5
Conclusions and Recommendations

Basic to the evolution of strong programs of military nursing research is the development of a culture deeply grounded in research and its use as a primary means for improving the military health care system. Creation of this culture requires commitment to generate the body of knowledge required to guide military nursing practice. In addition, it requires a commitment of time and resources, including extensive training, interdisciplinary and multidisciplinary interactions, and peer review of the proposed science.

The new era that results from this culture should increase the quality of scientists properly trained in nursing science as their primary field. It should generate new knowledge about the nature of military nursing, clarify the conceptual basis of military clinical practice, enhance the evaluation of clinical practices in the military, forecast health delivery system needs that can be met by military nurses, and expand the range and extent of influence of military nursing research. As the culture of the military nursing scientific community evolves, networking will build strong research groups through such strategies as use of the Internet, participation in conferences, and publication in journals.

In this emerging reality and era of rapid change, there is a need to develop nursing research that has high payoffs to military nursing practice. To meet this challenge, groups of military nurse researchers and their colleagues are encouraged to band together and, with other disciplines, ask important clinical questions and design and implement studies to answer them. In addition, mentoring is needed by pre- and post-doctoral students and fellows. This new research era should

  • demonstrate the value of military nursing research and the critical nature of its relationship to military nursing practice,


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--> 5 Conclusions and Recommendations Basic to the evolution of strong programs of military nursing research is the development of a culture deeply grounded in research and its use as a primary means for improving the military health care system. Creation of this culture requires commitment to generate the body of knowledge required to guide military nursing practice. In addition, it requires a commitment of time and resources, including extensive training, interdisciplinary and multidisciplinary interactions, and peer review of the proposed science. The new era that results from this culture should increase the quality of scientists properly trained in nursing science as their primary field. It should generate new knowledge about the nature of military nursing, clarify the conceptual basis of military clinical practice, enhance the evaluation of clinical practices in the military, forecast health delivery system needs that can be met by military nurses, and expand the range and extent of influence of military nursing research. As the culture of the military nursing scientific community evolves, networking will build strong research groups through such strategies as use of the Internet, participation in conferences, and publication in journals. In this emerging reality and era of rapid change, there is a need to develop nursing research that has high payoffs to military nursing practice. To meet this challenge, groups of military nurse researchers and their colleagues are encouraged to band together and, with other disciplines, ask important clinical questions and design and implement studies to answer them. In addition, mentoring is needed by pre- and post-doctoral students and fellows. This new research era should demonstrate the value of military nursing research and the critical nature of its relationship to military nursing practice,

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--> building the infrastructure and resources needed to facilitate military nursing research, and develop a commitment to generate the body of knowledge required to guide military nursing practice. The creation of a research culture will yield 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, readiness, and deployment. Conclusions Depth and Breadth of Military Nursing Research The research questions that must be addressed by military nurses are large in number and of great importance. Until recently, however, the number of military nurse scientists available to address these questions has been quite small, especially among the active component. The body of published peer-reviewed research focused on military nursing questions addresses a broad range of topics but is also small. Role of the TriService Nursing Research Program The TriService Nursing Research Program (TSNR Program) is central to improving nurses' capacity to carry out the mission of military nursing. Military nursing research is essential to expanding the body of knowledge needed to guide nursing practice that modern health care requires, not only for service members, but for their beneficiaries as well. Other sources of support for military nursing research appear to be severely limited. Despite the recent beginnings of the TSNR Program, it is showing modest success. The TSNR Program has begun to develop a body of research directly relevant to military health (see Chapter 3), to establish collaborative relationships with other scientists and disciplines, and to initiate a system for the development of novice researchers. TriService Nursing Research Program Operation From the inception of the TSNR Program, guidance was sought from the National Center for Nursing Research (now the National Institute of Nursing Research) to help build a strong and credible program. The request to the Institute

