Research is increasingly becoming a visible component of nursing practice. This growing focus on research results from several factors: (1) a greater number of nurses seeking advanced degrees for which research projects are required; (2) nurses seeking specialty certification often are required to conduct research; and (3) the increased concern that scientific data be collected systematically to improve the quality of patient care.
The American Nurses' Association, in establishing the Commission on Nursing Research, "reaffirmed the nursing profession's obligation to support the advancement of scientific knowledge toward the achievement of improved nursing practice and better patient care."1 Research is needed in all aspects of nursing, such as administration or education, but recent trends have placed emphasis on clinical research.2'3 Clinical research, however, is a particular challenge. Nurses must enhance their abilities to overcome organizational barriers to successful clinical research as well as master the methodological dilemmas. My experience as a gerontolgical clinical specialist, and particularly my experience with clinical research conducted in nursing homes, has yielded a number of critical findings regarding the research process in such patient care settings. This article will address four issues: (1) obstacles to qualitative and quantitative clinical research in nursing homes; (2) possible solutions to the obstacles identified; (3) ethical concerns; and (4) role of the director of nursing in facilitating research and in protecting the rights of patients.
Research may erroneously be perceived as an intimidating task but it is not, if one possesses basic research skills. A focus on the anticipation and prevention of "problems" can lead to an improved outcome and the generation of more qualitative gerontological nursing studies. In addition to improving patient care, clinical research can produce other benefits such as testing new patterns of care for the elderly, testing validity and reliability of findings as applied to long-term care settings, improving techniques, increasing motivation and job satisfaction, and providing fresh approaches for those who have become too "routinized" in patient care delivery.
Obstacles to Research
Inadequate Time for the Conduct of Research
In all settings of practice, time pressures of the job often prevent research from becoming a priority. Since nursing research is essential to improving our practice, we must find and make time to include research as part of our work setting. This can be operationalized by revising job descriptions to include research, negotiating prior to the taking of a position, or specific delineation of personal and/or institutional goals. Because research is time consuming, skill in the formation of short- and long-term goals combined with the virtue of patience are essential traits of the researcher.
Lack of Sufficient Educational Preparation in Research, Statistics, and Scientific Writing
Research is a relatively new focus in nursing as compared to the other more established disciplines. Therefore, in both academic and clinical facilities there may be inadequate numbers of nurses adequately prepared in research. Since knowledge of research is usually gained through graduate studies and since academic settings hire greater numbers of nurses with advanced degrees, it is logical to expect that a greater pool of human resources for research will be located in university, rather than nursing home settings. Outside of the academic setting there may also be fewer nurses experienced in scientific writing. This further hinders the goal of sharing research findings with colleagues in the field.
High Staff Turnover
The chronic problem of staff turnover further complicates the challenge of clinical research. The problem is compounded by a high turnover in the positions of directors of nursing in nursing homes. Nurses in administrative or staff positions who change jobs frequently are less efficient in identifying clinical problems and prioritizing them as research issues or in conceptualizing an issue into the components of the research process. High turnover also diminishes the time required to establish needed linkages with colleagues for consultation, collaboration, and participation in the research process. Therefore, clinical staff and directors who have remained in their positions for a period of time can play a crucial role in identifying meaningful clinical research problems. This skill is of paramount importance. Long-term care experience provides opportunities to observe clinical phenomena that might not be readily noted by transient visiting professionals.
Inadequate Resources; Personnel, Finances, Materials
Funding patterns for nursing homes may result in a scarcity of both professional and auxiliary personnel. This results in an overburdening of staff that further reduces the time and energy available for research. Nursing homes are less likely than universities and hospitals to have either personnel and/or monies budgeted for research. There is also less ready access to computers or data processing machines and equipment for inexpensively preparing questionnaires and forms. Research assistants, grant experts, and large libraries are often not readily available in nursing home settings.
Very few nursing homes have 250-300 beds, a common size of many hospitals. Small facilities create problems for research by decreasing the number of available subjects required for sound studies. While the case method is a useful research approach, large samples are required so that significant findings can be generalized to other populations and to reduce the effects of chance findings.
Proposed Solutions to the Problems Identified
The problems of inadequate time for conducting research and small facilities can be alleviated by the formation of a research group comprised of professional nurses from several nursing homes or other practice settings, such as community health centers, acute care hospitals, or state psychiatric hospitals. This provides a sharing of expertises, division of labor among the various steps of the research process, and access to more subjects. Increasing the sample size facilitates qualitative research while the division of labor should increase the palatability of conducting research.
