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6. Nursing Research
Problems encountered in the practice of nursing are
widely varied, important to the health care system,
and deserving of a national research effort. Research
on these problems, which cover issues ranging from
methods to a.Zleviate anxiety and pain to improving the
prospects for high-risk infants, ~ ~ ~ ~
is conducted mainly
by nurses with doctoral degrees in biomedical and
behavioral fields. There were about 2,500 such
individuals in 1980 but only 7 percent reported
research as a mayor activity. The numbers are
increasing, but a solid core of well-trained
investigators has not yet been developed to address
all nursing research issues.
INTRODUCTION
The goal of nursing research is to facilitate the development of
clinical nursing interventions which will improve health outcomes and
contribute to the optimal delivery of care. To this end, according to
the American Nurses' Association, nursing research "develops knowledge
about health and the promotion of health over the full life span, care
of persons with health problems and disabilities, and nursing actions
to enhance the ability of individuals to respond effectively to actual
or potential health problems. So defined, nursing research
Complements biomedical research, which is primarily concerned with
causes and treatments of disease.. ~
! Statements of the American Nurses' Association, 1981, as quoted in
ION, 1983.
131
1
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132
EXAMPLES OF NURSING RESEARCH
The scope of nursing research is very broad, including, for
example:
.
studies to reduce the complications of hospitalization and
surgery (such as respiratory or circulatory problems) and
factors that negatively influence recovery
studies to improve the prospects for high risk infants and
their parents (on prematurity, stress-induced complications in
childbirth, child abuse, and developmental disabilities, for
instance)
studies of methods to alleviate anxiety, stress, and pain
associated with illness or disability
studies to facilitate the utilization of new technological
developments in patient care (such as those concerned with
nasogastric tube feeding of hospital patients and techniques
for recovery and maintenance of eating and grasping abilities
following stroke), (Jacox and Walike, 1975, pp. 2-5).
The Division of Nursing of the Bureau of Health Professions,
Health Resources and Services Administration (DHHS) classifies nursing
research into six categories: Fundamental, nursing practice,
nursing profession, delivery of nursing services, nursing education,
and utilization. Although research in all these categories is likely
to have an impact on health outcomes or improved patient care, those
with the most direct impact are fundamental and nursing practice
research, which jointly accounted for the bulk of all Funded studies
as of the end of FY 1981 (HRSA, 1983).
The distinction between fundamental and nursing practice research
is important and is regarded both by the Division of Nursing and by
the nursing profession generally as central to an understanding of the
nature and scope of nursing research. Fundamental research is
research which addresses or focuses on the biological and/or
behavioral functioning of human beings, their environments, and their
social systems. It constitutes the science base from which nursing or
other clinical practice theories can be developed and tested. The
findings and theories developed through fundamental research
constitute the pool of knowledge and theories which health
practitioners and researchers of various types, including nurses, can
draw upon to develop clinical intervention strategies and/or to test
the effectiveness and efficiency of different practice methods (Bloch,
1981, p. 87~. Examples of fundamental biological and/or behavioral
research deemed relevant to the field of nursing and funded by the
Division of Nursing include studies on the responses of children to
pain, the perceptions of the elderly as concerns their physical
functioning and health care needs, the effects of radiotherapy on
cancer patients, and the effects of caffeine on pregnancy outcomes.
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133
Nursing practice research, on the other hand, specifically
addresses issues related to the practice of nursing as a profession--
with nursing interventions, procedures, techniques, and/or methods of
patient care being the focus of inquiry. Research designs used in
practice research are typically experimental, explicitly postulating
and testing the linkages between one or more nursing interventions,
procedures, or processes and patient outcomes in controlled experi-
ments. The processes, procedures, techniques, or interventions which
are "tested" may be technical, physical, verbal, cognitive, psycho-
social, and/or interpersonal. Practice research funded by the
Division of Nursing has included studies on endotracheal aspiration of
critically ill patients, nurse attention to psychological distress
among medical-surgical patients, the effect of nurse empathy on
patients, the stress of radiation treatment for cancer patients, and
the effectiveness of prenatal care provided to Navajo women, among
many others.
While nursing research ultimately aims at improving patient care
for persons with existing health impairments and reducing or
preventing health-related problems for others, some nursing research
explicitly addresses, or has implications for, the relative costs of
different types of interventions, procedures, settings, and providers
of care--that is, for cost-effective patient care. Fagin (Am. J.
