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CHAPTER SEVEN NURSING RESEARCH PERSONNEL Nursing research addresses critical issues of nursing practice and health care. It seeks to understand problems of living with acute and chronic illness, factors associated with health promotion and disease prevention, and the impact of nursing systems. Research on acute and chronic illness fo- cuses on patient and family responses to illness and disabil- ity, He biological and behavioral factors that contribute to these conditions, and ways to improve or remedy them. Health promotion and disease prevention research focuses on maintaining and improving general health status among diverse populations through effective nursing and health care practice interventions. It concerns such issues as preg- nancy, health behavior, adolescent heals habits, dieting practices, smoking and heals behavior, as well as early detection and treaUnent of particular diseases or conditions. Nursing systems research focuses on patient outcomes, new approaches to quality nursing services to improve patient care, studies of innovative nursing care delivery models, and issues of clinical decision-making. In recognition of the important role nursing research plays and the potential of its future contributions to the health and welfare of the American people, the National Center for Nursing Research, established in 1986, became the 17~ institute (National Institute of Nursing Research, NINR) the National Institutes of Health (NIH) on June 17, 1993. The primary mission of NINR is to provide a strong scientific base for nursing and heals care practice. Medi- cal research focuses on finding better ways to diagnose and treat illness, and nursing research complements it by focus- ing on people's responses to illness and treatment. For ex- ample, a medical researcher might study how to diagnose the human immunodeficiency virus (HIV) earlier or which drugs and what doses are best to combat HIV infection. A nurse researcher might study the symptoms associated win HIV, such as muscle wasting and pain. Nursing research 73 aims to develop interventions to maintain or improve the patient' s quality of life and functional status. With He enactment of the Health Research and Heals Services Amendments of 1976 (P.L. 94-278), the NRSA training authority was extended to include the research train- ing programs administered by the Division of Nursing of the Health Research and Services Administration. As a re- sult, the National Research Council in 1977 described changes taking place in the composition of Be nursing re- search labor force and training needs and specified how NRSA funds might contribute to He production of scien- tists in this area. Nursing research as the 1977 study com- mittee noted in its report (NRC, 1977) complements bio- medical and behavioral research by focusing on health outcomes and improved patient care. Since the inclusion of nursing research in the NRSA pro- gram in 1976, nursing research and nursing research train- ing have undergone many organizational changes within the federal government, ultimately resulting in the appearance last year in the National Institute of Nursing Research HAIR). NINR has a strong commitment to support re- search training. Its National Research Service Award MESA) program has primarily funded predoctoral fellows and trainees. However, there is a great need to increase the support for nurse researchers at the postdoctoral level and to shift toward a balance in the distribution of funding for predoctoral and postdoctoral fellows and trainees. ADVANCES IN NURSING RESEARCH Nursing research may be considered to be organized into three general categories: acute and chronic illness, heals promotion and disease prevention, and systems of care. Advances in each of these three overall areas of nursing research are summarized below.

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MEETING THE NATIONS NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS Acute and Chronic Illness Research topics on nursing care of acute illness range from sleep-wake patterns of preterm infants in the neonatal intensive care unit to the biobehavioral factors affecting re- covery after a myocardial infarction. Nursing studies of chronic illness address pain assessment and management, stress, orientation and cognitive dysfunction, and adapta- tion to decreased functional status (Hester, et al., 1990~. They also address symptom management for diverse dis- eases and conditions such as fatigue, dyspnea, nausea and vomiting, anxiety, cognitive impairment, and sleep distur- bances, as well as symptoms of specific diseases (McCorkle et al., 1994). There is a renewed focus in nursing research on the ap- plication of state-of-the-art biological