A quarter century ago, at around the time of the birth of what is now the National Institute of Nursing Research (NINR), inserting a nasogastric feeding tube carried a significant risk for patients. “We never had a really good way to know if we were getting the tubes in the right position,” says Ada Sue Hinshaw, Ph.D., R.N., F.A.A.N., dean of the Uniformed Services University Graduate School of Nursing. A feeding tube inserted by mistake into the lung, she says, could “do real damage.”
With support from NINR, Norma Metheny, Ph.D., R.N., F.A.A.N., searched for a way to verify proper placement of the tubes, and developed a straightforward solution that Hinshaw says, “changed the way textbooks are written.” By testing the pH of an aspiration from the tube, nurses and other providers could confirm that the tube had indeed found its way to the right location.
“As a patient,” says Hinshaw, “you’d never know it was the product of nursing research.”
Hinshaw was the founding director of NINR, nurturing it from its early years as the National Center for Nursing Research at the National Institutes of Health, through its transformation into one of NIH’s full-fledged Institutes. NINR marked its 25th anniversary this September, and Hinshaw says she’s excited by “the explosion of nursing research that you see now.... In the last 15 years, we’ve had a real blossoming of nursing research around very important issues, research that’s both clinically relevant and scientifically rigorous.”
RWJF Programs at Forefront of Nursing Research
Jacquelyn Campbell, Ph.D., R.N., F.A.A.N., national program director of the Robert Wood Johnson Foundation Nurse Faculty Scholars program, agrees. “Nursing research is in an incredibly exciting state. More and more it’s addressing questions needed by the country to improve our health, improve the health care system and to start closing the health inequities gaps.“ The specific objective of the Nurse Faculty Scholars program is to develop the next generation of national leaders in academic nursing, and research is a key component of that process. “Nursing research tends to do the translational piece,” Campbell says. “We look at what’s being found in basic science and physiology and genetics research, and then we translate it to the real world, to people, patients and communities.” Studies commonly focus on specific nurse interventions, often in collaboration with other health care professionals, or with communities and community organizations.
The RWJF Nurse Faculty Scholars program has supported countless studies by its scholars, maintaining a database of those studies on its Web site. “Some of the research being funded by RWJF through Nurse Faculty Scholars is quintessentially nursing research,” Campbell explains. She cites a number of examples, including a series of studies by Kathryn Laughon, Ph.D., R.N., of the University of Virginia, focused on interactions of intimate partner violence victims with the health care system; work by Kynna Wright-Volel, Ph.D., R.N., of UCLA, on racial and ethnic disparities in medication use by asthmatic children; and research by Robert Atkins, Ph.D., R.N., of Rutgers, who is exploring the health effects of poverty on youth in Camden, New Jersey, and working to identify promising interventions.
Other RWJF-supported programs have backed important nursing research, as well. Some examples:
- In 2005, RWJF’s Transforming Care at the Bedside (TCAB) program funded nine hospital associations and health care systems to work with at least 25 of their member hospitals to establish “rapid response teams”—groups of clinicians, including seasoned intensive care nurses, respiratory therapists and in some cases physicians—that nurses and other hospital staff can call upon at any time to provide critical care expertise at the bedside of a patient whose condition was deteriorating. The objective was to avoid “failure to rescue” hospital deaths that might be avoided if hospital staff observed and responded quickly to patients’ deteriorating health.
- In 2006, RWJF funded spin-off research from TCAB, this time focused on preventing patient falls in hospitals. Such falls can cause substantial injury, even death. With RWJF’s support, eight hospital organizations collaborated with the Institute for Healthcare Improvement (IHI) in Cambridge, Mass., to test a preliminary package of interventions aimed at preventing such falls. Informed by feedback from the hospital sites, an IHI team developed and disseminated a final package of strategies to prevent injuries from falls in acute care hospital units.
- RWJF Investigator Award recipient Linda Aiken, M.N., Ph.D., created a powerful database of all 210 hospitals in Pennsylvania that included information gathered from nurses at the hospitals about the working environment and hospital practices. The data have proved to be a mother lode of useful information that has helped pinpoint crucial interactions between nurses and their patients and other medical staff—from monitoring vital signs and managing pain to ensuring that precautions against infection are scrupulously followed. Using the database, researchers have been able to map out the consequences of understaffing, budget cutting, extended shifts and nurse burnout.
- RWJF’s Wisdom at Work program supported evaluations of 13 separate extant initiatives aimed at keeping experienced nurses in the workforce, so as to help alleviate the nursing shortage. Six of the studies focused on ergonomic issues, such as patient lift teams or equipment to reduce the physical burdens of nursing, four examined staffing projects intended to improve organizational culture, and three projects looked at other specific issues—employee wellness, clinical technology and leadership development.
