research programs that can provide a strong base for clinical knowledge and for research training are limited. These programs and the accompanying cadre of nurse-scientists need to be enhanced.

• The number of research-intensive environments that can respond quickly to health crises is limited but developing rapidly. The growth of such institutional environments needs to be facilitated to support research and research training.

• Access to clinical settings and to consenting human subjects needs to be enhanced. Both institutional and professional barriers are evident in clinical nursing research. Access for independent nurse-investigators is critical to the quality of the research conducted and the science developed for nursing practices.

The task force recommends the promotion of the development of mechanisms, long-term plans, and strategies to focus research efforts; the enhancement of the development of research-intensive environments for clinical nursing research and research training and career development; and increased funding and resources to support the rapid growth of clinical nursing and its focus on critical public health issues.

There are approximately 9,000 doctorate-prepared nurses in this country; about 20 to 25 percent of this group is conducting research. Approximately 80 percent of doctorate-prepared nurses hold educator or administrative positions in academic and service settings where there is little expectation for research. Only in the late 1970s could one note an expectation of nursing research by the faculty in schools with master's degree programs and developing doctoral programs. Even into the 1980s, however, only 15–20 schools of nursing had achieved a sufficient research base each year to qualify for Biomedical Research Support Grants, which require only that the institution have federal grant awards totaling $200,000 from at least three separate grant awards.

There is a need to encourage the development of nursing doctoral programs in research-intensive institutions and to develop cadres of nurse-researchers in schools that prepare nurse-researchers. Although nurses had received limited federal funding for research in the mid-1980s with the establishment of the National Center for Nursing Research at NIH, increased resources became available for nurse-researchers to engage actively in federally funded research. Additionally, nurse-researchers are encouraged to seek funding from other federal sources and from private funding sources.

In addition to the group of doctorate-prepared nurses conducting clinical research, there are tens of thousands of nurses trained at the master's level who are involved in clinical research. This involvement includes serving as research nurses in clinical centers, working as research project managers, serving as data collectors, or conducting small-scale, limited clinical practice studies.

Because doctoral programs in nursing are relatively new, many nurses who hold doctorates received them in related disciplines such as psychology, education, sociology, physiology, and the like. In 1963 there were 4 doctoral programs, whereas there were 52 in 1988. Doctoral programs in nursing currently are producing approximately 330 new graduates annually (Bednash et al., 1992).

An examination of the human resource profile of clinical researchers in nursing reveals two clear needs. First, although the number of nurses with doctorates has increased rapidly over the past 20 years, more are needed. Second, there is an equal need to maintain the productivity of those already engaged in research and research training. Because of the limited pool of nurses with doctorates prepared for and engaged in research, this small group bears the heavy burden of conducting clinical research studies to develop the underpinnings of clinical practice to improve care and of conducting research training at all levels. One mechanism that has been effective in developing nursing research has been to involve nurses in interdisciplinary clinical research centers and programs. Such participation by nurses has served both to provide nurses with valuable research experience and to add a nursing perspective to the study of patient problems.

The numbers of doctorate-prepared faculty are insufficient to fill positions in graduate programs, and heavy faculty workloads further compromise research activities. Of the full-time faculty teaching in graduate programs, 78 percent hold a doctorate (approximately 31 percent in nursing), and only 45 percent of the part-time faculty hold a doctorate (11 percent in nursing) (National League for Nursing, 1989). The lack of adequate numbers of nurses with doctorates to serve as faculty exercises a qualitative as well as a quantitative constraint on the continued growth in the numbers of doctorate-prepared nurses and hampers research training at all levels. Heavy faculty workloads are also problematic. Data from the National League for Nursing (NLN) indicate that only faculty teaching at the graduate level report any time devoted to research.

This same limited pool of doctorate-prepared nurses is also actively involved in clinical research. In funding year 1988, 91 percent of the research applications from schools, colleges, or departments of nursing were headed by doctorate-prepared investigators, compared with 76 percent in 1984 (U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989).

The barriers to increasing the numbers of doctorate-prepared nurses capable of conducting independent clinical research studies and research training include a lack of money for research training and the conduct of research, the lack of competitive salaries in academic settings to promote research and training, too few mechanisms to promote career development in clinical research, and a need to enhance the research intensity in some of the environments preparing doctoral students in the discipline.

Although increased numbers of doctorate-prepared nurses are needed, there is an equal need to maintain the productivity of those already engaged in the

conduct of research and research training. Salaries for doctorate-prepared nurse faculty are not competitive with those for nurses in the practice setting. In some areas of the country, the annual salaries of doctorate-prepared nurses working in academic settings are approximately equal to those of a newly graduated staff nurse with an undergraduate preparation. This disparity draws some doctorate-prepared nurses out of the academic setting and into more financially rewarding roles in the service and private sectors.

There is a need to enhance the research intensity at some research training sites to ensure the rigor of clinical research training. The current need for this enhancement has arisen, in part, from the rapid growth of doctoral programs in nursing, which draw from the limited pool of doctorate-prepared individuals in the discipline.

The task force recommends that the development of more Ph.D. programs in nursing at research-intensive institutions be encouraged. In addition, it urges the promotion of the development of more targeted research centers in schools of nursing that prepare nurse-researchers and the involvement of nurse faculty in strong interdisciplinary clinical research centers and programs. Organizational mechanisms that reward nursing faculty economically for conducting research should also be encouraged.

Formal research training in nursing is well developed. It begins at the undergraduate level and proceeds through the postdoctoral level and midcareer development. The NLN, the profession's educational accrediting body for the undergraduate and master's programs, emphasizes and requires instruction in research methods in the curriculum. In 1981 the American Nurses' Association Commission on Nursing Research outlined the investigative functions for nurses at the baccalaureate, master's, and doctoral levels on the basis of the research training provided to nurses.

