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6. Nursing Research Abstract The Division of Nursing of the Health Resources and Services Administration currently provides the major portion of funds for nursing research supported by the federal government. About $9 million in research grants and contracts was awarded by this agency in FY 1984. A substantial amount of nursing research is also sponsored by the NIB, the Veterans Administration, and private organizations such as the American Nurses Foundation and the Robert Wood Johnson Foundation. Funds provided by these organizations have supported recent studies on the health and care of premature infants which have shown how they respond to specific nursing interventions. Other studies have focused on care and prevention of disability in the elderly. In most but not all of these studies, the principal investigator is a nurse with a doctorate degree. Although the annual production of nurses with doctorate degrees is increasing, only about 8 percent of nurses serving as full-time faculty members held doctorate degrees in 1982. The lack of nurses with doctorates to serve as faculty exercises a qualitative, as well as quantitative constraint on the continued growth of doctoral programs in nursing. There does not appear to be any substantial amount of support available for training in nursing research other than that provided by the Division of Nursing, BRSA, under the NRSA program. - According to a recent statement by the American Nurses' Association: Nursing research generates knowledge about health and health promotion in individuals and families and knowledge about the influence of social and physical environments on health. Nursing research also addresses the care of persons who are acutely or chronically ill, disabled, or dying, as well as the care of their families. In addition, nursing research studies therapeutic actions that minimize the negative 123
124 effects of illness by enhancing the abilities of individuals and families to respond to actual or potential health problems. Nursing research also emphasizes the generation of knowledge about (a) systems that effectively and efficiently deliver health care, (b) the profession and its historical development, (c) ethical guidelines for the delivery of nursing services, and (d) systems that effectively and efficiently prepare nurses to fulfill the profession's current and future social mandate. Nursing research complements biomedical research, which is primarily concerned with causes and treatments of disease. In its attention to the study of nursing interventions, procedures, and methods of patient care it also complements clinical research by members of other health professions. And, in its attention to the costs and outcomes of different types of procedures, settings, and providers of care, it contains a large component of health services research. The Division of Nursing, HRSA, classifies nursing research into six categories: 1. Fundamental research, which establishes a foundation for further investigations rather than contributing to the solution of specific health problems. It may use human or animal subjects to investigate the ways in which human beings and human systems function and behave, and the ways in which humans think, feel, act, and interact, e.g., studies of the interaction of mothers or fathers with their new infants; Nursing practice research, which directly addresses nursing practice problems, often by assessing the effectiveness of nursing procedures, techniques, and methods, either physical, psychosocial, or cultural. Dependent variables usually involve client outcomes, and studies often employ experimental methods; 4. Nursing profession research, which addresses the nurse as a professional, with studies of cognitive, attitudinal, and behavioral characteristics of nurses which may influence nursing practice; Nursing services administration research, which investigates the structure in which nursing care is provided as well as the physical and social environment in which nurses and clients interact; Nursing education research, which is concerned with the educational process, including studies of the curriculum and student-faculty interaction; and 6. Utilization of research findings, which includes studies of the utilizatiion of research findings in practice and education.
125 EXAMPLES OF NURSING RESEARCH An important step in the maturation of nursing research came in 1983 with the publication of the first Annual Review of Nursing Research (Werley and Fitzpatrick, eds.~. This publication provides an overview of the field, highlighting significant advances and suggesting areas where additional research is needed. Nursing researchers have made important advances in the study of the health care of infants, young children, and the elderly. Nurse investigators, for example, "have been concerned with questions about how premature infants respond to extrauterine living and how nursing action influences the response and well-being of premature infants" (Barnard, 1984, p. 4~. In one clinical study, premature infants were given finger sucking opportunities twice a day, which appeared to promote neuromuscular coordination, alert activity, alert inactivity, and deep sleep (Anderson and Vidyasagar, 1979, cited in Barnard, 1984~. Another study showed that sucking during and after tube feedings advanced premature infants' readiness for bottle-feeding by several days. These infants gained weight faster and left the hospital four days earlier than comparison infants not on the sucking protocol {Measal and Anderson, 1979, cited in Barnard, 19841. The role of sucking as a regulator of infants' physiological and behavioral responses is an important area for research. Other significant nursing research is addressing the effects of various stimuli (tactile, auditory, kinesthetic, and visual) on preterm infants' neurological and mental development, and weight gain (Barnard, 1984~. This research has significant implications for the effectiveness and cost of neonatal nursing care. m e average cost of initial neonatal intensive care is estimated to exceed $13,000 (Institute of Medicine, 1985, p. 229), and almost 7 percent of newborns in the U.S. are at risk because of low birthweight. Nurse researchers also have addressed important questions in clinical geriatric nursing: the maintenance of health, prevention of illness and disability, and care of the ill elderly. This research is of great importance as life expectancy increases; data from the 1980 census show that 1.5 percent of persons age 65-74 were in nursing homes; the percentage rises to 6.6 percent for persons 75-84, and 22.7 percent for persons 85 and over. In 1983, almost $29 billion was spent on nursing home care (Gibson et al., 19841. Two issues in the clinical care of the ill elderly that are being addressed by nursing researchers are {1) the prevention and treatment of decubitus ulcers and (2) the prevention or reduction in the frequency of incontinence. Gerber and Van Ort (1979, cited in Wolanin, 1984), for example, tested the use of topical insulin in treating decubiti with good results. Catanzaro (1981, cited in Wolanin, 1984) conducted a qualitative study of the perceptions of the elderly regarding incontinence; other, experimental studies have employed behavior modification techniques to control incontinence (Wolanin, 19841. As these examples illustrate, the nature of problems studied by nurses is influenced strongly by the nature of problems they encounter in the clinical setting. While these problems might be studied by investigators from other health professions, they generally are not.
