5
Nursing Research

In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort.

—Florence Nightingale, 1860, p. 125

Population growth, urbanization, new energy sources, advanced technology, industrialization, and modern agricultural methods have enabled unprecedented progress. At the same time, they have created hazards to human health that are dramatically different from hazards of the past. Synthetic chemicals, new sources of toxic substances, and naturally occurring radiation are distributed throughout the environment. The potential risks from many of these agents were initially either unrecognized, underestimated, or accepted as inevitable and minor in comparison to the benefits of modernization and economic growth. Public awareness and perceptions have changed. Extensive research programs, carried out in public health and environmental agencies, are under way to determine the potential harmful effects of chemical agents on the environment and health.

—Healthy People 2000 (DHHS, 1990, p. 312)

Implicit in the Healthy People 2000 objectives is the recognition that within the next decade, research is certain to provide a better understanding of the relationship between exposure to environmental hazards and adverse health outcomes. Nursing research could also be expanded to address the nature of hazards in the physical environment and their impact on human health.

The impact of the human-physical environment interaction on the health of individuals and of all people has been an enduring theme in the development of the discipline and science of nursing (Donaldson and Crowley, 1978). Indeed, in the early nineteenth century Florence Nightingale, a pioneer in the development of nursing science, emphasized that the nature and quality of a patient's physical environment are determinants of the patient's recovery of health. A major therapeutic function of



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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 5 Nursing Research In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. —Florence Nightingale, 1860, p. 125 Population growth, urbanization, new energy sources, advanced technology, industrialization, and modern agricultural methods have enabled unprecedented progress. At the same time, they have created hazards to human health that are dramatically different from hazards of the past. Synthetic chemicals, new sources of toxic substances, and naturally occurring radiation are distributed throughout the environment. The potential risks from many of these agents were initially either unrecognized, underestimated, or accepted as inevitable and minor in comparison to the benefits of modernization and economic growth. Public awareness and perceptions have changed. Extensive research programs, carried out in public health and environmental agencies, are under way to determine the potential harmful effects of chemical agents on the environment and health. —Healthy People 2000 (DHHS, 1990, p. 312) Implicit in the Healthy People 2000 objectives is the recognition that within the next decade, research is certain to provide a better understanding of the relationship between exposure to environmental hazards and adverse health outcomes. Nursing research could also be expanded to address the nature of hazards in the physical environment and their impact on human health. The impact of the human-physical environment interaction on the health of individuals and of all people has been an enduring theme in the development of the discipline and science of nursing (Donaldson and Crowley, 1978). Indeed, in the early nineteenth century Florence Nightingale, a pioneer in the development of nursing science, emphasized that the nature and quality of a patient's physical environment are determinants of the patient's recovery of health. A major therapeutic function of

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health nurses was to control the physical environment (Nightingale, 1860). However, the centrality of studies of the physical environment to nursing science has been lessened by the emergence of competing realms, such as studies that address other types of human relationships (e.g., social and nurse-client) and their impact on human health. One of the challenges to nursing presented by the Healthy People 2000 report is to reemphasize the importance of research related to physical environmental hazards and the health of humans. NURSING RESEARCH PERSPECTIVE Nursing research emanated from and continues to develop because of a societal mandate and demand for professional nursing services. As a branch of disciplinary knowledge, nursing is a professional rather than an academic discipline (Donaldson, 1995; Donaldson and Crowley, 1978), and nursing research reflects the profession's focus on the health status and care of individuals and populations. According to the National Institute for Nursing Research, National Institutes of Health (established in 1993 to supersede the National Center for Nursing Research [National Center for Nursing Research, 1993, p. 5]): Nursing is the discipline associated with the science and art of caregiving. Although all health professionals care about those to whom they provide services, actual acts of care-giving in health and illness are most frequently performed by nurses. The nursing discipline grew out of public demand for educated, formal caregivers devoted to the public good. Throughout its history, nursing has espoused the idea that caregiving during health and illness must be organized around individuals, families, and communities rather than diseases (Lynaugh and Fagin, 1988). Nursing also recognizes the effect of culture in shaping the definition of health and illness and interpreting human responses to physiological and biological changes. The nursing research perspective focuses on understanding the biological and behavioral elements of human health rather than on elucidating diseases and their treatment or cure. Understanding the complex relationship between human behavior and the physical and biological environmental hazards with the aim of assisting in bringing about the requisite changes in societal action and human behavior is the major focus of nursing in environmental health. The knowledge generated from nursing research provides information on how humans achieve health, respond to threats to their health, and cope with disease, as well as how to treat disease. In nursing research the conceptualization of human (either individual or collective) is holistic, and a priority is the preservation of human autonomy in the achievement of health (Donaldson, 1995; Gortner, 1990).