At the baccalaureate level, the focus of training is to prepare a knowledgeable research consumer. All baccalaureate nursing programs have an identifiable research content, which may be taught in separate courses or integrated into several courses. Such courses often focus on the critique and basic design of research as a problem-solving process. Basic statistics may be required as a separate course or integrated into nursing research courses. The basic baccalaureate prepared nurse should be prepared to do the following:

• read, interpret, and evaluate research for applicability to nursing practice,

• identify nursing problems that need to be investigated and participate in the implementation of scientific studies,

• use nursing practice as a means of gathering data for refining and extending practice,

• apply established research findings of nursing and other health-related research to nursing practice, and

• share research findings with colleagues (American Nurses Association, Commission on Nursing Research, 1981).

At the master's level, the nurse is prepared to be an active collaborator in research. The focus of the research component of the master's curriculum in nursing is on a more in-depth critique of research, deriving testable hypotheses or research questions from theory or practice, and application or utilization of research in clinical settings. Applications may be focused in a clinical specialty area and functional area (practitioner, teaching, or management role). Most programs have at least one formal research course, statistics content, and basic computer science content that builds upon baccalaureate research instruction. A thesis is often required; some programs, however, require research focused clinical projects that involve literature review and critique in a topical area, written research reports, case studies, or research-oriented clinical assignments.

The American Nurses' Association (ANA) Commission on Nursing Research's (1981) guidelines for the investigative functions for the master's prepared nurse are as follows:

• analyze and reformulate nursing practice problems so that scientific knowledge methods can be used to find solutions,

• enhance the quality and clinical relevance of nursing research by providing expertise in clinical problems and by providing knowledge about the way in which these clinical services are delivered,

• facilitate investigations of problems in clinical settings through such activities as contributing to a climate supportive of investigative activities, collaborating with others in investigations, and enhancing nursing's access to clients and data,

• conduct investigations for the purpose of monitoring the quality of the practice of nursing in a clinical setting, and

• assist others in applying scientific knowledge in nursing practice.

At the doctoral level, nurses may be prepared for clinical research through a nursing doctoral program or through a doctoral program in a related discipline, such as in the biological, social, or behavioral sciences.

There are three kinds of doctoral nursing programs: doctor of philosophy (Ph.D.), doctor of nursing science (D.N.S., D.S.N., D.N.S.C.), and the doctor of education (Ed.D.). The Ph.D. focuses primarily on research and builds upon the clinical specialty training most nurses obtain at the master's level. The doctor of nursing science generally focuses on high-level preparation for nursing practice, with additional research training above the master's degree level. The Ed.D. in nursing emphasizes teaching of nursing and conducting research on nursing education problems. The standard doctoral program in nursing requires 60 semester credits above the master's degree, with about 75 percent of required credits in nursing and 25 percent in related cognate areas or electives. Approximately 50 percent of total required credits focus on research (Ziemer et al., 1992). The environments and actual mentorship experiences in research in doctoral programs in nursing, however, are uneven.

The ANA Commission on Nursing Research (1981) specified guidelines for the research functions of nurses from both practice-oriented and research-oriented programs. The graduate of a practice-oriented nursing doctoral program:

• provides leadership for the integration of scientific knowledge with other sources of knowledge for the advancement of practice,

• conducts investigations to evaluate the contributions of nursing activities to the well-being of clients, and

• develops methods to monitor the quality of the practice of nursing in a clinical setting and to evaluate contributions of nursing activities to the well-being of clients (American Nurses Association, 1981).

The graduate of a research-oriented program:

• develops theoretical explanations of phenomena relevant to nursing by empirical research and analytical processes,

• uses analytical empirical methods to discover ways to modify or extend existing scientific knowledge so that it is relevant to nursing, and

• develops methods for scientific inquiry of phenomena relevant to nursing (American Nurses' Association, Commission on Nursing Research, 1981).

Postdoctoral research training in nursing provides intensive research mentorship with a productive and established investigator in the area of specific research interest to the trainee. A nursing postdoctoral trainee may be mentored by a nurse-investigator, an investigator in a related discipline, or a nurse-investigator in collaboration with an investigator from another discipline. A nurse may receive National Research Service Award support for full-time postdoctoral study if approved for funding within the first five years after

graduation from a doctoral program. Nurses who choose to engage in their own postdoctoral research with the support of a mentor for 50 percent of their time while also working may obtain a FIRST award (R29). Approval for a FIRST award, however, must also be obtained within the first five years after graduating from a doctoral program. Academic Career Awards (K series awards) may be obtained by nurse-investigators who have been out of their doctoral program for more than five years and who wish to initiate a postdoctoral midcareer mentorship by becoming a coprincipal investigator or research associate on the R01 grant of a senior investigator. In addition to federal awards, some private foundations support nurses for postdoctoral training.

Nursing has relatively little difficulty attracting nurses into doctoral education or research-oriented programs. A major challenge, however, is developing nurse-researchers with a career commitment to clinical research. Clinical nurse-investigators need mentors and role models, as well as satisfactory rewards, resources, and environmental or institutional support, to help them to develop and maintain research careers.

In academic and clinical institutions, there is often a lack of nurse-mentors and role models with a lifetime career commitment to research. Strong nurse-mentors who are productive in clinical research are important in facilitating research-intensive environments that foster the research development of predoctoral students and the career development of doctorate-prepared nurses who are beginning their clinical research programs. Nurse-researchers who work in low-intensity research environments without adequate mentors or role models often feel isolated and that they do not have the necessary collegial support to launch and maintain a career that is characterized by sustained clinical research productivity.