126 SOURCES OF SUPPORT FOR NURSING RESEARCH AND TRAINING Division of Nursing, HRSA Nursing Research The Division of Nursing of the Health Resources and Services Administration (PHS, DHHS) is the primary source of funding for nursing research and research training in the federal government. Since January 1985, the Nursing Research Grants Program has been administered by a Center for Nursing Research. Replacing the research component of the former Nursing Research and Analysis Branch, the Center is intended to provide increased visibility to nursing research in DHHS. In establishing the Center, no additional budget allocation was made by the Secretary. The Division supports five types of grants under its Nursing Research Grants Program, as described below. NURSING RESEARCH PROJECT GRANTS support discrete, specified, circumscribed projects in an area representing the investigator's interest and competencies. NURSING RESEARCH PROGRAM GRANTS support clusters of at least three studies focused upon a single theme. NEW INVESTIGATOR NURSING RESEARCH AWARDS (NINRA) support small studies of high quality carried out by new investigators. UTILIZATION OF RESEARCH IN NURSING AWARDS (URNA) support projects to bridge the gap between the generation of knowledge through research and the utilization of such knowledge in nursing practice, nursing education, or nursing services administration. NU=ING SEARCH ISIS GRANTS FOR DOCK PRODS IN NURSING (NRE/DPN) stimulate nursing research in areas that emphasize special health needs of the nation, and advance the research efforts and resources of faculty in schools of nursing offering doctoral programs. The stated purpose of the Nursing Research Grants Program is "to enlarge the body of scientific knowledge that underlies nursing practice, nursing education, and nursing services administration; and to strengthen these areas through the utilization of such knowledge." Principal investigators need not be nurses. The NRS/DPN projects, however, are specifically designed for schools of nursing that offer doctoral programs. Applications for all five types of grants are submitted to the Division of Research Grants of the National Institutes of Health; they are then assigned to the Division of Nursing on the basis of nursing relevance, where they are subject to interdisciplinary peer review.
127 Grants are awarded in a number of content areas (Table 6.1~. As shown, most projects in recent years have been in the areas of fundamental research and research on nursing practice. Fundamental research provides basic knowledge about the person before intervention; nursing practice research looks at the interaction between the nurse and the patient. Examples of some recent projects include "Models of Newborn Nursing Services," "Stress Response: Assessment and Change," and "Acute Confusional States in Elderly Patients." Table 6.2 shows the earned doctorates of principal investigators (PIs) working under research grants from the Division of Nursing. Nurses have represented between 75 percent and 85 percent of the awardees in each year since 1974. The proportion of nurse PIs holding doctorates has increased from about 50 percent in 1974 to 96 percent in 1983. Nearly all of the non-nurse PIs have held doctorates. TABLE 6.1 Nursing Research Grants Active at End of Fiscal Years 1969~3, by Content Categorya Fiscal Year Content Category 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 A Fundamental 5 6 9 7 9 10 12 9 10 11 8 10 11 9 12 B Nursing Practice 6 6 4 7 11 9 9 6 9 14 20 25 23 16 19 C Nursing Profession 6 6 6 6 7 4 2 1 6 7 4 3 3 3 7 D Delivery of Nursing Services 9 6 6 4 5 6 4 2 1 1 1 1 2 2 5 E Nursing Education 4 4 1 3 2 1 1 1 1 1 0 0 0 0 1 F Research Conferences 3 3 3 5 5 0 ~ 0 0 0 0 0 0 0 0 G1,2 (Faculty) Research Development 16 17 14 16 13 15 11 9 12 10 9 4 0 0 0 G3 Program Grants 0 0 0 0 0 0 0 0 0 0 0 4 6 5 3 G4 NRE/DPN Grants 0 0 0 0 0 0 0 0 0 0 0 10 13 13 14 H Utilization of Research Findings 0 0 0 0 0 0 1 1c 1c 1c 1c 1c 0 0 0 4b Development of Methodology, Tools _ 4 1 1 2 2 _ _ 5 8 8 n/a n/a n/a n/a TOTAL 54 52 44 49 54 47 44 33 45 53 51 58 58 48 61 a Count includes projects which were extended without receiving funds during the fiscal year under consideration. b Category 4 was in the classification system used until 1979. c Also G2. SOURCE: Division of Nursing, HRSA.
