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• Volume 1, Issue 1

Nursing, research, and the evidence

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• Anne Mulhall , MSc, PhD
• Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

https://doi.org/10.1136/ebn.1.1.4

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Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research might best provide those answers.

What is nursing about?

Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors “cure” or “treat” and that nurses “care”, but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain. 5 Nurses justified their claim to “control” wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are “captives” together. 6 Questioning the relevance of scientific knowledge, she argues that nurses and patients are “focused on more immediate concerns and on ways in which experiences can be endured and transcended”. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an “intimate” and ongoing relationship with the person within the body. Thus nursing becomes concerned with “untidy” things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. “It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.” 7

What sort of evidence does nursing need?

These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler's work on how the body is managed by nurses illustrates this. 6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because “we also practice with living, breathing, speaking humans.” Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of “looking at” the world, and from our own professional and non-professional life experiences.

Picking the research design to fit the question

Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the “researched”. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.

This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have—why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or “being there”? Can such aspects be captured within the confines of research as we know it?

Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.

Research designs useful to nursing

Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research. 8 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials, 9 and cohort studies, 10 at the scientific end of the spectrum, through to grounded theory, 11 ethnography, 12 and phenomenology at the interpretist/naturalistic end. 13 Future issues of this journal will explore these designs in depth.

Maximising the potential of evidence-based nursing

Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. 14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners. 15

In summary, in embracing evidence-based nursing we must heed these considerations:

Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing

We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care

More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?

It must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science—hope, despair, misery, love.

• ↵ Bostrum J, Suter WN. Research utilisation: making the link with practice. J Nurs Staff Dev 1993 ; 9 : 28 –34. OpenUrl PubMed
• ↵ Lacey A. Facilitating research based practice by educational intervention. Nurs Educ Today 1996 ; 16 : 296 –301.
• ↵ Pearcey PA. Achieving research based nursing practice. J Adv Nurs 1995 ; 22 : 33 –9. OpenUrl CrossRef PubMed Web of Science
• ↵ Mulhall A. Nursing research: our world not theirs? J Adv Nurs 1997 ; 25 : 969 –76. OpenUrl CrossRef PubMed Web of Science
• ↵ Walby S, Greenwell J, Mackay L, et al. Medicine and nursing: professions in a changing health service . London: Sage, 1994.
• ↵ Lawler J. The body in nursing . Edinburgh: Churchill Livingstone, 1997.
• ↵ Lawler J. Behind the screens nursing . Edinburgh: Churchill Livingstone, 1991.
• ↵ Street AF. Inside nursing: a critical ethnography of clinical nursing practice . New York: State University Press of New York, 1992.
• ↵ Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997 ; 52 : 223 –8. OpenUrl Abstract
• ↵ Kushi LH, Fee RM, Folsom AR, et al . Physical activity and mortality in postmenopausal women. JAMA 1997 ; 277 : 1287 –92. OpenUrl CrossRef PubMed Web of Science
• ↵ Rogan F, Shmied V, Barclay L, et al . Becoming a mother: developing a new theory of early motherhood. J Adv Nurs 1997 ; 25 : 877 –85. OpenUrl CrossRef PubMed Web of Science
• ↵ Barroso J. Reconstructing my life: becoming a long-term survivor of AIDS. Qual Health Res 1997 ; 7 : 57 –74. OpenUrl CrossRef Web of Science
• ↵ Thibodeau J, MacRae J. Breast cancer survival: a phenomenological inquiry. Adv Nurs Sci 1997 ; 19 : 65 –74. OpenUrl PubMed
• ↵ Sackett D, Haynes RB. On the need for evidence-based medicine . Evidence-Based Medicine 1995 ; 1 : 5 –6. OpenUrl Abstract / FREE Full Text
• ↵ Gordon DR Tenacious assumptions in Western biomedicine. In: Lock M, Gordon DR , eds . Biomedicine Examined. London: Kluwer Academic Press, 1988;19–56.

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The power of nurses in research: understanding what matters and driving change

The next blog in our series focussing on how research evidence can be implemented into practice, Julie Bayley, Director of the Lincoln Impact Literacy Institute writes about the power of nurses in research and how nurses can support the whole research journey. 

Research is a funny old beast isn’t it? It starts life as a glint in a researcher’s eye, then like a child needs nurturing, shuttling back and forth to events and usually requires constant checking to make sure it’s not doing something stupid.

As someone who spends the majority of their working life on impact – the provable benefits of research outside of the world of academia – it is extraordinarily clear to me how research can make the world better. And as a patient advocate – having chronically and not exactly willingly collected DVTs over the last decade – it’s even more clear how good research and good care together make a difference that matters.

Having had some AMAZING care, nursing strikes me as both an art and a science. A brilliant technical understanding of healthcare processes combined magically with kindness, compassion and care.  Having been hugged by nurses as I cried being separated from my newborn (post DVT), and watching nurses let dad happily talk them through his army photo album as they check on his dementia, I am in no doubt that such compassion is what marks the difference between not just being a patient, but being a person .

One of the oddities about research is how we can so often get the impression that only big and shiny counts. ‘Superpower’ studies such as Randomised Controlled Trials, and multi-national patient cohort studies are amazing, but can mask the breadth of the millions of questions research can explore in endless different ways. Of course we need trials to determine ‘what works’, but we also need research to unveil the stories of those who feel their rarely heard, understand how things work, and connect research to people’s lives.

