The Program for Research in Military Nursing: Progress and Future Direction (1996)

Military nursing research is defined as nursing research with direct relevance to the military environment. Its objectives are to advance the practice of military nursing in support of mission readiness and deployment; to enhance nursing delivery systems and processes to improve clinical outcomes during peacetime, wartime, and humanitarian relief missions; to improve the health status and quality of life of military personnel and their beneficiaries; and to provide optimal nursing care in settings throughout the world. The fundamental purpose of military nursing research is to further the knowledge of military nurses and to enhance their capacity to provide quality nursing care for the armed forces.

At the time of this writing, the TriService Nursing Research Program (TSNR Program) is starting its fifth year of funding research proposals by military nurses for military personnel and their beneficiaries. The program has received increasing financial support from the U.S. Congress, from a $1 million appropriation in 1992 to $5 million in 1995 and again in 1996.

The TSNR Program functions in an environment in which the resources for conducting military nursing research differ across the three services, but the Army, Navy, and Air Force Nurse Corps have each demonstrated their support for nursing research.

To understand the environment of military nursing research better, the Institute of Medicine committee examined official positions of the military

Nurse Corps concerning military nursing research, information about positions that call for doctorally prepared nurses, the supply of doctorally prepared nurses, the number of nurses enrolled in advanced degree programs, and major resources for facilitating nursing research in each of the military services.

The following excerpts from policy statements indicate the support of the military Nurse Corps for nursing research.

The Army Nurse Corps (ANC, 1981) established its policy statement on the value of nursing research to the Corps in 1981; excerpts from this statement follow:

The Navy Nurse Corps (1993) demonstrated a commitment to increased nursing research in its strategic plan, which was first published in 1993:

The Air Force adopted a policy of support for nursing research within its ranks. A recent nursing operations manual (U.S. Air Force, 1994) includes the following excerpts from Air Force Instruction 46-101 in its outline of the responsibilities of a nurse executive: to

The Total Nurse Force Strategic Plan (Col. Nina Rhoton, USAF, NC, Professional Nursing Programs, Office of the Surgeon General, personal communication, 1996) includes a goal of fostering and supporting nursing research.

The number of approved positions for doctorally prepared nurses differs substantially among the three services, as indicated below.

Currently, the Army has 54 approved positions that call for doctorally prepared nurses to occupy roles in research, clinical practice, administration, or education; and it has 36 doctorally prepared nurses on active duty.

In 1987, the Navy Nurse Corps conducted a review of all billets (approved positions) worldwide and identified 11 billets that specify doctorally prepared

nurses. The Navy Nurse Corps currently has eight active-duty nurses with this educational preparation. Billets include clinical nurse researchers and directors of such programs as anesthesia nursing and education. Research billets are located at the National Naval Medical Center, Bethesda, Maryland; the Naval Medical Centers in Portsmouth, Virginia, and San Diego, California; and the U.S. Naval Hospital in Okinawa, Japan.

U.S. Air Force currently has two billets requiring doctorally prepared nurses: the director of nursing research at the Graduate School of Nursing at the Uniformed Services University of the Health Sciences (Bethesda, Maryland) and the senior health service researcher at the Air Force Surgeon General's Office at Bolling Air Force Base in Washington, D.C. There is one billet, currently unfilled, as senior clinical coordinator for students in the second year of the U.S. Air Force graduate program conducted with Texas Wesleyan University in Fort Worth, Texas, and a recently approved billet for a doctorally prepared nurse in the graduate education program at Uniformed Services University of the Health Sciences. There are 12 active-duty nurse officers with the earned doctorate.

As summarized in Table 3-1, there are currently 3,125 master's-level and 56 doctorally prepared nurses out of approximately 12,000 active-duty nurses in the three military services combined. Thus, approximately 25 percent of active-duty military nurses have at least a master's degree, and approximately 0.5 percent have an earned doctorate. By comparison, approximately 10 percent of civilian nurses have a master's degree or greater.¹

Although the percentage of master's-level nurses in the military is higher than that in the civilian population, both the percentage and the total number of doctorally prepared military nurses are small in relation to the many research questions confronting military nurses. As described below, not all of the active-duty doctorally prepared military nurses are involved in research. The majority (196) of the doctorally prepared military nurses are reservists (see Table 3-1).