128 TABLE 6.2 Doctoral Degree Status of Principal Investigators on Active Research Grants from the Division of Nursing, 1974483 Fiscal Nurses with Nurses without Non-Nurses with Non-Nurses without Year of _ Doctorates Doctorates Doctorates Doctorates Total Grant N % N % N % N To N 1974 17 37 18 39 11 24 O 0 46 1975 23 52 10 23 11 25 0 0 44 1976 19 58 7 21 7 21 0 0 33 1977 29 64 5 11 10 23 1 2 45 1978 32 60 8 15 12 23 1 2 S3 1979 30 59 10 20 11 21 0 0 51 1980 40 69 10 17 8 14 0 0 S8 1981 38 66 7 12 13 22 0 0 S8 1982 34 71 4 8 10 21 0 0 48 1983 49 80 2 3 9 IS 1 2 61 SOURCE: Division of Nursing, HRSA. Table 6.3 shows the amount of money appropriated and awarded to nursing research grants and contracts from 1956 through 1984. In 1956, 8498,000 was awarded. This amount has increased since then, reaching a plateau of $5 million in the late 1970s and early 1980s; it was increased to $9 million for FY 1984. Figure 6.1 shows this history from 1969 on, in constant 1972 dollars. Training for Nursing Research In FY 1984, 117 students were being supported under the NRSA awards funded through the Division of Nursing, for a total of $955,487 (Table 6.4~. Two million dollars have been appropriated for PY 1985 and about 170 trainees and fellows are expected to be supported. To be eligible under the predoctoral and postdoctoral Nurse Fellowship Program, applicants must be registered professional nurses with an active license and a degree in nursing at the appropriate level. Predoctoral stipends are $6,552 per year; postdoctoral stipends begin at $15,996. Institutions can receive $3,000 for each predoctoral trainee and $5,000 for each postdoctoral trainee annually. Support of research training by the Division of Nursing is primarily at the predoctoral level. In FY 1984, for example, of 102 applications received, just 5 were from postdoctoral applicants; 2 of these were approved (Table 6.5~.
129 TABLE 6.3 Nursing Research Grants and Contracts Awarded, FY 1956~4 ($ thousands) New Renewal Continuation T&(S) Amount Grants Grants Grants Grantsa Contracts Fiscal Approp- Amount Year riated Awarded N $ N $ N $ N $ N $ 1956 $ 498 1957 525 1958 725 1959 976 1960 1,208 1961 1,449 1962 1,476 1963 1,814 1964 $1,999 1,999 1965 1,953 1,952 1966 2,170 2,166 1967 2,230 2,087 1968 2,655 2,593 22 $ 744 4 $266 32 $1,475 2 + (3) $108 0 $ 0 1969 2,593 2,593 16 642 4 158 33 1,720 (4) 73 0 0 1970 2,625 2,155 10 524 1 76 28 1,390 (6) 165 0 0 1971 2,455 1,955 11 781 3 92 18 1,039 (4) 43 0 0 1972 2,455 2,439 18 865 1 56 21 1,283 (9) 99 1 136 1973 2,455 2,454 9 519 1 61 27 1,704 (8) 98 1 72 1974 2,660b 2,631 13 877 2 161 19 1,378 (10) 99 1 116 1975 1,200 3,374c 11 962 8 783 20 1,307 1 + (4) 2W 1 118 1976 2,804 2,801 1 80 0 0 29 2,617 (1) 11 1 93 1977 5,000 4,991 25 2,674 5 327 7 954 3 + (7) 484 3 553 1978 S,OOOd 4,979 15 1,413 1 103 31 3,447 (1) 16 0 0 1979 S,OOOe 4,944 10 929 3 366 30 3,514 2 + (1) 135 0 0 1980 5,000f 4,986 26 2,882 4 465 16 1,580 (4) 58 0 ~ 1981 5,000g 4,950 16 1,592 1 98 29 3,066 2 + (1) 195 0 0 1982 3,4006 3,376i 3 184 1 84 37 3,001 2 + (0) 107 0 0 1983 5,000, 4,995 30 3,030i 8 717 14 1,245 0 + (1) 2 0 0 1984 9,0001 8,986 45 4,591m 2 269 31 3,097 1 + (1) 80 3 868 a Transfers and supplements. A "transfer" is a change of grantee institution; a "supplement" refers to additional funds provided to a funded project. b Funds reprogrammed. c Includes $2,412,000 from Nursing Special Projects Funds. a' Minus $17,000 retained for BHM evaluation activities. e Minus $50,000 retained for BHM evaluation activities. f Minus $13,000 retained for BHPr evaluation activities. g Minus $50,000 retained for BHPr evaluation activities. h Minus $24,000 retained for BHPr evaluation activities. i Includes $1,000,000 appropriated for the Nursing Research Grants Program in urgent supplemental appropriation. i Minus $4,355 retained for BHPr evaluation activities. k Includes $197,094 transferred to NCHSR for one cooperatively funded project. ~ Minus $90,000 retained for BHPr evaluation activities. m Includes $747,376 transferred to NIA for 4 cooperatively funded projects. SOURCE: Division of Nursing, HRSA.
130 3.6 3.2 2.8 2.4 An 2 . 0 I_ Appropriated of Awa rded : 1.6 0.8 i' 60 62 64 66 68 70 72 PI SCAL YEAR 74 76 78 80 82 84 FIGURE 6~1 Funding for nursing research "rants and contracts, 1960-83 (1972 $, millions). Data are from the Division of Nursing, HRSA. TABLE 6.4 National Research Service Awards in Nursing, FY 1982-84a Predoctoral N Postdoctoral N Total N If 1982 New 56 2 58 492,400 Continuing 62 0 62 467,110 Total 118 2 120 959,510 1983 New 43 354,231 3 58,548 46 412,779 Continuing 64 513,562 2 33,590 66 547,152 Total 107 867,793 5 92,138 112 959,931 1984 New 47 389,724 2 45,952 49 435,676 Continuing 66 496,786 2 23,025 68 519,811 Total 113 886,510 4 68,977 117 955,487 a All awards represent fellowships. SOURCE: Division of Nursing, HRSA.
