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Bashir Y, Conlon KC. Step by step guide to do a systematic review and meta-analysis for medical professionals. Ir J Med Sci. 2018; 187:(2)447-452 https://doi.org/10.1007/s11845-017-1663-3

Bettany-Saltikov J. How to do a systematic literature review in nursing: a step-by-step guide.Maidenhead: Open University Press; 2012

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Carrying out systematic literature reviews: an introduction

Alan Davies

Lecturer in Health Data Science, School of Health Sciences, University of Manchester, Manchester

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Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making.

Since their inception in the late 1970s, systematic reviews have gained influence in the health professions ( Hanley and Cutts, 2013 ). Systematic reviews and meta-analyses are considered to be the most credible and authoritative sources of evidence available ( Cognetti et al, 2015 ) and are regarded as the pinnacle of evidence in the various ‘hierarchies of evidence’. Reviews published in the Cochrane Library ( https://www.cochranelibrary.com) are widely considered to be the ‘gold’ standard. Since Guyatt et al (1995) presented a users' guide to medical literature for the Evidence-Based Medicine Working Group, various hierarchies of evidence have been proposed. Figure 1 illustrates an example.

Systematic reviews can be qualitative or quantitative. One of the criticisms levelled at hierarchies such as these is that qualitative research is often positioned towards or even is at the bottom of the pyramid, thus implying that it is of little evidential value. This may be because of traditional issues concerning the quality of some qualitative work, although it is now widely recognised that both quantitative and qualitative research methodologies have a valuable part to play in answering research questions, which is reflected by the National Institute for Health and Care Excellence (NICE) information concerning methods for developing public health guidance. The NICE (2012) guidance highlights how both qualitative and quantitative study designs can be used to answer different research questions. In a revised version of the hierarchy-of-evidence pyramid, the systematic review is considered as the lens through which the evidence is viewed, rather than being at the top of the pyramid ( Murad et al, 2016 ).

Both quantitative and qualitative research methodologies are sometimes combined in a single review. According to the Cochrane review handbook ( Higgins and Green, 2011 ), regardless of type, reviews should contain certain features, including:

• Clearly stated objectives
• Predefined eligibility criteria for inclusion or exclusion of studies in the review
• A reproducible and clearly stated methodology
• Validity assessment of included studies (eg quality, risk, bias etc).

The main stages of carrying out a systematic review are summarised in Box 1 .

Formulating the research question

Before undertaking a systemic review, a research question should first be formulated ( Bashir and Conlon, 2018 ). There are a number of tools/frameworks ( Table 1 ) to support this process, including the PICO/PICOS, PEO and SPIDER criteria ( Bowers et al, 2011 ). These frameworks are designed to help break down the question into relevant subcomponents and map them to concepts, in order to derive a formalised search criterion ( Methley et al, 2014 ). This stage is essential for finding literature relevant to the question ( Jahan et al, 2016 ).

It is advisable to first check that the review you plan to carry out has not already been undertaken. You can optionally register your review with an international register of prospective reviews called PROSPERO, although this is not essential for publication. This is done to help you and others to locate work and see what reviews have already been carried out in the same area. It also prevents needless duplication and instead encourages building on existing work ( Bashir and Conlon, 2018 ).

A study ( Methley et al, 2014 ) that compared PICO, PICOS and SPIDER in relation to sensitivity and specificity recommended that the PICO tool be used for a comprehensive search and the PICOS tool when time/resources are limited.

The use of the SPIDER tool was not recommended due to the risk of missing relevant papers. It was, however, found to increase specificity.

These tools/frameworks can help those carrying out reviews to structure research questions and define key concepts in order to efficiently identify relevant literature and summarise the main objective of the review ( Jahan et al, 2016 ). A possible research question could be: Is paracetamol of benefit to people who have just had an operation? The following examples highlight how using a framework may help to refine the question:

• What form of paracetamol? (eg, oral/intravenous/suppository)
• Is the dosage important?
• What is the patient population? (eg, children, adults, Europeans)
• What type of operation? (eg, tonsillectomy, appendectomy)
• What does benefit mean? (eg, reduce post-operative pyrexia, analgesia).

An example of a more refined research question could be: Is oral paracetamol effective in reducing pain following cardiac surgery for adult patients? A number of concepts for each element will need to be specified. There will also be a number of synonyms for these concepts ( Table 2 ).

Table 2 shows an example of concepts used to define a search strategy using the PICO statement. It is easy to see even with this dummy example that there are many concepts that require mapping and much thought required to capture ‘good’ search criteria. Consideration should be given to the various terms to describe the heart, such as cardiac, cardiothoracic, myocardial, myocardium, etc, and the different names used for drugs, such as the equivalent name used for paracetamol in other countries and regions, as well as the various brand names. Defining good search criteria is an important skill that requires a lot of practice. A high-quality review gives details of the search criteria that enables the reader to understand how the authors came up with the criteria. A specific, well-defined search criterion also aids in the reproducibility of a review.

Search criteria

Before the search for papers and other documents can begin it is important to explicitly define the eligibility criteria to determine whether a source is relevant to the review ( Hanley and Cutts, 2013 ). There are a number of database sources that are searched for medical/health literature including those shown in Table 3 .

The various databases can be searched using common Boolean operators to combine or exclude search terms (ie AND, OR, NOT) ( Figure 2 ).

Although most literature databases use similar operators, it is necessary to view the individual database guides, because there are key differences between some of them. Table 4 details some of the common operators and wildcards used in the databases for searching. When developing a search criteria, it is a good idea to check concepts against synonyms, as well as abbreviations, acronyms and plural and singular variations ( Cognetti et al, 2015 ). Reading some key papers in the area and paying attention to the key words they use and other terms used in the abstract, and looking through the reference lists/bibliographies of papers, can also help to ensure that you incorporate relevant terms. Medical Subject Headings (MeSH) that are used by the National Library of Medicine (NLM) ( https://www.nlm.nih.gov/mesh/meshhome.html) to provide hierarchical biomedical index terms for NLM databases (Medline and PubMed) should also be explored and included in relevant search strategies.

Searching the ‘grey literature’ is also an important factor in reducing publication bias. It is often the case that only studies with positive results and statistical significance are published. This creates a certain bias inherent in the published literature. This bias can, to some degree, be mitigated by the inclusion of results from the so-called grey literature, including unpublished work, abstracts, conference proceedings and PhD theses ( Higgins and Green, 2011 ; Bettany-Saltikov, 2012 ; Cognetti et al, 2015 ). Biases in a systematic review can lead to overestimating or underestimating the results ( Jahan et al, 2016 ).

An example search strategy from a published review looking at web use for the appraisal of physical health conditions can be seen in Box 2 . High-quality reviews usually detail which databases were searched and the number of items retrieved from each.

A balance between high recall and high precision is often required in order to produce the best results. An oversensitive search, or one prone to including too much noise, can mean missing important studies or producing too many search results ( Cognetti et al, 2015 ). Following a search, the exported citations can be added to citation management software (such as Mendeley or Endnote) and duplicates removed.

Title and abstract screening

Initial screening begins with the title and abstracts of articles being read and included or excluded from the review based on their relevance. This is usually carried out by at least two researchers to reduce bias ( Bashir and Conlon, 2018 ). After screening any discrepancies in agreement should be resolved by discussion, or by an additional researcher casting the deciding vote ( Bashir and Conlon, 2018 ). Statistics for inter-rater reliability exist and can be reported, such as percentage of agreement or Cohen's kappa ( Box 3 ) for two reviewers and Fleiss' kappa for more than two reviewers. Agreement can depend on the background and knowledge of the researchers and the clarity of the inclusion and exclusion criteria. This highlights the importance of providing clear, well-defined criteria for inclusion that are easy for other researchers to follow.

Full-text review

Following title and abstract screening, the remaining articles/sources are screened in the same way, but this time the full texts are read in their entirety and included or excluded based on their relevance. Reasons for exclusion are usually recorded and reported. Extraction of the specific details of the studies can begin once the final set of papers is determined.

Data extraction

At this stage, the full-text papers are read and compared against the inclusion criteria of the review. Data extraction sheets are forms that are created to extract specific data about a study (12 Jahan et al, 2016 ) and ensure that data are extracted in a uniform and structured manner. Extraction sheets can differ between quantitative and qualitative reviews. For quantitative reviews they normally include details of the study's population, design, sample size, intervention, comparisons and outcomes ( Bettany-Saltikov, 2012 ; Mueller et al, 2017 ).