To locate nurses interested in joint research projects, one can utilize already established contacts with other gerontological nurses. Meetings sponsored by nursing associations, particularly those with special interest groups in gerontology, nursing home associations, or state health departments are also useful in identifying interested colleagues. The proximity of facilities should be considered as this influences the travel time requirements when joint meetings are held.
One should not overlook the opportunity of utilizing other health professionals such as pharmacists or audiologists when specialized research projects are contemplated. Interdiscipinary research in and of itself has numerous benefits. However, it should be noted that the use of subjects at facilities other than your own can present a constraint. In some facilities, formal ethics committees exist that review all research projects before their implementation. The committee's meeting schedule should be incorporated into your study's timetable. It is also useful to allow for extra time in case the proposal is rejected and additional time is needed for the recruitment of subjects elsewhere. In nursing homes, similar but often less formal review structures may exist. The astute researcher takes the time consuming process of these committees and processes into account.
The need for greater educational preparation in research and statistics might be partially offset by forming a research team in which at least one member has a master's or doctoral degree. Since the majority of the individuals with advanced degrees are employed within university settings, initial contacts should begin there. University linkages not only provide the potential of individuals with research and statistical expertise but also facilitate access to support systems such as large libraries and computers. Because some nurses in educational settings may have either little time or interest in research or gerontological research, your approaches might be met with negative replies. Beware of discouragement and continue your efforts to locate interested individuals in other departments or other facilities.
This is an essential ingredient of the research process and it is particularly useful for two or three nurses conducting research who do not publish their findings and minimize the value of their efforts. Numerous articles exist4'6 that discuss writing skills and books that are available from public and professional libraries to assist the novice. Continuing education courses in scientific writing are also helpful. Independent study with a review of the literature provides the potential researcher with information of which problems have been studied, those that need replication, or those where research is absent. An important part of research is developing priorities and this has been done by several groups.2'3 One nationwide survey reported research in the care of the aged ranked in the top 10% with the item "find means of enhancing the quality of life for the aged in institutions"3 ranking third. Often the most difficult barrier to overcome is the lack of resources. Funds are essential to systematically pursue research goals. Independent study is useful in reviewing literature on the criteria for grant writing7-9 and free booklets are available. *t A knowledge of the research priorities is useful. Many publications on sources of grant monies10"12 exist and can facilitate your search for funding.
Ethical Concerns in Nursing Research
The ethics of nursing research have been comprehensively presented by Armiger13 in her now classic article. Adherence to a few basic principles aids the protection of both facility's and patients' rights. The protection of rights is not the responsibility of a single individual. All who are involved with the patient, directly or indirectly, must be vigilent. The director of nursing in a nursing home holds a key role in the protection of patients' rights because of the leadership position held. I recommend that the director assume a moderate position between the extremes of "paternalism" and overprotectiveness versus a "laissez-faire" approach to patients' rights. Directors, as well as participating staff, should assert their right to full knowledge concerning the methodology of the study conducted by visitors from other facilities.
There are a number of activities the nurse can pursue to increase the personal knowledge of patients' rights:
1. Determine if any BUL· of Rights exist within your state. This is particularly important if a Bill of Rights has been promulgated as state law.J Survey the documents carefully to assess if they address research. Utilize the appropriate guidelines into your protocol. These bills may originate from a variety of groups such as nursing organizations (ie, The National League for Nursing's statement),** State Health Departments, private groups, or nursing home organizations (See Figure 1).
2. Have a clear understanding of the purpose, methodology, and ethical guidelines used in the research projects proposed by individuals from within and without your facility. Nurses must not tolerate vague replies from researchers and should not accept no as an answer to the demand for information. It is the right and obligation of every nurse to be fully informed of the research project and its implication for patient welfare. Only informed nurses can protect their patients' rights.
3. Review the guidelines established by the American Nurses' Association Commission on Nursing Research.1†† This booklet deals with the rights of staff who may be asked to participate in research, the rights of patients to privacy and anonymity, freedom from physical or emotional or social injury, in addition to the role of informed consent and mechanisms to protect the rights of individuals. It is a most useful resource tool.