and behavioral theory and measurement to the clinical problems patients experi- ence win illness and medical treatment. For example, one such study is measuring the effects of self-management bio- feedback therapy on the frequency of complex ventricular ectopia, events of sudden cardiac arrest, survival rate, and enhanced heart rate variability in subjects after an episode of sudden cardiac arrest (Cowan et al., 1991~. Other studies are investigating factors related to breast cancer, colorectal cancer, and depression after stroke. Investigators are com- bining data across studies in the areas of depression and biological immune responses (Johnston et al., in press; Tax et al., in press). Nursing studies also examine the effectiveness of nurs- ing procedures, such as open versus closed endotracheal suctioning. They compare different modes of oxygen de- livery to patients with chronic lung disease and develop accurate tests for confirming correct nasogastric tube place- ment at the bedside (Rudy et al., 1991~. Other procedures being investigated include feeding and handling of infants in the neonatal intensive care units, wound healing of decubiti, and behavioral strategies to maintain the functional indepen- dence of cognitively impaired nursing home residents. Nursing research holds great promise for increasing the effectiveness of patient care and improving the quality of life for patients and their families. New discoveries en- hance the potential for new and effective approaches to nursing. Health Promotion and Disease Prevention Nursing studies of health promotion and disease preven- tion examine ways in which behavioral change can be ef- fected to improve quality of life and encourage avoidance of heals risks across the life span. Descriptive and correla- tional studies have predominated in the past, exploring such variables as mental heals in postpartum mothers, neurometric measures of premenstrual syndrome, weight 74 management, fatigue, exercise regimens, and perimeno- pausal phenomena (Shaver et al., 1992~. Studies of inter- vention programs such as educational nrn~rnm.~ for .~.hnol- age children are also conducted. ~, . . ~ . ~. . r D Most health problems are complex and are linked to be- havior and lifestyle. They require multidisciplinary ap- proaches that combine knowledge from the biological, en- vironmental, and behavioral sciences. Nurse investigators are seeking ways to tap into the extraordinary advances in the basic biological and behavioral sciences to better under- stand how healthy behaviors are established and maintained. For example, nurse researchers investigate positive and negative health behaviors in childhood and early adoles- cence and Heir linkage to individual, family, social, bio- logical, and environmental factors. They work with col- leagues in the biological sciences to test interventions such as exercise and counseling. Women's health is another area of expanding interest for nursing research, including childbearing, nutrition, exercise, normal developmental processes, and stress and adaptation to life transitions (Woods et al., 1993~. The large studies on women's health issues initiated by NIH will provide addi- tional opportunities for nurse researchers to study the bio- logical, behavioral, and social factors that contribute to health and disease and to test interventions that will pro- mote health and prevent disease. Systems of Care Nurse researchers are evaluating the clinical context in which heals care is provided, the process of nursing care, and organizational factors that affect patient outcomes and quality of care delivery. For example, the cardiovascular effects of noise and light have been studied in neonatal in- tensive care units and coronary care units. Other studies have documented He cost effectiveness of nurse-coordinated care from the hospital into the home for high-risk popula- tions such as very-low-birth-weight infants, women with high risk pregnancies, and frail older people (Brooten et al., 1986~. A unique and challenging area of research is He explora- tion of bioethical issues in health care delivery. There is a tremendous need for empirical studies of treatment deci- sions, especially as they relate to advanced medical tech- nologies and access to innovative therapies. A major challenge for nurse investigators is the identifi- cation and measurement of interventions and clinical end- points of nursing care that are cost effective. New modes of health care delivery and financing will continue to exert pressures to develop measures of care Hat can monitor ap- propriateness and quality of care. To answer research ques- tions related to these issues, nurse investigators often col- laborate win researchers in health services research and other disciplines.