Quality appraisal

The quality of the studies used in the review should also be appraised. Caldwell et al (2005) discussed the need for a health research evaluation framework that could be used to evaluate both qualitative and quantitative work. The framework produced uses features common to both research methodologies, as well as those that differ ( Caldwell et al, 2005 ; Dixon-Woods et al, 2006 ). Figure 3 details the research critique framework. Other quality appraisal methods do exist, such as those presented in Box 4 . Quality appraisal can also be used to weight the evidence from studies. For example, more emphasis can be placed on the results of large randomised controlled trials (RCT) than one with a small sample size. The quality of a review can also be used as a factor for exclusion and can be specified in inclusion/exclusion criteria. Quality appraisal is an important step that needs to be undertaken before conclusions about the body of evidence can be made ( Sambunjak and Franic, 2012 ). It is also important to note that there is a difference between the quality of the research carried out in the studies and the quality of how those studies were reported ( Sambunjak and Franic, 2012 ).

The quality appraisal is different for qualitative and quantitative studies. With quantitative studies this usually focuses on their internal and external validity, such as how well the study has been designed and analysed, and the generalisability of its findings. Qualitative work, on the other hand, is often evaluated in terms of trustworthiness and authenticity, as well as how transferable the findings may be ( Bettany-Saltikov, 2012 ; Bashir and Conlon, 2018 ; Siddaway et al, 2019 ).

Reporting a review (the PRISMA statement)

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides a reporting structure for systematic reviews/meta-analysis, and consists of a checklist and diagram ( Figure 4 ). The stages of identifying potential papers/sources, screening by title and abstract, determining eligibility and final inclusion are detailed with the number of articles included/excluded at each stage. PRISMA diagrams are often included in systematic reviews to detail the number of papers included at each of the four main stages (identification, screening, eligibility and inclusion) of the review.

Data synthesis

The combined results of the screened studies can be analysed qualitatively by grouping them together under themes and subthemes, often referred to as meta-synthesis or meta-ethnography ( Siddaway et al, 2019 ). Sometimes this is not done and a summary of the literature found is presented instead. When the findings are synthesised, they are usually grouped into themes that were derived by noting commonality among the studies included. Inductive (bottom-up) thematic analysis is frequently used for such purposes and works by identifying themes (essentially repeating patterns) in the data, and can include a set of higher-level and related subthemes (Braun and Clarke, 2012). Thomas and Harden (2008) provide examples of the use of thematic synthesis in systematic reviews, and there is an excellent introduction to thematic analysis by Braun and Clarke (2012).

The results of the review should contain details on the search strategy used (including search terms), the databases searched (and the number of items retrieved), summaries of the studies included and an overall synthesis of the results ( Bettany-Saltikov, 2012 ). Finally, conclusions should be made about the results and the limitations of the studies included ( Jahan et al, 2016 ). Another method for synthesising data in a systematic review is a meta-analysis.

Limitations of systematic reviews

Apart from the many advantages and benefits to carrying out systematic reviews highlighted throughout this article, there remain a number of disadvantages. These include the fact that not all stages of the review process are followed rigorously or even at all in some cases. This can lead to poor quality reviews that are difficult or impossible to replicate. There also exist some barriers to the use of evidence produced by reviews, including ( Wallace et al, 2012 ):

• Lack of awareness and familiarity with reviews
• Lack of access
• Lack of direct usefulness/applicability.

Meta-analysis

When the methods used and the analysis are similar or the same, such as in some RCTs, the results can be synthesised using a statistical approach called meta-analysis and presented using summary visualisations such as forest plots (or blobbograms) ( Figure 5 ). This can be done only if the results can be combined in a meaningful way.

Meta-analysis can be carried out using common statistical and data science software, such as the cross-platform ‘R’ ( https://www.r-project.org), or by using standalone software, such as Review Manager (RevMan) produced by the Cochrane community ( https://tinyurl.com/revman-5), which is currently developing a cross-platform version RevMan Web.

Carrying out a systematic review is a time-consuming process, that on average takes between 6 and 18 months and requires skill from those involved. Ideally, several reviewers will work on a review to reduce bias. Experts such as librarians should be consulted and included where possible in review teams to leverage their expertise.

Systematic reviews should present the state of the art (most recent/up-to-date developments) concerning a specific topic and aim to be systematic and reproducible. Reproducibility is aided by transparent reporting of the various stages of a review using reporting frameworks such as PRISMA for standardisation. A high-quality review should present a summary of a specific topic to a high standard upon which other professionals can base subsequent care decisions that increase the quality of evidence-based clinical practice.

• Systematic reviews remain one of the most trusted sources of high-quality information from which to make clinical decisions
• Understanding the components of a review will help practitioners to better assess their quality
• Many formal frameworks exist to help structure and report reviews, the use of which is recommended for reproducibility
• Experts such as librarians can be included in the review team to help with the review process and improve its quality

CPD reflective questions

• Where should high-quality qualitative research sit regarding the hierarchies of evidence?
• What background and expertise should those conducting a systematic review have, and who should ideally be included in the team?
• Consider to what extent inter-rater agreement is important in the screening process

Nursing research in heart failure care: a position statement of the american association of heart failure nurses (AAHFN)

Affiliations.

• 1 School of Nursing University of North Carolina at Greensboro, 218 Moore Building, P.O. Box 26170, Greensboro, NC 27420, USA. Electronic address: [email protected].
• 2 Heart Failure Disease Management Program, Memorial Medical Center & Clinical Associate Professor, University of Illinois at Chicago, Chicago, IL, USA.
• 3 William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA.
• 4 Department of Nursing, Linkoping University, Linkoping, Sweden.
• 5 School of Nursing, Vanderbilt University, Nashville, TN, USA.
• 6 Cleveland Clinic Health System, Cleveland, USA.
• PMID: 29397988
• DOI: 10.1016/j.hrtlng.2018.01.003

Background: Heart Failure (HF) is a public health problem globally affecting approximately 6 million in the United States.

Objectives: A tailored position statement was developed by the American Association of Heart Failure Nurses (AAHFN) and their Research Consortium to assist researchers, funding institutions and policymakers with improving HF clinical advancements and outcomes.

Methods: A comprehensive review was conducted using multiple search terms in various combinations to describe gaps in HF nursing science. Based on gaps described in the literature, the AAHFN made recommendations for future areas of research in HF.

Results: Nursing has made positive contributions through disease management interventions, however, quality, rigorous research is needed to improve the lives of patients and families while advancing nursing science.

Conclusions: Advancing HF science is critical to managing and improving patient outcomes while promoting the nursing profession. Based on this review, the AAHFN is putting forth a call to action for research designs that promote validity, sustainability, and funding of future nursing research.

Keywords: Evidenced-based practice; Heart failure research; Nursing interventions; Nursing research, heart failure; Patient outcomes.

Copyright © 2018 Elsevier Inc. All rights reserved.

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• Heart Failure / nursing*
• Heart Failure / therapy
• Nursing Research*
• Nursing Staff, Hospital / education*
• Patient Education as Topic*
• Prospective Studies
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Research education and training for nurses and allied health professionals: a systematic scoping review

Olivia king, kristen glenister, claire quilliam, anna wong shee, hannah beks.

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Corresponding author.

Received 2021 Oct 14; Accepted 2022 Apr 22; Collection date 2022.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Research capacity building (RCB) initiatives have gained steady momentum in health settings across the globe to reduce the gap between research evidence and health practice and policy. RCB strategies are typically multidimensional, comprising several initiatives targeted at different levels within health organisations. Research education and training is a mainstay strategy targeted at the individual level and yet, the evidence for research education in health settings is unclear. This review scopes the literature on research education programs for nurses and allied health professionals, delivered and evaluated in healthcare settings in high-income countries.

The review was conducted systematically in accordance with the Joanna Briggs Institute scoping review methodology. Eleven academic databases and numerous grey literature platforms were searched. Data were extracted from the included full texts in accordance with the aims of the scoping review. A narrative approach was used to synthesise findings. Program characteristics, approaches to program evaluation and the outcomes reported were extracted and summarised.