Most positions for clinical nurse-researchers are in academic settings, which have lower entry-level salaries and fewer rewards than positions in clinical institutions. Academic positions are not enticing to nurses who have made major financial investments in their doctoral education, while at the same time foregoing income they could have made if they had remained in their clinical positions. In addition, the work demands above and beyond the research responsibilities in academia are great, and they pose problems if the nurse-researcher is to achieve promotion and tenure. Doctorate-prepared nurses often find greater financial rewards and support in nonresearch roles, particularly in clinical settings. Therefore, a lifelong research career, which is most often based in a university, does not have great appeal for many nurses.

Heavy workloads are problematic for clinical nurse-researchers in both academic and clinical settings. In the academic setting this is especially true for undergraduate faculty with heavy responsibilities for student clinical supervision. Survey data from the NLN indicate that there is, on average, no time reported as being devoted to research by faculty teaching at the undergraduate level. Doctorate-prepared nurses employed in clinical settings often face a workload

dilemma as well, because they have heavy administrative or managerial responsibilities that may not leave adequate time for clinical research.

Many nurses do not have adequate organizational and administrative support for a career in clinical research. Institutional support of research at all levels is necessary to facilitate research productivity and to foster research-intensive environments. This support is required in two forms: by the leadership at the university and school levels (or organizational and departmental levels) and through a valuing of research within the organizational culture. Researchers based in schools and departments of nursing require access to resources and rewards within their own divisions as well as in the broader institutional environment. Administrators often control the resources and rewards required to support the development of research careers and productivity. The policies of an institution often communicate institutional values that influence mores and norms and, thus, an organizational culture that can be supportive of research. Administrative behaviors and decisions at all levels are often important in helping to establish such a culture.

The careers of nurse-researchers could also be facilitated by bridging mechanisms between career steps in clinical research. In most cases, nurses reenter the practice arena between their educational degrees, which results in interruptions in research training. Although clinical experience is beneficial to the nurse-researcher because it helps to clarify research problems in need of investigation, such interruptions thwart progress in the research career and often keep nurse-investigators from proceeding with much-needed postdoctoral education. This problem can be addressed by making more flexible research awards available for clinical nurse-researchers. One approach that would help keep predoctoral trainees involved through postdoctoral education for up to five years would be to support three years of predoctoral training and to continue to support the trainee through two additional years of postdoctoral work. More flexible K series awards for nurses who require midcareer training or delayed postdoctoral experience would be useful.

There are three major barriers to the training of clinical nurse-researchers. These include a lack of understanding of research training of nurse, lack of funds for research training and career development, and lack of awareness of the needs of new and established clinical nurse-investigators by administrators within the research environment.

Although research training of nurses begins early in their careers in the baccalaureate program, the public, other health care providers, and many nurses do not understand the nature, depth, or breadth of research training and opportunities that are received by clinical nurse-researchers. The nurse's role is

still often perceived as totally delegated by the physician. There is not a clear understanding that nursing is a separate profession that defines the majority of its health care interventions independently and builds and seeks knowledge that will improve the quality and effectiveness of care through research. This lack of understanding of nursing and its role in health care research has not only limited the clinical nurse-researcher's access to necessary resources to conduct research programs but also to the funding necessary for research training.

Lack of funds for research training and development, particularly at the predoctoral and postdoctoral levels, has impeded the growth of an adequate pool of clinical nurse-researchers. Nurses who are interested in becoming clinical nurse-researchers are often older and have more financial responsibilities than trainees in other disciplines. In addition, research trainee support levels are very low compared with the salaries that can be earned by master's-prepared nurses who work in clinical settings. Hence, there is little financial incentive to pursue further training and a career in research.

Once clinical nurse-researchers receive their preparation, they often are employed in settings where administrators are unfamiliar with the needs and support required by young investigators to establish successful research programs and careers. As noted previously, it is not unusual for heavy workloads, isolation, lack of resources, and low-intensity research environments to mitigate against the productivity of new clinical nurse-researchers.

The task force recommends promotion of an institutional leadership that supports and values clinical nursing research and clinical nurse-investigators, increased availability and levels of funding for research training and career development in clinical nursing research, and promotion of the education of the public and people in other health care disciplines regarding the research training of nurses.

American Nurses' Association, Commission on Nursing Research. 1981. Guidelines for the Investigative Functions of Nurses. Kansas City, Mo : American Nurses' Association.

Bednash, G., L.E. Berlin, and L. Chan. 1992. 1991–1992 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, D.C.: American Association of Colleges of Nursing.

National League for Nursing. 1989. National Data Review: 1988. Publication No. 19-2290. New York.

Polit, D., and B. Hungler. 1978. Nursing Research: Principles & Methods. Philadelphia: J.B. Lippincott.

U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. 1989. Report of the 1989 National Institutes of Health Task Force on Nursing Research. National Institutes of Health Publication No. 89–487. Washington, D.C.

Wilson, H. 1985. Research in Nursing. Reading, Mass: Addison-Wesley.

Ziemer, M.M., J. Brown, M.L. Fitzpatrick, C. Manfredi, J. O'Leary, and T.M. Valiga. 1992. Doctoral programs in nursing: Philosophy, curricula, and program requirements. Professional Nursing 8(1):56–62.

Psychologists who perform clinical research have commonalities and differences from other professional groups involved in the research endeavor. Scientific advances such as the proliferation of the knowledge base in the neurosciences have benefited many clinical researchers, including psychologists. Some professional barriers are also shared by psychologists and at least some other professional groups engaged in clinical research. Shared barriers include the erosion of federal support for graduate training and continuous financial disincentives to pursue research as opposed to clinical practice.