Each of the military Nurse Corps has supported advanced educational preparation of selected active-duty nurse officers. Between 1990 and 1995, the Army Nurse Corps supported doctoral education for 24 Nurse Corps officers, the Navy Nurse Corps did so for 11, and the Air Force Nurse Corps for 7. Although this support for advanced education has been relatively consistent over the period examined, the net gain in the number of doctorally prepared Nurse Corps officers is low, primarily due to retirement.

The Nursing Research Service at Walter Reed Army Medical Center (Walter Reed AMC) has four approved positions for doctorally prepared active-duty nurses whose primary duty responsibilities are to manage or conduct nursing research projects and to mentor new nurse investigators. Recognized as the primary site within the Army for developing new nurse researchers, the service supports the implementation, dissemination, and utilization of research throughout the Department of Nursing.

Madigan Army Medical Center (Madigan AMC) in Tacoma, Washington, also has a Nursing Research Service, which combines military and civilian nurse research staff. This service supports the Madigan Department of Nursing in the implementation, dissemination, and utilization of nursing research.

In March 1992, the role of regional nursing research coordinator was created to decentralize the Army's nursing research structure (Kennedy, 1994). Regional sites include Walter Reed AMC; Madigan AMC; Tripler Army Medical Center in Honolulu, Hawaii; Brooke Army Medical Center in San Antonio, Texas; William Beaumont Army Medical Center in El Paso, Texas; Fitzsimmons Army Medical Center in Denver, Colorado; and Eisenhower Army Medical Center in Augusta, Georgia. The nursing research consultant integrates, facilitates, and guides the work of regional nursing research coordinators. In addition, the Nursing Research Advisory Board, which meets yearly or biennially, as needed, provides global oversight for research in Army Nurse Corps. The regional nursing research coordinators are doctorally prepared nurse officers who serve in this capacity in addition to their assigned position, which ideally has a research focus.

At present, there are no specific Navy facilities or commands designated as centers of research, nor is there one specific Navy-wide nursing research program. However, the Navy Nurse Corps expresses belief in the future of doctorally prepared nurses in the Navy Nurse Corps. As the inventory of master's and doctorally prepared nurse researchers grows, the Navy plans to assign two doctorally prepared nurses to selected tertiary care facilities, including the National Naval Medical Center, Bethesda, Maryland, and the Naval Medical Centers in San Diego, California, and Portsmouth, Virginia. These billets will provide novice Navy nurse researchers with a supportive environment and facilitate more collegial and collaborative relationships within the Navy and among the services.

Possible future assignments may include service as directors of clinical investigation departments, a headquarter's position to involve the Clinical Investigation Program throughout the Navy, assignment to various policy review and development positions within the Navy or the Department of Defense (DOD), or service as regional geographic coordinators.

The Air Force currently has no formalized centers of research. Nursing research committees exist in various Air Force medical centers, and nurses hold membership on multidisciplinary research committees at some treatment facilities. Also, nurses participate in institutional reviews of clinical research. The Air Force is in the process of coordinating the assignment of doctorally prepared nurses to its four Clinical Investigation Divisions, which operate at the largest Air Force medical centers: Andrews Air Force Base in Washington, D.C.; Travis Air Force Base in California; Wright-Patterson Air Force Base in Ohio; and Wilford Hall in San Antonio, Texas.

Examination of the body of published works in a field can help to identify strengths and areas needing increased attention. Ongoing civilian nursing research is likely to have considerable application to military nursing, especially with regard to improving nursing care and nursing care systems for beneficiaries of service members. Therefore, the committee conducted extensive literature searches to identify published works on military nursing research and targeted searches to identify studies being conducted as part of major programs of

ongoing civilian nursing research. Relevant citations from these searches appear in the companion publication to this report, Military Nursing Research: Bibliographies (IOM, 1996), along with annotations to the extent that abstracts were available. The search results are discussed briefly below.

Seven databases served as the source of research citations and abstracts of the published scientific literature directly applicable to military nursing, as shown in Table 3-2. Each database served as a unique source of relevant information, with distinct and discrete emphasis for the study. For the databases MedLINE, Current Information in Nursing and Allied Health Literature (CINAHL), Health Services/Technology Assessment Research (H-STAR), PsycInfo, and National Technical Information Service (NTIS), the following search strategy was used:

The search strategy for the database Technical Reports (TR) in the Defense Technical Information Center (DTIC) Defense Research On-line System (DROLS) and Dissertation Abstracts used the descriptor term [nursing] and the free text term [military] only.