Nursing, Dec. 1982), for example, reviews a number of studies
conducted over the past 10 years which demonstrate that innovations in
nursing practice and alternative methods of service delivery, treat-
ment, and care can provide equivalent or superior patient outcomes at
cost savings over more traditional or usual methods. Reducing
hospital length of stay, preventing rehospitalization, reducing the
number of outpatient visits, and reducing absenteeism have been among
the cost savings demonstrated by some of these studies. Long- or
short-term nursing intervention with mothers having a history of child
abuse, for example, was found to result in a lower rate of child
rehospitalization due to parental abuse or neglect; the addition of a
nurse practitioner to a small industrial company's health service was
found to reduce employee time lost from work; and patient education
programs and educational counseling of patients with a variety of
surgical or medical problems have been found to reduce hospital length
of stay, hospital readmission rates, the number of outpatient visits,
and so forth, compared to control groups not receiving such nursing
interventions.
Home care as an alternative to hospitalization was the focus of a
number of the studies Fagin reviewed, and all indicated potential or
actual savings of home care over hospitalization. For example,
training patients to administer intravenous antibiotics at home
reduced hospitalization time and treatment expense. Likewise, the
mean cost of home care for children dying of cancer with care
coordinated by nurses and provided by parents (and physicians serving
as consultants) was 18 times less expensive than that provided in a
hospital setting for similar children.
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134
FUTURE NURSING RESEARCH AGENDA
The Commission on Nursing Research of the American Nurses'
Association suggests an agenda for the 1980s that would give priority
to research that will generate knowledge alto guide practice" in the
following broad areas:
promoting health and well-being, as well as competency for
personal care and personal health, among all age groups
(including identification of the determinants of wellness and
health functioning in individuals and families)
decreasing the negative impact of health problems on coping
abilities, productivity, and life satisfaction of individuals
and families
designing and developing cost-effective health care systems in
meeting the nursing needs of the population
· ensuring that the nursing care needs of Vulnerable groups"
(including but not limited to racial and ethnic minorities and
underserved populations, such as the elderly, the mentally ill,
and the poor) are met (Nursing Research , 19801.
THE SUPPLY OF RESEARCH PERSONNEL
AND DEMAND FOR NURSES WITH DOCTORATES
Nursing research is conducted by investigators trained in numerous
disciplines, including general medicine, various medical specialties,
various branches of biomedical research, and the behavioral sciences.
This diffusion of investigators makes it hard to accurately estimate
the number of investigators performing nursing research. However,
most nursing research funded by the Division of Nursing, HRSA, is
being conducted by nurses, of whom the vast majority have doctorates
in nursing or other disciplines.2 This report therefore focuses on
the supply of nurses with doctorates.
The evolution of nursing from a nonacademic discipline relying on
apprentice-type training to a recognized profession with its own
academic credentials and body of research has been slow, and is still
progressing. Until the early 1970s the majority of new Registered
2 An informal review of principal investigators awarded research
grants by the Division of Nursing in HRSA revealed that through the
1960s nurses with masters degrees were awarded grants. Since the
early 1970s most principal investigators of funded projects have
doctorates.
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135
Nurses (RNs) were trained in hospital-based nursing schools that
conferred diplomas and prepared students for Registered Nurse
licensure. By 1981 that mode of preparation had fallen to less than
20 percent. Almost half of newly licensed RNs in 1981 were prepared
in associate degree programs (usually in community colleges) and
one-third were prepared in baccalaureate programs in 4-year colleges
and universities (IOM, 1983, p. 55). Although diploma prepared RNs
are declining both as a proportion of new RNs and in absolute numbers,
in 1980 they still represented half the supply of employed RNs.
Nurses trained in associate degree programs represented 20 percent and
RNs with baccalaureate or higher degrees represented 29 percent (IOM,
1983, p. 771. This last group, numbering 364,400 nurses, is the
actual and potential pool of nurse researchers since graduates of
diploma and associate degree programs are not eligible for advanced
degrees unless they upgrade their educational levels.
Number of Nurses with Doctorate Degrees
The most comprehensive and most recent study of nurses with
doctoral degrees was conducted by the American Nurses' Association
(1981). The study estimated that approximately 2,500 (0.15 percent of
1.66 million licensed RNs) held doctoral degrees in 1980 .4 However,
although the number is still relatively small, it is increasing
rapidly. Between 1963 and 1969 only about 30 nurses earned doctorates
each year (ANA, 1981, p. 14~. Today that figure is closer to 150
(NLN, 1981, Tables 72 and 73).