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--> of Medicine to conduct this study is indicative of the program's desire to improve its operation and its potential impact on military nursing research and ultimately on clinical practice. The committee recognizes that the TSNR Program has been operating under circumstances that are far from ideal—with continued funding uncertain from year to year and serious delays in the receipt of funds. Nonetheless, the TriService Nursing Research Group (TSNR Group) and program administrator have taken many steps to strengthen the program. The committee especially applauds the very recent changes that allow funding for periods longer than one year and the specification of maximum funding levels for the two grant award categories. Multiyear funding can encourage and enhance focused research and development efforts that transcend any one corps. The committee concludes that the TriService Nursing Research Group, which oversees the program, serves as a useful mechanism to ensure involvement of the individual services in the following areas: developing priorities, overseeing the procedures for the grant review process, approving the recommendations of the Scientific Review Panel, monitoring and reporting on the progress and accomplishments of the program, providing recommendations to the Department of Defense (DOD) principal staff assistant on an annual basis, and communicating activities of the TSNR Program to the triservice corps chief and directors annually, or more often, as necessary. The committee suggests that future functions of this group be expanded to include the following: Sponsor a biennial conference to establish research priorities for the program. Make use of varied technologies to foster rapid communication among military and civilian nurse scientists to disseminate research findings, share resources, and highlight contributions of military nurse researchers to military health care. Mechanisms might include use of the Internet, a newsletter, research journals, and conferences. Nurture and sustain relationships among active, reserve, and guard military nurse researchers and with nurse researchers with prior military service. Actively promote research that enhances military nursing practice and the administration of military health care programs. Peer Review 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. There is a burgeoning cadre of seasoned civilian nurse researchers who, if teamed with military reviewers, would greatly strengthen the review process.

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--> Major Recommendations The Committee on Military Nursing Research recognizes the great need for a strong program of military nursing research and the infrastructure required for such a program. It has therefore developed the following recommendations. The TriService Nursing Research Program should be continued into the foreseeable future. This program is relatively young and the knowledge base is evolving. The program represents a modest investment for the benefits it will provide in improved health and cost outcomes for military personnel and their beneficiaries. The TriService Nursing Research Program should have a stable, predictable funding base to develop and sustain research programs that have a positive impact on health care and the health status of military populations. A dependable source of funds allows efficient program management and planning for their most effective use. The TriService Nursing Research Program needs to be institutionalized in an operational sense. To accomplish this, the TSNR Program needs to become a permanent component of the 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 (Chapter 104, title 10, U. S. Code as amended), the Uniformed Services University for the Health Sciences appears to this committee to be an appropriate element within DOD to be designated to manage and administer the program, with oversight by the TSNR Group. Recommendations to Develop and Sustain a Military Nursing Scientific Community The development of a strong military nursing scientific community is integral to the productivity of a military nursing research program. To that end, the committee makes the following recommendations. Give close attention to the responsible conduct of science. Vigilance in adherence to ethical principles and maintenance of integrity in the conduct of science is a concern that pervades all of science, whether conducted in the military or civilian sector (IOM, 1989). Commitment to excellence in science demands that nurse investigators be socialized to the critical importance of

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--> integrity in science. Ethical considerations are at least equal in importance to any other aspect of research. The National Academy of Sciences' booklet On Being A Scientist (NAS, 1989, 1995) was developed in response to concerns about the ethical dimensions of the future careers of young scientists. The Institute of Medicine report The Responsible Conduct of Research, which fostered the writing of On Being A Scientist, briefly notes: "the value of mentoring should not be over-looked in institutional efforts to communicate responsible research practices" (IOM, 1989, p. 30). That report identified two important limitations in the role of mentors, however. First, institutions must recognize that the absence of support and rewards for mentoring are barriers to its effective occurrence. Second, the informal communications and other values socialization processes involved in mentoring may not be sufficient to ensure "awareness of the ethical and professional dimensions of research work" (IOM, 1989, p. 30). Thus, there must be formal instruction in the ethical conduct of research that seeks to expose nurse investigators to the highest standards of investigative ethics. The conception, conduct, and dissemination of research and scholarly activity in military nursing must attend to the ethical framework within which research is conducted. The integrity of the individuals performing the investigations, and thus the credibility of the results, both merit attention. In maintaining oversight of research ethics, the TSNR Program must continue to provide guidance and monitor the following: procedures for monitoring the use of animal and human subjects, consent procedures for human research, inclusion of minorities and high-risk groups such as those with posttraumatic stress syndrome, real or perceived conflicts of interest that may affect the investigator's judgment and behavior, and appropriate procedures for defining the ownership of ideas and materials and the authorship of papers. Develop mechanisms to facilitate programs of research rather than simply the completion of individual and possibly isolated projects. Very few problems, whether theoretical or applied, are resolved by single studies. Most advances in knowledge result from the cumulative results of sustained research programs. Ordinarily, programmatic research is accomplished by the continuing efforts of an investigator or research team or by several teams conducting related research. The programs of research need to be directed to areas of relevance to military nursing and to encourage investigator-initiated research that fits into the overall program.