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NURSING RESEARCH PERSONNEL Nursing studies utilize a variety of methods and mea- sures, integrating knowledge across disciplines in an effort to understand human behavior, health, and disease in the context of the individual, the family, and the social and cultural environment. These complex clinical questions re- quire the talents and perspectives of many disciplines as well as the expertise of nurses in clinical practice, who ask provocative questions about the patient care they are pro . . V1( lNg. ASSESSMENT OF THE CURRENT MARKET FOR NURSING RESEARCH PERSONNEL Approximately 12,000 nurses with doctoral training in the sciences were employed in the U.S. work force in 1992, up from 4,108 in 1980 (Bureau of Health Professionals, 1991~. Even with this increase in numbers of doctorally prepared nurses, He gap between supply and demand re- mains large. Nurses often begin their research careers at midlife, with an expansion of interests grounded in clinical experience. Clinical research is a strength of nursing re- search, with questions for basic biomedical and behavioral research most often emanating from clinical questions be- ing asked. Research opportunities are expanding for nurses, both within academia and in hospitals and other clinical settings (Moses, 1993~. The number of nurse researchers in clinical settings is growing. In 1984, 9.3 percent of doctorally prepared nurses worked in hospitals (Moses, 1986), whereas by 1988 it was estimated that 14 percent were working in hospitals (80 percent employed as faculty and 6 percent in other areas). In 1992, 18.5 percent of doctorally prepared nurses were employed in hospital set- tings (63.4 percent in nursing education and the remainder in other categories). Nurses with doctorates in nursing are more likely to be employed in nursing (4,141) than in nonnursing work (100~. Nurses win doctorates in related fields also tend to be employed in nursing positions (5,421), but increasing numbers are finding positions outside of nurs- ing (1,622) (Moses, 1993~. The average salary for nurses with doctorates employed in universities and 4-year col- leges was $54,468 in 1992 (AACN, 1992~. There is little influence of non-U.S. citizens on He sci- entific labor force in nursing because most non-U.S. citi- zens return to their countries of origin after doctoral study. OUTLOOK FOR NURSING RESEARCH PERSONNEL The need for skilled research personnel in nursing is ex- pected to expand in the decades ahead. Several new initia- tives are proposed to test innovative community-based strat- egies to provide for health promotion and disease prevention activities, especially for high-risk populations. There is new 75 interest in the implications of cultural diversity for health and for developing effective health care interventions. Nurse researchers have developed a track record in this area of research with vulnerable populations and have the col- laborative networks established to expand in this area. A very small proportion of nurses enrolled in doctoral nursing research programs receive NRSA support. NEAR supported 261 NRSA positions in 1991. This number rep- resented 9 percent of the total number of students enrolled in nursing doctoral programs and 22 percent of those who were full time students (Bednash et al., 1993~. Many nurses in research training programs study part time because of the lack of resources and the need to work. Financial support for doctoral or postdoctoral study in nurs- ing research is basically nonexistent from nongovernment resources. Nurses completing doctorates in nursing report the highest percent of primary support from personal re- sources (73 percent) compared with the biomedical sciences (22.1 percent) and behavioral sciences (59.4 percent). Nurses also report the lowest percent of support from the university (7.2 percent) compared win biomedical sciences (52.3 percent) and behavioral sciences (32.3 percent). Fed- eral support for nurses win degrees in nursing and the bio- medical or behavioral sciences was lower than federal sup- port for nonnurses (Survey of Earned Doctorates, 1993~. More nurses with doctorates are needed as faculty for schools of nursing. Only three-fifths (59.7 percent) of nurse faculty members with full-time appoinDnents in schools of nursing offering doctoral programs hold earned doctorates. And only one-quarter (24.7 percent) of He faculty in insti- tutions offering the baccalaureate degree hold a doctorate (Bednash et al., 19934. Nursing still has a great distance to go before its academic faculty are fully prepared educa- tionally. Another concern is the age of nursing school faculty. The mean age for faculty in schools with doctoral programs is 49.2 (Bednash et al., 1993~. If young nurse scientists are not trained and recruited to