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Thus, in the area of environmental health, nursing research addresses (1) human responses to potential and real environmental hazards and (2) interventions directed toward preventing exposure to environmental hazards (primary intervention), limiting exposure to the hazards (secondary intervention), and treating or rehabilitating individuals exposed to environmental hazards (tertiary intervention). Nursing research also addresses the quality and safety of the physical environment from the perspective of how humans interact with their environment in their general pattern of living. An example of this type of research is the work-related enhancement of person-environment compatibility by reducing ambient stresses such as noise and sound levels (Topf, 1994). Nursing research is also directed toward quality control of the human physical environment and public policy related to that goal. Nursing research thus spans from the individual human biological (e.g., physical symptoms of lead poisoning) and behavioral (e.g., ingestion of paint chips) responses to collective or group behavior (e.g., community-based efforts or regulatory policy to remove a hazard) in the area of environmental health. MULTIDISCIPLINARY RESEARCH BASE FOR NURSING PRACTICE As a profession, nursing's highest priority is professional practice that is research based and scholarly. The significant changes that are occurring in the scope of nursing clinical practice and the curricula of the professional educational programs require a supporting knowledge base. If the area of environmental health is to be incorporated into all realms of nursing practice, an appropriately conceptualized knowledge base must be available and continually expanded. In clinical practice, nurses provide service in a wide variety of settings that are significant to humans (e.g., health care facilities, home, workplace, school, and community). Nurses plan their intervention strategies in the context of the setting, the social network, and the resources of the client. Knowledge essential to this clinical practice is that derived from nursing research as well as the more traditional areas of environmental health research such as human disease manifestation, risk assessment, and risk management. Nurses in clinical practice need to have knowledge of these traditional realms to recognize and identify hazards, but they also must know how to control the quality of the physical environment and to effect change in human behavior (whether it be an individual's lifestyle or policy-making) to help individuals avoid, reduce, or eliminate environmental hazards. Nurses also participate in treating humans affected by these hazards. For example, radioactive contamination of soil has adverse

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health effects on the health of an individual (e.g., increased risk of cancer, adverse reproductive effects) and community health (e.g., contaminated food and water supplies). Studying this hazard and treating humans affected by this hazard are major challenges that should be addressed by many disciplines and professions, including nursing. Thus, research and clinical practice in environmental health best serve societal health when they are approached from an interdisciplinary perspective in both research and practice. REVIEW OF NURSING RESEARCH IN ENVIRONMENTAL HEALTH The committee conducted a review of recently funded research projects and recently published research reports to ascertain the scope and general nature of nursing research activity in environmental health. For the purposes of the review, nursing research grants were defined as environmental health and occupational health projects if they could be directly related to clinical nursing practice and to the discipline of nursing (i.e., nurse principal investigator and funded by a nursing organization or conducted in a unit of higher education with a formal professional nursing education program, such as a school of public health). In conducting the literature search, research reports were categorized as nursing research if they were published in a nursing journal and pertained directly to nursing practice, regardless of whether the author was a nurse. The databases surveyed for funded research projects were broad. They were chosen with the intention of capturing the majority of the funded projects in the general area of environmental and occupational health and included a survey of those professional and private research organizations known to fund nursing research (Table 5.1). Similarly, the survey of research reports in the published literature was broad and included surveys of large databases such as MEDLINE and CINAHL to capture as much nursing research as possible in the area of environmental and occupational health (Table 5.2). The search parameters for the various databases surveyed are given in Tables 5.1 and 5.2. Note that the funded projects identified as nursing research all had a nurse as a principal investigator and were funded by a nursing organization or conducted in a unit of higher education with a formal professional nursing program, such as a school of public health. For those funded grants and published reports identified as nursing research in environmental and occupational health in Tables 5.1 (21 grants) and 5.2 (14 papers), an additional content analysis was performed as shown in Table 5.3. The coded study characteristics and categories used in this content analysis of each project or report are given in Table 5.3; note that the published papers analyzed for Table 5.3

