Summary

Military nursing research focuses on enhancing health care delivery systems and processes to improve clinical outcomes, advancing the practice of military nursing in support of mission readiness and deployment, and contributing to the health status and quality of life of military personnel and their beneficiaries.

Military nurses (all nurses in the Army, Air Force, and Navy, regardless of whether they are in the active, reserve, or guard component) confront a range of health problems in ambulatory clinics, community hospitals, medical centers, hospital ships, field hospitals, ships, aircraft, and other sites. Patients vary in age from the neonate to the elderly and encompass those mortally wounded in combat and those who are chronically ill. The military nurse must have knowledge and skills that are transferable to a variety of challenging peacetime and wartime scenarios. The Army, Navy, and Air Force Nurse Corps all agree that the knowledge and skill sets of nurse officers must be research based.

In fiscal year (FY) 1992, Congress appropriated initial funding of $1 million to establish the TriService Nursing Research Program to support targeted research by military nurses. This program has continued to garner yearly support from Congress and was provided with $5 million in FY 1995 and again in FY 1996. Acting through the program administrator, the program's advisory group (the TriService Nursing Research Group) asked the Institute of Medicine (IOM) to make recommendations for program management, areas for future research funding, and allocation of resources to program functions and to identify both short- and long-term objectives. To undertake the stated task, the Institute of Medicine appointed a multidisciplinary committee consisting of 20 individuals, including experts with a background in military nursing.



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--> Summary Military nursing research focuses on enhancing health care delivery systems and processes to improve clinical outcomes, advancing the practice of military nursing in support of mission readiness and deployment, and contributing to the health status and quality of life of military personnel and their beneficiaries. Military nurses (all nurses in the Army, Air Force, and Navy, regardless of whether they are in the active, reserve, or guard component) confront a range of health problems in ambulatory clinics, community hospitals, medical centers, hospital ships, field hospitals, ships, aircraft, and other sites. Patients vary in age from the neonate to the elderly and encompass those mortally wounded in combat and those who are chronically ill. The military nurse must have knowledge and skills that are transferable to a variety of challenging peacetime and wartime scenarios. The Army, Navy, and Air Force Nurse Corps all agree that the knowledge and skill sets of nurse officers must be research based. In fiscal year (FY) 1992, Congress appropriated initial funding of $1 million to establish the TriService Nursing Research Program to support targeted research by military nurses. This program has continued to garner yearly support from Congress and was provided with $5 million in FY 1995 and again in FY 1996. Acting through the program administrator, the program's advisory group (the TriService Nursing Research Group) asked the Institute of Medicine (IOM) to make recommendations for program management, areas for future research funding, and allocation of resources to program functions and to identify both short- and long-term objectives. To undertake the stated task, the Institute of Medicine appointed a multidisciplinary committee consisting of 20 individuals, including experts with a background in military nursing.

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--> The committee had access to a broad array of information concerning the TriService Nursing Research Program and its portfolio. It also benefited from discussions with program staff and advisors; the chief and directors of the Army, Navy, and Air Force Nurse Corps; and a number of grantees and unfunded applicants. Extensive searches of published literature and of federally funded research in progress provided the committee with citations and abstracts for the body of research that is specific to military nursing as well as for other current major nursing research efforts. The committee used these information sources and called upon its collective expertise to assess the TriService Nursing Research Program and develop its recommendations. The committee's methods, findings, conclusions, and recommendations are described in much greater detail in the body of the report. Findings Resources for Military Nursing Research Each of the military Nurse Corps has official statements concerning the integral role of research to military nursing practice, and each corps has programs in place to support graduate education of selected active-duty nurse officers. The total number of doctorally prepared nurse officers is relatively small: 56 on active duty and approximately 200 members of the reserve component, which includes the guard. In contrast, the number with master's degrees is relatively large—approximately 3,600 counting only those on active duty. Nurse officers with master's degrees have received a majority of the TriService Nursing Research Program grants. The Army Nurse Corps has medical facilities that incorporate a strong focus on nursing research, and the Air Force and Navy are taking steps to increase their research capabilities. Previous Military Nursing Research Although historically military nurses were highly instrumental in establishing nursing research in general, the body of identifiable military nursing research articles published in peer-reviewed journals is relatively small, and the range of topics covered is large. The majority of the military nursing research literature is contained in theses, dissertations, and studies from training programs and is available only through the National Technical Information Service or the Defense Technical Information Service. Among studies funded by the TriService Nursing Research Program, the most common broad area of research is the delivery of military health care; the second is women's health; and the third is nursing care interventions under field conditions. To date,