Database searches for peer-reviewed and grey literature yielded 12,457 unique records. Following abstract and title screening, 207 full texts were reviewed. Of these, 60 records were included. Nine additional records were identified on forward and backward citation searching for the included records, resulting in a total of 69 papers describing 68 research education programs.

Research education programs were implemented in fourteen different high-income countries over five decades. Programs were multifaceted, often encompassed experiential learning, with half including a mentoring component. Outcome measures largely reflected lower levels of Barr and colleagues’ modified Kirkpatrick educational outcomes typology (e.g., satisfaction, improved research knowledge and confidence), with few evaluated objectively using traditional research milestones (e.g., protocol completion, manuscript preparation, poster, conference presentation). Few programs were evaluated using organisational and practice outcomes. Overall, evaluation methods were poorly described.

Research education remains a key strategy to build research capacity for nurses and allied health professionals working in healthcare settings. Evaluation of research education programs needs to be rigorous and, although targeted at the individual, must consider longer-term and broader organisation-level outcomes and impacts. Examining this is critical to improving clinician-led health research and the translation of research into clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-022-03406-7.

Keywords: Research education, Research capacity building, Evidence-based practice, Health settings

Introduction

The translation of research evidence into health practice and policy relies on healthcare organisations and systems having sufficient research capacity and capability [ 1 – 3 ]. Health organisation executives and policymakers globally, recognise the need to invest in research capacity building (RCB) initiatives and interventions that are delivered in healthcare settings [ 2 – 4 ]. RCB strategies encompass a range of initiatives designed to promote individual, team and organisation research skills, competence and to influence attitudes towards research [ 2 , 5 – 7 ]. Initiatives designed to build individual and organisational research capacity may include education and training programs, funding for embedded researchers (e.g., fellowships, scholarships) and other research support roles (e.g., research librarians, knowledge-brokers), strategic collaborations with academic partners and developing research infrastructure [ 2 , 6 , 8 ]. RCB strategies often comprise a combination of the aforementioned approaches [ 8 ] and notably, research education and training programs are a sustaining feature of many [ 2 , 3 , 6 , 8 – 11 ]. This is likely related to the insufficient coverage of research in undergraduate health curricula and the need for supplementary education to fill research knowledge and skill gaps, particularly for non-medically trained healthcare professionals. Medically trained healthcare professionals typically have a greater inclination toward and engagement in research than their nurse and allied health counterparts [ 4 , 8 , 12 , 13 ]. Given that nursing and allied health form the majority of the health workforce [ 14 , 15 ], there is increasing interest in RCB strategies that target nurses and allied health professionals to enhance the delivery of evidence-informed care across all healthcare settings and services [ 8 , 16 – 18 ]. Allied health comprises a range of autonomous healthcare professions including physiotherapy, social work, podiatry, and occupational therapy [ 16 ].

This review was commissioned by an academic health science centre in Australia, to inform the research education and training component of its health organisation RCB strategy. Given the typically multidimensional nature of RCB strategies, their functions and impacts at the various levels are inextricably related [ 2 , 5 ]. This makes the discernment between research education and training interventions and other elements of strategies a fraught endeavour. For example, embedded researchers may form part of a broader organisational RCB strategy, and in the scope of their work, may perform an ad hoc education function (e.g., through their interactions with novice researchers) [ 11 , 19 ]. Aligning with the purpose of this work, this review defines research education and training programs as organised initiatives or interventions that are either discrete (e.g., standalone workshops or research days) or longer in their duration (e.g., research courses or a series of workshops or lectures) wherein curriculum is developed and shared with multiple individuals or participants, with a view to develop and apply research skills [ 2 , 5 ]. Healthcare settings are considered those wherein the provision of healthcare is considered core business (e.g., hospitals, community-based health services, cancer care services, family medicine clinics) and is therefore the setting in which research evidence needs to be applied or translated to reduce the gap between research knowledge and practice [ 2 , 20 ].

An initial search of Cochrane Database of Systematic Reviews, Joanna Briggs Institute’s Evidence Synthesis, PROSPERO, and Google Scholar for reviews of research education and training programs delivered in health settings, yielded no existing or planned reviews. On further cursory review of the RCB and research education literature, and concomitant discussions with four content experts (i.e., educators, academic and clinician researchers concerned with research capacity building), it became apparent that research education programs take different forms, occur in pockets within health organisations across health districts and regions, are not always formally evaluated, and often fail to account for adult learning principles and theories. The decision to conduct a scoping review, rather than a conventional systematic review, was based on three key factors: 1) the heterogeneity evident in research education program characteristics; 2) the absence of an existing synthesis of evidence for research education programs delivered in health settings [ 5 ]; and 3) the need to identify the gaps in knowledge about these programs.

This systematic scoping review sought to scope the research education and training programs delivered to nurses and allied health professionals working in health settings and the evidence supporting these approaches. The specific review objectives were to describe the:

Types of research education programs delivered in health settings in high-income countries

Theoretical or pedagogical principles that underly the programs

Approaches to research education program evaluation

Types of outcomes reported

This review used the Joanna Briggs Institute’s (JBI) scoping review methodology. As per the JBI methodology, search terms were developed for Population, Concept and Context (PCC). The review question, objectives, inclusion/exclusion criteria and search strategies were developed and documented in advance (Additional File  1 Scoping Review Protocol). The review is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews (Additional File  2 PRISMA-ScR checklist [ 21 ]).

Search strategy

The researchers identified a set of key papers based on their knowledge of contemporary research education programs and in consultation with four content experts from two high-income countries. They used these papers to identify the key search terms. In consultation with the research librarians (SH and HS, see acknowledgements), the research team conducted preliminary scoping searches to test the search terms and strategy (between 3 March – 10 March 2022). These searches informed decisions about final search terms. A tailored search strategy was developed for each academic database (Additional file  3 Search Strategy).

Academic databases searched included PubMed, Ovid MEDLINE, Embase, CINAHL, VOCEDPlus, PEDro, Scopus, ERIC, Informit Health Database, JBI, and Google Scholar. Selected grey literature platforms as determined by our knowledge of relevant websites and organisations, were searched. Where larger search yields were observed (e.g., via Google and Google Scholar), the first 250 items were reviewed, only (Additional file  4 Grey literature search). The final research database searches were conducted between 12 and 15 March 2022 by a researcher with extensive systematic literature searching experience (Author 2) in consultation with a research librarian. Grey literature searches were conducted on 17 March 2022. Searches of the reference lists of included records and forward citation searches were undertaken.

Inclusion criteria and exclusion criteria

Literature was selected according to defined inclusion and exclusion criteria developed using the PCC framework (see Table  1 ). Research education or capacity building programs delivered to qualified health professionals, working in health settings (excluding programs delivered as part of tertiary study) in high-income countries (HIC) as defined by the Organisation for Economic Co-operation and Development (OECD), were included [ 22 ]. The decision to include studies published in HICs only was made with a view to introduce a level of homogeneity around the broader resource contexts of the study populations [ 23 , 24 ]. No date limits applied, and all types of literature published up to 17 March 2022 were included. Literature published in English only was included, due to resource limitations.

Inclusion and exclusion criteria

a Health professionals were not limited to those that are accredited or registered, but rather included any health worker that was situated in a healthcare setting

b Evaluation was considered if there was an informal or formal approach to measuring and describing the outcomes and/or impacts of the program, to determine whether it met its objectives

Study selection, quality appraisal and data extraction

Citations were imported into Covidence (Veritas Health Innovation, Melbourne, Australia) for screening. Titles and abstracts were independently screened by two reviewers initially, with conflicts resolved by a third (independent) reviewer. Similarly, full texts were reviewed by two researchers and the reasons for exclusion were noted (Additional file  5 Excluded studies). Data was extracted from the included texts by five researchers. Formal quality appraisal is not typically undertaken as part of scoping review methodology and was not undertaken for the papers included in this review [ 25 ].

Data extracted were tabulated and results were synthesized using a descriptive approach guided by the review objectives as per a scoping review methodology. Outcomes measured and reported in the papers were mapped to the modified Kirkpatrick’s educational outcomes typology [ 26 , 27 ]. Recognising the complex interactions between individuals, research education programs, organisational and other factors, and the various outcomes produced [ 2 ], the modified Kirkpatrick’s typology gives rise to the identification of outcome measures at multiple levels or within these inter-related domains [ 26 ].