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health TABLE 5.1 Recently Funded Research Grants from the Government and Professional or Private Research Organizations Related to Environmental Health Content in Nursing Databases Surveyed for Funded Research Parameters No. of Citations No. of Nursing Research Grants Directly Related to Environmental Health Government Agencies Department of Defense Grants involving nurses, 1993–1994 30 2 National Institute of Environmental Health Sciences Grants active in 1994 737 0 National Institute of Justice Grants active in 1993 98 0 National Institute for Nursing Research Grants active in 1993 500 6 National Institute for Occupational Safety and Health Grants involving nurses, 1990–1994 2 1 Subtotal   1,367 9 Professional or Private Research Organizations American Cancer Society All environmentally related grants, 1990–1993 345 0 American Heart Association All awards to individuals, 1992–1993 2,476 0 American Association of Occupational Health Nurses Environmentally related research, 1990–1994 8 8 American Nurses Foundation All grants, 1990–1993 109 1 Association of Women's Health, Obstetrics and Neonatology All grants, 1990–1994 24 0 Oncology Nursing Society All grants, 1990–1994 95 0 Sigma Theta Tau International All grants, 1990–1993 68 3 Subtotal   3,125 12 TOTAL   4,492 21

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health TABLE 5.2 Recently Published Research Reports Related to Environmental Health in Nursing Literature Databases Surveyed Parameters No. of citations No. of Nursing Research Reports Directly Related to Environmental Health CINAHL Medline ERIC NTIS Conference Paper Index Terms used include: community health nursing, maternal or child health and nursing, nursing and environment, occupational health nursing, pediatric nursing, and public health nursing (1990–July 1994) 1,098 14 did not have to have a nurse principal investigator or a nursing organization affiliated with the principal investigator. For all of the survey data collection and content analysis of individual research projects, two committee members developed and pilot tested a coding sheet to test the reliability and the completeness of the data collected. All discrepancies in coding between coders were resolved by consensus. Results of Review Results of the survey of funding agencies are reported in Table 5.1. The total pool of grants reviewed was large (4,492), but only a small proportion (21 of 4,492, or 0.5 percent) was identified as nursing research in environmental or occupational health. Similarly, only a small proportion (14 of 1,098, or 1.3 percent) of the relevant research literature was in the area of nursing research in environmental or occupational health (Table 5.2). Government agencies, professional nursing organizations, and private organizations participated in funding of the grants and published research articles. The results of the content analysis of the 35 projects and publications identified as nursing research in environmental or occupational health are displayed in Table 5.3. The data reported in Table 5.3 reflect a high proportion (94.3 percent) of nurse principal investigators, which was somewhat expected, since all of the funded grants (n = 21) had a requirement of a nurse principal investigator. But even in the review of the literature, 12 of the 14 (85 percent) published papers that were categorized