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--> according to program records, only one study funded by the TriService Nursing Research Program appears to have been published in a peer-reviewed journal. TriService Nursing Research Program Operation Over its 4-year history, the TriService Nursing Research Program has developed a $9.68 million portfolio of 77 projects conducted by nurses in the armed forces. Awards have been granted to members of all three military services, including active, reserve, and guard components. The program has instituted yearly improvements in its Requests for Proposals and scientific peer review process; implemented grants-writing workshops to assist military nurses to develop sound proposals; produced monographs that summarize completed projects; and recently subcontracted services to support peer review of proposals, program management, and grants-writing workshops. The subcontracted services should result in improved timeliness, monitoring, and dissemination of information. In 1996, in a marked departure from its first years of operation, the program made an early announcement of the probable availability of funds and will allow the funding to support grants for either a 2- or a 3-year period. Research Premises In the course of its deliberations, the committee agreed that the following premises concerning research would lay a foundation for its conclusions and recommendations: The quality of research is best enhanced by a rigorous system of peer review. The peer review of scientific merit must remain separate from policy decisions related to program management. In general, progress in science is best served by investigator-initiated research. Research requires extensive and increasingly demanding preparation to meet rigorous standards for the production and integration of knowledge. Research, education, and practice go hand in hand. Strongly focused programs of research are increasingly essential to meet strategic needs for knowledge production and utilization in response to the health needs of military beneficiaries. Programs of research are successful when they build on strengths. The development of programs of research requires a critical mass of individuals with the appropriate credentials to be scientists.

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--> Because of the nature of the questions that must be answered in nursing research, multidisciplinary research teams with varied skills and perspectives are essential. Research programs benefit from a stable infrastructure for the setting and reviewing of priorities, administration of grants, development of information systems, consultation, and other services and activities. Conclusions Depth and Breadth of Military Nursing Research The Committee on Military Nursing Research concluded that the researchable problems that should be addressed by the TriService Nursing Research Program are large in number and potentially of great importance. Presently, the number of military nurse scientists available to address these questions and the infrastructure to support a robust and productive research program are quite small, especially among the active-duty component. Until recently, however, the funding available for military nursing research was extremely limited. Because of these limitations, the body of peer-reviewed research literature focused on military nursing is also small and needs to be expanded. In order to develop the critical mass and infrastructure necessary to establish military nursing research as a viable component of the Department of Defense's (DOD's) Health Care Program, the committee concluded that there is a need to establish the value of military nursing research and the essential nature of its relationship to military nursing practice, build the infrastructure and resources needed to facilitate military nursing research, and generate the body of knowledge required to help guide military nursing practice. The creation of a research culture will facilitate a program of knowledge generation required to improve standards of military nursing practice and to improve the health of service members and their beneficiaries. It will contribute to understanding the uniqueness of nursing services in circumstances of war, peacetime operations, mission readiness, and deployment. Role of the TriService Nursing Research Program The TriService Nursing Research Program is central to the mission of military nursing because research is essential to generate the scientific knowledge upon

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--> which nurses base their practice. The delivery of modern health care to service members and beneficiaries requires nothing less. Hence, the TriService Nursing Research Program has begun to establish a program of research that is directly relevant to military health, that fosters collaborative relationships with other scientists and disciplines, and that creates a mentorship system for the development of junior investigators. The committee recognizes that the TriService Nursing Research Program has been operating under circumstances that are far from ideal—namely, uncertain funding from year to year and serious delays in receipt of funds. Nonetheless, the committee concludes that the TriService Nursing Research Group, which oversees the program, serves as a useful mechanism; and it commends both the TriService Nursing Research Group and the TriService Nursing Research Program administrator for their accomplishments and continuing efforts to strengthen the program. Peer Review Although the peer review process used by the TriService Nursing Research Program is intended to ensure the scientific merit of funded proposals, currently there is a fundamental problem in the peer review process: research proposals submitted by military nurses are reviewed exclusively by military personnel. This practice limits the pool of qualified reviewers and restricts scientific scrutiny. Major Recommendations The Committee on Military Nursing Research, recognizing the great need for a strong program of military nursing research and the infrastructure required for such a program, has developed the following recommendations. The TriService Nursing Research Program should be continued into the foreseeable future. The program is relatively young and the knowledge base is evolving. This program represents a modest investment—one whose potential benefits are judged to exceed the costs—an investment regarded as necessary in all other sectors of health care. The TriService Nursing Research Program should have a stable funding base to develop and sustain research programs that will have demonstrable impact on health care and the health status of military populations. A dependable source of funds allows efficient program management and planning for the most effective use of resources and individuals' time. The TriService Nursing Research Program needs to be institutionalized in an operational sense. To accomplish this, the TriService Nursing Research Program needs to become a permanent component of the