Of the 207 citations considered for full text screening, 60 met the inclusion criteria and nine additional papers were located through a citation search of the initial set (Fig.  1 PRISMA Flow Diagram) [ 28 ].

PRISMA Flow Diagram

Research education program characteristics

When, where and to whom research education programs were delivered

A total of 69 papers, describing 68 research education and training programs were reviewed. The implementation of the programs spanned five decades, with almost half ( n =  33) implemented in the most recent decade. Research education programs were delivered in the United States of America ( n =  22), Australia ( n =  20), the United Kingdom ( n =  9), Canada ( n =  5), Denmark ( n =  2), Qatar ( n =  2), and one each in Argentina, Finland, Japan, Italy, Singapore, Sweden, Spain, and The Netherlands. The geographical distribution of programs by country is presented in Fig.  2 . Research education programs were targeted and delivered to different healthcare professional groups. Programs were delivered most frequently to nurses and midwives ( n =  35), then mixed professional groups ( n =  18), allied health ( n =  13), and pharmacists ( n =  2). The characteristics of included programs are provided in Table  2 .

Geographical distribution of research education programs. This image was generated by the authors via Microsoft Excel using the Map function

a PEAK program is described in [ 72 ] and the evaluation is reported in linked paper [ 102 ]

How research education programs were formatted and delivered

Research education programs were delivered in several different formats and over different types of durations. Some were delivered as standalone single study days, workshops or sessions [ 29 – 34 ], and others as a series of several short sessions or workshops [ 35 – 45 ]. The majority of papers described integrated research education courses of either a short duration, (i.e., one to 4 months) [ 46 – 65 ], medium duration (i.e., five to 11 months) [ 9 , 66 – 76 ], or longer-duration (i.e., 1 year or longer) [ 77 – 94 ].

Programs almost always included a didactic element (e.g., lectures, seminars), delivered by an experienced academic or clinician-researcher (researcher with a primary healthcare qualification; [ 95 ]) or an individual with content expertise (e.g., biostatistician [ 48 ], librarian [ 33 , 57 , 66 ], ethics committee member [ 57 ] or data manager [ 42 ]). Most of the programs were multifaceted and included a mix of didactic teaching as well as either group discussion, online teaching (e.g., teleconferences or modules), or the practical application of theoretical principles between education sessions. Several were described as single mode research education programs (e.g., seminars, lectures, or online modules only) [ 29 – 31 , 33 , 37 – 39 , 46 , 48 , 49 , 53 – 55 , 87 ]. Timing was described as an important consideration in several papers, with an emphasis on minimising impact on participants’ working day or clinical duties. For example, by holding sessions early (8 am) prior to the working day [ 9 , 51 ] or on weekends [ 32 , 63 , 71 ].

Features and content of research education programs

The curricula or research education content described in the papers reflected the aims of the programs. Program aims were broadly categorised according to the level of intended participants’ research engagement: research use or consumption ( n =  28) and research activity ( n =  31) [ 96 ]. Where the program content focused on searching, retrieving, and appraising research literature, and considering in the context of clinical practice (i.e., evidence-based practice), this was considered engagement at the research user or consumer level. Slightly more programs were concerned with developing research skills to engage in and conduct research activity. These programs included content related to research methods, data collection and analysis techniques, protocol development and ethics application [ 31 , 35 , 37 , 39 , 42 , 43 , 48 , 49 , 52 , 53 , 57 , 59 , 63 , 64 , 67 , 68 , 73 , 77 – 85 , 90 – 92 ]. Seven programs were orientated toward developing participants’ skills for research dissemination, typically writing for publication [ 9 , 32 , 33 , 47 , 51 , 74 ] or preparing research posters and seminars [ 88 ]. It was assumed that the participants in the programs concerned with writing for publication had already undertaken a research activity and needed further education and support to formally disseminate their findings. Two programs were specifically focused on developing participants’ skills to complete a systematic review [ 46 , 76 ]. Three programs included content directly related to implementing research in practice [ 60 , 80 , 86 ].

Fourteen programs required that participants had overt support from their manager to participate (e.g., written approval or direct selection of participants) [ 46 , 51 , 58 , 62 , 75 , 79 – 81 , 83 , 85 , 91 – 94 ]. Two papers described participants’ departments being actively supportive of their participation in the research education program [ 59 , 86 ]. One paper referred to managers’ positive role modelling by engaging in the research education program [ 39 ] and another described the criteria used to determine the suitability of participants based on their context (i.e., supportive managers who were interested in research and willing to release participating staff for half day each week) [ 88 ]. Five papers described manager or leadership support as being a key enabler to participants engaging in the education program [ 56 , 60 , 75 , 89 , 91 ] and four papers referred explicitly to the lack of organisational, managerial, or collegial support as key limitations to, or a negative influence on participants’ learning experience [ 49 , 77 , 84 , 88 ].

Nine papers described the integration of opportunities to acknowledge the achievements of program participants. Opportunities were described as formal events held at the conclusion of the program to celebrate the participants’ completion [ 58 , 66 , 80 , 83 ], recognition via staff communications or at an organisation-wide event [ 37 ], opening participants’ project presentations to a wider healthcare organisation audience [ 92 ], or by managers providing opportunities for participating staff to present their work to colleagues [ 81 , 82 ]. One program included the acknowledgment of contact hours for nurse participants to attain continuing professional development points for their professional registration [ 54 ] and another referred to participants’ “recognition and exposure” within and beyond their organisation, as a participant-reported benefit (46, e–145).

Theories and pedagogical principles

Understanding how people learn effectively is fundamental to the design of any educational program. Thus, the second aim of this review was to determine what pedagogies (teaching methods) were employed for adult learners undertaking research education and training. Few of the studies ( n =  13) included in this review explicitly stated which pedagogical strategies informed the design and delivery of the education programs. However, where possible we extracted pedagogical strategies that appear to be present (see Table 2 ).

Education programs generally included a mix of active and passive learning strategies. Active learning can be defined as an activity which engages students as participants in the learning process whereas with passive learning, students receive information from the instructor but have little active involvement [ 97 ]. Passive forms of learning or didactic approaches that were employed included seminars, lectures, reading, and exams. Five programs were described with respect to the didactic learning component only, with no reference or implication of any underlying pedagogy or learning theory [ 39 , 45 , 48 , 49 , 53 ].

Commonly, education programs included some form of experiential learning. Experiential learning, or “learning by doing” is a type of active learning whereby students apply knowledge to real-world situations and then reflect on the process and experience [ 98 ]. Examples of experiential learning described in the education programs include simulations, role-play, preparation of research protocols, grant proposals, manuscripts, and appraisal of research. Lack of experiential learning, or “practical experience”, was described as a limitation in one paper [ 38 ]. Quizzes were utilised in two programs [ 42 , 66 ] to reinforce participants’ learning.

Social cognitive theories of learning, such as self-efficacy theory [ 99 ], were explicitly mentioned in seven studies [ 31 , 47 , 54 , 56 , 61 , 71 , 72 ]. Self-efficacy theory posits that a person’s belief in their capabilities provide the foundation for performance and accomplishment. If a person has low self-efficacy (little belief in their capabilities) and fear related to the task at hand, they will likely avoid that task for fear of failure. Education programs using a self-efficacy framework focused on increasing participants self-efficacy through coaching, support, social modelling, and mastery experiences. Five studies referred to Roger’s Diffusion of Innovation theory [ 37 , 50 , 60 , 68 , 71 ], which posits that identifying and working with highly motivated individuals is an efficient way to promote the adoption of new behaviours and practices more widely [ 8 ].

Two studies were informed by the Advancing Research and Clinical practice through close Collaboration (ARCC) Model which is based on cognitive-behavioural theory and control theory, and therefore designed to address barriers to desired behaviours and practice [ 65 , 100 ]. Other programs described drew on the transtheoretical model of organisational change [ 62 ], Donald Ely’s conditions for change [ 37 ], the knowledge to action framework [ 52 ] and the Promoting Action on Research Implementation in Health Services (PARiHS) Framework [ 72 ].