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health TABLE 5.3 Characteristics of Nursing Research in Environmental or Occupational Health: 1990–1994 (n = 35 grants and published reports from Tables 5.1 and 5.2) Characteristics of Nursing Research Description of Characteristic % of Nursing Research (n) Investigator Nurse 94.3 (33)   Other 5.7 (2) Affiliation of principal investigator School of nursing 48.6 (17)   Corporate 20.0 (7)   Unknown 14.3 (5)   Other university 11.4 (4)   Government 5.7 (2) Funding source None or not noted 22.9 (8)   American Association of Occupational Health Nurses 22.9 (8)   National Institute for Nursing Research 17.1 (6)   Emergency Room Nursing Foundation 8.6 (3)   Sigma Theta Tau International 8.6 (3)   Department of Defense 5.7 (2)   Occupational Safety and Health Administration 5.7(2)   American Nurses Foundation 2.8 (1)   Centers for Disease Control and Prevention 2.8 (1)   National Institute for Occupational Safety and Health 2.8 (1) Funding amount Unknown 60.0 (21)   <$1,000 14.3 (5)   $1,000–$50,000 14.3 (5)   $50,000–$100,000 2.8 (1)   >$100,000 5.7 (2)   None 2.8 (1) Focus Occupational 91.4 (32)   Environmental 8.6 (3) Topics Populations at risk 74.3 (26)   Disease or condition 22.9 (8)   Prevention 22.9 (8)   Particular hazard 20.0 (7)   Education 14.3 (5)   Policy 11.4 (4) Population studied Industrial workers 22.9 (8)   Nurses 20.0 (7)   Office/municipal workers 20.0 (7)   Agricultural workers 17.1 (6)   Pregnant women/new mothers 8.6 (3)   Neonates 5.7 (2)   Disabled 2.8 (1)   Rats 2.8 (1)

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Characteristics of Nursing Research Description of Characteristic % of Nursing Research (n) Health hazards/conditions studied General health 28.6 (10)   Musculoskeletal 17.1 (6)   Hearing impairment 11.4 (4)   Accidents 8.6 (3)   Lead exposure 2.8 (1)   Conjunctivitis 2.8 (1)   Natural disasters 2.8 (1)   Disability 2.8 (1)   Pesticides 2.8 (1) Study designs Descriptive 80.0 (28)   Intervention/experimental 20.0 (7) as nursing research in environmental or occupational health were authored by nurses. Most (48.6 percent) of the principal investigators of the research grants and published papers were affiliated with schools of nursing; other nonnursing units of universities represented 11.4 percent of the principal investigators, making institutions of higher education the primary source of nursing research in environmental or occupational health. Corporations were affiliated with 20 percent of the research. The data in Table 5.3 also indicate that there are funding sources for nursing research in environmental health, such as the Centers for Disease Control and Prevention (CDC), Emergency Room Nursing Foundation, and the Occupational Health and Safety Administration (OSHA) that were not included in the databases that were searched for funded grants (Table 5.1). The focus of the grants and published reports (Table 5.3) was primarily occupational health (91.4 percent), the topics, subject groups, and health hazards or conditions were broad, and the design of the research projects was predominantly descriptive (80 percent). Discussion of Review On the basis of the survey results, there is, in general, a dearth of research in environmental or occupational health related to the practice of nursing. Nursing research represents an extremely small component of the portfolio of funded research of the agencies and organizations polled (Table 5.1; 9 of 1,367, or 0.6 percent, of government grants and 12 of 3,124, or 0.4 percent, of grants from professional and private research organizations). The reason for this underrepresentation of nursing research in environmental or occupational health was not explored, but it likely reflects