There has also been a radical change in the education of nurses
with doctorates. The ANA study identified 17 different doctoral
degrees obtained by nurses. Up to 1965 the most frequently earned
degree was the Ed.D., which was succeeded by the Ph.D. in the 1970s.
The professional nursing degree (DNS) was first awarded in the 1960s
and has become increasingly represented in new doctoral degrees (ANA,
1981, p. 30). The increase in nursing doctoral degrees has been
paralleled by an increase in the number of doctoral programs in
nursing education departments--22 in 1981-82 compared to 2 in 1959-60
(NLN, 1983).
3 It should be noted that a significant number of nurses advance
through the educational system. Thirty-five percent of nurses with
baccalaureates and half of the nurses with graduate degrees initially
prepared for RN licensure in associate degree or diploma programs.
4 Health Resources and Services Administration estimated the number
of nurses with doctorates to be 4,100 in 1980 (U.S. Department of
Health and Human Services, 1982, Table 3~. Although this is
substantially higher than the ANA estimates it still represents only
0.25 percent of licensed RNs.
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136
Tune Spentin Research
However, not all nurses with doctorates are engaged in research
activities. Table 6.1 shows that 75 percent of nurses with doctorates
in schools of nursing (largely those that offer
are employed
baccalaureate and higher degrees). Not surprisingly, the amount of
time spent in research varies according to the type and place of
employment, but overall fewer than 7 percent of the nurses surveyed
reported research as a major function (ANA, 1981, p. 44~. Table 6.1
also shows that the nurses employed in nursing schools spend, on
average, less time on research than nurses in some other settings--for
example, other health professional schools. Since most nurses with
doctorates work in schools of nursing, this is of concern to those
attempting to generate increased nursing research.
In 1970, an evaluation of a program designed to encourage faculty
research noted that deans and directors of programs found it difficult
to free faculty for research, and questioned how much could be
expected from faculty in terms of a combined teaching and research
load (Abdellah, 1970).
TABLE 6.1 Average Percent of Time Spent in Research by Work Setting and Percent of
Nurses with Doctorates, 1980
Setting
% Time ~0 of Nurses
in Research with Doctorates
School of Nursing (Baccalaur. and Higher)
School of Nursing (Hospital)
School of Nursing (Associate Degree)
Other Health Professional School
Other Department or School
Hospital in Service
Hospital Nursing Admin. Work
Public/Community Health Agency
Federal/State/Local Government
Other
11.8
0.8
2.3
28.4
11.1
11.5
12.3
4.0
20.6
14.3
70.1
4.6
7.1
2.9
6.0
9.3
100.0
SOURCE: American Nurses' Association (1981).
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137
A comment of this sort indicates that research activity may have
been regarded as a secondary activity for faculty in nursing schools.
In the intervening decade, however, there has been a radical change.
More recent data suggest that the expansion of nursing education has
increased the demand for doctorally prepared faculty. A survey of 58
graduate nursing programs in 40 states found a need for 1,080 faculty
with doctorates in the next 5 years. The survey found that the
greatest need was for faculty with preparation that emphasized
research and nursing theory development (McElmurry, et al., 1982, pp.
5-10~.
The Institute of Medicine in 1983 estimated that 5,800 nurses with
doctorates would be working by the end of 1990--3,000 with doctorates
from nursing programs and 2,800 with doctorates in other fields (ION,
1983, p. 1441. This represents an increase of 2,800 nurses with
doctorates from the 1980 estimate of 3,000--probably just enough to
fill the demand in the 40 states mentioned earlier, but far less than
the 1990 projection of need for 14,000 doctorally prepared nurses made
by the Health Resources and Services Administration, Division of
Nursing (IOM, 1983, p. 145). The U.S. Department of Health and Human
Services based its projections of the need for doctorally prepared
nurses on the judgment-of-need criteria developed by the Western
Interstate Commission on Higher Education. A national panel of expert
consultants was convened to establish criteria for staffing patterns
and the educational preparation of RNs to meet service needs in
different health care settings (hospitals, nursing homes, home care,
etc.) and in units within those settings (E.R., newborn units, etc.).
If this estimate of demand is even approximately accurate, nurses with
doctorates should have no problem finding employment for the next
decade at least.