131 TABLE 6.5 NRSA Applications Reviewed by Scientific Review Groups, by Status of Application, FY 1984 Date of Review Total Number Number Number Applications Approved Disapproved Deferred 34 23 10 20 13 _ 3 102 67 October 13-14, 1984 February 2-3, 1984 May 10-11, 1984 TOTAL APPLICATIONS 16 32 Predoctoral Applications 96 64 29 3 Postdoctoral Applications 5 2 3 0 Institutional Training Grants 1 1 0 0 SOURCE: Division of Nursing, HRSA. Most of the applicants and trainees sponsored through the division are doing work in nursing (Table 6.6~. Of approved applicants in 1984, 66 percent were in the nursing discipline. Among the stated research interests of 1984 awardees were "Coping with Spinal Cord Injuries and Rehabilitation," "Psychometric Methods for Nursing Research," "Nursing Care Delivery Systems in Rural Areas, n and "Nursing Strategies in Infection Prevention of Cancer Patients." It is estimated that approximately 1,000 individuals have received training grants in the area of nursing since the inception of the NRSA awards. TABLE 6.6 Disciplines of NRSA Applicants, by Status of Application, FY 1984 Discipline Total Number Number Number Number Applications Approved Disapproved Deferred Withdrawn 64 44 18 4 1 2 1 Nursing Human Development Physiology Epidemiology Anthropology Psychology Sociology Social Psychology Education Educational Psychology Health Services Public/Community Health History Rehabilitation Education Policy/Ethics TOTAL SOURCE: Division of Nursing, HRSA. l 2 2 6 2 1 2 2 2 102 44 1 l 2 1 l 3 2 2 2 67 1 l 3 2 32 1 3 l
132 National Institutes of Health In December 1984, an NIH Task Force on Nursing Research delivered its report to the NIH Director. The report focused primarily on the support of nursing research by NIH in fiscal year 1983. The report uses a working definition of nursing research at NIH: research conducted by the nurse principal investigator (PI); or nursing care research.) The task force was able to classify 108 extramural activities funded by NIH in FY 1983 as nursing research or as having components of nursing research. A total of $6.6 million was awarded to the nursing portions of these activities. The awards were made through 14 types of activities in the extramural program (Table 6.7~. Table 6.8 shows which unit of NIH supported the activities. Seventy percent of the total funding came from either the National Cancer Institute or the National Institute on Aging. A major program of the National Cancer Institute involving nursing research is the Clinical Cooperative Group Program. The 15 cooperative groups support oncology nursing or nursing research subcommittees. Activities of nurses in the clinical research effort include participa- tion in protocol development (with particular emphasis on the potential impact of different treatment options on patient compliance), facilita- tion of the informed consent process, development of nursing care and patient education approaches to dealing with side effects of therapy, data management, attendance at scientific meetings, and presentation and publication of research results. The individual units were asked to classify their projects into one of five focus areas. These areas were defined as follows: Research--scientific inquiry in the cause, diagnosis, and prevention of diseases, in the promotion of health, in the processes of human growth and development and in the biological effects of environmental contaminants. The principal investigator iS a nurse. The full definition follows: 1. Research conducted by the nurse principal investigator: scientific inquiry in the causes, diagnosis, and prevention of diseases; in the promotion of health; in the processes of human growth and development; and in the biological effects of environmental contaminants. 2. Nursing care research: research directed to understanding the nursing care of individuals and groups and the biological, physiological, social, behavioral, and environmental mechanisms influencing health and disease which are relevant to nursing care. Nursing research develops knowledge about health and the promotion of health over the full lifespan, 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 (Task Force Report, p. 1~.
133 TABLE 6.7 Activities of NIH Grants with Nursing Research Components, FY 1983 Activity (Code) Research Project (Rot) Research Demonstration and Dissemination (R18) Comprehensive Center (P60) Biomedical Research Support Grant (S07) Specialized Center (P50) Research Program Projects (P01) Academic Teacher Award (K07) General Clinical Research Center (M01) Research and Development Contracts (N01) Contracts (unspecified) New Investigator Research Award (R23) Intragency Agreement (Y01) Small Grants (R03) Small Business Innovation Research (R43) TOTAL SOURCE: NIH Task Force on Nursing Research, December 1984. Number of Awards 21 20 19 15 8 5 2 l l 108 TABLE 6.8 NIH-Funded Extramural Projects in Nursing Research or with Nursing Research Components, by Supporting Unit, FY 1983 Institute/Division Nat'l. Cancer Institute Nat'l. Institute on Aging Division of Research Resources Nat'l. Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases Nat'l. Heart, Lung, and Blood Institute Nat'l. Institute of General Medical Sciences Nat'l. Institute of Allergy and Infectious Diseases Nat'l. Institute of Neurological and Communicative Disorders and Stroke TOTAL SOURCE: NIH Task Force on Nursing Research, December 1984. Number of Awards $ Funded % of Total $ 40 30 30 22 20 13 11 6 3 _ 658,000 108 6,646,682 2,641,012 2,025,456 173,133 194,645 713,726 156,359 84,342 3 11 2 1 0 00