To provide a context for what follows, it may be helpful to describe some of psychology's relatively novel features as a profession and scientific discipline. One unusual characteristic is that training in the research enterprise begins at the undergraduate level and progresses continuously through the first several years of graduate school. It is not uncommon for promising young students to become involved in a laboratory under the tutelage of a research mentor, to author or coauthor one or more empirical publications before graduation, and to continue research, progressing toward a Ph.D. dissertation in the laboratory of a graduate school mentor. This progression reflects the strong emphasis that is placed on training in the scientific method at all phases in the educational process. The origins of this training philosophy reside in the beginning of academic psychology, which started with a tradition of experimentalism modeled after that in physics (Cronbach, 1957). The field's core scientific values have always included a commitment to empirical research and hypothesis testing. Only relatively recently has this orientation been brought to bear upon explicitly clinical research problems. Psychologists did not become extensively engaged in addressing clinical problems until World War II, when they were called to the task of developing personality tests to assess the fitness of potential recruits for military service. Clinical psychology only emerged as a subspecialty when, as the war effort continued, psychologists were recruited into psychiatric hospitals, initially to assist in the assessment and later in the treatment of combat veterans.

Once in the medical setting, their research expertise was enlisted to study a growing variety of health problems.

Clinical psychology's academic and scientific roots are preserved in its philosophy about the optimal balance between research and clinical training. Major professional accrediting groups have repeatedly endorsed the scientist-practitioner (or Boulder) model, which emphasizes a strong training base in science as a precondition for beginning to undertake thoughtful clinical practice. Unique among the professional groups drawn to clinical research, doctorates in clinical psychology complete at least three years of research-oriented training in the content and scientific methodology of the discipline before embarking upon the intensive clinical internship. The intent is to develop a conceptual framework that enables students to critically evaluate the scientific grounding of the current knowledge base rather than assimilating a static collection of facts (McGovern et al., 1991). An additional aim is to encourage students to adopt a scientific approach to clinical practice, generating hypotheses about the mechanisms that sustain maladaptive or unhealthy behaviors, consulting the relevant empirical literature, and subjecting their interventions to the test of clinical response. Because the modification of cognition and behavior is a core training area in most accredited programs (Sayette and Mayne, 1990), clinical psychologists are unusually well-equipped to study and intervene in the behavioral factors that initiate and maintain a variety of psychological and physical disorders.

Throughout this appendix it will be important to note that other groups of psychologists are also well-trained to make important contributions to clinical research. Examples include Ph.D.s in the areas of developmental, personality, social, and experimental psychology. Although lacking specific training in techniques of clinical assessment and therapy, nonclinical psychologists also possess extremely strong grounding in research methodology. Nonclinical psychologists also possess intensive training in one or more of the areas of human learning, perception, cognition, motivation, physiology, emotion, and interpersonal behavior. This training background leaves both clinical and nonclinical psychologists well-equipped to make important discoveries about the mechanisms that give rise to mental and physical health problems.

Excellent scientific training has enabled Ph.D. psychologists to make important contributions to the understanding of many clinical problems. Substantial faculty expertise and research funding are already consolidated in certain domains (Sayette and Mayne, 1990), where the field is poised to fulfill its research promise.

Behavioral Medicine and Health Psychology Health psychology is a relatively new area of investigation that aims to understand the biopsychosocial factors that promote or prevent illness. Despite the field's youth, expertise and interest in behavioral medicine have grown rapidly, giving the area nearly twice the faculty and funding as any other domain of clinical psychology research (Sayette and Mayne, 1990). Two examples of psychologists' important contributions to clinical research in behavioral medicine concern cardiovascular risk factors and the influence of psychosocial factors on immune system function. Risk factors for cardiovascular disease have also been studied intensively, with much research focusing upon the type A personality, including its emergence during childhood. A significant new discovery concerns the heightened cardiovascular risk that is associated with repeated cycles of weight loss and gain. Although the underlying cause of the weight cycler's heightened risk remains unclear, the finding suggests a need to reevaluate potential health risks that may arise from the culturally ubiquitous practice of dieting.

Another area that holds enormous excitement and promise is psychoneuroimmunology, which examines the interdisciplinary interface among psychological, neural, and endocrine influences on the immune system. Understanding how psychosocial factors may mediate the initial susceptibility or the course of cancer or AIDS may one day enable clinicians to harness such influences in treatment.

Psychopathology Accredited clinical psychology programs possess resources in many areas of psychopathology. Expertise in schizophrenia and the affective disorders is well-established. During the past decade, new pools of talent and funding have emerged in the areas of anxiety disorders, eating disorders, and childhood psychopathology. Research in psychopathology is shedding light on genetic and psychosocial contributions to the etiology of mental disorders, their development across the life span, behavioral and pharmacologic treatments, and wider psychosocial problems, such as the homeless mentally ill.

Neuropsychology Embracing a broad knowledge base that reaches from molecular findings in the neurosciences to clinical rehabilitation efforts with brain-injured individuals, neuropsychology has become a well-established domain of inquiry. Neuropsychologists have profited from the emergence of new technologies in neuroimaging, which permit them to study the neural substrates for cognitive and affective processing of information. Findings are being applied to understand and remediate the behavioral and emotional effects of brain injury.

Children Psychologists have had a longstanding commitment to the study of children. Interest and expertise in assessing emerging cognitive capabilities have contributed to the development of programs like Head Start. Much current interest now focuses on the nature and origins of temperamental traits such as shyness and how these dovetail or clash with an individual's environmental niche. The socioemotional impacts of broader social influences including television, day care, and parental work roles have also been studied, as have a variety of societal problems. The latter include issues such as the short-and long-term effects of family conflict, abuse, criminality, and maternal psychopathology.

