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5. HEALTH SERVICES RESEARCH AND NURSING RESEARCH Since the Committee's last report, little improvement has been made in the funding of the Committee's recommended programs in the areas of health services research and nursing research. In the past year, a hiatus has existed in the Committee's work in these areas. In this year' s report, the Committee reviews its approach to health services research (HSR) and presents the results of a 1977 survey of HER trainees and researchers. In nursing research, the Committee reviews the status of the federal programs for the support of training in nursing research. HEALTH SERVICES RESEARCH PERSONNEL From its inception, the Committee has strongly supported the need for training in the area of health services research. Early attention by the Committee led to the recognition of health services as an area to be specif ically included under the purview of NRSA. However, passage earlier this year of the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35) deleted from the NRSA Act the authority for the National Center for Health Services Researob (NCHSR) to use this mechanism to support research training. The Committee views with concern this diminished and unfocused federal role in health services researab training as limiting the supply and quality of personnel who are trained to study the many pressing problems in this area. The Committee continues to believe that the increasing importance of health care and the implications that the provision of health services has for the quality of life for all Americans have made health services research an essential area. The training of competent health services researchers remains central to this task. The nature of health services research provides challenges not present in the other areas under the Committee's purview. Because health services research is not a traditional discipline, but rather the selected application of a variety of disc iplines to health services, the Committee and its Panel on Health Services Research had f irst to def ine what constitutes this area. The problem was magnified by the fact that health services research lacks readily identif table boundaries. Previously used def initions therefore have varied according to the policy issues being studied at a particular time. In its 1978 Report, the Committee provided a definition of health services research that it still believes encompasses the diverse aspects of this area: Health services research is theoretical or applied re- search which examines the organization and performance of health care delivery systems and makes possible in- formed health care policy. It is a distinct area of inquiry in which systematic methods are applied to pro- blems of the allocation of f inite health resources and the improvement of personal health care services. Because health services researab utilizes the perspectives of many disciplines, it is useful to view it in terms of a matrix of research disciplines and research problems. Figure 5.1 presents the matrix, slightly modif fed from its first use in the 1978 Report (p. 115) of disciplines (e.g., behavioral and social sciences, biomedical sciences, and other fields) and problem areas (e.g. , health personnel, ambulatory 105

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care, mental health services, health insurance, quality assurance, and legal stud ies) . The Committee has also emphasized that health services research is not simply an applied f ield, but one that involves f undamenta' research as well. A full range of research methodolog ies may be utilized, including statistical and computer analysis, case studies, clinical studies, survey research, evaluation research, technology assessment, and dec ision and policy analyst s. Evaluation of the labor market in an interdisciplinary area suab as this is cliff ~cult. For health services research, measuring the flow through the training pipeline cannot be done in the usual ways because so much of the training occurs outside of traditional degree granting departments. In addition, many health services researchers have received nontraditional training, coming to the f ield with professional degrees or academic doctorates in associated disciplines. To obtain such informa- tion, a survey was undertaken in 1977 of two cohorts of individuals who could be ident if fed as important segments of the health services research labor force: 1) approximately 770 individuals who received support f rom the health services research training programs of the NCHSR and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMS) between 1970 and 1976, and 2) approximately 600 individuals who were principal investigators on NCHSR research grants and contracts between 1960 and 1976. The response rate of both cohorts was 80 percent. The survey results indicate that there are two distinct populations of health services researchers. One, principal investigators, is older, almost exclusively men ~ 91 percent) and is comprised of a large number of medical degree holders {36.8 percent) as well as research doctorate holders (41.3 percent). The second group, former trainees, is younger, includes more women (46 percent), and is comprised predominantly of research doctorate holders (68. 4 percent) with a much smaller portion of medical doctorates (9.4 percent). The changing pattern of degree holders conf irms the Committee's earlier judgment that health services research has been moving f rom an earlier period, where either no formal graduate training was received or where training was received informally in midcareer, to a time when formal training is the norm. As for employment, health services researchers compare favorably with their biomedical and behavioral science counterparts. Over 90 percent of HSR trainees and principal investigators were employed full- or part-time, as was the case in these other fields. Furthermore, un- employment was very low (2 percent or less) in all f ields. Almost 70 percent of HSR trainees and 64 percent of the principal investigators were employed in educational institutions, slightly lower than for biomedical scientists and somewhat higher than for behavioral scientists. Eighty-nine percent of HSR trainees spent some time in research, with an overall average of 38 percent in research. Once again biomedical trainees s bonged a higher average time spent in research (56 percent) than HSR trainees, with behavioral trainees somewhat lower (24 percent). Most importantly, approximately 77 percent of trainees and 81 percent of the principal investigators were engaged in health services research at the time of the survey. Overall' the results of the survey indicate that federal support for training in health services research teas generated a cadre of health services researchers who are fully employed and actively utilizing their HSR skills. In addition, there has been no significant loss of federally supported HSR trainees from academic to industrial employment. 107