Mentoring was a feature of more than half of the programs ( n =  37). This is where novice researchers were paired with an experienced researcher, typically to support their application and practice of the knowledge gleaned through their education or training [ 101 ]. In three papers describing programs that did not include mentoring, this was identified as a critical element for future research education programs [ 37 , 78 , 92 ]. Several evaluations of programs that included mentoring illustrated that it was required throughout the life of the program and beyond [ 9 , 32 , 67 , 68 , 73 , 81 , 84 ]. Harding et al. [ 46 ] found that mentors as well as mentees, benefited from the research education program, in terms of their own learning and motivation.

Social theories of learning, or collaborative learning approaches, were also frequently utilised ( n =  40). Collaborative learning approaches are based on the notion that learning is a social activity at its core, shaped by context and community. Such approaches promote socialisation and require learners to collaborate as a group to solve problems, complete tasks, or understand new concepts. Collaborative approaches utilised included journal clubs [ 38 , 50 , 54 , 69 , 70 , 87 ], writing groups [ 32 , 51 ], classroom discussions [ 33 , 36 , 72 , 76 , 80 , 94 ], interactive group workshops or activities [ 29 , 31 , 46 , 47 , 56 , 75 , 82 , 84 , 86 , 93 ], and development of team research projects [ 78 , 79 ]. These approaches were often reported to enhance cultural support with participants networking, sharing resources, and celebrating successes together. One program employed a self-guided learning approach through the use of computer-based learning modules [ 55 ].

Approaches to program evaluation

Less than half of the included papers accurately and comprehensively described the methodology and methods used to evaluate the research education program [ 9 , 30 , 38 , 46 , 54 – 56 , 60 – 63 , 65 , 69 – 71 , 75 , 77 , 79 , 82 , 84 – 86 , 89 , 100 , 102 ]. The remaining papers either referred to the data collection techniques used without describing the overarching approach or methodology. Therefore, in Table  3 rather than referring to the approach to program evaluation as quantitative, qualitative or mixed methods, reference is made to the data collection techniques (e.g., surveys, interviews, facilitator reflections, audit of research outputs).

Research education program evaluation and outcomes reported

Most programs were evaluated using surveys ( n =  51), some of these in combination with other outcome measures. More than half of the program evaluations ( n =  38) used pre- and post-intervention surveys. Other evaluation methods included interviews, focus groups, attendance rates, and outcomes audits (e.g., ethics applications, manuscripts submitted for peer review or published, grant applications, grants awarded, or adherence to evidence-based guidelines). Twelve evaluation studies included a control group [ 36 , 38 , 51 , 60 , 65 , 68 – 70 , 77 , 79 , 86 , 100 ]. Three evaluations were informal and did not explicitly draw on evaluation data but rather on general feedback, authors’ own reflections and observations, including observed research progress [ 35 , 37 , 94 ]. Evaluation of the longer-term outcomes were described in seven papers, where surveys were undertaken or outcomes were otherwise measured between one and 5 years after the programs were completed [ 44 , 51 , 76 , 84 , 85 , 89 , 93 ].

Outcomes measured and described

Program outcome measures were mapped to Barr et al.’s modified Kirkpatrick educational outcomes typology [ 27 ]. The typology categorises educational outcomes reported according to their level of impact. The outcomes levels range from individual learner-level outcomes through to the impact of educational program on their organisation and healthcare consumer outcomes. See Table  4 below for descriptions of the outcome levels and the corresponding citations.

Evaluation outcomes according to Barr et al.’s modified Kirkpatrick typology

Almost all program evaluations included a mix of outcome measure types or levels. In addition to the modified Kirkpatrick level outcomes, other types of outcomes and impacts were measured and reported. Program participant engagement was measured and reported with reference to interest and uptake, attendance, and drop-out rates in five evaluations [ 48 , 54 , 74 , 78 , 87 ]. Twelve program evaluations explored participants’ experiences or perspectives of barriers to engaging in research in their health setting [ 34 , 36 , 49 , 56 , 71 , 77 , 81 , 82 , 84 , 86 , 88 , 89 ] and four evaluations included program cost calculations [ 51 , 60 , 83 , 90 ]. One evaluation measured group cohesion, participant (nurse) productivity and nursing staff retention [ 100 ].

Programs that were evaluated over a longer period demonstrated a high success rate with respect to manuscript publication [ 34 , 51 , 76 ], longer term development of research skills, experience, and engagement [ 44 , 84 , 89 ], and highlighted the value of mentoring to participants’ enduring engagement with research and to their development of research confidence and leadership skills [ 84 ]. One evaluation study included administrative leaders [ 89 ], one included training participants’ managers [ 93 ], however none included senior executives or healthcare consumers.

To the authors’ knowledge, this is the first systematic scoping review of the research education literature. The findings of the review support existing evidence of the continued relevance of research education and training to RCB endeavours [ 2 , 16 ]. Indeed, research education appears to be a mainstay RCB strategy over the last five decades. This review sought to explore the features or characteristics of research education and training programs delivered to nurses and allied health professionals working in health settings in HICs, the pedagogical principles or learning theories underpinning the programs, how programs were evaluated, and the types of outcomes reported.

Common features and approaches to the delivery of research education were identified. Some common pedagogical features of research education programs: multifaceted delivery to allow for flexibility in engaging with the program and content [ 5 , 103 ], experiential learning [ 2 , 103 ] and social or collaborative learning principles [ 103 ]. These underpinning principles were implied more frequently than they were explicitly stated. The integration of mentoring to reinforce the knowledge gleaned through research education programs appears to be a critical element and a key component of contemporary research education and capacity building [ 2 , 3 , 104 ].

This review also highlights some differences in the programs, particularly in terms of duration, which varied from single sessions or workshops to three-year programs. The curricula or educational content tended to reflect the aims of the programs which mapped to two different levels of engagement with research: research use or consumption and research activity. Some programs were specifically focused on advanced research skills, namely writing for publication, which is a particularly challenging aspect of the research process for clinicians [ 7 , 51 ].

Findings indicate that organisational context and support are pivotal to the cultivation of and completion of research activity [ 2 , 6 , 7 , 49 , 77 , 84 , 88 , 105 ]. Although this review focused specifically on papers describing research education programs targeting individual-level research capacity, there were several organisation-related factors that were integrated into the programs. Middle or executive level manager support for program participants was evident in numerous papers either through explicit support or permission, or positive role modelling. This resonates with the findings of existing evidence related to organisational factors enabling research [ 7 , 106 , 107 ]. Schmidt and colleagues [ 106 ] have previously highlighted a lack of managerial support for research training participants and their projects, as a factor influencing withdrawal. Several programs incorporated events or other opportunities for participants to present their work or to be otherwise recognised [ 37 , 46 , 54 , 66 , 80 – 83 ]. This facilitated organisation-level acknowledgement and celebration of individuals’ research activity and achievement, reinforcing organisational support for research [ 2 ].

This scoping review highlights some evidence of the impact of research education beyond the individual participants, and on their colleagues and organisations more broadly. This broader impact can be attributed to participants actively sharing their new knowledge and skills with their colleagues and teams [ 108 ]. Roger’s Diffusion of Innovation Theory can also underpin RCB strategies that are targeted at the individual level and explain how and why they have a broader impact on organisational research capacity and culture [ 104 ].

Research education program outcome measures tend to reflect lower levels of Kirkpatrick’s modified typology, with comparatively few studies reporting organisation-level impacts and none reporting health consumer outcomes. Although it is recognised that measuring and demonstrating direct links between RCB initiatives and health consumer outcomes is difficult [ 109 ], RCB initiatives including research training typically aim to promote the delivery of evidence-informed care, which in turn improves health consumer outcomes [ 110 ]. Some program evaluations included self-reported measures by participants that did not engage in the research education program, providing for comparisons between groups. Senior and executive managers, and healthcare consumers, however, were not involved in any evaluations reported. This limits knowledge of the outcomes and impacts beyond the individual participant level. Moreover, the program evaluation methods were generally poorly described. This is somewhat paradoxical, given the subject matter, however it is not a problem unique to research education and capacity building. Indeed poor evaluation is a widespread problem evident in multiple key healthcare areas such as Aboriginal Health in Australia [ 111 ] supportive care services for vulnerable populations [ 112 ], and in continuing education for healthcare professionals [ 113 ]. Factors contributing to poor program evaluation likely include time constraints, inaccessible data, and inadequate evaluation capacity and skills, as described in other scoping reviews of health and health professions education programs [ 111 – 113 ].