134 2. Nursing Care Research--research directed to understanding the nursing care of individuals and groups and the biological, physiological, social, behavioral, and environmental mechanisms influencing health and disease which are relevant to nursing care. Nursing research develops knowledge about health and the promotion of health over the full lifespan, 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. 3. Clinical Training--activities directed to the improvement or expansion of education and training of nursing students and practitioners. Development of Researchers--activities directed to assisting or extending training of individuals preparing for research. 5. Other--activities that are supportive of the research process or basic or applied research that involves nursing but where the project is not headed by a nurse principal investigator. Table 6.9 breaks down the total by the investigator (nurse or non-nurse) and by the focus of the award. In contrast to the Division of Nursing, the majority of projects funded by NIH in the area of nursing research did not have nurses as principal investigators. About 26 percent of the projects were headed by PIs who were nurses; this accounts for about 21 percent of the total money awarded to nursing activities. An example of a project headed by a PI who is a nurse is a project on sickle cell anemia sponsored by the National Heart, Lung, and Blood Institute. The study focuses on consolidating and strengthening programs which provide screening, education, counseling, and patient care to persons with sickle cell anemia. Most of the funding, 62 percent overall, was classified as nursing care research. In the "Development of Researchers" category, there was one project, accounting for 6 percent of the total amount awarded. TABLE 6.9 NIH-Funded Extramural Projects in Nursing Research or with Nursing Research Components, by Focus of Award and Type of Investigator, FY 1983 All Nurse Principal Investigators Principal Investigators Non-Nurse Principal Investigators $ % of $ % of $ % of Focus of Award N Funded Total $ N Funded Total $ N Funded Total $ Research 6 63,930 1 6 63,930 4 Nursing Care 54 4,130,813 62 13 694,658 50 41 3,436,155 66 Clinical Training 21 448,224 7 3 237,659 17 18 210,585 4 Development of Researchers 1 386,000 6 1 386,000 27 Other 26 1,617,695 24 5 29,078 2 21 1,S88,617 30 TOTAL 108 6,646,682 100 28 1,411,32S 100 80 S,23S,3S7 100 (100%) (21%) (79%) SOURCE: NIH Task Force on Nursing Research, December 1984.
135 The task force report does not analyze the awards for 1984. It does indicate, however, that there were 64 applications in 1984 from schools, departments, or colleges of nursing; that the total request from these applications was for $6.4 million; and that the total award was $1.5 million. The report states that there are 20 current intramural projects with nurse researchers as participants, through the Department of Nursing's Nursing Research Committee at the Clinical Center of NIH. Veterans Administration The Veterans Administration (VA) supports nursing research in several areas. Nurses within the VA can receive support from the research components of the VA for medical research, health services research, and rehabilitation research. Researchers compete for awards with others in the VA. VA nurses seek and receive outside support as well; sources include HHS's Division of Nursing, the American Nurses' Foundation, Sigma Theta Tau, and various pharmaceutical companies. Research responsibilities appear as a component of job descriptions for nurses in the VA for the intermediate grades and above. Research positions for nurses in VA Medical Centers include Associate Chief Nurse for Research, for which a doctorate is needed, and Nurse Researcher, requiring a master's or a Ph.D. The VA also has a trainee program for chief nurses, including both research and administrative training. The VA lists 190 approved research projects with nurses as principal investigators for FY 1984. They are broken down by position of research and area of research as shown in Table 6.10. Of these projects, nearly 80 percent are in the clinical area, and the VA reports that this proportion has been growing over the past several years. The clinical projects are further broken down into the areas of nursing procedures (25), quality of life (19), patient education (17), patient experience (14), nursing intervention (13), nutrition (13), quality of care (10), patient behavior (8), injection (6), rest/exercise (6), incontinence (6), pain (3), and miscellaneous (111. The Gerontologic Nurse Fellowship Program provides salary and dissertation support for doctoral nursing students for a two-year period. Two fellows are chosen each fiscal year; during the fellowship period, each participant is based at one of the 172 VA Medical Centers. The VA anticipates that at least half of those who complete the program will be hired by the VA. American Nurses' Foundation The American Nurses' Foundation, a body of the American Nurses' Association, awards grants to nurses through its Competitive Extramural Grants Program. The program is funded by corporate and individual contributions to the foundation. Proposals are evaluated by the Foundation's Research Review Committee, made up of experienced researchers holding doctorates. In 1981, 10 of 69 applications were funded; in 1982, 12 of 86; in 1983, 25 of 109; and in 1984, 34 of 119.
136 TABLE 6.10 V.A. Research Projects with Nurse Principal Investigators, by Position of Principal Investigator and Area of Research, FY 1984 Position of Principal Investigator Staff Nurse Head Nurse Instructor ACNS/E Nurse Practitioner Infection Control Nurse Clinical Specialist Supervisor/C oordinator ACNS Nurse Researcher ACNStResearcher Other TOTAL SOURCE: Veterans Administration. Clinical 24 12 6 5 12 27 7 6 14 38 151 Area of Research Administration 4 3 2 3 1 6 24 Education 5 2 l 5 The grants program supports nursing research directed by a registered nurse. It is designed primarily for beginning nurse researchers, but experienced researchers entering a new area of investigation are also considered for awards. From 1955 through 1984, the program awarded 206 grants for a total of more than $1 million. In 1985, 32 grants of up to $2,500 each are expected to be awarded. Robert Woocl Johnson Foundation Total 29 12 11 5 6 13 34 10 3 8 20 - 190 ~ ~ _ _~ ~ The Robert Wood Johnson Foundation supports nursing research through its grants program and through its relatively new Clinical Nurse Scholars Program. Since 1982, the Foundation has supported, or is supporting, 17 projects in the area of nursing research, for a total commitment of $3.5 million. Research subjects have included "Increasing Communication Ability in Stroke Patients," ''Program to Improve Health Outcomes for Teenage Mothers and Their Infants, n "Survey of the Role of Nurse Midwives in United States Health Care, and "Sources of Nurse Satisfaction and Nursing Shortages in Hospitals." The Clinical Nurse Scholars Program supports individual researchers during two-year postdoctoral fellowships for advanced, in-hospital clinical practice and research. Scholars are based at the academic health centers of one of three institutions: the University of California, San Francisco; the University of Pennsylvania; or the University of Rochester. The first group of nine scholars received awards for 1983-85, and nine additional scholars were funded for 1984-85 and for 1985-86. Up to nine awards may be made each year.