Research essentially is just the act of questioning in a structured, ethical and transparent way. It might seek to understand things through numbers (quantitative) or words and experiences (qualitative), and may reveal something new or confirm something we already believe. Research is the bedrock of evidence based care, allowing us – either through new (‘primary’) or existing (‘secondary’) data – to explore, understand, confirm or disprove ways patients can be helped. Some of you reading this will be very research active, some of you might think it’s not for you, some may not know where to start, and others may hate the idea altogether. Let’s face it, healthcare is an extremely pressured environment, so why would you add research into an already busy day job? The simple truth is that research gives us a way to add to this care magic, helping to ensure care pathways are the best, safest and most appropriate in every situation.

The pace and scale of research stories can make it easy to presume research is something ‘other people’ do, and whilst there are many brilliant professionals and professions within healthcare, nurses have a unique and phenomenally important place in research in at least three key ways:

• Understanding what matters to patients. A person is far more than their illness, and being so integral to day to day care, nurses have a lens not only on patients’ conditions, but how these interweave with concerns about their life, their livelihood, their loved ones and all else. And it is in this mix that the fuller impact of research can be really understood, way beyond clinical outcome measures, and into what it what matters .
• Understanding how to mobilise and implement new knowledge. Even if new research shows promise, the act of implementing it in a pressured healthcare system can be immensely challenging. Nurses are paramount for understanding – amongst many other things – how patients will engage (or not), what can be integrated into care pathways (or can’t), what unintended consequences could be foreseen and what (if any) added pressures new processes will bring for staff. This depth of insight borne from both experience and expertise is vital to mobilising, translating and otherwise ‘converting’ research promise into reality.
• Driving research . Nurses of course also drive research of all shapes and sizes. Numerous journals, such as BMC Nursing and the Journal of Research in Nursing bear testament to the wealth of research insights driven by nurses, and shared widely to inform practice.

Research isn’t owned by any single profession, or defined by any size. Whatever methods, scale or theories we use, research is the act of understanding, and if nurses aren’t at the heart of understanding the patient experience and the healthcare system, I don’t know who is. So when it comes to research:

• Recognise the value you already bring. You are front and centre in care which gives you a perspective on patient and system need that few others have. Ask yourself, what matters?
• Recognise the sheer breadth of research possibilities, and the million questions it hasn’t yet been used to answer. Ask yourself, what needs to be understood?
• Use – or develop – your skills to do research. Connect with researchers, read up, or just get involved. Ask yourself, how can I make my research mark?

Research is important because people are important. If you’re nearer the research-avoidant than the research-lead end of the spectrum, I’d absolutely urge you to get more involved. Whether you shine a light on problems research could address, critically inform the implementation of research, or do the research yourself….

….from this patient and research impact geek…

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BMJ Journals

Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review

Affiliations.

• 1 Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing & Healthcare, College of Nursing, The Ohio State University, Columbus, Ohio, USA.
• 2 St. John Fisher University, Wegmans School of Nursing, Rochester, New York, USA.
• 3 Sinai Hospital, Baltimore, Maryland, USA.
• 4 Summa Health System, Akron, Ohio, USA.
• 5 The Ohio State University, College of Nursing, Columbus, Ohio, USA.
• 6 Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
• 7 Family CareX, Denver, Colorado, USA.
• 8 Affiliate Faculty, VCU Libraries, Health Sciences Library, Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA.
• PMID: 36751881
• DOI: 10.1111/wvn.12621

Background: Evidence-based practice and decision-making have been consistently linked to improved quality of care, patient safety, and many positive clinical outcomes in isolated reports throughout the literature. However, a comprehensive summary and review of the extent and type of evidence-based practices (EBPs) and their associated outcomes across clinical settings are lacking.

Aims: The purpose of this scoping review was to provide a thorough summary of published literature on the implementation of EBPs on patient outcomes in healthcare settings.

Methods: A comprehensive librarian-assisted search was done with three databases, and two reviewers independently performed title/abstract and full-text reviews within a systematic review software system. Extraction was performed by the eight review team members.

Results: Of 8537 articles included in the review, 636 (7.5%) met the inclusion criteria. Most articles (63.3%) were published in the United States, and 90% took place in the acute care setting. There was substantial heterogeneity in project definitions, designs, and outcomes. Various EBPs were implemented, with just over a third including some aspect of infection prevention, and most (91.2%) linked to reimbursement. Only 19% measured return on investment (ROI); 94% showed a positive ROI, and none showed a negative ROI. The two most reported outcomes were length of stay (15%), followed by mortality (12%).

Linking evidence to action: Findings indicate that EBPs improve patient outcomes and ROI for healthcare systems. Coordinated and consistent use of established nomenclature and methods to evaluate EBP and patient outcomes are needed to effectively increase the growth and impact of EBP across care settings. Leaders, clinicians, publishers, and educators all have a professional responsibility related to improving the current state of EBP. Several key actions are needed to mitigate confusion around EBP and to help clinicians understand the differences between quality improvement, implementation science, EBP, and research.

Keywords: evidence-based decision making; evidence-based practice; healthcare; patient outcomes; patient safety; return on investment.

© 2023 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.