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--> DOD Health Care Program, and adequate funds to support the program should be incorporated into the DOD Health Care Program Objective Memorandum (POM). This change would eliminate dependence on yearly congressional appropriations, as has been the case in the past, and facilitate forward planning and efficient operation. Consistent with the language in the fiscal year (FY) 1996 Department of Defense Authorization Act, the Uniformed Services University for the Health Sciences appears to this committee to be an appropriate element within DOD to be designated to administer the program, with oversight by the TriService Nursing Research Group. Other Recommendations Responding to the charge to the Institute of Medicine, the committee developed additional recommendations covering four key aspects of the program: (1) program management, (2) areas for future research funding, (3) allocation of resources to program functions, and (4) identification of short- and long-term objectives. Many of its recommendations are highlighted below. Additional recommendations and explanatory information appear in the complete report. Recommendations for Program Management Management Structure The committee deliberated on the existing management structure of the TriService Nursing Research Program and recommends the following: The TriService Nursing Research Group should continue to provide oversight to the program. The TriService Nursing Research Group (TSNR Group) founded the program and serves as a useful mechanism for ensuring appropriate attention to the needs of all three military services and components. A doctorally prepared military nurse researcher should be employed as director of the TriService Nursing Research Program. Strategic direction of the program requires the expertise and the dedication of a full-time, doctorally prepared nurse researcher. Ideally, the director would continue conducting research on a part-time basis, thus serving as a role model for military nurse researchers. The TriService Nursing Research Program administration should develop mechanisms to facilitate programs of research rather than simply the completion of individual and possibly isolated projects. Most advances in knowledge result from the cumulative results of sustained research programs.

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--> Programmatic research is accomplished by the continuing efforts of an investigator or research team or by complementary studies by several investigators in a focused area of research. The TriService Nursing Research Program administration should develop and implement a plan for ongoing monitoring and evaluation of the program. Well-conceived and implemented evaluation is integral to the success of any program. In addition, the committee strongly urges the TriService Nursing Research Group to monitor and report on the progress and outcomes of the program within 3 years and at established intervals, as documented by systematic criteria that include evidence of peer-reviewed research publications and applications to practice. Peer Review Two major changes would help the program to achieve significant improvements in its scientific review process: Appoint a Scientific Review Panel chair who has experience in outside grant reviews and who shows evidence of being a seasoned leader in bringing about consensus and decision making in groups. A chair who has served on outside scientific review panels would help to ensure fair and rigorous review, including the solicitation of critiques by outside experts for topic areas not adequately represented on the panel. Include at least three nonmilitary scientists with experience on outside scientific review panels on the TriService Nursing Research Program Scientific Review Panel. This action would expand the pool of potential reviewers and make it possible for military panel members to benefit from exposure to scientists with experience on civilian research review panels. Recommendations for Areas of Research The research agenda for the TriService Nursing Research Program was initially established by legislation and included broad areas of research. The committee agreed that the program's areas of research should complement those currently receiving priority attention from the National Institute of Nursing Research and the Department of Veterans Affairs. Each of the program's areas of research should give attention to contexts of care that are peculiar to or highly prevalent in the military. The committee recommends that future research be focused primarily in four broad areas, as listed below. In addition, the committee