137 The goal of the program is to prepare a group of nursing faculty and clinicians who can place renewed emphasis on clinical teaching, practice, and research at their own institutions. Applicants must be registered nurses with earned doctorate degrees. Most recipients take a leave of absence from their employing institutions in order to accept the fellowship; stipends are based on the recipient's current salary level. A total of $3.3 million has been allocated to this program thus far; much of this amount was in start-up and administrative costs. Sigma Theta Tau Sigma Theta Tau, the national honor society of nursing has awarded a small number of nursing research grants each year since 1936. The purpose of its grant program is "to encourage qualified nurses to contribute to the advancement of nursing through research." Applicants must be registered nurses holding a master's degree or a doctorate. The maximum award is for $3~000O In 1984, the program received 33 applications. Ten were funded, for a total of $27,532. Local chapters of Sigma Theta Tau commonly make a small number of research awards each year, usually not exceeding $1,000, to their members. NURSES WITH DOCTORAL DEGREES Doctorate Degrees Awarded The number of nurses receiving doctorates each year has been accelerating since 1978 (Figure 6.2~. Data from the National League for Nursing show that 31 doctorates were awarded to nurses in academic year 1964-65; by 1981-82 that number had increased to 204. Many nurses earn doctorates in fields other than nursing, however. According to the American Nurses' Association, before 1950 nurses earned the Ph.D. and the Ed.D. in equal numbers; between 1950 and 1964, more than half received Ed.D. degrees; but since 1965, the Ph.D. has been the most prevalent of doctoral degrees earned by nurses. The nursing science doctorates, D.N.S. and D.N.Sc., have been awarded only since the 1960's, but their numbers have been increasing. Of the 3,648 nurses with doctorates surveyed by ANA in its 1984 study, 53.9 percent held the Ph.D., 32.5 percent the Ed.D., and 7 percent the D.N.S./D.N.Sc. The remaining 6.6 percent had other doctoral degrees. The ANA's 1984 survey also collected data on the major area of the degree awarded. Respondents reported that 37 percent of the degrees were in education, 12 percent in nursing, 3 percent in public health, and 4 percent in the biomedical sciences. The remainder had a variety of major areas or did not report a major area. For its 1980 survey, the ANA identified 2,348 U.S. nurses with earned doctorates. Of these, 1,964 completed and returned the questionnaires (83.6 percent response).
138 220 200 180 160 140 120 100 80 60 40 20 lo it/ Al l Departments ~ / X~ w~ sex an All ~ 64 x ~ Nursi ng Education Departments xx , - ~~+ xx I , I I l I I I I 66 68 70 72 74 76 78 80 82 YEAR FIGURE 6.2 Research doctorates awarded to nurses, 1965-82 (academic years). Data are from the National League for Nursing (1981-84~. The federal government has been the most common source of support for nurses during doctoral study. Since 1950 more than 40 percent of the nurses with doctorates who had outside support while studying for the degree received that support from a federal grant for training or research (ANA, 1981, p. 37~. Doctoral Programs in Nursing The number of doctoral programs in nursing also has been increas- ing steadily over the past 20 years (Figure 6.3~. According to the NLN, in 1962-63 there were four programs in nursing schools or departments that awarded doctorates. In 1983-84 there were 30 such programs. Of that number, 21 granted the Ph.D. degree, 8 awarded a nursing science degree, and 1 awarded the Ed.D. (Table 6.113. The enrollment of nurses in doctoral programs has been increasing as well (Figure 6.4~. The NLN reports that much of this increase is due to the rising number of part-time students.
139 30 28 26 24 22 `,, 20 CC ~3 o 18 16 14 12 10 8 6 4 2 o - 62 64 66 68 70 72 74 76 YEAR 78 80 82 84 FIGURE 6.3 Research doctoral programs administered by schools or departments of nursing 1963-84 (academic years). Data are from the National League for Nursing (1981-84~. TABLE 6.11 Doctoral Programs in Nursing, 1983-84 Degree Granted Ph.D. D.N.Sc. D.N.S. D.S.N. D.N. Ed.D. Number of Programs 21 3 2 l TOTAL SOURCE: Sigma Theta Tau (1984a). 30
140 1.8: 1.6 t 1.4 O 1.0 - LLJ J To By Lo 1.2 Q.8~ 0.6: 0.4 0.2 ~ .v. ~,4~.,F, ~ ~ ,,,,t, ~ ~ ~ ,,x+~+ ~x~ 65 67 69 71 73 75 YEAR All Doctoral Programs /~/ xx.~* ~ / xx / x+~+ ~ ax J fix x x xx x "xX ~ Nurs i no Doctoral Prnarams 1 1 _ t ~ 77 79 81 83 FIGURE 6.4 Nurses enrolled in research doctoral programs, 1965-83 (academic years). Data are from the National League for Nursing (1981-84~. Nurse Faculty with Doctorates In nursing education programs, the number of faculty members who hold doctorates has been increasing but still is a small proportion of the total faculty (Figure 6.5~. In 1982, only 8.4 percent of all full-time nurse-faculty members held doctorates; 16.1 percent of those employed in programs offering the baccalaureate and higher degrees held the doctorate. The NLN reports that of the 1,657 full-time nurse faculty holding doctorates, 92 percent were employed in programs offering the baccalaureate and higher degrees. Employment of Nurses with Doctorates In 1980, 91 percent of the nurses with doctorates were employed, most (88 percent) full-time (ANA, 1981~. Approximately 6 percent were retired, and approximately 2 percent were in temporary positions. Only about 1 percent were reported to be unemployed and seeking employment.