Publication types

• Systematic Review
• Delivery of Health Care*
• Evidence-Based Practice* / methods
• Quality Improvement

Nursing Research

Nursing research worldwide is committed to rigorous scientific inquiry that provides a significant body of knowledge to advance nursing practice, shape health policy, and impact the health of people in all countries. The vision for nursing research is driven by the profession's mandate to society to optimize the health and well-being of populations (American Nurses Association, 2003; International Council of Nurses, 1999). Nurse researchers bring a holistic perspective to studying individuals, families, and communities involving a biobehavioral, interdisciplinary, and translational approach to science. The priorities for nursing research reflect nursing's commitment to the promotion of health and healthy lifestyles, the advancement of quality and excellence in health care, and the critical importance of basing professional nursing practice on research.

As one of the world leaders in nursing research, it is important to delineate the position of the academic leaders in the U.S. on research advancement and facilitation, as signified by the membership of the American Association of Colleges of Nursing (AACN). In order to enhance the science of the discipline and facilitate nursing research, several factors need to be understood separately and in interaction: the vision and importance of nursing research as a scientific basis for the health of the public; the scope of nursing research; the cultural environment and workforce required for cutting edge and high-impact nursing research; the importance of a research intensive environment for faculty and students; and the challenges and opportunities impacting the research mission of the discipline and profession.

Approved by AACN Membership: October 26, 1998 Revisions Approved by the Membership: March 15, 1999 and March 13, 2006

The primary purpose of nursing research is to create science that informs nursing practice, allowing nurses to provide the best care to their patients. Nurse scientists can help ensure that findings from nursing research studies are adapted into everyday patient care. They stay involved in practice and share findings with nurses engaged in direct patient care, and with those who have input into the development of clinical practice guidelines and standards.

Including direct care nurses in the design and implementation of studies ensures clinical relevance and feasibility and helps facilitate rapid integration of nursing research findings into clinical practice.

Related publication

A practice-based model to guide nursing science and improve the health and well-being of patients and caregivers.

Mayo Clinic nurse scientists seek solutions to complex healthcare needs among patients and their caregivers. Research falls into three broad categories:

• Caregiving science.
• Self-management science.
• Symptom science.

Research findings are used to improve the health and well-being of patients. The Mayo Clinic nursing research model serves as a guide for the conduct of clinical research in these three distinct scientific areas in a practice-based setting.

Caregiving science

Care interventions for caregivers.

Lead researcher: Sherry S. Chesak, Ph.D., M.S., R.N.

Clinicians are at high risk of experiencing stress and burnout, which has consequences at both the personal and professional levels, including a negative impact on patient care. In addition, care partners — family, friends, others — take on major responsibilities in patient care. The latter, often thrust into their roles unexpectedly, tend to experience high levels of care burden.

Research on care for the caregiver is particularly focused on investigating resilience-promoting interventions for both professional caregivers and care partners. It also involved developing and evaluating methods to instill a sense of belonging among healthcare workers.

Self-management science

Using technology to support patient healthcare choices.

Lead researcher: Elizabeth E. Umberfield, Ph.D., R.N.

Every day, people make choices about the care they receive. These choices can include decisions about how they allow healthcare teams to handle personal biospecimens and health information. Dr. Umberfield's research program centers on making these choices discoverable, interpretable, actionable and interoperable throughout the digital health information ecosystem. Her research prioritizes patient agency — often defined as a patient's ability to act — and patient-centered systems.

Symptom self-management in adults with inflammatory bowel disease

Lead researcher: Samantha Conley, Ph.D., R.N.

People with many chronic conditions face a high symptom burden, and the daily management of their symptoms is challenging. Symptom self-management research aims to better understand how symptoms co-occur in people with chronic conditions. Researchers also study how people living with chronic conditions can better self-manage their symptoms using behavioral interventions to improve their daily functioning and quality of life.

Toxicities of cancer therapies and psychosocial concerns and decision-making at end of life

Lead researcher: Cindy Tofthagen, Ph.D., ARNP, AOCNP, FAANP, FAAN

Cancer treatments have side effects that create significant physical, emotional and financial burdens for patients as well as their families. The goal of this research is to find effective ways to prevent or treat these side effects and help patients better manage side effects at home. This includes specific emphasis on:

• Chemotherapy-induced peripheral neuropathy.
• Psychological distress associated with cancer.
• Pain related to cancer treatment.

Symptom science

Delirium prevention and symptom management in older adults.

Lead researcher: Heidi L. Lindroth, Ph.D., R.N.

Nurse scientists improve patient outcomes through holistic scientific discovery that considers the whole healthcare team, including the patient and family, as part of the discovery-translation-application cycle.

Gut microbiome link to chemotherapy-induced nausea

Lead researcher: Komal P. Singh, Ph.D., R.N.

People with cancer experience several neuropsychological and gastrointestinal symptoms during and after treatment. Debilitating symptoms include:

• Depression.
• Cognitive changes.
• Sleep disturbance.
• Lack of appetite.
• Change in taste.

Investigating patient risk factors associated with these symptom experiences can help identify people at high risk for symptom burden. In addition, omics-based methodologies can help pinpoint underlying biological mechanisms associated with patient symptoms.

A multidisciplinary team at Mayo Clinic is collaborating with additional world-renowned academic institutions to investigate associations between oncology patient symptom experiences and chemotherapy-induced changes in the microbiome-gut-brain axis. Identifying precise changes in patients most at risk of experiencing debilitating symptoms after chemotherapy can help in developing targeted interventions to alleviate the adverse side effects of oncology treatments.