POSSIBLE FORCES PROTECTING PATIENTS' RIGHTS THAT THE DIRECTOR OF NURSING MIGHT RELATE TO REGARDING CLINICAL RESEARCH ACTIVITIES.
4. Identify the decision-making body in the facility that decides upon the conduct of research. Decisions on research proposals may reside with a single individual such as the administrator or director of nursing or with a group such as an ethical board or patient/resident committee. Directors should consider forming an ethics committee in their facility to provide for more objectivity and a broader approach to deciding on research proposals. Nursing home residents may sit on research councils but there are limitations to comment on the technical aspects of the research. Even if patients are not on decision making committees regarding the conduct of research in the facility, their rights are still protected because ethical research always permits the patients to refuse to participate or to drop out of the study regardless of whether an administrator, director, ethics committee, or patients' committee has approved the project.
5. Communicate with the researcher. Request additional information that is needed to make a decision and communicate the need to appear before a research committee and the time framework for decision making.
6. Determine if the patient has received informed consent. Sample consent forms14 have been published. The subject is complex and must be assessed by both the researcher and the facility.15 Nurses are often highly influential in influencing the behavior of patients and should assess their overt and covert behavior as well as environmental factors that might pressure patients to participate in research studies.
The director of nursing plays a key role in facilitating clinical research and in protecting patients' rights. She/he also serves as a role model and a motivator to the staff to participate in research.16 Directors should include some nursing research findings in staff development classes. The feasibility of including the research role in job descriptions should be considered. Issues and obstacles to research have been identified17-19 and if anticipated, will facilitate clinical research studies. If research seems overwhelming and the obstacles too burdensome, it is useful to remember that it is better to start off with a small study than not to start at all. Participation in small studies will prepare the nurse for greater studies in the future.20 Cumulative experiences in clinical research help the skills of the researcher. And it is only through more clinical studies in nursing that we will acquire the data necessary to improve the quality of patient care and to justify the importance of such care delivery.
- 1. American Nurses' Association: Human rights guidelines for nurses in clinical and other research. Kansas City, 1975.
- 2. American Nurses' Association: Priorities for research in nursing. Kansas City. 1976.
- 3. Western Interstate Commission for Higher Education: Delphi survey of priorities in clinical nursing research. Boulder, Colorado, 1974.
- 4. Burkhalter P: So you want to write. Supervisor Nurs 7(6):54-56, 1976.
- 5. Carnegie ME: Editorial - the referee system. Nurs Res 24(4):243, 1975.
- 6. Lewis EP: Editorial- the term paper. Nurs Outlook 25(11):691. 1977.
- 7. Masterman I.E: On writing federal grant applications. J Ment Health Admin 3(2):17-30. 1974-1975.
- 8. Merrill D: Grantsmanship: An exercise in lucid presentation. Clin Res 11(4):375-377. 1963.
- 9. Allen EM: Why are research grant applications disapproved? Science 132 (3439):1532-1534, 1960.
- 10. Western Interstate Commission for Higher Education: Private monies for nursing research. Boulder, Colorado, 1975.
- 11. Western Interstate Commission for Higher Education: Funding resources for research in the health sciences. Boulder, Colorado, 1975.
- 12. Health Funds Institute: The health funds directory, vol 1 - Research; vol 2 - Education and planning: vol 3 - Facility improvement and equipment; vol 4 - Miscellaneous, 355 Western Avenue, Boston 02135.
- 13. Armiger B: Ethics of nursing research: Profile, principles, perspectives. Nurs Res 26(5):330-336. 1977.
- 14. Thigpen LW: Guidelines for Research in Clinical Nursing. New York, The National League for Nursing. League Exchange No. 81, 1967.
- 15. Freedman B: A moral theory of informed consent. Hastings Center Report 5(4):32-39. 1975.
- 16. Davis BA: The nursing director and patient care research in nursing homes. J Nurs Admin 4:26-27, March-April 1974.
- 17. Martinson IM: Nursing research: Obstacles and challenges. IMAGE8 (1):3-5. 1976.
- 18. O'Connell KA: Research in nursing practice: Its nature and direction. IMAGE 8(1):6-I2, 1976.
- 19. Wilcox R. Gerber RM. DeWalt E: Clinical research in nursing homes. Nurs Outlook 25(4):255-257. 1977.
- 20. Schwartz DR: The value ol small local nursing studies. Am J Nurs 66:1327-1329. June 1966.