4
Status and Future Role of Academic Nursing in Clinical Research
Nurses with doctoral training are needed not only to train the nursing workforce but also to conduct research and oversee research training. Yet the number of doctorally trained nurses is insufficient to meet the demand in academic and clinical settings. The lack of doctorally trained nurses to serve as faculty is a significant constraint to training nurses for practice as well as for future faculty.
The challenges facing nurse-scientists are quite daunting. In academic and clinical institutions, there is a lack of nurse mentors with a career commitment to clinical research. The creation of research-intensive environments that foster the development of students is necessary to both attract nurses into research and support their development. Nurses interested in research who work in low-intensity research environments without adequate mentors or role models feel isolated and without the necessary support to begin a clinical research career (Reame, 2003).
THE ADVANCING AGE OF NURSING FACULTY
In 2000 nearly 6,000 qualified applicants were not admitted into nursing programs, despite the shortage of nurses. In more than a third of the cases the nonadmittance stemmed from a shortage of nursing faculty. In 2003, 11,000 applicants were turned away.1 In the next few years almost
1 |
American Association of Colleges of Nursing at http://www.aacn.nche.edu. Date accessed November 22, 2004. |
34 percent of the nursing faculty is expected to retire, exacerbating the current situation. The maturing R.N. workforce is a product of two phenomena: (1) a shrinking pool of young nurses entering the R.N. population and (2) large cohorts of the R.N. population moving into their 50s and 60s (Spratley et al., 2000).
The average age of nursing faculty members is over 50, most likely a function of the discipline’s conventional late entry to doctoral study. The advanced age of nursing Ph.D.s may stem from the norms of the profession, which encourages its members to acquire considerable professional experience before seeking research training (NRC, 2000).
The average age of nurses upon completion of the doctorate is 46 years, well beyond that of other disciplines where the average age is 33 years. Those receiving National Research Service Award (NRSA) funds, which demand full-time study, are generally over 40 by the time they complete their studies (NRC, 2000). About 49 percent of all nurse-Ph.D. graduates enter the service sector rather than academia.
The Nursing Pipeline
There is an urgent need for enhanced recruitment of men and women into graduate and nursing education programs. In March 2000, R.N.s enrolled in formal education programs leading to a nursing or nursing-related degree represented only 6.7 percent of all the country’s R.N.s, or 180,765 of the 2,696,540 population (Spratley et al., 2000). Enrollees tended to be part-time students (76 percent) and to be employed full-time in nursing (72 percent). Of the 180,765 nurses pursuing formal education, about 53 percent were enrolled in programs leading to a baccalaureate degree, 36.4 percent in programs leading to a master’s degree, and less than 4 percent in doctoral programs.
All baccalaureate programs in nursing education have built-in components: basic research methods, statistics, and research utilization. The overwhelming majority of master’s programs have a research obligation. Often this obligation takes the form of a requirement to carry out an evaluation study while receiving clinical experience or perhaps a requirement to do a secondary analysis of an existing clinical database. Doctoral training for nurses is by nature research intensive, just as it is in other disciplines. Many postdoctoral programs in nursing expect fellows to submit an individual grant proposal for external funding (e.g., NRSA) by the end of the fellowship period (McBride, 2003).
In general, students enter academic nursing programs to prepare themselves as clinicians, not researchers. Students and future clinical researchers often are not aware of the possibility of becoming clinical researchers, have incorrect assumptions about research, or believe that research would simply not be a good career match for them (Woods, 2003).2
Clinical Research as a Career
One of the principal pushes in the nursing field is to encourage research as a career track; B.S.N.-Ph.D. and fast-track programs are the most common mechanisms. Development of an honors program at the B.S.N. level is a positive step toward this goal. A small number of institutions offer undergraduate and graduate education and postdoctoral training in an accelerated manner and provide mentoring throughout the education (McGivern, 2003). Nursing is a field populated largely by women; multiple relocations of families for graduate, postdoctoral, and finally permanent faculty positions may not be a possibility. Another problem in nursing is that the shortage is so great that every faculty member is expected to educate more people to replenish the workforce rather than build the science (McBride, 2003).