Aging Psychologists have also turned their attention to problems associated with aging, including determining the extent to which declining cognitive functions and deteriorating physical health are inevitable, as well as what can be done to delay or minimize their impacts. Studies are progressing on the development of family and community support systems, strategies for coping with chronic health problems, and the interaction between emotional and biological functioning.

Clinical research into complex, entrenched sociobehavioral problems is less mature. Promising beginnings have been made, however, that put the field in a position to contribute significant advances to understanding and influencing some costly and demoralizing problems that plague U.S. society. Promising, high-need areas include the following.

Violence and Aggression At both individual and sociocultural levels, clinical psychology has begun to develop a knowledge base aimed at understanding the effects of such violent acts as homicide, rape, and child abuse on victims and survivors. Intervention methods are being developed to minimize that impact. In addition, a coherent pattern is starting to emerge from the multiple factors that cause an individual or group to commit violent acts, and deterrent interventions are beginning to show promise.

Substance Abuse At a time when intravenous drug abuse has become a major vehicle for the transmission of AIDS and drug-related crimes and violence plague many communities, the societal impact of substance abuse is only too apparent. Important progress has been made in unraveling the processes that lead to abuse and dependence upon a variety of psychoactive substances ranging from caffeine to tobacco, alcohol, opiates, and cocaine. One significant contribution to this area has been the discovery of conditioned physiological compensatory

(drug-opposite) responses, whose activation thwarts the likelihood of death from drug overdose. A second area of progress concerns efforts to understand the nature and relapse relevance of the phenomenon of drug craving. A third concerns studies of nicotine's apparently increasing appeal to American females as a weight-suppressing agent, and the consequences of this phenomenon for initiating and sustaining cigarette smoking among females.

Prevention An overriding research opportunity that unites all of the areas previously mentioned involves psychological research on the prevention of clinical problems. Once established, the treatment refractoriness of chronic medical illness, psychopathology, violence, and substance abuse is impressive, arguing for the need for prevention before these disturbances become firmly entrenched. To be maximally successful, it is essential that preventive research and intervention be grounded upon a firm interdisciplinary base. For example, it is critical to muster the expertise of developmental psychologists who can tailor interventions to mesh with the capacities and interests of children. Similarly, population impact is maximized by interdisciplinary efforts that draw upon the skills of epidemiologists trained with a public health perspective. Clinical psychologists bring to the collaborative enterprise an extremely strong training background in research design and methods and an academic history of openness to interdisciplinary work. Their research expertise can be applied readily to almost any problem in which behavior potentially enhances or allays risk. This flexibility contributes to the broad diversity of clinical research opportunities in psychology.

There exists a large pool of psychologists who have been well-trained to conduct clinical research. The National Science Foundation's latest biennial survey registered 60,596 Ph.D. psychologists employed as scientists (Brush, 1991). More doctorates are awarded in the health service provider areas of psychology, of which the largest subdiscipline is clinical psychology, than in any other discipline of psychology. For example, of the 3,209 Ph.D.s awarded in 1989, approximately 1,840 doctorates were awarded in the subfields of clinical, counseling, and school psychology, with the remainder divided among six other subfields (National Research Council, 1990). Over half of full-time doctoral students (56 percent) and about two thirds of full-time master's students were enrolled in the health service provider subfields in 1989–1990 (Kohout et al., 1992).

The pool of students who want predoctoral training in clinical psychology remains deep; there are many more applicants for graduate school than there are slots available. This applicant pool is also quite intellectually talented. In

1989, the median Graduate Record Examination scores of students entering graduate training in psychology were: verbal, 601; quantitative, 620; total, 1,220. Separate figures could not be obtained for clinical psychology alone, but in the vast majority of psychology departments, the applicants' credentials are the most outstanding and the competition is keenest for admission into the clinical area.

It is difficult to ascertain that percentage of psychologists who engage in clinical research after completing the doctorate, but some estimates can be made. Considering clinical psychologists in particular, it can be inferred that those entering private practice are least likely to conduct research. Thus far, private practice has claimed only a minority of clinical psychologists. In 1983, for example, 30 percent of those clinical psychologists in the labor force were primarily self-employed. Of the remaining 70 percent, 24 percent were in academic positions, 22 percent were employed in hospitals and clinics, and the remainder were employed by government, industry, or the nonprofit sector, where there is at least the opportunity to engage in clinical research. Of nonclinical psychologists in the 1983 labor force, the vast majority (64 percent) were employed in academic positions (Institute of Medicine, 1985), where research is a primary activity. In total volume, the pool of psychologists who in 1991 identified themselves as scientists (n = 60,596) compares favorably with that of other groups of scientists who can potentially engage in clinical research (for example, medicine [n = 32,079]) (Brush, 1991). Also, at 36 percent, the representation of women in clinical psychology is the greatest of the scientific disciplines sampled by the National Science Foundation (Brush, 1991).

The number of women who receive training in psychology has increased dramatically. Women now constitute more than half of the applicant pool for graduate education in psychology, and they are in the majority as trainees in clinical psychology programs. In 1950 women received 37 percent of baccalaureate and 15 percent of doctoral degrees awarded in psychology. By 1988 women received 70 percent of baccalaureate and 55 percent of doctoral degrees, including 57 percent of the degrees in clinical psychology (National Science Foundation, 1990; Ostertag and McNamara, 1991). Women still hold only a minority of faculty positions, occupying slightly more than one fourth of the full-time faculty appointments in graduate departments of psychology (Kohout et al., 1992). More entry-level positions are opening to women, however. In 1989–1990, 48 percent of new appointments were made to women. Moreover, there are encouraging signs that the increasing ''feminization" of the profession is not exacting a toll in loss of occupational prestige or salary (Ostertag and McNamara, 1991; Wicherski et al., 1992).