These strategies intentionally limited the search to articles that deal with nursing care of military populations and other nursing topics with either a military focus or a focus on a subject highly relevant to the military, such as flight nursing or telemedicine. Information retrieved in the search of published works was, in many cases, different from areas of research funded by the TSNR Program. The committee recognizes that if some of the funded studies had already resulted in publications, several might not have been uncovered by employing the specified search strategies, especially those that did not use military study populations.

Having access only to citations and abstracts (and sometimes only to citations), committee members did not assess the quality of the studies retrieved in the literature searches. Neither did they explore all aspects of a specific topic as would be done if they were preparing a research proposal. Instead, they focused on the number and range of studies in an area; the approaches used in addressing the topic; the extent to which citations were likely to represent peer-reviewed research articles; and the extent to which cultural background was considered, if applicable. The bibliographies produced from the search results (IOM, 1996) include citations to some studies that committee members considered might be seriously flawed. Such citations are included because they are a part of the information processed. No indications of quality are to be assumed.

Of the more than 2,000 citations retrieved from the databases MedLINE, CINAHL, H-STAR, and PsycInfo, 161 were identified by the committee as research reports or reviews relevant to military nursing. Many of these did not address military populations. Citations and abstracts for research articles identified through search of NTIS and Technical Reports in DROLS (DTIC) were examined separately since a majority have limited distribution and have not undergone the peer review that is typical for scientific journals. From the combined retrieved citations for technical reports, 150 were identified as obvious research reports, a large percentage of which were master's theses.

The search of Dissertation Abstracts yielded 73 relevant abstracts, 51 of which were for doctoral dissertations. All of these dealt, at least in part, with military nurses or with patients who were current or retired service members or their dependents. An additional 15 dissertations addressing military topics (titles only) were uncovered in the search of CINAHL and PsycInfo. The committee

categorized the research reports retrieved from the search of journals, technical reports, and dissertations separately into 10 topic areas, as shown in Table 3-3.

It is clear that health services planning or health services and resources is the topic area that has been studied most extensively overall. This category covers many subjects, including a number of published research articles on topics related to aeromedical evacuation, technical reports on medical supply systems, and such service-specific topics as tasks of the shipboard independent duty hospital corpsman. Nurses' career development has also received much attention, with recruitment and retention of personnel major topics of concern. After military nursing history (48 titles), stress and coping is the topic with the most titles (25) obtained from the search of the databases covering professional journals, but this number includes many dissertation abstracts retrieved from PsycInfo. A number of these stress and coping articles deal with posttraumatic stress. Few articles address cultural topics related to military nursing. References to historical articles appear separately in Military Nursing Research: Bibliographies (IOM, 1996).

In addition to the above sources of research articles, each of the three military services has these and dissertations on file at selected repositories. For instance, there are 192 Navy Nurse Corps theses and dissertations on file at the Stitt Medical Library in Bethesda, Maryland; their titles appear in the

companion bibliography. The Air Force's Air University Library at Maxwell Air Force Base, Alabama, has approximately 100 theses covering nursing research conducted by members of the Air Force. Although the Army does not require a formal filing of dissertations, there are dissertations on file at Walter Reed AMC library. All Army theses and dissertations are abstracted at the Nursing Research Service at the Walter Reed AMC.

The committee searched specifically for articles that covered racial and ethnic background. Several of the articles on recruitment and retention did (Kocher and Thomas, 1994; Shigley, 1988; Simpson, 1992; Thomas et al., 1988, 1989). Smith (1993) addressed language and cultural barriers during Operation Desert Shield/Desert Storm. Erickson-Owens and Zdenek (1988) focused on removing cultural barriers to care during childbearing by Philipino, Korean, and Mexican-American mothers. The committee found no other articles that clearly focused both on the military and on cultural issues.

The published literature contains many nonresearch articles relating to the history of military nursing, anecdotal reports of challenging aspects of nursing care, and articles that address recruitment and job satisfaction. The retrieved titles and abstracts (and the articles themselves) may stimulate identification of potentially fruitful areas for military nursing research. To this end, selected titles are included in the companion publication to this report, Military Nursing Research: Bibliographies (IOM, 1996).

To avoid making recommendations that would duplicate ongoing research, the committee examined results of searches of databases providing information on two major nursing research programs: those conducted by (1) the National Institute for Nursing Research (NINR) and (2) the Department of Veterans Affairs. Brief descriptions of these programs follow, along with brief summaries of the search results. The companion publication Military Nursing Research: Bibliographies (IOM, 1996) gives listings of the studies that were retrieved and annotations (where abstracts were available).