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--> recommends that the TriService Nursing Research Group hold research priority-setting conferences on a regular basis, such as biennially. Current and emerging issues or problems with clear and direct application to military nursing care during wartime and operations other than war: The focus here is on improvement of the results of nursing services under circumstances that are relatively unique to the military. Consideration should be given to the development of research capabilities for circumstances of deployment since military deployments often occur suddenly and evolve into circumstances that present both challenges to nursing practice and opportunities for gains in knowledge not often available in civilian settings. Current and emerging issues or problems related to the diverse needs of service members and their beneficiaries during peacetime, with consideration of the contextually different aspects of care in the military: The focus should be on supporting or validating nursing science to enhance the practice of nursing that will improve patient care outcomes and/or result in efficient resource utilization. Cultural aspects of military nursing: Military nursing affords rich opportunities to examine the cultural implications and dimensions of the provision of nursing care. The committee urges investigators to formulate research questions that address nursing care problems and opportunities related to this extensive exposure to cultural differences. Evaluation of research utilization and clinical relevance: Studies in this area incorporate a process by which research results can be reviewed, evaluated, and implemented into the delivery of nursing care, with evaluation of the practice implementation. The overall goal is to facilitate state-of-the-science standards of care. Recommendations for Allocation of Funds The committee recommends that approximately 10 percent of appropriated funds be used to cover administrative costs, which are to include the costs of workshops and travel support in addition to funds needed for essential program operation. The remainder of funds should be used for the various grant awards, as described below. Workshops in scientific writing are an urgent need. Recommendations for Programmatic Investment Strategies The committee recommends expanding the current grant award categories and using more stringent requirements for grant applicants, as indicated below. It provides recommendations for award categories for the short term and for

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--> incorporating a long-term strategy to augment current award categories as funds and other resources allow. The committee encourages flexibility for the awarding group in terms of the distribution of awards among the various categories. Short-Term Goals for Grant Award Categories The committee recommends continuing the current grant award categories—Experienced Investigator Award and New Investigator Award—with the specifications given below. Experienced Investigator Awards. Experienced investigators are licensed registered nurses who fulfill one of the following criteria: (1) military nurses with a doctoral degree or (2) military nurses with a master's degree who have a co-principal investigator with a doctoral degree. The co-principal investigator may or may not be in the military and may have his or her doctoral degree in nursing or another discipline. To qualify as an experienced investigator, the applicant should have capability in investigation as demonstrated by completed research, publication of peer-reviewed research papers, and presentations at national or international professional meetings. New Investigator Awards. New investigators are defined as licensed registered nurses who fulfill one of the following criteria: (1) military nurses with a doctoral degree; (2) military nurses with a master's degree who have a co-principal investigator with a doctoral degree; or (3) military nurses in a doctoral degree program who request funding for a dissertation proposal. The co-principal investigator may or may not be in the military and may have the doctoral degree in nursing or another discipline. The committee recommends adding the following award categories to the short-term goals of the program. Senior Investigator Awards. Doctorally prepared nurses who served in the active or reserve component of the Army, Navy, or Air Force Nurse Corps within the past 3 years are eligible to apply. The applicant must show evidence of an established program of research with multiple articles published in the peer-reviewed literature; must include a co-principal investigator who is currently an active, reserve, or guard nurse in the Army, Navy, or Air Force; and must provide evidence of current institutional resources to carry out the proposed research.

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--> Utilization and Evaluation of Research-into-Practice Awards. Active, reserve, and guard nurses in all services who fulfill one of the following criteria are eligible: (1) nurses with a doctoral degree or (2) nurses with a master's degree who have a co-principal investigator with a doctoral degree. Long-Term Goals for Award Categories The committee recommends the addition of the following award categories as long-term goals, to the extent feasible. Infrastructure Enhancement Awards. Research in military nursing may be facilitated by increased access to institutional resources. Examples of such resources include systems of instrumentation including computers; development of registries of patient outcomes during different modes of air evacuation; development of registries on DOD beneficiaries before, during, and after deployment; and software development for telemedicine and other information systems pertinent to military nursing. Mentored Research Investigator Awards. The post-doctoral mentorship concept gives talented investigators adequate mentorship in research and offers one of the best opportunities to accelerate the pace of advance of empirically based nursing care for service members and their beneficiaries. Centers of Excellence in Military Nursing Research. The development of Centers of Excellence in Military Nursing Research as part of the organizational structure of military medical centers or treatment facilities would enhance the career development of military nurse researchers and increase the probability of successful completion of grants awarded by this program to active-duty military nurses. With the implementation of these recommendations and others contained in the complete report, the TriService Nursing Research Program has the potential to evolve into a strong force for the advancement of military nursing practice.