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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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138 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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139 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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140 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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141 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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