Another example of influential nursing research singled out by former NINR Director Hinshaw was a project conducted by Mary Naylor, R.N., Ph.D., F.A.A.N. With funding from NINR, Naylor and her team completed randomized clinical trials testing the effectiveness of a collaborative, nurse-led Transitional Care Model, designed to improve post-hospital discharge outcomes. Too often, patients, particularly elderly ones, end up back in hospitals soon after their release. As many as one-third of these re-hospitalizations are considered preventable, so improving outcomes not only improves patients’ quality of life, but reduces health care costs. Naylor’s research influenced a number of the transitional care provisions in the Affordable Care Act.
In a recent podcast discussing NINR’s anniversary, the Institute’s current director, Patricia Grady, R.N., Ph.D., F.A.A.N., noted that Naylor’s work was particularly significant because it examined readmissions from the systemic perspective of cost: “At the point that Mary introduced the cost piece into this, [and] was able to explain how much of a difference this made, along with quality of life and patient outcomes, I think the transitional care model went to being something that was more exportable. So that was an important turning point.”
Taking an Interdisciplinary Research Approach to Quality
Naylor now serves as program director of the RWJF-sponsored Interdisciplinary Nursing Quality Research Initiative (INQRI), where she and her colleagues support a broad range of nursing research. Central to the Initiative’s work is its commitment to an interdisciplinary approach, a design that played a key role in Naylor’s transitional care research. “The research is so much more robust,” she explains, “when you approach from the various perspectives of nurses, social scientists and others.”
Another project-design priority for INQRI is bringing key stakeholders into the project early on. Says Naylor, “We want the end users of the research involved in helping shape the project, so that the research teams have the perspective not just of the different disciplines, but of the users themselves.”
Among the many research initiatives supported by INQRI are efforts aimed at improving acute care and pain management, preventing medical errors, learning more about the effects on patient safety of nurse staffing and the work environment, and the development of quality measures for nursing.
One INQRI project at Johns Hopkins University focused on reducing rates of central-line-associated bloodstream infection in intensive care units. Some estimates fix the number of catheter-induced bloodstream infections at 80,000 each year, causing up to 28,000 deaths at an average cost to the health system of $45,000 per patient. This makes the effort to prevent such infections a major battle in the larger war against medical errors.
The study, conducted in ICUs in 12 states, has shown in preliminary analysis that substantial reductions in infections can be widely achieved, and can do so with nurses leading the infection-control efforts. The study builds on the well-known work of Peter Pronovost, M.D., Ph.D., creator of the line insertion “checklist.” Hospitals that followed the components of the ICU safety program, as well as adopted a safety improvement environment that fostered nurse involvement in quality improvement efforts, reduced—and in some cases completely eliminated—bloodstream infections for several months at a time. The research is also showing that higher nurse turnover is related to higher infection rates.
In addition to the various advances such research has generated and continues to generate, Naylor notes that it has also helped strengthen the role of nursing. The research projects, she says, “have made the case through rigorous science that nurses are central to solving almost all the problems we confront in health care.”
The Role of Nursing Research Going Forward
Nursing research played an important role in the work of the Committee on the RWJF Initiative on the Future of Nursing at the Institute of Medicine. In preparing its landmark study, The Future of Nursing: Leading Change, Advancing Health, the Committee drew on the intellectual resources of the RWJF Nursing Research Network, led by Lori Melichar, Ph.D., M.A., RWJF director. RWJF launched the Network as a parallel project to the Committee, and it provided reams of research data and analysis on workforce to assist the Committee’s deliberations.
Not surprisingly, the Committee recognized the important role of nursing research going forward. Noting that nursing research to date has “led to many fundamental improvements in the provision of care,” the Committee observed that “nursing’s research capacity has been largely overlooked in the development of strategies for responding to the shortage of nurses or effecting the necessary transformation of the nursing profession. The result has been a serious mismatch between the urgent need for knowledge and innovation to improve care and the nursing profession’s ability to respond to that need, as well as a limitation on what nursing schools can include in their curricula and what is disseminated in the clinical settings where nurses engage.” The Committee concluded that an “expansion of knowledge about the science of nursing is key to providing better patient care, improving health, and evaluating outcomes.”
The cumulative effect of current and future threads of nursing research is improved care and prevention, greater cultural sensitivity in patient care and, gradually, policy choices that support those objectives. Along the way, NINR, RWJF and others have helped build an infrastructure for nursing research—institutions committed to the task, and highly trained nurse researchers. “Before [NINR], there was about $3.5 million spent in the country on nursing research,” says Hinshaw. “That wasn’t enough to be able to build the knowledge base needed for nursing practice.... There are now long-term research programs, and major programs for training of post-doctoral students.”
Ironically, NINR’s forerunner, the National Center for Nursing Research, was created only over a presidential veto based on objections to expanding NIH. Discussing policy-makers at the time, Hinshaw says: “I think they didn’t know what nursing research was. So it was a matter of really educating people about what it is, and how we could collaborate with other research programs.” Twenty-five years on, that mission is accomplished, and nursing researchers and institutions across the nation are continuing their work learning more about how to improve health care for all.