Symptom management for patients on mechanical ventilators in the ICU

Lead researcher: Linda L. Chlan, Ph.D., R.N., ATSF, FAAN

Research in this area develops and tests interventions to help patients manage feelings of anxiety. Patients often feel anxiety when receiving mechanical ventilatory support in the intensive care unit (ICU). Our research team seeks solutions for how to best assess and empower patients to co-manage or self-manage symptoms safely while in the ICU .

Nursing research model

Nursing research is centered on the health and well-being of patients with complex care needs. Research in caregiving science, symptom science and self-management science is conducted through team science using big data, technology and innovation. Discoveries are translated to patient care and applied in the clinical setting to transform the practice.

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How nursing research informs nursing practice

Research can help improve patients’ outcomes as well as nurses’ professional lives, National Institute of Nursing Research director says at UND

Last Friday, a high-profile member of the nursing profession visited the UND College of Nursing & Professional Disciplines. The visitor was Shannon Zenk, director of the National Institute of Nursing Research, a part of the National Institutes of Health that conducts research and establishes a scientific basis for evolving nursing practices.

During a 45-minute fireside chat with CNPD Dean Maridee Shogren , Zenk shared her insights with the nearly 250 students in attendance. She emphasized the importance of the symbiotic relationship between nursing practice and research.

“They need to be interconnected. One informs the other,” Zenk said. “What we see in our practice informs the types of research questions we ask, and it’s really important that we take the evidence generated from research and apply it to our practice. There’s a continuum, and nurses are involved in the whole process.”

Zenk developed an interest in research after transitioning from the more traditional surgical-medical setting to one focusing on homecare. As she visited patients in their homes and interacted more directly with communities, she began to recognize common problems faced by populations with higher rates of illness — and this led to a growing interest in research.

“I was really struck by the differences in the resources people have, the differences in the communities and the implications that those factors had for people’s health,” Zenk said.

Early on in their conversation, Shogren asked Zenk what she believes to be the most urgent struggles faced in healthcare. Zenk replied that research increasingly shows a need to address gaps in health outcomes based on socioeconomic and racial differences.

“These disparities are among the biggest challenges we face, and we cannot address those challenges unless we take a big-picture approach to understanding health detriments and solutions,” Zenk said. “That means we’re looking upstream at the most fundamental drivers of what shapes our health: poverty, race, housing and food access and affordability.”

An increased focus on research regarding “upstream” contributors to overall health will equip healthcare professionals with the tools to address the root causes of illness before they manifest, Zenk said. And nurses, she said are uniquely positioned to help identify and solve these problems.

“The scope of our practice, the depth of our knowledge — from biological to societal — and our focus on individual patients, families and the community makes nursing research distinct,” she said. “Nurses have always had a really holistic perspective on health, and I think social determinants are a part of that.”

This broader approach to looking at community health outcomes has sparked an increased interest in healthcare equity, which Shogren says she’s seen flourishing in UND’s programs.

“We’ve seen a growing number of our students being especially interested in Indigenous health,” Shogren said, referencing the Recruitment & Retention of American Indians into Nursing or RAIN program. “We know that 79 percent of our nursing graduates from that program have gone on to be employees in Indigenous health centers in their home communities.”

In reply, Zenk said that that supporting a more diverse workforce is the next step toward creating a more equitable healthcare system.

“Both practice and research settings require people with diverse perspectives and diverse experiences to come together to really understand what is needed to improve people’s health,” she said. “We want to bring in people who haven’t had as much chance to have a seat at the table and give them opportunities to engage in research.”

Accordingly, Zenk hopes that as the table expands, nurses and nurse researchers will have more opportunities to improve the health of their communities.

“I’m always looking for opportunities to bring the nursing perspective — our voice, our viewpoint — to the table,” she said. “I hope that, as we move forward, we’ll apply our expertise and our experience to make a difference in reducing and eliminating health disparities.”

Following Shogren and Zenk’s discussion, the leaders opened the floor to questions from students and faculty, including questions about how students can get involved with research as undergraduates and how to find internships in the state.

A student looking ahead to graduation in May asked how she could integrate nursing research into her career when she is a practicing nurse.

“Don’t let go of those skills and the motivation you’re acquiring in class to look at and understand the research and literature,” Zenk replied. “I think it’s critically important to stay on top of the evidence and best practices to inform what you’re doing.”

Another student, interested in a research career, asked what being a nurse researcher is like. Zenk replied that while research roles and career paths are varied, the most fulfilling part of her work is the ability to connect with patients and the community.

“The most enjoyable part in my role is getting to talk with people and engage with communities to learn what’s important to them and what they think will work to improve their health,” she said. “Just like in practice, you’re getting to spend time with patients, families and communities. In research, that just looks a little different.”

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6 Nursing Research

Research training in nursing prepares investigators who are a part of the larger health sciences workforce. Study questions are raised from the nursing perspective but contribute to knowledge in general. For scientists in the discipline of nursing, the ultimate intent of the knowledge generated through research is to provide information for guiding nursing practice; assessing the health care environment, enhancing patient, family, and community outcomes; and shaping health policy.