The Infrastructure for Research
A simple enumeration of the number of people qualified to conduct
research and the amount of time spent in that activity does not
encompass all the important variables that affect the amount of
research being conducted. One of these is research funding, which
will be discussed later. Another, which is a prerequisite for
research, can be described as the infrastructure--the elements that
need to be in place before a research area can become established and
grow. For nursing research some of the infrastructure is still in the
process of development. In 1977 this Committee noted that seven today
there are less than 2,000 registered nurses who have completed
doctoral education, scarely more than an average of one doctorally
trained nurse for each school of nursing in the United States" (NRC,
1975-81, 1977 Report, p. 156~. By 1980 only 7 percent of full-time
nurse-faculty held doctoral degrees (NLN, 1982, p. 941. This compares
unfavorably with other disciplines. Well over 50 percent of the
faculty of 20 schools of public health held doctorates and more than
90 percent of faculty held doctorates in schools offering doctoral and
other degrees in departments of psychology, physical sciences,
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biological sciences, mathematical and social sciences, and engineering
(IOM, 1983, p. 136~.
The relative scarcity of doctorally prepared faculty in nursing
schools is likely to have several effects. First, nurses with new
doctorates can find ready employment in schools of nursing and are
less likely to pursue pure research careers where funding is hard to
obtain. Second, as mentioned earlier, nursing school faculty with
doctorates are likely to be heavily engaged in teaching and administra-
tion at the expense of research, and third, nurses being educated by
faculty who do not have the research degree and are not primarily
engaged in research do not have role models who might lead them to
research careers. Finally, as this Committee noted in 1981, the rapid
growth of doctoral training programs (which the data suggest has
outstripped the growth in supply of doctorally prepared faculty) has
resulted in programs of less than optimal quality (NRC, 19811.5 In
short, nursing research still lacks the solid core of research trained
and oriented teachers that are vital to any area of research.
Funds for Nursing Research
The Division of Nursing, HRSA, provided about $5 million annually
in funds targeted to nursing research. In 1982 this dropped to close
to S3.5 million. The Institute of Medicine in its 1983 study said
that this "is not a level of visibility and scientific prestige to
encourage scientifically oriented RNs to pursue careers devoted to
research... (IOM, 1983, p. 19~. n The same report notes that HA
substantial share of the health care dollar is expended on direct
nursing care... n and that "Despite the fact that nurses represent the
largest single group of professionals in the providing of health
services to the people of this country, there is a remarkable dearth
of research in nursing practices (IOM, 1983, pp. 216-2171. In a
stronger statement the study says that Research in nursing has been
handicapped by inadequate levels of support. and contrasts the $5
million annually for nursing research with $1.7 billion for biomedical
research between 1976 and 1981, and with dental research which
receives five times as much as nursing research (IOM, 1983, p. 1371.
The study committee suggests that Han increase on the order of $5
million per year for research could have a substantial impact in
stimulating growth of capacity for research on nursing-related
matters" (IOM, 1983, p. 221.
s Under the Nurse Training Act (P.L. 94-63) some special funding is
available to institutions with graduate nursing programs. About 90
programs receive support each year, 10 percent of them being doctoral
programs. Appropriations for this Advanced Nursing Training program
were at the $12 million level for 3 years, falling to $9.6 million in
FY 1982.
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Other federal money is available for nursing research through the
National Institutes of Health, the National Institute of Mental
Health, the National Center for Health Services Research, the National
Science Foundation, and other agencies. How much these agencies spend
for nursing research is not clear. The National Institutes of Health
in 1982 made awards worth roughly $2.8 million for projects that were
defined as having nursing as a primary component. However, many of
these were for training or curriculum development rather than research
into nursing practice, and in many cases the abstracts of projects
indicated only tangential nursing interest (National Institutes of
Health, 1983).
Other sources of funds include the American Nurses' Foundation,
which makes small (up to $2,100) awards. The number depends on
available funds--23 in 1983, 12 in 1982.
Training Grants and FeNowships
If an adequate supply of qualified individuals to educate
researchers and conduct research is an essential component of the
infrastructure for research, training grants are a mechanism that can
help the development of that infrastructure.