According to its mission statement, the NINR (1995) seeks to

Under this broad mandate, NINR launched its first National Nursing Research Agenda in 1987 by implementing seven research priorities (NINR, 1993) designed to provide a structure for selecting scientific opportunities and initiatives; these priorities were

1. low birth weight: mothers and infants;
2. HIV (human immunodeficiency virus infection): prevention and cure;
3. long-term care for older adults;
4. symptom management: pain;
5. nursing informatics: enhancing patient care;
6. health promotion for older children and adolescents; and
7. technology dependence across the life span.

In 1992, the National Nursing Research Agenda (NINR, 1993) established five more research priorities designed to guide a portion of NINR funding from 1995 through 1999:

1. community-based nursing models;
2. effectiveness of nursing interventions in HIV/AIDS;
3. cognitive impairment;
4. living with chronic illness; and
5. biobehavioral factors related to immunocompetence.

The search of the database CRISP identified 317 studies being conducted by NINR, most of which could be categorized in the areas described above. None of these has a study focus that is related specifically to military nursing, but management of pain, nursing informatics, and biobehavioral factors related to immunocompetence would have direct applicability to service members and their beneficiaries alike.

The Department of Veterans Affairs began a small but similar program of nursing research in 1993 called the Nursing Research Initiative. This program is designed to "(1) encourage new research projects pertaining to nursing topics; and, (2) expand the pool of nurse investigators within the VA health care system" (U.S. Department of Veterans Affairs, 1995).

A search of the database Federal Research in Progress identified current nursing research projects funded by the Department of Veterans Affairs, including one that was not initiated. A broad scope of topics was covered, including responses to touch, various aspects of mental disorders, biological rhythms in intensive care patients, roles and competencies of nurses, and comparative studies of selected nursing techniques.

The committee closely examined the content of abstracts of the 77 research proposals that were funded by the TSNR Program during the fiscal year (FY) 1992 through FY 1995. References for these studies are listed in Appendix D, and the complete abstracts are given in the companion publication Military Nursing Research: Bibliographies (IOM, 1996). To develop an understanding of the scope and types of studies that received funding, the abstracts were analyzed in two ways: by examining (1) the distribution of grants among priority areas identified by the TSNR Program in its annual Request for Proposals and (2) characteristics of the studies. Because military populations are very diverse culturally, the committee also examined the abstracts for attention to this topic.

Priority areas for the TSNR Program are listed in Table 3-4 for 1992 and 1993, in Table 3-5 for 1994, and in Table 3-6 for 1995, along with the number of projects and total funding in each priority area. The committee categorized the abstracts since this information was not available from the program. Over the first 2 years of the program, with $1 million in funding during FY 1992 and $2 million in FY 1993, grants were distributed unevenly among the five priority areas, with two areas receiving no awards (Table 3-4). The major area funded was health care delivery. Seven grants out of 30 (totaling nearly 20 percent of the total budget of $3 million) appeared to the committee to fall outside priority areas.

In 1994, with its budget increased to $3 million, the TSNR Program listed 10 priority areas and specified that research applying to the military would be given highest priority. As shown in Table 3-5, the priority area "Evaluation of nursing/women's health programs/deployment" received the largest dollar value of the awards, followed by the area "Application of clinical nursing to a military environment." The committee's categorization indicated that 4 of the 10 priority areas designated in 1994 received no grants and that 25 percent of the awards,

totaling $660,000, went to study topics (e.g., history of military nursing, health advisory program evaluation) outside the TSNR Program's priority areas.

The priority areas changed again in 1995, and the TSNR Program appropriation was increased to $5 million. Table 3-6 shows that of the 10 priority areas, "Women's health issues" and "Prevention of complications associated with battle injuries" received the highest number of awards and total funding.

The committee's synthesis of topic categories for all funding for the years 1992–1995 is presented in Table 3-7. After reviewing the data in this configuration, several conclusions were drawn.

The delivery of military health care is the category that has received most funding from the TSNR Program. This is important in that military health care is going through a number of transitions based on the need for cost containment in health care, access to health care issues, and a more peacetime health care service. For example, the new military managed care system known as Tricare has introduced a major change in health care delivery to beneficiaries.

Studies that address women's health issues have received the second-most TSNR Program funding. Since the proportion of women in the military is

growing and relatively few studies have been conducted on this population (IOM, 1995), strong support in this area is easily justified.

Since 1994, 11 studies of nursing care under field conditions in the military have been funded by the TSNR Program. This topic is of obvious military relevance, and further work in this area should be encouraged through the funding of carefully selected studies.