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--> The requirements of military nursing careers may not easily accommodate the long-term involvement of individual investigators. Among many alternate mechanisms that might facilitate the development of programs of research are the following: giving preference in funding to sound proposals coming from evolving but continuously productive research groups that publish their results in a timely fashion in peer-reviewed journals, or the formation, perhaps by natural growth, of research centers through which nurse scientists might rotate and to which they might return as their careers and interests permit. Increase mechanisms to recognize military nursing research and to provide for career advancement. Because of the potential for programs of research to have a positive impact on nursing practice in the military and on health outcomes for service members and their beneficiaries, the committee encourages reconsideration of the mechanisms used to assign nurse scientists. Promising mechanisms for recognizing military nursing research include stabilization of assignments for those receiving research funding and wide recognition of contributions their research brings to the care of service members and their beneficiaries. The development of protocols for the initiation of research projects at the beginning of an assignment could help the researcher to obtain funding, complete the study, and prepare publications before reassignment. Currently, much of the research being conducted by active-duty nurse officers with funding by the TSNR Program is added to an already demanding duty schedule. Establishing programs of research would sanction research activities and expedite the scientific process. Develop a cadre of nurse scientists in each service. Mentoring, scientific writing workshops, grants-writing workshops, other technical assistance mechanisms, and support for continuing education all contribute to the development of skills of beginning and experienced nurse scientists. Formal and informal mentoring of junior researchers can pay dividends in their professional development and commitment to the advancement of nursing science. The value of creating opportunities to keep former military nurse researchers involved in overseeing the research process is clear: it utilizes talents and resources associated with experience. Structured mentoring programs are needed that include assigned mentors and that involve both education and support to facilitate the process of research dissemination. The need for scientific writing workshops is apparent from the small number of published research articles. Funding for participation in scientific meetings helps link nurse scientists with other researchers and disseminate study results.

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--> Research utilization conferences can help incorporate research findings into practice. Establish close linkages between the TriService Nursing Research Program and the larger arena of health care research and nursing research. This can be achieved through the application of a rigorous peer review process; the formation and active involvement of a multidisciplinary advisory board; a director who is a doctorally prepared military nurse researcher; an increased emphasis on publication, especially of peer-reviewed research articles; and participation in science networks. The function of a multidisciplinary advisory group would be to provide input on strategic direction and program improvement, advise about prioritization of research, and facilitate communication within the military and civilian research communities. Members could be drawn from the National Institute of Nursing Research, the Association of Health Service Research, DOD Medical Research and Development, American Academy of Nurses, Sigma Theta Tau, and others. 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. Recommendations for Program Management Management Structure The committee deliberated on the existing management structure of the TSNR Program and recommends the following: The TriService Nursing Research Group should continue to provide oversight to the program. The 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. The committee suggests that the TSNR Group consider expanding to include a senior Medical Corps officer who is a research scientist. A doctorally prepared military nurse researcher should be employed as director of the TriService Nursing Research Program. The committee believes it essential that the administrative mechanism be designed to manage the program; implement reporting requirements; conduct evaluations; provide for consistent structure and continuity in the TSNR Program grants and

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--> research support effort; address the scientific conduct of research, and cultivate a network of research support, research training, and career development. 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 and mentor for military nurse researchers. Strategic direction of the program requires a full-time position and adequate support personnel and budget. Recent retirees or members of the reserve or guard components would have the advantage of bringing a military perspective with less chance of causing the discontinuity that results from reassignment of active-duty personnel. On the other hand, an active-duty position that would rotate among the military Nurse Corps could be advantageous in the recruitment and retention of outstanding military nurse researchers. Application Process The committee recommends that there be a permanent yearly submission date to facilitate the preparation of complete and well thought-out proposals. The committee also recommends that the form used by Institutional Review Boards at different medical facilities be standardized for each service (if not for all three services), to streamline the application and decision-making process. Grant Review Process Peer Review for Scientific and Technical Merit. The mechanisms used for peer review should be consistent with those used by such bodies as the National Institutes of Health. To achieve this, the chair of the TriService Nursing Research Program Scientific Review Panel should have experience in outside grant reviews, and he or she should show evidence of being a seasoned leader in bringing about consensus and decision making in groups. The committee strongly recommends that the peer review panel continue to consist of 15 to 20 individuals, no fewer than 3 of whom should be nonmilitary scientists and scholars. The nonmilitary reviewers must have experience on peer review committees for research, for example, of proposals submitted to the Division of Research Grants of the National Institutes of Health, or peer review committees in research programs such as those of as the American Heart Association or the American Cancer Society. The rest of the