Although it is encouraging to see broadening interest in RCB initiatives for the nursing and allied health professions including research education, investment in rigorous, carefully planned, broadly targeted and long-term evaluation is required. This will ensure that research education programs maximise the outcomes for individuals and organisations and the most crucial impact on health consumer outcomes can be measured.

Strengths and methodological limitations

The strengths of this scoping review are the adherence to an established and systematic approach and the wide and comprehensive search including 11 research databases, multiple grey literature databases and search engines. The methodological and content expertise within the research team, including expertise in scoping review, systematic review, realist review methodologies and research education and capacity building strategies strengthened the rigour of the review. Moreover, the consultation with content experts during the development of the search strategy ensured the review was well-informed and shaped to meet the needs of those concerned with RCB.

Nonetheless, this review is limited by several factors. Research education, training, and RCB more broadly are poorly defined concepts [ 2 ], as such, it is acknowledged that the search strategy was developed in such a way that it may not have resulted in the retrieval of all relevant literature. This is acceptable, given the scoping review aimed to provide an overview of the breadth and depth of the literature and used content expertise to balance the comprehensiveness of the review with the capacity to answer research questions [ 114 ]. It is, however, recommended that the findings of this review inform a more focused and systematic review of the literature.

It is well-established that research education and training alone, do not sufficiently influence research capacity and capability at an individual or organisational level [ 1 , 7 ]. Indeed, barriers to nurse and allied health-led research include time constraints, demanding clinical workloads, enduring workforce shortages, a lack of organisational support and research culture, funding, and inadequate research knowledge and skills, persist [ 7 , 12 , 39 , 47 , 115 ]. These factors were not analysed as part of the review. The explicit focus on research education meant that some RCB strategies with education as a component may have been missed.

The authorship team were situated in Australia, with limited knowledge of other, complementary search engines internationally and lacked the resources to execute extensive international grey literature searches. These limited grey literature searches introduce a level of publication bias. Publications in languages other than English were excluded for reasons related to feasibility and limited resourcing. Through engagement with content experts early in the review, it was noted that many education programs are not formally documented, evaluated, or published in peer-reviewed or grey literature and therefore not accessible to others outside the organisation. This means that the review of published literature may not entirely represent research education programs in health settings.

Research education is a cornerstone RCB strategy for nurses and allied health professionals working in health settings. Education is typically aimed at enhancing individual clinician-level RCB however, there is some evidence that the outcomes of individual-level research education can influence organisational research capacity and culture. Moreover, strategies targeted at the organisational level can be integrated into research education programs. Mentoring, experiential, and collaborative learning have gained recognition as key features of research education programs and facilitate the application of new knowledge and skills in practice. Evaluation continues to focus on lower levels of educational impact or traditional research outputs; there is need for greater attention to organisational culture, longer-term capacity building outcomes and health consumer impacts. Approaches to the evaluation of research education programs should incorporate the experiences and perspectives of managers, executives, health consumers and other stakeholders concerned with research capacity and the delivery of evidence-informed care. This will ensure that RCB strategies and initiatives with greater impact at the individual and organisational level can be supported and that the impact of such initiatives can be measured at the population health level.

Acknowledgements

The authors acknowledge and sincerely thank Sarah Hayman and Helen Skoglund, Research Librarians at Barwon Health for their invaluable contributions to developing the literature search strategy, conducting the scoping and initial literature searches and retrieval process. They also thank the expert panel for their invaluable contributions in shaping the review.

Authors’ information (optional)

Olivia King (PhD) is Manager of Research Capability Building for Western Alliance.

Emma West is a PhD scholarship holder and research assistant at Deakin University and Program Officer, Research Capability Building for Western Alliance.

Sarah Lee is a PhD candidate at the Monash Centre for Scholarship in Health Education at Monash University.

Kristen Glenister (PhD) is a Senior Research Fellow (Rural Chronic Ill Health) for the Department of Rural Health, University of Melbourne and funded by the Rural Health Multidisciplinary Training program (Australian Government).

Claire Quilliam (PhD) is a Rural Nursing and Allied Health Research Fellow at The University of Melbourne and funded by the Rural Health Multidisciplinary Training program (Australian Government).

Anna Wong Shee (PhD) is Associate Professor Allied Health at Grampians Health and Deakin University.

Hannah Beks (MPH) is an Associate Research Fellow with Deakin Rural Health and funded by the Rural Health Multidisciplinary Training program (Australian Government).

Abbreviations

Evidence based practice

Joanna Briggs Institute

High-income countries

Organisation for Economic Co-operation and Development

Population, Concept and Context

Preferred Reporting Items for Systematic reviews and Meta-Analyses

PRISMA extension for scoping reviews

Research capacity building

Randomised control trial

Authors’ contributions

The first three authors (OK, EW, SL) conceived the research idea. Five authors (OK, EW, SL, AWS, and HB) contributed to the title and abstract screening, and review of full texts. Five authors (OK, EW, SL, KG and CQ) contributed to the extraction of data from papers. The first author (OK) drafted the manuscript. The last author (HB) provided methodological expertise and guidance. All authors contributed to the development of the manuscript, read, and approved the final version.

The authors thank Western Alliance for funding the initial stages of this review and co-funding the publication of this paper with Deakin Rural Health.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate.

Barwon Health’s Research Ethics, Governance and Integrity Office conferred ethics approval for the engagement of the expert panel (Ref. 19/164). Written informed consent was obtained for all expert panel participants. All methods were conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Nursing: Evidence-Based Practice: Evidence Levels, Recommendations & Types

• PICO & PICo Questions
• Acquiring Evidence
• Databases & Research Resources
• Evidence Levels, Recommendations & Types
• Evidence Appraisal Resources
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EBP Process

1. Ask a clear clinical question

2. Acquire  best available evidence

3. Appraise  evidence for quality

4. Apply  evidence to practice

5. Assess  the outcomes

What are Levels of Evidence?

When you start researching you will encounter many different types of evidence such as systematic reviews, randomized controlled trials, clinical guidelines and opinion articles.  These different resources will not all have the same "weight" in terms of reliability and trustworthiness.  To assist you in determining what is the most reliable, the levels of evidence hierarchies will guide you.

Evidence Hierarchies are systems used to rank evidence according to certain criteria.  There are many hierarchies, including the examples on this page.

Hopp, L., & Rittenmeyer, L. (2012). Introduction to evidence-based practice: A practical guide for nursing . Philadelphia: F.A. Davis.

Levels of Evidence Tutorial

• UIC Evidence-Based Practice in the Health Sciences: Evidence-Based Nursing Tutorial Tutorial describing the levels of evidence. The Research Design section provides helpful definitions and information.

These resources provide additional information on the levels of evidence.

Grades of Recommendation

View grades of recommendations at the following links:

JBI Grades of Recommendation

Levels of Evidence Pyramid

This evidence pyramid provides a concept of higher to lower levels of evidence.

Source:  UIC Evidence Based Practice Tutorial, ebp.lib.uic.edu

JBI Levels of Evidence

The Joanna Briggs Institute adopted a new hierarchy for levels of evidence as of March 1, 2014.  The chart below outlines the levels of evidence for effectiveness questions.

The Joanna Briggs website contains levels of evidence charts for other types of questions.

Additional Definitions and Sample Articles

Definitons of research designs from Introduction to Evidence Based Practice:  A Practical Guide for Nursing by Lisa Hopp and Leslie Rittenme yer .

Case Controlled studies are where researchers conduct a comparison of cases with a particular outcome and cases without a particular outcome to evaluate the participants’ exposure.  

Case Series/Case Report  is a research design that track patients with a known exposure given similar treatment or examines their medical records for exposure and outcome.  

Cohort studies with a control group are those where a group of people with something in common (a cohort) are followed.   This group is compared to another group with similar characteristics/circumstances, with the exception of the factor being investigated.

Cross-sectional studies involve data collected at a defined time, providing a snapshot of a disease in the population (observational studies).