The science of nursing is characterized by three themes of inquiry that relate to the function of intact humans: (1) principles and laws that govern life processes, well-being, and optimum function during illness and health; (2) patterns of human behavior in interaction with the environment in critical life situations; and (3) processes by which positive changes in health status are affected. 1 Thus, within the health sciences, nursing studies integrate biobehavioral responses of humans. The science of nursing can also be classified as translational research because it advances clinical knowledge and has the directional aims of improved health care and human health status. 2 As stated in a classic policy paper, research for nursing focuses on ameliorating the consequences of disease, managing the symptoms of illnesses and treatments of disease, facilitating individuals and families coping or adapting to their disease, and dealing in large part with promoting healthy lifestyles for individuals of all ages and under different backgrounds and disease conditions. 3 In addition, nursing research focuses on enhancing or redesigning the environment in which health care occurs in terms of the factors that influence patient, family, and community outcomes.

Focusing on ameliorating the consequences of illnesses or their treatment is the intent of many research programs conducted in nursing. For example, a new protocol for endotracheal suctioning has been tested and implemented in a number of hospital critical care units. Endotracheal suctioning is a frequently performed procedure that can have serious consequences if not done correctly. Another example in the area of symptom management is understanding the factors that influence common problems such as pain. In one study that focused on developing a longer-acting pain medication, investigators found that gender is a major factor in whether drugs are effective, with women responding well to seldom-used kappa-opioid drugs while men have little benefit from such drugs.

Another major area for research in nursing is facilitating individuals and families as they cope or adapt to long-term chronic disease. An excellent example of this area of study is a self-help program developed for Spanish-speaking people with arthritis. For many years, Hispanics with arthritis did not have many educational resources for how to cope with or adapt to their illness. Two investigators at Stanford University's medical center have now developed and tested for effectiveness a self-management program with accompanying exercise and relaxation tapes. This self-help program is being considered for nationwide dissemination by the National Arthritis Foundation.

Research in nursing also has a strong focus on health promotion and risk reduction. The intent is to promote healthy lifestyles for individuals of all ages and backgrounds and with various disease conditions. One example is a school-based program now adapted by most North Carolina schools that is a tested health promotion program in exercise and diet for young children at risk for cardiovascular disease. The research results from this school-based intervention program are impressive; the young people's total cholesterol levels and measurements of body fat were significantly reduced following the education and exercise interventions, and their fitness levels, physical activity, and knowledge about cardiovascular disease risk factors improved. 4

Together, influencing, redesigning, and shaping the environment for patients, families, and communities is another major area of study in nursing. For example, over 80 studies have shown the influence of nursing surveillance and presence on positive patient outcomes. 5 The shortage of nurses, a critical factor, in a health care environment has been demonstrated to increase patient mortality and morbidity. 6 Other studies show the benefit of home visits by nurses in improving the health and quality of life of low-income mothers and children. 7

Research in nursing is often referred to as “nursing science” or “nursing research,” which has led some to confuse it with the nursing profession. This terminology exists at the National Institutes of Health (NIH) in the name of the National Institute for Nursing Research (NINR); however, the funding from NINR supports scientific research relevant to the science of nursing, and the investigators may be nurses or nonnurses. Nursing science is a knowledge structure that is separate from the profession and clinical practice of nursing. 8 Furthermore, the term “nurse-scientist” is not reserved for graduates of Ph.D. programs in nursing; it refers to any scientist conducting research in the disciplinary field of nursing. For example, highly trained nurses under the supervision of a principal investigator could conduct the bulk of the work in a clinical trial.

Research training for nurses, as for other biomedical and behavioral researchers, needs to occur within strong research-intensive universities and schools of nursing. Important characteristics of these training environments include an interdisciplinary cadre of researchers and a strong group of nursing research colleagues who are senior scientists in the sense of consistent extramural review and funding of their investigative programs and obvious productivity in terms of publications and presentations. These elements are essential to the environment required for excellence in research training.

The NINR has traditionally placed a greater emphasis on research training in relationship to the relative size of the institute's budget than is evident with NIH in general. This is due to the current stage of development of nursing research and the need for greater numbers both as investigators and academic faculty. At least 8 percent of NINR funds go to research training, which is roughly twice the percentage invested by other institutes. 9 This commitment has been consistent for a number of years. This committee's Nursing Research Panel members commend the wisdom of this tradition and encourage its continuation.

This chapter focuses on the following two areas that are of major concern to the discipline: (1) changing the career trajectory of research training for nurse-scientists to include earlier and more rapid progression through the educational programs to and through doctoral and postdoctoral study as well as increasing the number of individuals seeking doctoral education and faculty roles, and (2) enhancing postdoctoral and career development opportunities in creative ways.

• CHANGING THE CAREER TRAJECTORY FOR NURSE-SCIENTISTS

The following three major factors motivate the critical need to change the career trajectory for nurse-researchers: (1) enhancing the productivity of nurse-researchers to build strong, sustained research programs generating knowledge for nursing and health practice as well as shaping health policy; (2) responding to the shortage of nursing faculty and the advancing age of current nurse-investigators, and (3) emphasizing the need for strong research training of nurse-investigators in research-extensive and research-intensive universities with equally strong interdisciplinary research opportunities.