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health a very small pool of nurse researchers in general. Thus, nurse researchers and nursing research in the area of environmental or occupational health are underrepresented in terms of numbers and activity, respectively. Nonnurse investigators in the area of environmental or occupational health do not appear to be conducting studies directly related to the knowledge base for nursing practice. Expansion of the research directly related to the practice of nurses in the area of environmental or occupational health is most likely to be accomplished by expanding the research conducted by nurse investigators. Currently, nurse principal investigators in the area of environmental and occupational health identified in the survey are primarily affiliated with schools of nursing (48.6 percent; Table 5.3). Of interest is that the principal nurse investigators in corporate settings identified in the review (Table 5.3) make up a higher proportion (20 percent) than the proportion in other, nonnursing university units (11.4 percent), for example in schools of public health. This finding is most likely a reflection of the predominant occupational health focus of the studies captured as part of the survey of the literature (91.4 percent; Table 5.3). Schools of nursing and universities are the administrative homes for the majority of the nurse investigators in environmental or occupational health. However, there is evidence that the private sector is active in nursing research. The scope of the research studies surveyed (grants and published papers) seems to be broad in terms of topics, subject groups, and health hazards or conditions. In contrast, the type of design (i.e., descriptive studies) and total funding for nursing research appear to be limited. Current nursing research in the area of environmental or occupational health appears to be predominantly descriptive rather than clinical studies employing experimental or other nonexplorative designs. This is a limitation because the application of knowledge to practice generally follows clinical intervention studies. The reason for the preponderance of descriptive nursing research studies is not known, but descriptive work usually signifies a research realm in which the problems and variables are not well defined or little is known about the area. In other words, to conduct research that can serve as a basis for clinical nursing practice in environmental or occupational health, it may be necessary to conduct some descriptive studies to identify appropriate and valid biobehavioral models from which nursing interventions could emanate. However, the highly descriptive research found in the survey might also reflect an inadequate focus of the research on clinical intervention strategies for nurses, even though it is conducted by nurse investigators. It is difficult to ascertain information regarding the nurse's role in multidisciplinary team research where the nurse is not a co-investigator.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Regardless of the reason for the predominantly descriptive nature of the work, it is clear that scant research supports the clinical practice of nursing in environmental or occupational health. Because nursing, like the other health professions, strives to base its clinical practice and educational programs on knowledge generated from research, the volume of relevant clinical research in environmental health must be increased to support nursing practice in this area. To generate an adequate knowledge base to support nursing practice in environmental or occupational health, the numbers of nurse researchers and funded projects must be increased, and the design of the work must be broadened to include experimental and intervention studies. MEETING THE NEED FOR NURSING RESEARCH IN ENVIRONMENTAL HEALTH Development of the Cadre of Nurse Researchers Nurses at all educational levels can contribute to the research enterprise in meaningful ways, be it problem identification, risk assessment, investigation, data analysis, dissemination of knowledge, research utilization, policy formulation, or risk communication. However, nurses at the doctoral level must be prepared to guide these investigations. Because of their unique access to people in multiple settings, nurses are essential for identifying researchable problems and questions. For example, maternal and child health nurses could be continuously screening children who may have been exposed to residential lead-based paint or pesticides on farms; emergency room nurses could attempt to decipher how individuals are exposed to toxic wastes or environmental poisons; occupational health nurses could be screening for the vast array of workplace exposures resulting in illness and injury such as reproductive toxicity, cancer, neurological dysfunction, and musculoskeletal disorders; and pediatric nurses could be linking childhood illnesses to toxins transported from a parent's workplace to the home. Nurses working in community health, especially those in inner-city and rural settings, have a key role in environmental health. Some nurses in community-based practice are involved in identifying group patterns of illnesses and sentinel health events that may have their origins in environmental exposures (Lipscomb, 1994b; Rogers, 1994). For example, a draft U.S. Environmental Protection Agency (EPA) report stated that epidemiological studies of extremely low-frequency electromagnetic field exposures and leukemia, lymphoma, and cancers of the nervous system among children and workers show a consistent pattern of response that suggests but does not prove a causal link (EPA, 1990). This conclusion is

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health supported by several epidemiological investigations that have shown higher rates of brain tumors and leukemia among children who lived near high-distribution lines (Savitz, 1988); greater risk for brain cancer in workers with high levels of exposure to electromagnetic radiation (Savitz and Loomis, 1995); developmental delays and miscarriages from exposure to electric blankets and ceiling cable heating systems (Wertheimer and Leeper, 1986, 1989); and a possible link between male breast cancer and electromagnetic field exposure in telephone linemen (Demers, 1990; Matanowski et al., 1989). Clearly, public health or community health nurses could be involved in identifying and investigating these types of problems. Nurses who complete a thesis as part of their masters degree requirements are prepared to conduct preliminary or pilot studies related to their specialties, work settings, or problems identified through their clinical practice. For example, community health nursing programs identify, collect, and analyze population-based data. However, although research is a component of their practice, it is not the focus of their professional responsibilities. As in the other health professions and sciences, the leaders and principal investigators of nursing research are best prepared in educational programs that require a dissertation in either the field of nursing or other disciplines. The graduate degrees in nursing that correspond to this preparation are the PhD, DNS, DNSc, and DSN (Doctor of Nursing Science). Although research is one component of the curriculum in baccalaureate and master's programs in nursing, the purpose of these non-doctoral-level programs is to prepare nurses to apply research and to act as participants in the research process. The preparation of independent investigators is the domain of the graduate-level doctoral programs. Currently there are 49 PhD programs and 11 DNS/DNSc/DSN programs in institutions of higher education in the United States (American Association of Colleges of Nursing [AACN] 1994–1995 Enrollment and Graduations Baccalaureate and Graduate Programs in Nursing). Postdoctoral nursing research programs are also available at 12 institutions. Existing nurse researchers might use postdoctoral programs in nursing or environmental health-related sciences (e.g., toxicology and public health) to gain expertise in conducting research in environmental health. Because of the interdisciplinary nature of environmental health, educational programs and mentorships involved in interdisciplinary research are desirable. Additionally, nurses with doctorates in related environmental health sciences may be particularly helpful in integrating nursing research and facilitating the interdisciplinary nature of research. Solutions to the problems and questions presented by the complex interaction between humans and their environment generally require the collaboration of investigators in several disciplines. Nursing has a place