Meta-analysis uses statistical methods to pool the results of independent studies (quantitative).  Meta-synthesis is a qualitative analysis of a group of individual studies in which the finding of the studies are pooled.

Randomized Clinical Trial is an experiment using human beings in which the investigator randomly assigns participants in the trial either to a treatment or control (no treatment) group.

Systematic Reviews attempt to synthesize and summarize evidence from existing primary studies. They use explicit and transparent methods to include/exclude studies on a topic, and rigorously analyze the results to form a conclusion.

• Example of Case Control Study
• Example of Case Report
• Example of Case Series
• Example of Cohort Study
• Example of Cross-Sectional Study
• Example of Randomized Controlled Trial
• Example of a Systematic Review
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The Future of Nursing: Leading Change, Advancing Health (2011)

Chapter: 7 recommendations and research priorities, 7 recommendations and research priorities.

Reflecting the charge to the committee, the purpose of this report is to consider reconceptualized roles for nurses, ways in which nursing education system can be designed to educate nurses who can meet evolving health care demands, the role of nurses in creating innovative solutions for health care delivery, and ways to attract and retain well-prepared nurses in a variety of settings. The report comes at a time of opportunity in health care resulting from the passage of the Affordable Care Act (ACA), which will provide access to care for an additional 32 million Americans. In the preceding chapters, the committee has described both barriers and opportunities in nursing practice, education, and leadership. It has also discussed the workforce data needed to guide policy and workforce planning with respect to the numbers, types, and mix of professionals that will be required in an evolving health care environment.

The primary objective of the committee in fulfilling its charge was to define a blueprint for action that includes recommendations for changes in public and institutional policies at the national, state, and local levels. This concluding chapter presents the results of that effort. The committee’s recommendations are focused on maximizing the full potential and vital role of nurses in designing and implementing a more effective and efficient health care system, as envisioned by the committee in Chapter 1 . The changes recommended by the committee are intended to advance the nursing profession in ways that will ensure that nurses are educated and prepared to meet the current and future demands of the health care system and those it serves.

This chapter first provides some context for the development of the committee’s recommendations. It details what the committee considered to be its scope and focus, the nature of the evidence that supports its recommendations,

cost considerations associated with the recommendations, and how the recommendations might be implemented. The chapter then presents recommendations for nursing practice, education, and leadership, as well as improved collection and analysis of interprofessional health care workforce data, that resulted from the committee’s review of the evidence.

CONSIDERATIONS THAT INFORMED THE COMMITTEE’S RECOMMENDATIONS

As discussed throughout this report, the challenges facing the health care system and the nursing profession are complex and numerous. Challenges to nursing practice include regulatory barriers, professional resistance to expanded scopes of practice, health system fragmentation, insurance company policies, high turnover among nurses, and a lack of diversity in the nursing workforce. With regard to nursing education, there is a need for greater numbers, better preparation, and more diversity in the student body and faculty, the workforce, and the cadre of researchers. Also needed are new and relevant competencies, lifelong learning, and interprofessional education. Challenges with regard to nursing leadership include the need for leadership competencies among nurses, collaborative environments in which nurses can learn and practice, and engagement of nurses at all levels—from students to front-line nurses to nursing executives and researchers—in leadership roles. Finally, comprehensive, sufficiently granular workforce data are needed to ascertain the necessary balance of skills among nurses, physicians, and other health professionals for a transformed health care system and practice environment.

Solutions to some of these challenges are well within the purview of the nursing profession, while solutions to others are not. A number of constraints affect the profession and the health care system more broadly. While legal and regulatory constraints affect scopes of practice for advanced practice registered nurses, the major cross-cutting constraints originate in limitations of available resources—both financial and human. These constraints are not new, nor are they unique to the nursing profession. The current economic landscape has magnified some of the challenges associated with these constraints while also reinforcing the need for change. To overcome these challenges, the nursing workforce needs to be well educated, team oriented, adaptable, and able to apply competencies such as those highlighted throughout this report, especially those relevant to leadership.

The nursing workforce may never have the optimum numbers to meet the needs of patients, nursing students, and the health care system. To maximize the available resources in care environments, providers need to work effectively and efficiently with a team approach. Teams need to include patients and their families, as well as a variety of health professionals, including nurses, physicians, pharmacists, physical and occupational therapists, medical assistants, and social

workers, among others. Care teams need to make the best use of each member’s education, skill, and expertise, and health professionals need to practice to the full extent of their license and education. Just as physicians delegate to registered nurses, then, registered nurses should delegate to front-line caregivers such as nursing assistants and community health workers. Moreover, technology needs to facilitate seamless care that is centered on the patient, rather than taking time away from patient care. In terms of education, efforts must be made to expand the number of nurses who are qualified to serve as faculty. Meanwhile, curricula need to be evaluated, and streamlined and technologies such as high-fidelity simulation and online education need to be utilized to maximize available faculty. Academic–practice partnerships should also be used to make efficient use of resources and expand clinical education sites.

In conducting its work and evaluating the challenges that face the nursing profession, the committee took into account a number of considerations that informed its recommendations and the content of this report. The committee carefully considered the scope and focus of the report in light of its charge (see Box P-1 in the preface to the report), the evidence that was available, costs associated with its recommendations, and implementation issues. Overall, the committee’s recommendations are geared toward advancing the nursing profession as a whole, and are focused on actions required to best meet long-term future needs rather than needs in the short term.

Scope and Focus of the Report

Many of the topics covered in this report could have been the focus of the entire report. As indicated in Chapter 4 , for example, the report could have focused entirely on nursing education. Given the nature of the committee’s charge and the time allotted for the study, however, the committee had to cover each topic at a high level and formulate relatively broad recommendations. This report could not be an exhaustive compendium of the challenges faced by the nursing workforce, nor was it meant to serve as a step-by-step guide detailing solutions to all of those challenges.

Accordingly, the committee limited its recommendations to those it believed had the potential for greatest impact and could be accomplished within the next decade. Taken together, the recommendations are meant to provide a strong foundation for the development of a nursing workforce whose members are well educated and well prepared to practice to the full extent of their education, to meet the current and future health needs of patients, and to act as full partners in leading change and advancing health. Implementation of these recommendations will take time, resources, and a significant commitment from nurses and other health professionals; nurse educators; researchers; policy makers and government leaders at the federal, state, and local levels; foundations; and other key stakeholders.

An emphasis of the committee’s deliberations and this report is nurses’ role in advancing care in the community, with a particular focus on primary care. While the majority of nurses currently practice in acute care settings, and much of nursing education is directed toward those settings, the committee sees primary care and prevention as central drivers in a transformed health care system, and therefore chose to focus on opportunities for nurses across community settings. The committee believes nurses have the potential to play a vital role in improving the quality, accessibility, and value of health care, and ultimately health in the community, beyond their critical contributions to acute care. The current landscape also directed the committee’s focus on primary care; concern over an adequate supply of primary care providers has been expressed and demand for primary care is expected to grow as millions more Americans gain insurance coverage through implementation of the ACA (see Chapters 1 and 2 ). Additionally, many provisions of the ACA focus on improving access to primary care, offering further opportunities for nurses to play a role in transforming the health care system and improving patient care.

The committee recognizes that improved primary care is not a panacea and that acute care services will always be needed. However, the committee sees primary care in community settings as an opportunity to improve health by reaching people where they live, work, and play. Nurses serving in primary care roles could expand access to care, educate people about health risks, promote healthy lifestyles and behaviors to prevent disease, manage chronic diseases, and coordinate care.

The committee also focused on advanced practice registered nurses in its discussion of some topics, most notably scope of practice. Recognizing the importance of primary care as discussed above, the committee viewed the potential contributions of these nurses to meeting the great need for primary care services if they could practice uniformly to the full extent of their education and training.

Available Evidence

The charge to the committee called for the formulation of a set of bold national-level recommendations—a considerable task. To develop its recommendations, the committee examined the available published evidence, drew on committee members’ expert judgment and experience, consulted experts engaged in the Robert Wood Johnson Foundation Nursing Research Network, and commissioned the papers that appear in Appendixes F through J on the CD-ROM in the back of this report. The committee also called on foremost experts in nursing, nursing research, and health policy to provide input, perspective, and expertise during its public workshops and forums (described in Appendix C ).