• ENHANCING SUSTAINED PRODUCTIVITY FOR NURSE-SCIENTISTS

Nurse-scientists play a critical role in the conduct of research and the generation of new knowledge that can serve as the evidence base for practice and improvement of patient health outcomes. However, nurses delay entering Ph.D. programs. There is particular concern because of inherent limitations in the number of years of potential scientific productivity. Starting assistant professors in other scientific fields typically have a research career trajectory of 30 to 40 years in duration. The average age of an assistant professor in nursing is 50.2 years. Hinshaw reasons that for a faculty member who enters the nursing academic workforce at the age of 50 and retires at 65, this productive period will be only 15 years for developing research programs and contributing to science for nursing and health practice in general. 10 Thus, nurse-investigators tend to have a short career span. This limitation severely constrains the growth of nursing research and thus knowledge for nursing practice.

The median time elapsed between entry into a master's program to completion of a doctorate in nursing is approximately 15.9 years compared to 8.5 years in other disciplines. 11 In addition to having a long period of graduate training, the time has increased by 3 years since 1990, and there are no signs of the trend being reversed. Because there are many factors that reinforce the late entry of nurses into Ph.D. programs, there is a need to create incentives to change the career path. The challenge of promoting earlier entry into science careers was discussed by this panel. Of several proposals considered, there was strong support for one that would encourage and support education trajectories with fewer interruptions. To facilitate this, there needs to be greater awareness of nursing as a scientific discipline. Once students enter undergraduate programs in nursing, those students with interests in science should be identified early and encouraged to consider doctoral education. Exposure to nurse-scientists during the undergraduate program would also entice students to consider research as a primary focus in nursing. A few programs of this type exist, such as the Early-Entry Option in the school of nursing at the University of Wisconsin, Madison. In this program highly talented undergraduates are moved directly into the Ph.D. program.

A “fast tracking” of undergraduates into doctoral programs also necessitates dispelling myths related to the need for clinical practice prior to graduate school entry. There is a need to evaluate the requirement of the master's degree for individuals interested in an academic career with an emphasis on research. The lengthening of most master's programs due to certification requirements for advanced-practice roles has resulted in two plus years for master's program completion, which further delays entry into doctoral education.

In addition, the average number of years registered in a doctoral program is longer for nursing than for other fields. On average, it takes 8.3 years for nursing Ph.D. students to complete their degrees compared to 6.8 years for all research program doctoral students. 12 This is due in part to the fact that the majority of doctoral nursing students are part-time students. As of 2002, there were 81 research-focused doctoral programs in nursing with a total of 3,168 enrollees; 55 percent of enrollees were part-time students. This accounts for the low percentage of graduates; 12.8 percent of enrollees graduate each year. 13

Nursing developed both its Ph.D. and its D.N.Sc. 14 programs to build on the master's degree in nursing as well as to accommodate breaks between degrees for clinical practice. Early reliance on the master's degree is understandable in that it was nursing's highest degree for many years before the establishment of a significant number of research doctoral programs. As doctoral programs were developed, they built on the master's content, which at the time was predominantly research and theory focused. Over time the master's programs have changed to become primarily preparation for advanced clinical practice, yet nursing continues to require the master's degree for entry into doctoral study in most programs. Currently, very few doctoral programs in nursing admit baccalaureate graduates directly into the program, and for those that do, the master's degree is usually required as a progression step. This requirement for entry into the Ph.D. program makes the group of advanced nurse-practitioners, rather than baccalaureate students, the major pool from which applicants are recruited into research. This is problematic in that this practitioner pool has the same demographic characteristics as the profession and thus is older in average age and more limited in diversity compared to applicants for science Ph.D. programs in general. Incorporation of the clinical/professional content from the master's degree as foundational to the Ph.D. in nursing also encourages faculty to recruit and teach only nurses. Currently there are only a few doctorate programs in nursing that admit nonnurses.

Even though there are other fields that require a master's degree as a requirement for earning the professional research doctorate, such as the M.P.H. for the Dr.P.H., the master's degree has a completely different meaning relative to the science Ph.D. degree. The master's degree is usually awarded as a “consolation prize” for students who are unable to complete the requirements for the science Ph.D. By making the master's degree a requirement for its Ph.D. program, nursing has created confusion as to the meaning of the degree outside the nursing profession.

In considering strategies for increasing the number and length of productive research years for scientists in nursing, it is important to distinguish between the educational needs and goals of nursing as a practice profession that requires practitioners with clinical expertise from nursing as an academic discipline and science that requires independent researchers and scientists to build the body of knowledge. 15 To improve the productivity and research focus of the Ph.D. in nursing, doctoral programs need to be reengineered to admit directly from baccalaureate programs, to admit nonnurses, to decrease the number of years from high school to Ph.D. graduation, and to expand the interdisciplinary scope of the program and the research. The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new nonresearch clinical doctorate, similar to the M.D. and Pharm.D. in medicine and pharmacy, respectively. The concept of a nonresearch clinical doctorate in nursing is controversial, but some programs of this type exist.

Nursing should be encouraged to reengineer some of its doctorate programs to exclusively meet the goal of producing scientists and researchers who are the most capable in terms of skills and projected career life, to meet the needs of nursing as a science and for the development of its research-based disciplinary knowledge. Doctorate programs currently require core coursework in theoretical systems, philosophy of science, qualitative and quantitative methods, and statistical/data analysis techniques. What is different from other science degrees is the amount of advanced practice usually required prior to the doctoral program. Some educational depth in a clinical area or in practice is important for the study of clinical questions, but how much is the issue.