academic institutions, there will be few well- qualified researchers to replace He present pool of scientists as they retire in the next two decades. Most of the projections of need for nurses with doctoral preparation have focused on predoctoral training and have not addressed He needs of nurses with a basic research preparation to build a program of research. Because Here is such a tremendous demand for nurses with doctorates in schools of nursing, faculty have many other teaching re- sponsibilities and often delay developing an active program of research. Fewer than 50 nurses were supported in 1992 by the NRSA program for postdoctoral study. There is also a growing demand for nurses with doctor- ates in service settings where the focus is on clinical re- search, clinical therapeutics, and quality of care. The small supply of nurses with doctoral research preparation con

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS trasts with the large demand for more researchers to gener- ate nursing information and necessitates formulation of a plan to revitalize funding for nursing research training. ENSURING DIVERSITY OF HUMAN RESOURCES Minorities Although the number of minority nurses with doctoral preparation has steadily increased since 1985, minorities represent a very small proportion of faculty members in schools of nursing. Table 7-1 displays relative distribution of U.S. nursing school faculty by racial and ethnic composi- tion in 1992. If we are to adequately address issues of minority representation and health concerns, recruitment of minorities into doctoral programs and as faculty members is a high priority. Age On average, nurses completing doctoral work are a de- cade older than their colleagues in other disciplines. They are moving into clinical practice after obtaining a bachelor of science degree and a master's degree, and proceeding into advanced clinical practice or academic roles before en- tering doctoral programs. This lock-step career progression does not encourage talented young nurses to pursue an in- terest in research training early in their careers. Table 7-2 shows the relative distribution of basic biomedical science and nursing work force by gender and age. In 1992 the mean age of assistant professors with an earned doctorate was 46.8 years. Gender Despite efforts to attract men to this area, nursing re- search continues to be dominated by women. Between 1985 and 1991, 96.5 percent of people with nursing doctorates were women and only 3.5 percent were male. THE NRSA PROGRAM IN NURSING RESEARCH Research Gaining and career development are a major component of He long-range plan of the NINR and have consistently received strong interest from Congress. The NINR supported a total of about 255 trainees in 1991 and 1992 (Table 7-3), although more trainees were supported in 1991 and 1992 Han in 1993. The number remains well below the level recommended by He National Academy of Sciences of 320 trainees by 1990 (NRC, 1985~. Only 16 percent of trainees funded are in postdoctoral Gaining, a figure which has remained relatively constant since 1988.i Table 7-4 provides data on He total number of trainees (liTTPs) supported by year and by individual (F31, F32, and F33) and institutional (T32) awards Trough 1990. The proportion of individual fellowships to traineeships pla- teaued at approximately 60 percent individual and 40 per- cent institutional awards in 1989. As of FY 1992, there were 18 institutional awards. The number of institutional awards is expected to increase gradually as programs of research develop within the schools of nursing that are research intensive (NINR files). The individual award (F31 and F32) has provided nurses with the flexibility to create programs of study within geo- graphic proximity to their homes and to cross discipline boundaries, obtaining doctorates in a variety of health-re- lated fields. Individual trainees have been encouraged to create a team of mentors, led by one primary sponsor, who can provide the specific expertise in methods, measurement, and clinical content that fits He needs of the student. NRSA postdoctoral support increased from 14 full-t~me Gaining positions (FTTPs) (8 percent of total Fl1Ps) in 1986 to 42 FlTPs (16 percent of total FTTPs) in 1992 (Table 7-3~. The benefits of postdoctoral study are begin TABLE 7-l Relative Distribution of U.S. Nursing School Faculty by Racial and Ethnic Composition, 1992 (All Faculty) l Racial and Ethnic CategoryNumber Percent , White6~959 91.8 Black391 5.2 Hispanic95 1.2 Native American20 0.3 Asian108 1.4 SOURCE: American Association of Colleges of Nursing, 1992. 76