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health in these interdisciplinary endeavors. Fostering interdisciplinary research, in which nurses interact to identify and study environmental topics of concern, will result in a wide range of contributions that can be used to solve problems. Moreover, the fairly recent revolution in academic nursing research was created, above all, by scientists pursuing not only support for their own investigations, but also opportunities to participate in exciting science. To benefit from the valuable observations and powers of reasoning of those nurse researchers with firsthand knowledge of humans in their environments, communication with the broad research community, both intradisciplinary and interdisciplinary, must be improved. The NIOSH-sponsored Educational Resource Centers (see Chapter 4) can be a tremendous resource to researchers in environmental health because of their multidisciplinary nature. The number of openings for students in existing doctoral programs in nursing is limited, and environmental health is not a current focus in these programs. Thus, there are major challenges to increasing the cadre of nurse researchers in environmental health. Stimuli are needed to expand doctoral programs in nursing and to redirect the programmatic offerings to emphasize research in environmental health. Implicit in such efforts is support for faculty research programs in environmental health and for researchers who can mentor doctoral and postdoctoral students. There is also value in nurses seeking doctorates in nonnursing disciplines (e.g., toxicology and epidemiology). The interaction of environmental factors associated with acute and chronic illness, health promotion, and disease prevention are important foci of nursing research to improve the health of the community and patient care. To take advantage of the rapid changes taking place in the environmental sciences and to explore these environmental linkages, training and career development resources should be focused on the areas of environmental science that underlie and influence nursing practice (e.g., human response to environmental exposures and conditions). Thus, there is a need for research training and career development in the environmental sciences to (1) develop a cadre of nurse scientists with research training at the predoctoral and postdoctoral levels in environmental science and nursing science and (2) enhance the knowledge base of midcareer nurses with doctorates whose research relates to or might be redirected to environmental sciences. The overall goal of a training initiative would be to increase the number of nurse researchers in the environmental sciences who are prepared to explore the environmental linkages to nursing practice and research as they affect the public's health. To accomplish this goal, it is important that applicants for research funding include a nurse scientist as cosponsor when the sponsoring environmental scientist (i.e., mentors) does not have