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These findings support the Conunittee's previous recommendations that a broad program of federal support for HSR training is warranted. Unfortunately, a positive federal response to this call has not been made. The only current HSR training program is limited to mental health services research in which ADAMHA supports 174 trainees ~ 87 predoctoral and 87 postdoctoral) and 2 f allows as of FY 1980. NIH, which had previously indicated that it did support HSR training, has recently reviewed its prog rams and cono luded that it does not provide such support. NCHSR, which supported 440 students in 1972, was forced to phase out its training prog rams shortly thereat ter because no f unds have been provided to NCHSR for this purpose. Recommendation. It is recommended that 330 health services research trainees and fellows be supported annually through FY 1985. NURS ING BESEECH PERSONNEL Since the inclusion of nursing research by Congress under the authority of the NRSA Act in 1976, the Committee has examined personnel requirements in this area and come to recognize it as a distinct and emerging area of scientific inquiry. Thus, in addition to its numerical recommendations of modest increases in student support, the Committee has made several recommendations in earlier reports designed to improve the research training capability of doctoral nursing programs: ( 1) increasing use of training grants, (2) utilizing basic science departments with established relationships with nursing schools, (3) focusing support on ~well-qualif led" schools of nursing with existing capability for research training, ~ 4) phasing out fellowship support in the consciences, (5) provide ng a limited amount of postdoctoral support for advanced training, and ~ 6) instituting a midcareer training program for the upgrading of research skills of current nursing school faculty. Although the HRA Division of Nursing had research training authority prior to 1977, it initiated awards under NRSA only at that time. Having made its initial recommendations, the Committee has taken the position that the programs should be given an opportunity to become established before an evaluation is attempted. Therefore, while a full evaluation of these training programs will not be undertaken in this report, a review of their status will be useful. The Committee wishes to thank the HRA Division of Nursing for its cooperation in providing relevant information. The principal observation to be made about the development of the HRA nursing research training program is that it has not been funded at a level that would permit reasonable, modest growth. After a start-up increase from FY 1977 to FY 1978, funding teas remained level at just under $1 million annually through FY 1980. With high inflation rates, the number of individuals supported has declined f rom 127 to 109 between FY 1978 and FY 1980 and is anticipated to fall further in FY 1981. The number of fellowships, primarily predoctoral, has decreased from 122 to 95 in that period. In FY 1977, 3 institutional training grants, primarily postdoctoral, were awarded and renewed through FY 1980 ; however, no new awards have been made since then. The training grants have been quite small, supporting a total of 30 trainees over the entire FY 1977-1980 period. Because of the budgetary constraints, the nursing programs have not reached the level recommended by the Committee, which was 270 fellows and trainees by FY 1981. 108

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While recommending that the preponderance of support be directed to the predoctoral level, the Committee also supported the use of up to 15 percent of the awards as postdoctoral appointments as high-quality candidates present themselves. To date, 13 postdoctoral fellowships and 20 traineeships have been awarded between FY 1977 and FY 1980, or 7 percent of all new awards. One of the primary objectives of the Committee's recommendations for federal support for nursing research training has been to provide seed money not previously available for nursing schools to develop high- quality training programs. The Committee believes that the impact of the limitations on funding thus far provided has been to inhibit this development. Furthermore, the proliferation of doctoral training programs in nursing schools in the last few years has also detracted from efforts to develop quality training. The number of doctoral granting nursing schools has risen f ram 16 in 1977 to 23 in 1981, an increase of over 40 percent. The Committee remains concerned, therefore, that the unevenness in quality of research training programs evident in its 1977 survey and site visits (1978 Report, pp.131-138) has been perpetuated rather than alleviated. Given the limited resources, both federal and nonfederal, for nursing research training, the Committee has suggested that available funds be directed toward improving programs of demon- strated capability and that an expansion of doctoral programs be avoided until a core of quality programs teas been developed. One positive program designed precisely to strengthen nursing research has been the Nursing Research Emphasis (NRE) grants of HRA. A onetime opportunity, the NRE grants were awarded in the fall 1980 to 10 schools of nursing with doctoral programs at an average level of support of $115, 000 per grant per year. The grants are for 3 years, with a possible renewal to 5 years. The purpose of the the development of nursing research by providing program is to stimulate funds for faculty research. Applicants were required to demonstrate their research capacity and specify the projects that would be conducted. Among the 10 grants, there are 47 component studies on children; adolescents; beginning families and parenting; aged, chronically ill, and terminally ill; and minorities and other underserved groups. The Committee is ~ ~ . . . . . _ . . . . . this important effort to enhance the research capabilities of doctoral nursing programs. pleased that the Division or Nursing at HRA iS making Recommendation. NBSA support for nursing research train- ing should rise to 300 trainees and fellows annually from FY 1982 through FY 1985e No more than 15 percent of these trainees should be at the postdoctoral level. am. 109 en!