PREPARING A DIVERSE AND REPRESENTATIVE CLINICAL RESEARCH WORKFORCE
The scientific community should encourage children’s exposure to the nursing field as early as elementary and middle school to prepare a diverse and representative clinical research workforce. Graduates from baccalaureate, master’s, and doctoral programs in nursing demonstrate a lack of racial and ethnic diversity (see Table 4-1). A more representative workforce will require continuing and seamless opportunities to nurture interests in clinical research careers. There is a multiplicity of programs—some that involve children in grade school, some that engage middle schoolers, and some that work with high school and college students—but they are not always coordinated.3
Priority should be given to retaining, not just recruiting, a representative and diverse workforce. Changing the cultural demographics of nurse
TABLE 4-1 Race and Ethnicity of Graduates from Baccalaureate, Master’s, and Doctoral Programs in Nursing, 1999-2002
|
1999-2000 |
2000-2001 |
2001-2002 |
|||
Number |
Percent |
Number |
Percent |
Number |
Percent |
|
Total baccalaureate enrollment (generic [basic] and R.N. to baccalaureate) |
||||||
White |
26,063 |
81.2 |
24,405 |
79.5 |
25,031 |
78.5 |
Black or African American |
3,125 |
9.7 |
3,241 |
10.6 |
3,448 |
10.8 |
Hispanic or Latino |
1,383 |
4.3 |
1,559 |
5.1 |
1,696 |
5.3 |
Asian, Native Hawaiian, Other Pacific Islander |
1,332 |
4.1 |
1,293 |
4.2 |
1,480 |
4.6 |
American Indian or Alaskan Native |
210 |
0.7 |
192 |
0.6 |
227 |
0.7 |
Total |
32,113 |
|
30,690 |
|
31,882 |
|
Total minority |
6,050 |
8.8 |
6,285 |
20.5 |
6,851 |
21.5 |
Master’s enrollment |
||||||
White |
8,117 |
86.3 |
7,781 |
83.7 |
7,306 |
83.0 |
Black or African American |
565 |
6.0 |
696 |
7.5 |
690 |
7.8 |
Hispanic or Latino |
275 |
2.9 |
366 |
3.9 |
349 |
4.0 |
Asian, Native Hawaiian, Other Pacific Islander |
400 |
4.3 |
400 |
4.3 |
397 |
4.5 |
American Indian or Alaskan Native |
52 |
0.6 |
58 |
0.6 |
61 |
0.7 |
Total |
9,409 |
|
9,301 |
|
8,803 |
|
Total minority |
1,292 |
13.7 |
1,520 |
16.3 |
1,497 |
17.0 |
Doctoral enrollment |
||||||
White |
346 |
89.4 |
286 |
85.1 |
374 |
91.0 |
Black or African American |
21 |
5.4 |
20 |
6.0 |
21 |
5.1 |
Hispanic or Latino |
3 |
0.8 |
8 |
2.4 |
6 |
1.5 |
Asian, Native Hawaiian, Other Pacific Islander |
16 |
4.1 |
19 |
5.7 |
10 |
2.4 |
American Indian or Alaskan Native |
1 |
0.3 |
3 |
0.9 |
0 |
0.0 |
Total |
387 |
|
336 |
|
411 |
|
Total minority |
41 |
10.6 |
50 |
14.9 |
37 |
9.0 |
SOURCE: AACN (2002a ). |
clinical researchers will require seeking initiatives that lead to both the graduation and retention of minority students (Nugent et al., 2004). One way to achieve this goal is by building learning communities of mentors who are working clinical scientists and students who represent all levels of the university curricula, bridging the disciplinary boundaries. According to the National Learning Communities Project, “In higher education, curricular learning communities are classes that are linked or clustered during an academic term, often around an interdisciplinary theme, and enroll a common cohort of students. A variety of approaches are used to build these learning communities, with all intended to restructure the students’ time, credit, and learning experiences to build community among students, between students and their teachers, and among faculty members and disciplines.”4 Nurse educators are valuing diversity and cultural competence with the growing diversity of the American population (Christman, 1998).
Retaining a representative and diverse workforce can also be achieved by helping students find meaning in the work of clinical researchers. Students can understand what a study or particular health problem may mean to them personally, to their culture, or to their ethnic group. Students can see the relevance of the issue to them and to their community and can understand who will benefit from the work. Nurses can create some learning opportunities that help students address these questions as part of their training (Woods, 2003).
NATIONAL INSTITUTE OF NURSING RESEARCH
The National Institute of Nursing Research (NINR), established in 1985 as the National Center for Nursing Research at the National Institutes of Health (NIH), provides funds for training nurse-researchers and sets a national nursing research agenda.
The National Institute of Nursing Research5 devotes about 8 percent of its budget to training, which is more than twice the average across NIH. NINR’s budget support for training reflects a commitment to developing the next generation of researchers.
4 |
National Learning Communities Project at http://www.pewundergradforum.org/project%20washington%20center.html. Date accessed December 6, 2004. See also http://learningcommons.evergreen.edu/02_nlcp_entry.asp. Date accessed November 16, 2004. |
5 |
National Institute of Nursing Research at http://www.nih.gov/ninr/index.html. Date accessed November 16, 2004. |
In terms of success across NIH, schools of nursing, with few exceptions, are funded by all NIH institutes and centers. The NINR collaborates with other institutes and centers in many areas of shared interest, including joint funding of research project grants and requests for applications (RFAs). Collaboration extends to other agencies within the Department of Health and Human Services and beyond, including the Health Resources and Services Administration, Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention.
As part of the NIH roadmap initiative, NINR created five expert panels to look at the future needs of nursing research. NINR’s scientific goals for 2000-2004 are to (1) identify and support research opportunities that will achieve scientific distinction and produce significant contributions to health; (2) identify and support future areas of opportunity to advance research on high-quality, cost-effective care and to contribute to the scientific base for nursing practice; (3) communicate and disseminate research findings resulting from NINR-funded research; and (4) enhance the development of nurse-researchers through training and career development opportunities.