Asian, Hispanic, and African-American applicants remain very much in the minority, constituting 6 percent of full-time faculty members in graduate departments of psychology in 1989–1990 (Kohout et al., 1992). African-Americans constitute the largest single subgroup.

Intensive efforts to increase minority representation continue through fellowships and recruitment efforts at all levels of the academic ladder. In 1989–1990, 12 percent of new faculty appointments were made to members of minority groups (Kohout et al., 1992). Although the applicant pool remains small, the quality of minority student and faculty candidates is quite good. The diversity brought about by more women and minorities in clinical psychology has also broadened the field and enriched the knowledge base, especially in such areas as women's health, child and sexual abuse, and minority health.

The excellence of the pool of clinical psychology researchers is validated by their ability to compete successfully for federal research support. Even though the total dollar amount going to support behavioral research is relatively low (approximately 3.5 percent of the federal research support budget), psychologists (especially clinical psychologists) have a better than average "hit rate" for obtaining "approved and funded" grants. About 35 percent of the National Institute of Mental Health research dollars are awarded to psychologists, and 45 percent of the principal investigators supported are psychologists (Leshner, 1991).

The education of psychologists traditionally has been characterized by the incorporation of strong training in research. Emphasis on the methods of science prior to professional training is uniquely associated with the training of psychologists. The scientific training begins early in the undergraduate curriculum and includes courses in experimental and laboratory methods as well as statistics. Experientially, psychology undergraduates participate in a variety of research activities, frequently serving as research assistants, which allows them to learn a variety of research skills. In many cases psychology undergraduates enter mentor relationships with faculty and become active members of ongoing research teams where they participate in the conceptualization, analysis of results, and preparation of manuscripts. As a result, many graduate with publications to their credit. Finally, but particularly important, is that the approach to understanding and interpreting the psychological literature is objective and critical. Hence, there is encouragement of the development of critical thinking skills. In general, through early socialization into the culture of science, the foundation for a scientific approach to the understanding of human behavior is laid.

Although there are diverse specialties within psychology, there are some common, unifying themes. These are found in the form of a shared undergraduate experience and a relatively common core background of knowledge in the areas of research design and experimental methodology, statistics, psychological measurement, individual differences, biological bases of behavior,

social bases of behavior, and cognitive and affective bases of behavior. In short, psychology is the science of human behavior, and its trainees are uniquely qualified to study behavior from an integrative perspective, taking into account the biological, social, and individual factors associated with patterns of behavior.

The shared emphasis on the scientific method during all phases of training and the shared educational content concerning the mechanisms that govern learning, experience, and behavior equips those trained across all psychological specialties to conduct clinically related research. In addition to clinical psychologists, developmental, social, and experimental psychologists have made and continue to make important research contributions that affect the general health as well as the mental health of the nation.

The clinical psychologist is particularly well-suited to engage in clinical research because the model of training adhered to by most Ph.D. training programs is that of the scientist-practitioner, sometimes referred to as the Boulder model (for example, Belar and Perry, 1990; Raimy, 1949). This model calls for the integration of science and practice throughout the graduate training years. Thus, the clinical psychology trainee receives clinical and scientific training simultaneously. A particularly important aspect of this training is the reciprocal influence of each component on the other, resulting in continuous cross-fertilization (Kanfer, 1990). This model of training produces graduates who have a strong scientific approach to problem-solving in the research laboratory as well as in clinical practice. These individuals are well-equipped to function in either the research or the practitioner role, or in both.

Following graduate course work, the clinical psychologist normally undertakes a one-year internship where there is additional intensive training in clinical assessment and intervention that continues in the scientist-practitioner tradition. Clinical psychologists are beginning to pursue postdoctoral training in increasing numbers. Some postdoctoral opportunities are to acquire further clinical training, some are to attain added research experience, and some are for both. The postdoctoral experience also allows for subspecialization in a domain of research or practice. Within the psychological research community, clinical psychologists are particularly well-suited to engage in research that pertains to understanding and modifying the basic mechanisms that govern maladaptive behavior patterns.

Although it is difficult to ever know for certain how many psychologists are engaged in clinical research and whether this number is sufficient to meet the need for clinical researchers, there is consensus among the task force members

that many well-trained, talented individuals who could engage in clinical research are no longer doing so. The bulk of these persons are clinical psychologists who never do a single study beyond their doctoral dissertation. The others gradually cease research activity and choose instead to concentrate on other activities, principally clinical work. The reasons for this "failure to retain" clinical researchers are many, but most reduce down to the simple fact that there are more disincentives to pursue or stay in a career that is research-intensive than there are positive incentives.

Economic disincentives deter many well-trained clinical psychologists from pursuing academic research careers. For example, in 1991–1992, the average academic year salary in a department of psychology for assistant professors who were between zero and five years beyond their Ph.D. was $35,000 (American Psychological Association, 1992). Postdoctoral positions pay still less, with many offering salaries in the low $20,000s. Many service agencies, in contrast, are willing and able to pay a new clinical Ph.D. a salary in excess of $60,000 to do full-time clinical practice. If, instead, the graduate chooses to go into independent practice, it is not uncommon for a clinical psychologist to gross over $100,000 once the practice has become established (a process that usually takes from two to five years).