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--> panel shall consist of doctorally prepared nurses from the active, reserve, and guard components, with representation from each of the services. The members would be assigned staggered terms of 3 to 4 years. If there is not the necessary expertise on the panel for review of individual grants, collateral ad hoc reviewers should be sought. During the annual grant review meeting, proposals within the same award category should be reviewed as a group, using established criteria for each category, as recommended in the 1995 After Action Report (see Chapter 4). This process will help to ensure fair treatment since expectations vary widely for different types of grants. Explicit criteria need to be established in advance for each award category. Other Review Considerations. The primary criterion for awarding grants should continue to be scientific excellence. The peer review panel would classify the relevance of the proposed study to military nursing as high, moderate, or low; but this classification would not be considered in the determination of scientific excellence. Once scientific excellence has been established, programmatic relevance is the next level of review (level 2). That is, when the advisory council (TSNR Group) receives more excellent proposals than it can fund, the awards would go to the proposals that best meet the programmatic goals of military nursing and that describe satisfactory contingency plans for deployment. As a new recommendation, members of the Scientific Review Panel may submit grant applications during their term of office on the panel; however, they may not be physically present in the room during the review of their grant applications, and no committee member may talk with them about the review. If at all possible, the applicant should be excused from the entire peer review at that submission time and be replaced by another ad hoc member who has the same expertise. The committee realizes that most guidelines for conflict of interest should prohibit study sections from reviewing applications submitted by their own members and prohibit panel members from participating in reviews of applications from their own institutions. The committee agrees that the primary reviewer should not be from the same institution. However, because of the small number of doctorally prepared nurses in the military, the committee recommends the slightly different conflict-of-interest guideline described above to facilitate the growth of military nursing research without hampering peer review. The committee further recommends allowing the primary reviewer to be from the same service. Disallowing primary review by a member of the same service is unnecessarily restrictive, especially since areas of expertise may be concentrated in a service.

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--> Evaluation Well-conceived and implemented evaluation is integral to the success of any program. Evaluation mechanisms are most effective if introduced in the early phase of the program. The committee strongly recommends the following: Develop and implement a plan for ongoing monitoring and evaluation of the TriService Nursing Research Program. Recommended basic elements of such a plan are presented in Box 5-1. Data files should be established to facilitate analysis and report generation. Conduct outcome and impact evaluations of the program within 3 years and at scheduled intervals, as documented by systematic criteria that include evidence of peer-reviewed research publications and applications to practice. Recommendations for Areas of Research The research agenda for the TSNR Program was initially established by legislation and has included broad areas of research. The committee agreed that these areas of research should complement those currently receiving priority attention from the National Institute of Nursing Research and the Department of Veterans Affairs. In particular, they should give attention to contexts of care that are peculiar to or highly prevalent in the military. Proposals for basic and clinical research programs must have the potential ultimately to improve patient care and guide practice. The committee recommends that future research be focused primarily in four broad areas, as described below. In addition, the committee recommends that the TriService Nursing Research Group hold a conference to set a research agenda on a regular basis (e.g., biennially). 1.   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 directly applicable to the military. Examples of research topics include the prevention of complications associated with battle injuries; staffing of aircraft for transportation of large numbers of stabilized and unstable patients; nursing health care issues related to rapid deployment; protection against adverse interactions of the human and physical environments; and preventive health measures during deployment. Consideration should be

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--> Box 5-1 Recommended Elements of Ongoing Monitoring and Evaluation of the TriService Nursing Research Program Input Evaluation Administrative costs Costs of review process Personnel costs, including indirect Funds allocated to each project Full-time equivalent commitments to research and their dollar value Actual time taken from other military duties Value and marginal costs of space and equipment Time taken from other activities by research subjects Process Evaluation Peer review process Grants received and reviewed Approval rates Composition of review panels Results of the review process Quality of studies Qualifications of investigators Adequacy of research settings Completion of projects and fulfillment of reporting requirements Outcome Evaluation Publications Other forms of dissemination Impact Evaluation Citation counts Impact on costs of health and medical services, quality of life of service members and their families, readiness of military units, return to service of personnel—as possible Impact on the careers of military nurses Subsequent research productivity Professional recognition