141 20 at ,_, 10 Lo lo L r --Al ~ Programs Baccalaureate & Higher It LO Led _ {.,; ~ l iffy i,/..` 64 66 68 70 72 74 76 78 80 82 YEAR FIGURE 6.5 Percentage of full-time nurse faculty who hold research doctorate degrees, 1964-82 (academic years). Data are from the National League for Nursing (1981-84~. By far the largest proportion of all nurses with doctorates (61 percent) were employed in schools of nursing offering the baccalaureate and higher degrees; 4 percent worked in schools of nursing offering less than the baccalaureate. Another 6 percent ware faculty members in other departments of educational institutions. Government agencies {4 percent), hospitals (2 percent), and public health settings (1 percent) accounted for the other specified employment settings of nurses with doctorates. In institutions having both baccalaureate and higher degree programs in 1982, about 20 percent of full-time nurse faculty were assigned exclusively to the graduate programs, and another 18 percent were assigned part-time to graduate programs and part-time to baccalaureate programs. The remainder spent full-time with the undergraduate programs. As indicated in Table 6.12, 4.6 percent of nurses with doctorates reported that their major function was research. This percentage was highest (18.1 percent) for those employed by government agencies. When broken down by degree {Table 6.13), the percentage was highest for those whose doctorate was in the biomedical sciences. Table 6.14 shows the responses of nurses with doctorates as to what percentage of time is spent on research (ANA, 1981~. Nurses in health professions schools other than nursing reported spending almost 30 percent of their time on research. Those in nursing programs at the baccalaureate and higher level spent only about 12 percent of their time on research.
142 oo o ._ o .~ Ct Ct ~D C) o ¢ o .~ Cq - C. s" o C~ o ~S: ·3 CQ CQ z ~n ._ ¢ o~ ~o s" o .~ Zo~z 1 ~ I o ~ ·;- C) o ~ s :G z .~ ~ ._ ~ Z . - o Z ~s ._ .= Z s" s o Z ~s £= Z ca - o Z o ._ o .~ 1 1 1 1 ~ _ 1 - 1 ~ X o U) ~ ~ U) ~ ~ o . . . . . . . . - _ ~ ~ ~ ~ ~ o _ _ o t~ ~ ~ oo U) 0~1 u~ O _ ~ ~ U) _ =1 _ _ ~ U) vo i oo ~ oo I ~ o t 1 _ ~ _ 1 t O _ _ _ _ _ o , 1 ~ ~ ~ 1 - 1 t- - ) ~ u) ~ - ~ ~ o . . . . . . . . - _ ~ ~ ~ ~ r~ 0 ~ ~ - - - o u~ ~ ~ _ ~ oo ~ t1 x - ~ - o ~ ~ ~ ~ ~ - - Go I oo t o~ x ~ ~ u~ 1 . . . . . . . o ~ ~ ~ _ ~ o~ ~ _ r~ ~ X ~ 1 _ oo \0 ~ t1 _ ~ _ ~o _ U) o ~ ~o . . . . . . . . o ~ _ ~ o ~ _ o _ _ _ ~ ~ ~ ~~ ~ ~ ~ - °1 U) ~ ~ _ oo ~ ~ _ . . . . . . . . _ ~ ~ _ o' oo ~ _ o _ ~ ~ ~ oo ~ - 1 u~ 1 X o X ~ U) ~ ~ ~ ~ o . . . . . . . · - ~ ~ _ ~ ~ _ ~ ~ _ o ~ ~o u~ ~ ~ ~ 1 _ _ U) ~ _4 ~ 1 _ _ ~ o _ ~ ~ ~ ~ o ~ o . . . . . . . . ~ ~ teP, ~ ~ ~ o m° ~ -1 U) U) ~ ~ =^ ·C E E ::, ~ ~ ,, & ~v~Oz U, ._ - CL c ;~ o x o~ - - U' - o o - U, U' c C~ o ~o c o c o - e~ - - en . - u c, CL u: en - - c u, · - c - c e~ u, c~ . - u, · - c~ - c~ uO o c c o - · o c~ ~n c en - c o - e' - . - c c a: - °e ._ c~ c' - ~c - u: c o ._ - oe c .0 2 0 0 c O ._ 0 _ ~ ._ ~ ~, 0 0 o CJ ° ~ o~ _ e~ s E O ~ e e ~ ~ e s: C) ~ Ji 5 u, ~2 u, cn z e ~s c~ ._ ·. _ O es c~ ~