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health a nursing degree. Training and career development programs could provide opportunities for nurses to conduct supervised clinical and basic research at the interface between nursing and at least one of the traditional environmental disciplines. The academic, clinical, and laboratory environments could facilitate growth and development for promising students, new research scientists, and midcareer scientists. Important elements of training would include, for example, ongoing interactive departmental seminars; a faculty well published in refereed journals; and an interactive, interdisciplinary research team funded by multiple sources. This type of training opportunity links research and graduate education—the defining strength of academic research and the education enterprise. The National Institute for Nursing Research is committed to promoting the development of a career trajectory for research training of nurse investigators. The purpose of the trajectory is to operationalize the philosophical stance that research training is a career commitment. Such a trajectory allows researchers to remain updated and in the forefront of the content and methodologies of their scientific fields. A series of award mechanisms are available to facilitate research training and career development. Current Priorities of Funding Sources for Nursing Research Nursing research and research education in environmental and occupational health sciences have several sources of interdisciplinary support. Those organizations most likely to be interested in environmental health and nursing are listed in Table 5.1 and were included in the survey. However, it is also apparent from the survey that there is some private-sector corporate funding for nursing research. The potential of this funding source has not been explored. Sigma Theta Tau International Since 1992 Sigma Theta Tau International (STTI) has engaged in joint endeavors with several specialty organizations to fund collaborative research projects. Rogers (1994) reported on such efforts between STTI and the American Association of Critical Care Nurses, STTI and the Oncology Nursing Society, STTI and the Emergency Nurses Association, and STTI and the American Association of Diabetes Educators, whereby research projects are jointly funded and overall administrative coordination is handled by the specialty organization. The participating organizations jointly recognize the award recipients.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health National Institute for Nursing Research, National Institutes of Health The National Institute for Nursing Research (NINR) and the National Institute of Environmental Health Sciences (NIEHS) have announced their interest in receiving individual and institutional National Research Service Award (NRSA) applications for support of training at the pre- and postdoctoral levels for nurses interested in pursuing research careers combining environmental health and nursing sciences. Applications for predoctoral awards will be considered only by NINR. The purpose is to provide a cadre of nurse investigators who can apply the principles of clinical nursing research to environmental health research problems and to achieve the health promotion and disease prevention objectives of Healthy People 2000 (DHHS, 1990). Targeted NRSA fellowships in environmental sciences must focus on environmental science development, advanced clinical science development, and supervised research training experience. Applicants must integrate an area of environmental theory with a relevant nursing problem. It is necessary that the sponsor be an environmental nurse scientist or an environmental scientist with a nurse scientist as cosponsor. The following are currently available NRSA fellowships: The predoctoral environmental science fellowship is designed to provide predoctoral nurses with supervised clinical or basic environmental research training leading to the PhD. Applicants must be registered nurses. The postdoctoral environmental science fellowship is designed to provide postdoctoral research training to nurse scientists who wish to refine their research interests, initiate independent research programs, and gain depth of knowledge in their clinical or basic environmental research area. To prepare scientists to explore the environmental underpinnings of nursing practice and research, applicants must integrate environmental science with a nursing problem or a clinical practice issue. Priority status will be given to nurses with doctorates who submit a successful postdoctoral NRSA application, which would enable continued training without a break between doctoral and postdoctoral programs. To ensure maximum growth and development as a research scientist and to increase the integration of new theories and ideas, postdoctoral fellows are advised to choose universities or departments other than the site of their doctoral training. The senior biological science fellowship award provides advanced training for experienced nurse scientists (with at least 7 years of relevant research or experience beyond the doctoral level). These awards are designed to enable nurse scientists to take time off from their regular professional

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health responsibilities to make major changes in the direction of their research careers or to broaden their scientific backgrounds by acquiring new research capabilities. This award is directed at nurse researchers who are well prepared in environmental science and who desire to learn new methodologies and techniques. For example, a nurse scientist might combine sabbatical time with senior biological science fellowship funding. NINR also has available the full menu of National Institutes of Health-type research (e.g., investigator-initiated R01) and training awards (K type) for investigator-initiated projects, which could include environmental health. One such opportunity, the Exploratory Center Award mechanism (e.g., P20) has worked well for establishing centers of excellence in multidisciplinary research in various realms of nursing science. National Institute for Occupational Safety and Health In recent years the National Institute for Occupational Safety and Health (NIOSH) began to fund nursing research and nursing research training originally related to the 10 leading causes of morbidity and mortality that are biomedical in origin. The effort to emphasize the linkage of nursing research to national priorities gives graduate students more opportunities to participate in interdisciplinary research that is relevant to occupational health, safety, and related issues. Students thereby gain increased experience working in multidisciplinary and often multisectional groups on projects designed to highlight connections between new knowledge and the health and well-being of society. NIOSH offers a variety of research awards that are frequently related to the cause and prevention of leading work-related problems identified by NIOSH. This source provides a specific funding avenue for nurses who desire to investigate occupational health, safety, and related issues. American Association of Occupational Health Nurses The American Association of Occupational Health Nurses (AAOHN) offers competitive annual awards to promote and recognize research and innovative projects that focus on issues and problems within occupational health nursing. Research priorities established by AAOHN identify a wide range of researchable topics for occupational health nursing investigations.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Recommendations Scope of Nursing Research in Environmental Health Recommendation 5.1: Multidisciplinary and interdisciplinary research endeavors should be developed and implemented to build the knowledge base for nursing practice in environmental health. Rationale: Despite the match of the nursing research perspective with the realm of environmental health, there is a dearth of research to support environmental health in clinical nursing practice. Furthermore, designs for nursing research projects in environmental health are of inadequate methodological depth, and are primarily descriptive. Strategies for Achieving Recommendation 5.1: Establish multidisciplinary environmental health training grants that include content in physical, biological, and behavioral sciences relevant to nursing practice. Provide incentives for multidisciplinary mentorship for pre- and postdoctoral research fellowships that include nursing research. Provide incentives to include a nursing research component in environmental health program projects. Establish mechanisms for nurse researchers to interact with and access the resources of the existing National Institute for Occupational Safety and Health's Educational Resource Centers and the National Institute of Environmental Sciences' Environmental Health Centers. Use existing mechanisms for establishing multidisciplinary centers of research excellence, such as the NIH Exploratory Center Award (P20), to develop sites for nursing research in environmental health. Individual nurse researchers should seek collaborative research opportunities in environmental health. Include nurses as members of editorial boards and institutional review boards (IRBs). Availability of Researchers Recommendation 5.2: The number of nurse researchers should be increased to prepare to build the knowledge base in environmental health as it relates to the practice of nursing. Rationale: Few researchers, nurse or nonnurse, have published data and findings that support environmental health in the clinical practice of