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--> given to the development of research capabilities for circumstances of deployment. 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. The development of a structure with plans and tactics in place to facilitate investigation of important nursing problems could be a distinct opportunity for and contribution of military nursing research. 2.   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. Examples include but are not limited to the following: studies of nursing care measures that will reduce problems when postpartum women return to duty; health promotion measures targeted to staying within body weight limits after smoking cessation; disease prevention measures such as exercise and stress reduction; protection against excessive incidents of violence in the workplace; prevention of spousal and child abuse; military health systems organization and care delivery (e.g., managed care, case management, and home care management). 3.   Cultural aspects of military nursing: Military nursing affords extensive opportunities to examine cultural implications and dimensions of the provision of nursing care to service members and their beneficiaries. For example, a large number of service members and their beneficiaries are from racial and ethnic minority groups, spouses may be from countries other than the United States, and care may be delivered to many military or civilian individuals from a host country. Nursing recognizes that culture helps shape the definition of health and illness and interpret human responses to physiologic and biological changes. The committee urges investigators to formulate research questions that address nursing care problems and opportunities related to this rich exposure to cultural differences. These may include the ways in which culture can constrain access to health care, the need for health care providers to adjust their traditional moral values and approaches to care, the identification of culturally-appropriate educational strategies, and the influence of culture on ethical recommendations. Attention to cultural aspects of nursing care could have far-reaching benefits in the military and civilian sectors alike. The most obvious benefit of research that leads to cultural competence is excellence in practice. Cultural competence involves the awareness of cultural differences and the integration of this awareness into practical skills that enhance one's ability to serve a diverse population. 4.   Evaluation of research utilization and clinical relevance: Although scientific advances are apparent within nursing research, the interval between discovery and utilization in practice must be shortened to ensure timely

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--> incorporation of findings into the provision of military nursing care. Military nursing must develop efficient processes to implement care recommendations and direct research-based information to practitioners. An example in this area would be the preparation of guidelines for practice based upon findings of programs of research. This area of research provides a process by which research results can be reviewed, evaluated, and implemented into nursing care, with evaluation of the practice implementation under conditions relevant to the military. The overall goal is to facilitate state-of-the-science standards of care. These four recommended areas of research encompass research topics identified in previous congressional authorizations of the TSNR Program. They were based upon the committee's review of presentations by members of the military Nurse Corps, examination of results from literature searches, review of past and current research funding, and deliberations concerning the need for further research that addresses the unique needs of military nursing. In seeking proposals, the committee urges the TSNR Program to encourage applicants to build on and further develop strengths to achieve and develop a strong program of research. This process could be greatly enhanced by a priority-setting conference. The committee encourages collaborative research with investigators from other institutions and other disciplines. Such an interdisciplinary approach facilitates strong research and enables scientists to be at the forefront of their research area. Use of expert interdisciplinary teams with the sets of skills necessary to address strategic research questions productively would help produce positive impacts on the health of military populations. The development and focusing of research resources should be an outcome of implementation of the recommendations in this report. The committee recommends the setting of priorities for funding that would lead to a focused portfolio of research aimed at specific areas of importance to military nursing. The priorities for research funding would be developed by the TSNR Program following one of several conventional processes for strategic planning and consensus building for research priorities. Since investigator-initiated research is often creative, innovative, and highly productive, priority areas should be sufficiently broad to accommodate a range of investigator interests, including partnerships with basic scientists whose work has relevance to military nursing. Recommendations for Allocations of Funds The committee recommends that approximately 10 percent of appropriated funds be used to cover administrative costs, which are to include workshops, conferences, and travel support in addition to funds needed for essential

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--> program operation. The remainder of funds should be used for the various grant awards. Recommendations for Grant Award Categories 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 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 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, and adding: (1) Senior Investigator Awards, and (2) Utilization and Evaluation of Research-into-Practice Awards. Although two of the award categories remain the same, the committee recommends the use of more stringent requirements for grant applicants, as indicated under each of the categories below. Suggested maximum funding levels are given, but the committee advises that funding decisions and levels be made carefully in light of limited resources and that funding generally not exceed that for comparable work in such other agencies as the National Institute for Nursing Research. Funding in excess of $200,000 per year should be examined with great care but not necessarily prohibited. 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. Awards will support research for 1, 2, or 3 years. The suggested maximum funding level is $200,000 per year inclusive of direct and indirect costs.