The NINR supports the research training of about 200 predoctoral students and about 70 postdoctoral fellows a year. In FY 2004 about 2,420 trainees were participating in T32 training grants in schools of nursing across the United States.6
The NINR supports developmental centers and institutional training awards, as well as 10 P30 grants, 8 of which focus on health disparities in minority populations. Approximately 20 percent of the NINR budget is directed toward research and training that has specific objectives related to minority health and the broader area of health disparities. NINR collaborates with historically black colleges and universities, especially those few that provide nursing education. In the broader area of health disparities NINR plans to undertake the following in the future: (1) the institute will continue to provide links between NINR-funded investigators and minority researchers who are interested in participating in large multicenter studies; (2) specific RFAs will be issued to target minority researchers and infrastructure development to support research on health disparities; and (3) the Research Supplement for Underrepresented Minority (RSUM) mechanism will continue to target minority students and faculty early in their nursing
6 |
CRISP database at http://crisp.cit.nih.gov. Date accessed October 19, 2004. |
careers to stimulate their interest in research. In addition to the developmental centers and institutional training awards, the NINR intramural program offers an intensive summer genetics institute. The institute also has developed online information for junior investigators preparing to launch their independent careers.
The NINR and the National Center for Minority Health and Health Disparities are funding exploratory centers across the country called Nursing Partnership Centers on Health Disparities (P20). These 17 centers encompass traditionally black colleges and universities and institutions serving Hispanic and American Indian students.
The centers have a two-pronged approach: (1) to boost the numbers of minority researchers and (2) to improve the quality of minority health research itself. To achieve these goals, they are funding pilot studies to entice people to enter a research career track.
FUTURE NEEDS AT THE INTERFACE OF NURSING AND CLINICAL RESEARCH
For the new paradigms in clinical research training, interdisciplinary exposure is the foundation for team science; for example, the Human Genome Project has already altered the future landscape of nursing—the underlying genetic foundation is known for diagnosis and the treatment of disease, affecting all of medicine and nursing (Horner et al., 2004). Nursing science is beginning to utilize genetic principles in research design and methodologies. Collaboration among nursing researchers and researchers in related disciplines is important for successful integration of genetic concepts into nursing science. In order to participate in the knowledge becoming available about the connections between genetics, health, and nursing, nurses must grasp genetic concepts (Williams et al., 2004). One study, which examined several surveys, found a near absence of genetics curricula in nursing schools. To address the lack of genetics contents in nursing curricula, the Genetics Program for Nursing Faculty (GPNF) was created, and it led to the formulation of a Genetics Curriculum Checklist to consolidate genetics material into curricula (Hetteberg and Prows, 2004).
Challenges also lay ahead in dealing with the nursing shortage. One workshop participant finds that a high percentage of the students who enter his clinical research administration program are nurses who either are tired of the patient care component of nursing or have left the profession for something different. The retention of nurses is an issue related to the
nursing shortage, and clinical research is a tremendous draw, bringing nurses who have left back into the profession.
Another workshop participant added that even when nurses become coordinators of clinical research activities, they are perceived as having left the nursing field. Instead, clinical research needs to be seen as a part of the range of what constitutes nursing. Much of what must be done to engage people in a study, keep them enrolled, and work with them over time involves the basic skills that are part of nursing education and preparation. The percentage of nurses who do not stay in clinical nursing for longer than two years is very high. Retention is as critical an issue as recruitment into the field.
This workshop participant also observed that although there is a worldwide nursing shortage, some Asian entrants come into American doctoral programs because they are attracted to the American model of nursing education. The Asian entrants want to develop research-intensive programs, and many of them, depending on their country and the year, have full-time funding from their governments. Indeed, in a given year the strongest applicants to nursing programs have been from other countries, because they have had government funding to support full-time study. American-born individuals have not had the same kinds of resource options for doctoral study. Moreover, international students, particularly for graduate studies, do not necessarily remain in the United States; many of them come with the expectation that the support is contingent on returning to their country for at least two years. The proportion of foreign-born nurses has grown steadily since 1998, topping 14 percent in 2003 (Brush et al., 2004).
The nursing field wants the best and the brightest undergraduate students at the top institutions to consider nursing as a possibility. It can be quite challenging to make this appeal, especially in cultures where nursing is not considered a status profession and especially at a time when many other barriers for women (particularly minority women) are falling, thereby providing new options that might be more appealing from a cultural and social standpoint.
BOX 4-1 Nursing’s Clinical Research Workforce
Increasing the Numbers of Women and Minorities
Evaluating Existing Training Efforts
Addressing Health Disparities
|
Addressing the Nursing Faculty Shortage
Retaining a Representative and Diverse Workforce for Clinical Research
Education of Future Clinical Researchers
|
Resources for Educating Clinical Researchers
New Paradigms in Clinical Research Training
|