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NURSING RESEARCH PERSONNEL TABLE 7-2 Relative Distributions of Nurses with Doctorates Compared with the Basic Biomedical Science Work Force by Gender and Age, 1991 Gender Nurses with Age Group DoctoratesC Biomedicalb MenWomen TOTAL N 11,235 91,959 70,30921,605 25-29 % .5 2.4 2.03.9 30-34 4.8 13.1 11.318.7 35-39 10.0 22.2 20.726.8 4044 26.9 19.9 19.421.4 4549 16.0 18.4 19.415.1 50-54 18.6 11.6 12.97.4 55-59 15.0 6.5 7.53.3 60~4 4.7 4.0 4.52.3 65~9 3.6 1.8 2.00.9 70+ .7 0.2 0.20.2 Total 100.8 100.1 99.9100.0 (Median Age) (47.0) (42.0) (43.6)(39.1) fin percent, may not total 100 because of rounding. Moses, 1993, CIncludes Ph.D. holders working in biomedical science fields and includes postdoctorates. SOURCE: National Institute of Nursing Research, special tabulations, 1993. ning to be recognized in the nursing research community. However, with the current funding levels of postdoctoral trainees and fellows combined with an attractive job market and the average age of 41 for nurses completing doctoral study, it is difficult to attract large numbers into the program. To date, most of the NINR's NRSA program has sup- ported predoctoral fellows and trainees because of the ur- gent need to increase the number of adequately prepared researchers. Less than 20 percent of the awards support postdoctoral research training. Efforts need to be expanded to encourage nurses who recently have completed their doc- toral studies to pursue postdoctoral training. Increases in the stipends will be a first step in recognizing the need to provide financial incentives. These issues underscore the need to incorporate creative and flexible procedures for managing NNSA awards, such as allowing interrupted appointments for other work and personal responsibilities. Multiple alternative methods for 77 research training need to be developed to decrease the time needed for nurses to complete their doctorates after obtain- ing their professional nursing degrees and to enhance their research productivity. RECOMMENDATIONS In fiscal 1993, NINR had approximately 236 positions available for NRSA awards.2 An increase in positions is needed to increase the number of well-qualified nurse re- searchers in the field and to advance He science of nursing research. Program Size On the basis of the number of doctoral programs in nurs- ing and the number of research-intensive environments, an adequate infrastructure already exists within the nursing re

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS TABLE 7-3 Aggregated Numbers of NRSA Supported Trainees and Fellows in Nursing Research for FY 1991 through FY 1993 Fiscal Type of Support Year Level of Training TOTAL Trameeship Fellowship 1991 Number of awards 255 93 162 Predoctoral 220 67 153 Postdoctoral 35 26 9 1992 Number of awards 257 103 154 Predoctoral 217 75 142 Postdoctoral 40 28 12 1993 Number of awards 236 112 124 Predoctoral 188 76 112 Postdoctoral 48 36 12 . . . NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1. search community to respond to an increase in the number of awards. The growth in the number of schools with re- search-intensive environments is expected to continue, thus providing a sufficient number of programs and resources for an expanded NRSA program in nursing research. With the proposed changes in health care reform, contin- ued development of a strong scientific base from nursing research for practice is essential for preparing advanced practice specialists to care for the rapidly changing needs of high-risk and underserved patient populations. RECOMMENDATION: The committee recommends Hat the number of positions available for preparation in nursing research increase from approximately 236 awards in fiscal 1993 to 500 positions in fiscal 1996. These posi- tions should be phased in yearly as properly qualified can- didates and training sites present themselves (Table 7-5~. Balance in Mechanisms of Support Because nursing research is a burgeoning field of sci- ence, Here is a critical need to have an increased number of highly trained nurse researchers to develop information Hat is at the cutting edge for nursing practice and health care. Support for research Paining at He Predoctoral level must be expanded to increase the number of nurse researchers prepared at the postdoctoral level. As the number of NRSA positions increase by the year 1999, there will be a progres- sive shift toward an eventual balance between He propor- tion of funding to Predoctoral and postdoctoral fellows and trainees. NRSA awards at both pre- and postdoctoral levels re- main the primary mechanism for financial support for ~ain- ing of nurse researchers. There is a critical need to prepare an adequate pool of qualified nurse researchers to fill He TABLE 7- 4 Numbers of NRSA Supported Trainees and Fellows Supported bv NINR in FY 1986 through FY 1990. Type of Support Fiscal Training Grants TOTAL Year Number Positions Fellowships POSITIONS 1986 2 14 151 165 1987 9 36 131 167 1988 1 1 55 13 1 186 1989 12 69 150 219 1990 16 89 168 257 SOURCE: National ldstitute of Nursing Research, Special Tabulations, 1993. 78