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--> Active, reserve, and guard nurses in all services are eligible to apply for this funding. 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 of criterion (2) may or may not be in the military and may have the doctoral degree in nursing or another discipline. Awards will support research for 1 or 2 years. The suggested maximum funding level is $40,000 per year inclusive of direct and indirect costs. Active, reserve, and guard nurses in all services are eligible to apply for this funding. Senior Investigator Awards. Doctorally prepared nurses who have been out of service (active, reserve, or guard) for less than 3 years in the Army, Navy, or Air Force 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. The goal of this new award is to retain the special expertise of experienced investigators within the military arena, facilitate mentoring, and enhance possibilities for the career trajectory. Awards will support research for 1, 2, or 3 years. The suggested maximum funding level is $200,000 per year inclusive of direct and indirect costs. Utilization and Evaluation of Research-into-Practice Award. 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. The suggested maximum funding level is $40,000 for 1 year. The committee recommends that the TSNR Group establish a policy concerning the priority that it wants to place on this type of study. The goal of this special award is to improve nursing care for DOD service members and beneficiaries by providing a process by which research results can be reviewed, evaluated, and implemented into nursing care—followed by

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--> evaluation of practice implementation. The overall goal is to facilitate state-of-the-science standards of care. Long-Term Goals for Grant Award Categories The committee recommends the addition of the following funding mechanisms as long-term goals, to the extent that funding allows: infrastructure enhancement awards, post-doctoral fellowships for research training, and centers of excellence. Infrastructure Enhancement Awards. The suggested award level is approximately $20,000 to $50,000 for 1 year. Active, reserve, and guard nurses in all services would be eligible to apply for this funding. Research in military nursing may be facilitated by improved access to institutional resources that are appropriate for sharing. Examples include, but are not limited to systems of instrumentation including computers; development of registries of patient outcomes (such as hemorrhage or dehydration) during different modes of air evacuation; development of registries of follow-up data on DOD beneficiaries before, during, and after deployment; and development of software for telemedicine and other information systems pertinent to military nursing delivery of care. The committee encourages the broadest use of research resources in the military installations that are enhanced by these awards, including multidisciplinary research. Accordingly, the committee recommends that applicants specify how such resources will be made available to at least three other military scientists who have ongoing funded research projects. Mentored Research Investigator Awards. The suggested award level is $40,000 per year for a period of 1 or 2 years, inclusive of a discretionary travel fund to work with a mentor who is an established scientist. After finishing doctoral preparation in a 3-year period, military nurses are at a critical juncture. Many have not had the necessary preparation in research to become established scientists. Giving talented investigators adequate mentorship in research offers one of the best opportunities to accelerate the pace of advance of empirically based nursing care for DOD beneficiaries.

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--> The post-doctoral mentorship concept usually implies a freeing of military nurses from some of their clinical responsibilities so that they can devote most of their time to research. The committee recognizes that the latter will involve an authorization of a change in role expectations for military nurses that is beyond the committee's purview. Thus, the committee recommends research mentorship for military nurses as a long-range goal. Centers of Excellence in Military Nursing Research. To optimize the career development of military nurse researchers and to enhance the probability of successful completion of grants awarded by this program to active-duty military nurses, it is highly desirable that Centers of Excellence in Military Nursing Research be included in the organizational structure of a significant number of armed services' medical centers of treatment facilities. These centers would be incorporated in the mission of the medical center or hospital and would be appropriately staffed with active-duty nurses who have advanced research training and who have been assigned to nurse researcher validated positions (doctoral or master's level). The primary duty assignment would be to conduct and manage military nursing research projects funded by the TSNR program and to develop and mentor the research training of junior officers. The chief or director of the respective Nurse Corps should ensure that nurses assigned to these positions are stabilized for at least 3 to 4 years so that they will have sufficient opportunity to develop research proposals and complete their projects in order to publish the results prior to moving to another assignment. Centers of Excellence in Military Nursing Research would require a disproportionately large amount of funding from the current fiscal year's TSNR Program funds and would limit the development of military nursing research to one or two military facilities nationally. Therefore, the committee recommends the funding of centers of excellence as a long-range goal for military nursing research, with careful consideration given to triservice active, reserve, and guard representation at such centers. With the implementation of these recommendations and others contained in the earlier chapters, the TSNR Program has the potential to evolve into a strong force for the advancement of military nursing practice. References IOM (Institute of Medicine). 1989. The Responsible Conduct of Research in the Health Sciences. Committee on the Responsible Conduct of Research, Division of Health Sciences Policy . Washington, DC: National Academy Press. NAS (National Academy of Sciences). 1989. On Being a Scientist: Responsible Conduct in Research. Committee on the Conduct of Science. Washington, DC: National Academy Press.

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--> NAS (National Academy of Sciences). 1995. On Being A Scientist: Responsible Conduct in Research, 2nd ed. Committee on Science, Engineering, and Public Policy. Washington, DC: National Academy Press.