It was formerly the case that clinical psychology Ph.D.s differed from their medical counterparts in lacking large debts that had to be repayed after graduation. This is no longer true, largely because of the erosion of federal funds for graduate training and the somewhat disproportionate loss of funds for graduate clinical training. In 1989 more than two-thirds of graduating psychologists had some level of debt to repay (Kohout et al., 1992). Of the enrolled full-time graduate students, almost half were relying primarily on self-support, and 95 percent had relied chiefly on personal financial resources at some point during their graduate education (Kohout et al., 1992). Graduates in clinical psychology had the highest levels of debt to repay and were less likely to have received federal fellowships or research and training grants than students in other nonclinical areas of psychology (Kohout et al., 1992). Graduate training funds in clinical psychology have eroded markedly during the past decade. For example, in 1977, 29 percent of clinical psychology graduates noted that federal fellowships and traineeships had provided the major support for their graduate training compared with 22 percent of psychology graduates in nonclinical areas. In 1986, by contrast, only six percent of new clinical psychology doctorates versus eight percent of nonclinical doctorates had relied primarily upon federal support for their graduate training. Although many major universities have been able to replace the lost federal training funds by using their own resources, it can no longer be assumed that the modal clinical psychology graduate contemplates professional options from a debt-free base. Research and academic settings need to take these market forces into account in setting salary levels for both

incoming and continuing faculty, just as they do for other professional areas such as law, medicine, and business.

Clinical Ph.D.s who do enter academic positions, where research activity is desired and valued, soon encounter the frustration of competing for research funding in an environment of increasingly scarce funds to support even good-quality research. For example, although the National Institutes of Health budget has increased by more than 50 percent since 1980, the number of grants awarded annually has actually fallen by almost one third. At the National Science Foundation, only 30 percent of those who apply can hope to be funded (Holden, 1991). Although clinical psychologists have a relatively good "hit rate," their grant proposals are four times more likely to be unfunded than funded. If they turn to clinical practice to support their research and supplement their salaries, the time and energy requirements of clinical work soon swamp their ability to do research.

Powerful deterrents for clinical psychologists to remain in research can only be balanced by a concerted effort at all institutional levels to bolster the enticements to continue in research. One part of a solution will need to address the problem of noncompetitive salaries. As a beginning, there needs to be a mechanism whereby postdoctoral research positions in clinical psychology can be funded at more than minimal levels. A subsequent strategy, carrying on into the academic appointment, might be to allow clinical researchers who successfully compete for research awards to supplement their salaries from grants. In addition or as an alternative strategy, institutions might permit clinical faculty to supplement their salaries or their research resources by delivering some clinical services through a university clinic practice plan. This latter approach would have the added benefit of integrating clinical practice within the academic and research settings. University-based practice activities might also stimulate more clinical research, especially compared with the alternative, in which faculty divorce their clinical activities (and therefore their time and energy) from the university setting.

Greater institutional support is needed both to eliminate obstacles that plague the clinical research psychologist and to provide tangible resources to encourage research. An example of an obstacle is that in many clinical training programs course credit is no longer allocated for supervision of graduate students' clinical practical work. Thus, in addition to the usual faculty course load involving lecture and seminar courses and research supervision, clinical faculty may shoulder, without credit, the extra burden of providing individual supervision for students engaged in clinical practice. Course credit needs to be awarded for clinical supervision. Another barrier has been the gradual erosion of the university's realization that preparation for engaging in research is an ongoing process. Researchers need to continually upgrade and refine their skills and knowledge by becoming immersed in the community of scholars in their particular area. Sabbaticals and release time from other academic duties to attend

professional meetings are essential if clinical researchers are to remain competitive in the increasingly constricted funding arena. The ability to pursue these activities requires financial support that needs to be generated by university development offices. Although faculty sabbaticals offer an indispensable vehicle for rejuvenation, respecialization, or refinement and upgrading of skills, they are no longer available at many institutions. Task force members were in agreement that reestablishing paid sabbaticals for clinical researchers at five- to seven-year intervals throughout all levels of the career pathway offers one of the most effective incentives to retain researchers in clinical psychology.

The general difficulties of retaining clinical psychologists as researchers will now be influenced by the increasing proportion of women who are entering the profession. Great strides have been made in recruiting women into the early career stages as clinical psychology researchers. Women now constitute the majority of those entering graduate programs of clinical psychology, and almost half of new faculty appointments are being made to women. Continued initiatives, as well as the passage of time, will be required, however, before women achieve more than a toehold of representation in the academic community, and it will be still longer before balance is achieved at the upper levels of salary and academic rank. For example, despite new hiring initiatives, female graduate students still enter an academic environment in which women hold only a minority (about 25 percent) of faculty positions, and their representation at senior levels remains sparse. In 1989–1990, for example, women represented only 19 percent of tenured faculty (Kohout et al., 1992). The gains that have been made at the entry levels of academic rank are just beginning to be perceptible at higher levels. For example, in 1989–1990, women were more than twice as likely as men to be assistant professors, somewhat more likely to be associate professors, but almost a third less apt to be full professors (Kohout et al., 1992). Thus, although the situation is improving, female graduate students and faculty may still experience a sense of isolation in the academic environment and perceive a lack of support for their work. Until there is a critical mass of females within a department, networking needs to be done with women in other departments to provide support.

Retention of women at the upper rungs of the academic ladder will depend upon how successfully women are able to dovetail the demands of the tenure clock with those of the biological clock. Completing a Ph.D. and postdoctoral training places many women in their late twenties or early thirties by the time they obtain a first academic position. The tenure clock then allows five or six years to produce a sufficient volume of first-rate publications and grants to earn a permanent position. The demands of caring for young children during the

tenure-probationary interval severely impede the pace of progress that is necessary to acquire tenure at many universities.