143 ·~ AD ._ I a o a CQ - ~5 a Cal o IS . 3 Ut sit z 5 - of P: c - - C} Cal o Z ° ~ ;-, ~ a C) >0 .C} a ~ C' - o 0£ In Z -o O a Cal - O C s 8 o IS ~ ~ eel U. _ ~ as e~ ~ ~ C) at o z o z z z z z z _ en E" Z . o IX ~ ~ ~ o o o ~ _ _ ~ o oo _ 1 ~ ~ ~ =1 _ , ~ 1 ~ ~ ~ ~ X ~ ~ 0 ~ 0 . . . . . . . . - ~ U) oo ~ _ ~ U) ~ 0 _ _ _ ~ _ _ \0 U) ~ ~ ~ _ ~ ~ 1 0 ~ ~ ~ ~ ~1 ~ o~ ~ ~ _ ~ U) 0 ~ 0 . . . . . . . . - U) ~ _ ~ ~ ~ 0 ~ _ _ ~ 0 oN ~ ~ U) _ ~ u~ ~ 1 ~ 1 00 =~ - 1 ~ 1 ~ o. ~ ~ U) U) U) U) 0 U) ~ 0 _ ~ - - 1 - 1 -1 ~ ~ ~ 0 ~ _ ~ 0 _ 0 . . . . . . . . - ~ ~ ~ ~ ~ X ~ ~ g ~) ~ ~ ~ - 1 ~ 1 ~ 0 ~ ~ _ ~ ~ ~ ~o 0 . . . . . . . . - _ 0 ~ ~ oo ~ ~ 0 _ 0 _ u: ~ ~ ~ =1 ~ _ o. 1 ~ 1 ~ ~ ~ _1 o _ ~ ~ _ U) 0 _ ~o ~ 1 - 1 ~ _ - ~1 ~ U) ~ ~ ~ ~ X 0 o. ~ 0 0 ~ ~ ~ ~ ~ _ oo U) U) _ _ _ 0 _ ~ ~ ~ ~ 0 ~ 0 oo ~ _ ~ 0 ~ ~ ~o g 0 ~ ~ _ ~ 0 ox V) ~ ~ Ct' C~ U) t- ~ ~ U) ~ ~ 0\ _ ca C) ~0 A y e e u U2 a e o x - Le oc - o o ~5 - ._ 5) U, e o s - U' s C~ c e o - e~ - C~ ._ e ._ ._ C~ e' - . C} e o ._ - · ~ o~ e e ._ C_ e ~o 0 ~ ~ 0 ._ 0 _ e' ~ .5 o o · C~ g ~ ;^ _ ,~ o o ~ s~ _ ~ _ ~ ~ o O ~ e e ~ ~ ~ 4, e' c e `. ~ e o - :' - - .e~ C~ C~ - e ._ U: ;^ e e¢ - ~e U, C~ ._ - U, ._ - Ct - U, C~ e e o ._ - ._ C~ o U) U, U, U, z as ._ · . o ~ u,
SOURCE: American Nurses' Association (1981). 144 TABLE 6.14 Average Percentage of Time Spent in Research by Work Setting and Percentage of Nurses with Doctorates, 1980 % Time % of Nurses Setting in Research with Doctorates School of Nursing (Baccalaureate and Higher) 11.8 ~ 70 1 School of Nursing (Hospital) 0.8 J School of Nursing (Associate Degree) 2.3 ~ 4 6 Other Health Professional School 28.4 | Other Department or School 11.1 ~ 7 1 Hospital in Service 11.5 | Hospital Nursing Administration Work 12.3 . 2 9 Public/Community Health Agency 4.0 . Federal/State/Local Government 20.6 6.0 Other 14.3 9.3 100.0 SUMMARY In 1983, an Institute of Medicine committee (IOM, 1983a, p. 149) concluded that: Unlike the situation with respect to the basic supply of generalist nurses, where we have found the likelihood of a general balance between supply and demand in 1990, the committee concludes that there is both a serious current and probable 1990 shortage of nurses educationally prepared for administration, teaching, research, and advanced clinical nursing specialties. ... there is such an obvious gap between the present supply ... and even conservative estimates of future advanced positions required ... that existing program capacity and sources of student support at the graduate level should be expanded. We agree with these findings. nurses with doctorates, - · ~ ~ ~ _ ~ e ~ ~ ~ The low rate of unemployment of the low percentage of nurse faculty members wean aoccorates, ana one rapid growth in the number of doctoral programs in nursing lead the committee to conclude, even in the absence of numerical projections, that there is and will continue to be unfilled demand for researchers in this area. There is also a growing need for training support in nursing research. In FY 1985, appropriations for NRSA programs of the Division of Nursing more than doubled from the previous year to 82 million, and the number of trainees and fellows increased to 168. Applications for fellowships increased by about 50 percent in FY 1985 and are expected to increase by another 30 percent in FY 1986. .
145 NRSA fellowships and traineeships constitute one of the principal sources of support for nurses pursuing predoctoral and postdoctoral research training. However, the committee notes that funding levels, although increasing, have not been sufficient to allow programs to reach the levels it has recommended in the past. The importance of the problems addressed in nursing research, the continued demand for nurse faculty with research training, and the growing pool of fellowship applicants all indicate that nursing research is a rapidly developing area. Research training levels should be raised from the current number (168 in FY 1985) to about 320 in 1990.