The Division of Nursing, HRSA, currently administers two programs
that support graduate nurse training. The largest is for Advanced
Training of Professional Nurses. This program awards grants to
graduate schools of nursing and schools of public health which
allocate the funds to full-time graduate students. Funding for this
program totaled $7 million in 1965, and increased to $13 million in
1974. Until 1977 awards were made to undergraduate as well as
graduate students. Since 1977 eligibility has been confined to
graduate students. In 1983 funding dropped to $9.5 million. Those
funds supported approximately 3,500 students in 137 schools, with each
student receiving an average of $2,715 (Buchanan, 19831.
The second program--the National Research Service Awards (NRSA)--
offers pre- and postdoctoral fellowships to students in nursing and
relevant disciplines and institutional grants to schools to support
full-time training in research. This program has been funded at about
$1 million annually for the past 5 years (see Appendix Table D2). A
few additional training awards in nursing research are made by the
NIH. The Division of Nursing expects to make 38-45 new awards in
FY 1983 (Wood, 1983). Only three institutional awards have been made
since 1977 and all were phased out in 1981.
Since 1977 this Committee has developed recommendations concerning
the number of students to be supported under the NRSA authority in the
area of nursing research, the distribution between pre- and post-
doctoral students, and the distribution between schools of nursing and
other schools and basic science and non-science departments. The
general view has been that federal support for nursing research
training should emphasize the improvement of programs of demonstrated
capability rather than the further proliferation of nursing doctoral
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programs. The Committee has also recommended that the emphasis of the
fellowship programs should be on Predoctoral support to increase the
pool of research personnel, and provide research faculty to staff the
proliferating doctoral nursing programs. In 1977 the Committee
recommended that 29 percent of fellowships be awarded to students in
graduate schools of nursing in 1979 and should rise to 57 percent by
1981. It was anticipated that schools of nursing would substantially
increase their ability to provide research training. In the same
report the Committee recommended that the proportion of fellowships in
non-science departments fall from 29 percent to zero between 1979 and
1981. -
Although the data are not available to show whether the
recommendations concerning the training sites of students have been
Implemented, Table 6.2 shows the Committee's recommendations compared
to actual awards where the data are available. Two points are clear
from the table. First, funding has not allowed the NRSA fellowship
program to reach the recommended levels of support. Second, the
proportion of postdoctoral awards has remained well within the limits
recommended by the Committee.
Table 6.2 shows the Committee's recommendations compared to actual
awards and demonstrates that for each year funding has failed to allow
the programs to reach the recommended levels of support--by substan-
tial shortfalls. For example, in 1979 total awards were only 56
percent of the recommendations. In the following two years that pro-
portion fell to 49 percent. In each year the shortfall in traineeships
was greater than in fellowships, with traineeships reaching only 26
percent of the recommended number in 1979, compared to 65 percent for
fellowships. In 1981 the gap was even wider with trainees attaining
only 17 percent of the recommended level and fellowships achieving 66
percent.
TABLE 6.2 Actual and Recommended NRSA Training Awards in Nursing Research, FY 1979-81
FY 1979
FY 1980
FY 1981
Total Trainees Fellows Total Trainees Fellows Total Trainees Fellows
Actual Awards
Total 127 13 114 118 22 96 132 16 116
Predoctoral 110 4 106 108 12 96 126 12 114
Postdoctoral 17 9 8 10 10 0 6 4 2
Committee
Recommendations
Total 225 50 175 240 65 175 270 95 175
Predoctoral 193 43 150 205 55 150 230 80 150
Postdoctoral 32 7 25 35 10 25 40 15 25
SOURCE: National Research Council (1975-81).
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The Institute of Medicine in its study of nursing education
reviewed the programs of federal support and recommended an expansion
of support of fellowships, loans, and programs at the graduate level
"to assist in increasing the rate of growth in the numbers of nurses
with masters and doctoral degrees in nursing and relevant disciplines
(ION, 1983, p. 9~. (It should be noted that two members of the
committee made a statement of exception to the words "and relevant
disciplines. They argued that nurses should have advanced education
in their own discipline--nursing--for a number of reasons including
preparation for leadership in nursing and to develop competencies
unique to nursing.)
In view of the continued high demand for doctorally prepared
nurses and the relative immaturity of the emerging field of nursing
research, we agree with the general conclusions of the IOM study.
There is a need to continue to promote expertise in nursing research,
and financial support for graduate students is a proven mechanism for
doing so. As stated in Chapter 1, the Committee reiterates its past
recommendations for research training programs in nursing research
under the NRSA Act and extends them through 1987.
,l
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Representative terms from entire chapter:
doctoral degrees