There is no clear research career trajectory evident among scientists in nursing today. The common thread is that they entered their doctoral programs later than most other scientists and have not benefited from postdoctoral education. This is because most nurses enter doctoral programs following receipt of the clinical master's degree, also often with many years of clinical experience, and their primary socialization has been as practitioners. As such, they bring with them rich experiences that may help shape the focus of their inquiry. However, they also carry with them enormous burdens relating to their readiness for entering rigorous science training, their interest in continuing training following their predoctoral experience, and their long-term capacity for developing a research career. In addition, when nurses complete their doctoral training, most move directly into an academic career. There they frequently encounter settings in which the demands for teaching and lack of pervasive research programs, socialization, and further mentoring make continuing progress as a scientist difficult.

There is evidence to suggest that a successful career in science is the result of a number of key factors across the life span. These factors include inspiration and “connection” to science and the field; involvement in the enterprise of discovery and science; knowledge, skill, and leadership development; opportunities for coaching, role modeling, and mentoring; a scientific community with peer engagement, assessment, support, and critique; an intensive research environment; and adequate support for research in all of its phases. With these factors in mind, each stage of nursing from precollege, undergraduate, predoctoral, and postdoctoral to the career scientist can build strategies to enhance the career path.

The development of future scientists begins very early in the educational experiences of young people. These include education in school but also beyond. This begins with exposing students interested in nursing at the precollege level to both the profession and nursing science. Undergraduate development of scientists moves individuals from a more general interest in and connection to science to actually beginning to embark on a career in science. The context should be designed to support both the acquisition of a solid academic foundation for further study, a clear notion of pathways for becoming a scientist, and educational experiences that move the student into actual conduct of research. Predoctoral training should begin before the doctoral student starts a course of study. The student's program should assure a very strong match between the research interests of the student and the capacity of the program and faculty. Programs should be fundamentally grounded in a commitment to and processes that support the development of scientists. The postdoctoral phase is the point at which one's own science career should begin to take hold and the intrinsic rewards of science and discovery drive the work of the postdoctoral fellow. Ultimately, the career scientist is at the stage of developing and maintaining his/her program of research. For academic scientists this is the point at which mentoree becomes mentor and teacher, based on the program of research. It is also the point at which the scientist should become an active member of the academic community.

• RESPONDING TO THE SHORTAGE OF NURSE-INVESTIGATORS

It has been well established that there is both a current shortage and a projected continued shortage of nursing faculty, especially those who are scientists and researchers. At this time, approximately 50 percent of faculty that teach in nursing baccalaureate programs are doctorally prepared. This represents a marked increase from the late 1970s, when only 15 percent were. This 50 percent level was achieved in 1999 but has not increased since then despite a large increase in the number of doctoral degree programs available to nurses during the same time period (e.g., in 2002 there were 81 research-focused programs). Two factors that likely contribute to this stalemate are (1) the relatively constant number of doctoral degrees earned each year, despite the increase in the number of programs, as shown in Table 6-1 , and (2) the older age of graduates, as evidenced by an increase in the average age of assistant professors from 45 to 49.6 years for the period 1996 to 1999. In 2002 the average age of doctorally prepared faculty was 53.3, compared to 50.2 in 1999 and 2000. 16 These statistics suggest that the doctorally prepared faculty is aging, and because the percentage of faculty members with doctorates is not increasing, it does not appear that younger replacements are being put in place. Thus, this older group of doctorally prepared faculty members in nursing is likely to retire from the academic workforce over the next few years, leaving nursing programs with too few faculty members to conduct research and educate the next generation of scientists.

Nursing Doctorates from U.S. Institutions, 1991–2003 .

The need to dramatically increase, even double, the number of nurse-scientists is acute, especially at earlier points in their careers. A recent Special Survey of Vacant Faculty Positions conducted by the American Association of Colleges of Nursing indicated that 59.8 percent of the vacancies require an earned doctoral degree. 17 Training opportunities are available, including predoctoral and postdoctoral fellowship programs offered primarily by the NINR. The number of applicants for these awards has remained relatively stable over time, consistent with the flat doctoral graduation rate for nursing. It is important to provide research training incentives that increase the number of nurses selecting a research career and at a much earlier point in their professional development.

• EMPHASIZING RESEARCH-INTENSIVE TRAINING ENVIRONMENTS

Strong, research-intensive environments are critical in both the general universities and the schools of nursing for doctoral, postdoctoral, and career development preparation. Such environments provide the experience of being immersed in scientific inquiry with mentors and the intellectual cohort of investigators required for the preparation of nurse-researchers. Research-intensive environments also promote crucial interdisciplinary research opportunities. Nursing research confronts complex questions. Thus it needs to involve multiple perspectives and bodies of interdisciplinary expertise.

To date, scientific training for nurses and others committed to nursing research has utilized a variety of National Research Service Awards (NRSAs) and Career Development K awards. These research training awards are funded by the NINR. The individual predoctoral awards (F31) have been slowly increasing, with very limited numbers of individual postdoctoral awards (F32) evident. The NRSA institutional awards (T32) have grown considerably over time, with 43 such awards made between 1986 and 2002 and 27 operational in 2003. Within the T32s, 65 postdoctoral trainees and 93 predoctoral awards were anticipated for 2003. For the individual NRSA awards there were five postdoctoral awards (F32) and 100 predoctoral awards (F31) for 2003 (see Figure 6-1 ).

Training positions at the postdoctoral and predoctoral levels. SOURCE: National Institute for Nursing Research Budget Office.