Studies concerning the health of military personnel, including their readiness for deployment, have been funded each year, and this category ranks fourth in funds awarded by the program. Substantial support in this area is desirable since one of the goals of the program is to develop nursing knowledge that is useful in the military setting.

As a further analysis of funded grants, the committee also categorized the 77 funded TSNR Program projects under six design parameters: (1) target population, (2) study population, (3) study design, (4) environment, (5) research topic, and (6) primary exposure. As can be seen in Table 3-8, this categorization

of funded grants yields some interesting results. For example, although these studies were being conducted by military personnel, almost 40 percent focused on nonmilitary target populations. However, more than 25 percent focused specifically on military nurses. The largest single grouping (70 percent) focused on adults, whereas 12 percent focused on family issues. Nearly half were experimental or quasi experimental in design. The most common topic area was psychosocial/behavioral research (30 percent). Trauma/injury accounted for 17 percent, and infectious diseases, 3 percent.

The committee found evidence of attention to racial, ethnic, or cultural influences or issues in four studies funded by the TSNR Program (DeCasares, 1993; Giger, 1995; Johnson, 1995; Stotts, 1994), ranging from electrical stimulation and foot skin perfusion in black and white individuals with diabetes mellitus (Stotts, 1994) to coronary heart disease risk factors and behavioral risk reduction strategies for premenopausal African-American women (Giger, 1995). Other studies funded by the TSNR Program may address cultural issues, but they cannot be identified from review of the abstracts.

The committee recommends that the TSNR Program develop a system to categorize grants by research priorities and by other characteristics, such as those in Table 3-8, as part of its evaluation plan. These data could then be retrieved quickly to respond to inquiries.

The dissemination and utilization of research are integral aspects of the research process. In the field of nursing, the dissemination of nursing research results has already yielded many health benefits and cost savings for the public. Examples are provided by programs of research reported in the Annual Review of Nursing Research that have resulted in beneficial protocols: protocols that serve to protect battered women and their children (Campbell and Parker, 1992); endotracheal suctioning protocols that avoid adverse side effects such as hypoxia, mucosal trauma, and bronchospasm (Stone and Turner, 1990); protocols for inspiratory muscle training to improve functional status of the chronically ill (Kim, 1988); and protocols to manage acute pain, permit the reduced use of opiates, and minimize common opiate side effects (Hegyvary, 1993).

Military nurse researchers have a history of presenting research findings at conferences, especially those sponsored by the military. However, the committee found no articles that dealt with research utilization in military settings. In the civilian nursing research literature, findings related to a number of nursing interventions, such as those listed above, would have direct application and merit evaluation for field conditions or other settings unique to the military.

The Army, Navy, and Air Force Nurse Corps each support the integral role of nursing research as the basis for nursing practice. Resources for nursing research differ among the military services, but each corps is seeking to strengthen its research environment. The TSNR Program is one mechanism to accomplish this.

Review of citations and abstracts for peer-reviewed articles related to military nursing research indicates a broad array of research topics but a relatively small number of studies. Most of the relevant research reports that actually address military nursing do not appear in scientific journals. The military services have paid close attention to historical lessons related to nursing research, and the TSNR Program has allowed further work in this area.

The TSNR Program's $9.7 million portfolio of 77 studies includes a wide range of topics, with the greatest proportion of awards and dollars given to studies dealing with the delivery of military health care.

ANC (Army Nurse Corps). 1981. Policy Statement on the Value of Nursing Research to the ANC. Washington, DC: U.S. Army.

Campbell, JC, and B Parker. 1992. Battered women and their children. Annu. Rev. Nurs. Res. 10:77-94.*

DeCasares, E. 1993. Army Women's Breast Cancer Risk. DeWitt Army Hospital, Fort Belvoir, VA.

Erickson-Owens, DA, and RM Zdenek. 1988. Removing Cultural Barriers to Care During Childbearing: A Continuing Education Module, Master's thesis. Air Force Institute of Technology, Wright-Patterson Air Force Base, OH. AFIT/CI/NR-88-94.

Giger, JN. 1995. Behavioral Risk Reduction Strategies for Chronic Indicators and High Risk Factors for Premenopausal African-American Women (25-40) with Coronary Heart Disease. University of Alabama at Birmingham.*

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Johnson, AD. 1995. The Effects of Culturally Sensitive Messages and Health Beliefs. University of Texas, San Antonio, TX.*

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Stotts, NA. 1994. Electrical Stimulation and Diabetic Foot Skin Perfusion. University of California-San Francisco.*

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