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Fiscal Year 1994 NURSING RESEARCH PERSONNEL TABLE 7-5 Committee Recommendations for Relative Distribution of Predoctoral and Postdoctoral Tra~neeship and Fellowship Awards for Nursing Research for FY 1994 through FY 1999 Type of Support TOTAL Trameeship Fellowship 340 290 50 Level of Training Recommended number of awards Predoctoral Postdoctoral 130 95 35 210 195 15 1995 Recommended number of awards 420 160 260 Predoctoral 360 120 240 Postdoctoral 60 40 20 1996 Recommended number of awards 500 195 305 Predoctoral 430 145 285 Postdoctoral 70 50 20 1997 Recommended number of awards 500 195 305 Predoctoral 430 145 285 Postdoctoral 70 50 20 1998 Recommended number of awards Predoctoral Postdoctoral 1999 Recommended number of awards Predoctoral Postdoctoral 500 430 70 500 430 70 195 145 50 305 285 20 195 305 145 285 50 20 demands for faculty positions in research-intensive envi- ronments. Flexible and creative mechanisms must be es- tablished to meet the increasing demand for qualified fac ulty in research-intensive environments. RECOMMENDATION: As the number of awards in nursing research expands, emphasis should be given equally to the development of Predoctoral and postdoc- toral awards. NOTES 1. The predoctoral/postdoctoral split in nursing research was 86 per- cent/14 percent in 1988, 85 percent/15 percent in 1989 and 84 percent/16 percent 1990. 2. According to the National Institute for Nursing Research, the num- ber of positions in 1993 was reduced due to an increase in Predoctoral stipends in the absence of budget adjustments. REFERENCES American Association of Colleges of Nursing (AACN) 1992 May/June 1992. Syllabus. Washington, DC. Bednash, G., L.E. Berlin, and O. Alsheimer 1993 1992-1993 Enrollment and Graduation in baccalaureate and graduate programs in Nursing. Washington. American Asso- ciation of Colleges of Nursing. Brooten, D., S. Kumar, L. Brown, P. Butts, S. Finkler, S. Bakewell-Sachs, 1986 A. Gibbons, and M. Delivoria-Papadapoulos A randomized clinical trial of early discharge and home followup of very low birthweight infants. The New England Journal of Medicine 315:934-9. Bureau of Health Professions, Division of Nursing, U.S. Department of Health and Human Services. 1991 National Sample Surveys of Registered Nurses, 1977-1988. Health Personnel in the United States: 8th Report to Con- gress. Cowan, J., H. Kogan, R. Burr, S. Henderson, and L. Buchanan 1991 Power speckal analysis heart rate variability after biofeed- back training. Journal of Electrocardiology, 23(Suppl):85- 94. Hester, N., R. Foster, and K. Kristensen 1990 Measurement of pain in children: Generalizability and valid ity of the pain ladder and the poker chip tool. In Advances in Pain Research and Therapy, ed. D. Tyler and E. Krane, pp. 79-84. New York: Raven Press. 79

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS Johnston, C., A. Tax, A. Barsevick, F. Whitney, L. Luborsky, B. Lowery, and R. McCorkle In press Exploration of depressive symptomatology in colorectal can- cer patients, stroke patients, and psychiatric outpatients. Psy- chological Review. McCorkle, R., C. Jepson, D. Malone, E. Lusk, L. Braitman, K. Buhler- Wilkerson, and J. Daly 1994 The impact of post-hospital home care on patients with can- cer. Research in Nursing and Health 17:4. Moses, E.B. 1986 The registered nurse population. Findings from the National Sample Survey of Registered Nurses, November 1984. USDHHS, Bureau of Health Professionals, Division of Nurs ing, #32. Moses, E.B. 1993 The registered nurse population. Findings from the National Sample Survey of Registered Nurses, November 1992. USDHHS, Bureau of Health Professional*, Division of Nurs- ing, Prepublication. Rudy, E., B. Turner, M. Baun, R. Stone, and J. Bruccia 1991 Endotracheal suctioning in adults with head injury. Heart & Lung 20(6):667-674. 80 Shaver, J., M. Lentz, M. Heitkemper, and N. Woods 1992 Gastrointestinal, musculoskeletal and fatigue symptoms: Sleep in midlife women. Sleep Research 21:339. Survey of Earned Doctorates Sponsored by five Federal Agencies (National Science Foun- dation (NSF), National Institutes of Health (NIH), U.S. De- partment of Education (USED), National Endowment for the Humanities (NEH), and the U.S. Department of Agriculture (USDA), and conducted by the National Research Council (NRC). Tax, A., A. Orsi, M. Lafferty, A. Barsevick, L. Luborsky, M. Prystowsky, D. Nahess, B. Lowery, and R. McCorkle 1994 A descriptive study of immune status in colorectal surgical patients: Lymphocyte phenotypes. Oncology Nursing Forum, 21(9). Woods, N., Haberman, M., and Packard, N. 1993 Demands of illness: Individual, dyadic and family function- ing. Westem Journal of Nursing Re*earch 15(1):10-25.