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health nursing. Of this very small number, the researchers contributing to the knowledge base for clinical nursing practice and environmental health are almost exclusively nurses. Nurse researchers are also the faculty most likely to incorporate research findings into the curricula of nursing education programs. Strategies for Achieving Recommendation 5.2: Increase the numbers of new investigator awards available to nurse researchers in environmental health. Create mechanisms for recognizing achievement in developing the body of knowledge in environmental health. Use research and other funding mechanisms to create centers of research excellence in environmental health with nurse researcher principal investigators. Create incentives for faculty in general and for faculty of schools of nursing and other units of higher education to incorporate environmental health content into a research-based curriculum. Plan consensus and other conferences in which nursing and other faculty can identify and coalesce current research-based content in environmental health with regard to the clinical practice of nursing. Provide incentives for nursing faculty to develop expertise in environmental health. Priorities for Nursing Research in Environmental Health Recommendation 5.3: Research priorities for nursing in environmental health should be established and used by funding agencies for resource allocation decisions and to give direction to nurse researchers. Rationale: The descriptive nature of the existing nursing research in environmental health suggests an underdeveloped approach to building the knowledge base for clinical practice. In addition, despite the breadth of topical areas, nursing research in environmental health lacks depth in any one area. Strategies for Achieving Recommendation 5.3: Use multidisciplinary teams of experts in environmental health (including nurse researchers, advanced-practice nurses, and public health nurses) jointly to identify the nursing research priorities.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Include private-sector corporations in setting priorities for funding. Provide incentives for nurse researchers to be primary investigators on interdisciplinary research directed towards the clinical practice of nursing. Encourage joint programs among different institutions to help achieve ''critical mass" and to have the broadest possible impact. Dissemination of Research Findings Recommendation 5.4: Current efforts to disseminate research findings to nurses, other health care providers, and the public should be strengthened and expanded. Rationale: The impact of research on nursing practice is enhanced by effectively communicating the research findings to nurses, other health care professionals, and the public. For this reason, it is important that the findings be published in peer-reviewed journals and other media—including nursing and interdisciplinary journals as well as the public press—that will reach the appropriate target audiences. An emphasis on interdisciplinary dissemination is particularly important in regard to occupational and environmental health research. Strategies for Achieving Recommendation 5.4: In addition to publishing reports, articles, and other documents, the dissemination of environmental health research results at a wide variety of professional meetings should also be pursued (e.g., through presentations and posters). Researchers should be encouraged to share research instruments as a way of furthering the body of knowledge and the replication of studies. Focused research conferences on environmental health in nursing could be used to disseminate research findings to nurse clinicians and educators.