Alternatively, if a woman postpones childbearing, the tenure clock and the biological clock may seem to be running out in uncomfortably close proximity. A number of possible solutions have been proposed (Brush, 1991), including a longer tenure-probationary period, such as 9–10 years; one semester of paid "family care" leave; up to two years of unpaid leave for any reason; subsidized day care for preschool children; on a temporary non-tenure-track position for a qualified spouse when a nonuniversity position is unavailable. Such solutions are urgently needed if the intensive efforts that have successfully recruited women into the field are not to be wasted by having them drop out before they can contribute.

Much of what has been said about the retention of women can be reiterated for minorities, with the added comments that the problem is more acute and initial recruitment efforts have been less successful. In 1989–1990, minorities comprised 6 percent of full-time faculty members in U.S. departments of psychology, with African-Americans constituting the largest subgroup (Kohout et al., 1992). Minority representation also diminishes as academic rank increases: minorities comprise 13 percent of lecturer/instructors, 8 percent of assistant professors, 6 percent of associate professors, and 2 percent of full professors. Task force members felt that the most important corrective action is to remember that minority retention is a continuous process that begins rather than ends with successful recruitment of a minority student or faculty member. Efforts to combat isolation, to diversify the areas of study that are encouraged and rewarded for research and scholarship, and to enhance the flexibility of career timing all need to be encouraged.

Until recent years, the bulk of clinical psychologists were trained as scientist-practitioners (the Boulder model) in university-based departments of psychology. This model builds practitioner training on top of a solid foundation in behavioral science. Today, however, approximately 50 percent of the doctorates in clinical psychology are awarded by "freestanding" professional schools of psychology, where scientific training clearly takes a back seat to preparing clinicians. Most professional schools lack the dissertation and the research requirements of Boulder model programs and greatly dilute the required training in scientific methods. The American Psychological Association has accredited

35 professional schools and estimates that from 33 to 59 percent of all doctoral students are currently enrolled in them (Craighead, 1991; Garfield, 1992).

Some professional school graduates are awarded the Psy.D. degree, but others are awarded the Ph.D. Thus, it now is difficult to determine by degree alone what the research training background has been for any given clinical psychologist. It would be difficult to overstate the degree to which the proliferation of professional schools has flooded the market with clinical psychologists. In the three-year period between 1978 and 1980, about 1,050 clinical psychologists a year received doctorates. In this three-year period alone, more clinical psychologists entered the field than were in the entire field 35 years earlier (Garfield, 1992). Unfortunately, it can no longer be assumed that a majority of these new clinical psychologists are well-equipped to engage in clinical research. Nor, certainly, can it be said that they are interested, since the vast majority of the clinical psychologists trained in professional schools enter nonresearch-or nonacademic-related occupations. In contrast, students entering the university-based programs usually are seeking either research careers (a minority) or state an openness to combining research and clinical practice.

Since programs embracing a professional model are now producing about half of the new doctoral-level clinical psychologists, there can be no doubt that proliferation of the professional schools is serving to erode the base of scientific training of the profession as a whole. The solution to this problem will not be easy, but at least two paths can be recommended. First, the science training base should be strengthened in all clinical psychology programs, particularly in professional schools. Some movement in this direction is evident in the recommendations from the 1990 Report of the Joint Council on Professional Education in Psychology (Stigall et al., 1990), which reinforced the necessity for research training for all professional psychologists, including those being trained as practitioners. Accordingly, many professional schools have begun to strengthen their scientific training. Second, it is urged that the specific recommendations of the Utah Conference on Graduate Education and Training in Psychology (Beckman, 1987) be adopted. The Utah Conference advised that all nonuniversity-affiliated professional schools be required to have university affiliation by 1995 to receive continued accreditation by the American Psychological Association.

A large proportion of clinical research in psychology involves evaluating the effectiveness of a modality of therapy or the mechanisms by which a treatment achieves its effects. The right to independently administer psychological treatment, even for primarily research purposes, is restricted to

those who are licensed clinical psychologists, having met the licensing requirements of the state in which they reside. Eligibility for licensure depends partly upon passing a written national examination and partly upon performing a requisite number of hours of supervised psychological practice. Recent changes in the practice portion of the licensure requirements in most states have made it increasingly difficult for new clinical psychologists who engage in research or academic activities to achieve eligibility for licensure. Most states now require two years of postdoctoral experience to be eligible, and they will rarely credit instruction, research, or even the provision of clinical supervision as eligible practice activities. Many states specify that at least 10 or often 20 hours a week must be spent in direct client contact to meet the criteria for licensing. Moreover, it is often mandated that the practice requirements must be met during a consecutive two-year period. These time constraints make it very difficult if not impossible for a new Ph.D. who has chosen a research postdoctoral fellowship or an academic position to achieve eligibility for licensure while trying to meet research or tenure requirements. Increasingly, clinical researchers who wish to become licensed are needing to interrupt their research training or delay the start of an academic appointment to log in the necessary hours of supervised clinical practice. Nor can the individual with clinical research aspirations safely ignore or postpone the requirement for licensure, because potential employers fear that hiring an unlicensed psychologist will create insurance liabilities and jeopardize the site's professional accreditation.

The knowledge base that is the foundation for the practice of clinical psychology would clearly best be served by accommodating the professional needs of those who wish to integrate a career in clinical research and practice. Rigid licensure requirements that are increasingly unfriendly to the clinical researcher and academic do much to thwart this goal, adding to the list of factors that deter well-trained psychologists from embarking on clinical research careers. Solutions to this problem are badly needed and might take the form of expanding the definition of activities that are construed as psychological practice or increasing the flexibility of the temporal requirements for achieving licensure.

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