The level of scientific productivity differs among the NRSA mechanisms for the individuals and institutions funded by the NINR. Analysis of the funding record for successfully acquiring either research (R) or career (K) development awards later in the career shows a pattern similar to that of the total NIH research training programs. NINR trainees and fellows funded on individual NRSAs are more apt to successfully acquire R and K awards (see Table 6-2 ) at a later date.

Analysis of Pre- and Postdoctoral Fellows with Subsequent Funding .

The difference is sizable, with predoctoral awards being 17 percent of the individual awards (F31) and 5 percent of the T32 predoctoral positions. The pattern is similar with a greater difference for the postdoctoral fellows—38 percent for the F32 and 18 percent of the T32 positions. However, productivity in terms of publications shows the opposite pattern (see Figure 6-2 ).

Publications, T32 versus non-T32. SOURCE: Outcome analysis by National Institute for Nursing Research at NIH.

The 2 years 1997 and 1999 illustrate a consistent pattern of higher publications for trainees and fellows on the T32 awards. In 1997 and 1999, 158 and 154 publications resulted from trainees and fellows on the institutional T32 awards versus 66 and 23, respectively, for doctoral students holding the individual F awards.

Both institutional and individual research training awards under the NRSA program should continue. The individual awards build strong scientific capability and independence when working with a research-active mentor. With the T32 institutional awards, the cadre of strong senior researchers forming a scientific community is valuable in terms of mentoring and publications. The individual predoctoral awards (F31) can be used for a variable length of study. The NINR/NIH is encouraged to allocate three to four years per award in order to support full-time, consistent progression for research training.

The lower productivity of trainers and fellows, who have been funded on the institutional NRSAs (T32) and later obtain R01 and K awards, is of concern. The research training offered through T32 mechanisms needs to be strengthened in the following manner:

• T32 awards should be placed in research-intensive universities with strong interdisciplinary opportunities and research funding, and research interdisciplinary activities should be a critical aspect of the initial NRSA application and annual reports.
• The T32 awards should be allocated only to schools with research-intensive environments, including a cadre of senior investigators with extramurally funded research or research track records and research infrastructures that support research and research training.
• The application process for T32 positions as predoctoral trainees or postdoctoral fellows should be more formalized, with specific proposals submitted in relationship to their research and the match with faculty at the institution made explicit.
• Trainees and fellows on a T32 award position should provide evidence of the interdisciplinary strength that is part of their program of study.
• Criteria for selection of T32 fellows and trainees should be based on a consistent, full-time plan for research training and long-term potential for contribution to science and nursing.
• The monitoring and tracking of trainees and fellows should be formalized, with changes in research plans or mentor(s) filed as part of the annual report.

A small but growing cadre of nurse-investigators is supported in their research development by K awards. In addition to the awards from NINR, other institutes and centers also support nursing research through the K mechanisms, since elements of nursing research are intrinsic to other fields. These awards are usually awarded to nurse-scientists in their early or midcareer stages when they are shifting the substantive or methodological focus of their research. NINR has primarily used the following four types of career awards: K01, Mentored Research Scientist Development Award; Minority K01, Mentored Research Scientist Development Award for Minority Investigators; K22, Career Transition Award, and K23, Mentored Patient-Oriented Research Career Development Award; and K24, Mid-Career Investigator Award in Patient-Oriented Research. 18

These awards could be important in advancing both career development and science development. Unfortunately, there is limited information regarding the outcomes of these awards, including successful research grants and publications by awardees.

In summary, three major factors influence the recommendation to change the research training career trajectory pattern for nurse-scientists: the need to enhance the productivity of each investigator's study for nursing practice and for shaping health policy; increasing the numbers of nurse-investigators to respond to the investigator and faculty shortage; and emphasizing the need for research training within strong research-intensive environments.

• RECOMMENDATION

Recommendation 6-1: The committee recommends that a new T32 program be established that focuses on rapid progression into research careers. Criteria might include predoctoral trainees who are within 8 years of high school graduation, not requiring a master's degree before commencing with a Ph.D., and postdoctoral trainees who are within 2 years of their Ph.D.

This new program would produce strong research personnel and lengthen the research careers of the trainees. These grants should be placed in research-intensive universities with strong interdisciplinary opportunities and research funding, including a cadre of well-established senior investigators.

Donaldson, S. K. and D. M. Crowley. 1978 .

Sung, N. S., et al. 2003 .

American Nurses Association. 1985 .

National Institute for Nursing Research. 2003 .

Aiken, L. H., et al. 2002 .

National Institute of Nursing Research. 2003 . op. cit.

Donaldson and Crowley. 1978 . op. cit.

Grady, P. A. 2003 .

Hinshaw, A. S. 2001 .

National Opinion Research Center. 2001 .

American Association of Colleges of Nursing. 2003b .

American Association of Colleges of Nursing. 2003a .

McEwen, M., and G. Bechtel. 2000 .

Donaldson and Crowley. 1973. op. cit.

American Association on Colleges of Nursing. 2004 .

Grady. 2003 . op. cit.

See Appendix B for a complete explanation of awards.

• Cite this Page National Research Council (US) Committee for Monitoring the Nation's Changing Needs for Biomedical, Behavioral, and Clinical Personnel. Advancing the Nation's Health Needs: NIH Research Training Programs. Washington (DC): National Academies Press (US); 2005. 6, Nursing Research.
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