In addition to the peer-reviewed literature and newly commissioned research, the committee considered anecdotal evidence and self-evaluations for emerging models of care being implemented across the country. Evidence to support the

diffusion of a variety of promising innovative models informed the committee’s deliberations and recommendations. Many of these innovations are highlighted as case studies throughout the report, and others are discussed in the appendixes. These case studies offer real-life examples of successful innovations that were developed by nurses or feature nurses in a leadership role, and are meant to complement the peer-reviewed evidence presented in the text. The committee believes these case studies contribute to the evidence base on how nurses can serve in reconceptualized roles to directly affect the quality, accessibility, and value of care. Cumulatively, the case studies and nurse profiles demonstrate what is possible and what the future of nursing could look like under ideal circumstances in which nurses would be highly educated and well prepared by an education system that would promote seamless academic progression, in which nurses would be practicing to the full extent of their education and training, and in which they would be acting as full partners in efforts to redesign the health care system.

The committee drew on a wealth of sources of evidence to support its recommendations. The recommendations presented are based on the best evidence available. There is a need, however, to continue building the evidence base in a variety of areas. The committee identified several research priorities to build upon its recommendations. For example, data are lacking on the work of nurses and the nursing workforce in general, primarily because of a dearth of large and well-designed studies explicitly exploring these issues. Accordingly, the committee calls for research in a number of areas that would yield evidence related to the future of nursing to address some of the shortcomings in the data it encountered. Boxes 7-1 through 7-3 list research questions that are directly connected to the recommendations and the discussion in Chapters 3 through 5 . The committee believes that answers to these research questions are needed to help advance the profession.

Costs Associated with the Recommendations

The current state of the U.S. economy and its effects on federal, state, and local budgets pose significant challenges to transforming the health care system. These fiscal challenges also will heavily influence the implementation of the committee’s recommendations. While providing cost estimates for each recommendation was beyond the scope of this study, the committee does not deny that there will be costs—in some cases sizable—associated with implementing its recommendations. These costs must be carefully weighed against the potential for long-term benefit. Expanding the roles and capacity of the nursing profession will require significant up-front financial resources, but this investment, in the committee’s view, will help secure a strong foundation for a future health care system that can provide high-quality, accessible, patient-centered care. Based on its expert opinion and the available evidence, the committee believes that, despite the fiscal challenges, implementation of its recommendations is necessary

to increase the quality, accessibility, and value of care through the contributions of nurses.

Implementation of the Recommendations

Each of the recommendations presented in this report is supported by a level of evidence necessary to warrant its implementation. This does not mean, however, that the evidence currently available to support the committee’s recommendations is sufficient to guide or motivate their implementation. The research priorities presented in Boxes 7-1 through 7-3 constitute key evidence gaps that need to be filled to convince key stakeholders that each recommendation is fundamental to the transformation of care delivered by nurses. For example, to be convinced to purchase equipment necessary to expand the number of nurses that can be educated using expensive new teaching technologies, such as high-fidelity

simulation, distance learning, and online education modalities, decision makers in nursing schools will likely need evidence for the impact of these technologies on increasing the capacity of the nursing education system, as well as assurance that these technologies are an effective way to educate students. Likewise, before agreeing to reorganize care and training in a way that supports nursing residencies, hospitals will likely want to understand the true costs of such programs, as well as the key ingredients for their success. And before state political leaders can be persuaded to enact legislation to expand and standardize the scope of practice for advanced practice registered nurses, they will need messages to convey to their constituents about what these changes will mean for acquiring timely access to high-quality primary care services.

The committee urges the health services research community to embark on research agendas that can produce the evidence needed to guide the implementation of its recommendations. At the same time, the committee recognizes, from

the work of Mary Naylor and colleagues (2009), that a strong evidence base, even if supported by the results of multiple randomized clinical trials funded by the National Institutes of Health, will not be sufficient to propel a new model, policy, or practice to a position of widespread acceptance and implementation. “Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly—if at all. Diffusion of innovations is a major challenge in all industries including health care” (Berwick, 2003).

Experience with the Transitional Care Model (TCM), described in Chapter 2 , illustrates this point. In this case, barriers intrinsic to the way care is currently organized, regulated, reimbursed, and delivered have delayed the ability of a cost-effective, quality-enhancing model to improve the lives of the chronically

ill. Learning from barriers to diffuse evidence-based health care interventions within health systems, Naylor and colleagues identified several ingredients crucial to successful diffusion. First, the model or innovation should be a good fit in response to a critical need, either within an organization or nationwide. Second, without strong champions, especially those with decision-making power, there is very little chance of widespread adoption. The researchers learned the hard way the cost of failure to engage all stakeholders in a project—early, continually, and throughout. Engagement with the media is especially important. An understanding of the landscape is necessary as well and should guide efforts to market the innovation to others. Milestones and measures of success are important to all team members and throughout the entire diffusion process. Finally, flexibility, or the willingness to adapt the model or innovation to meet environmental or organizational demands, increases the probability of success (Naylor et al., 2009).

Planning for the implementation of the committee’s recommendations is beyond the scope of this report. However, the committee urges health care providers, organizations, and policy makers to carry out the eight recommendations presented below to enable nurses to lead in the transformation of the health care system and advance the health of patients and communities throughout the nation.

The committee believes the implementation of its recommendations will help establish the needed groundwork in the nursing profession to further the

work of nurses in innovating and improving patient care. The committee sees its recommendations as the building blocks required to expand innovative models of care, as well as to improve the quality, accessibility, and value of care, through nursing. The committee emphasizes that the synergistic implementation of all of its recommendations as a whole will be necessary to truly transform the nursing profession into one that is capable of leading change to advance the nation’s health.

RECOMMENDATIONS

Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions.

For the Congress:

Expand the Medicare program to include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered.

Amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities.

Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services.

Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).

For state legislatures:

Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).

Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law.

For the Centers for Medicare and Medicaid Services:

Amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff.

For the Office of Personnel Management:

Require insurers participating in the Federal Employees Health Benefits Program to include coverage of those services of advanced practice registered nurses that are within their scope of practice under applicable state law.

For the Federal Trade Commission and the Antitrust Division of the Department of Justice:

Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so.

Recommendation 2: Expand opportunities for nurses to lead and diffuse col laborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices.

To this end:

The Center for Medicare and Medicaid Innovation should support the development and evaluation of models of payment and care delivery that use nurses in an expanded and leadership capacity to improve health outcomes and reduce costs. Performance measures should be developed and implemented expeditiously where best practices are evident to reflect the contributions of nurses and ensure better-quality care.

Private and public funders should collaborate, and when possible pool funds, to advance research on models of care and innovative solutions,

including technology, that will enable nurses to contribute to improved health and health care.

Health care organizations should support and help nurses in taking the lead in developing and adopting innovative, patient-centered care models.

Health care organizations should engage nurses and other front-line staff to work with developers and manufacturers in the design, development, purchase, implementation, and evaluation of medical and health devices and health information technology products.

Nursing education programs and nursing associations should provide entrepreneurial professional development that will enable nurses to initiate programs and businesses that will contribute to improved health and health care.

Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.

The following actions should be taken to implement and support nurse residency programs:

State boards of nursing, in collaboration with accrediting bodies such as the Joint Commission and the Community Health Accreditation Program, should support nurses’ completion of a residency program after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.

The Secretary of Health and Human Services should redirect all graduate medical education funding from diploma nursing programs to support the implementation of nurse residency programs in rural and critical access areas.

Health care organizations, the Health Resources and Services Administration and Centers for Medicare and Medicaid Services, and philanthropic organizations should fund the development and implementation of nurse residency programs across all practice settings.

Health care organizations that offer nurse residency programs and foundations should evaluate the effectiveness of the residency programs in improving the retention of nurses, expanding competencies, and improving patient outcomes.

Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.

The Commission on Collegiate Nursing Education, working in collaboration with the National League for Nursing Accrediting Commission, should require all nursing schools to offer defined academic pathways, beyond articulation agreements, that promote seamless access for nurses to higher levels of education.

Health care organizations should encourage nurses with associate’s and diploma degrees to enter baccalaureate nursing programs within 5 years of graduation by offering tuition reimbursement, creating a culture that fosters continuing education, and providing a salary differential and promotion.

Private and public funders should collaborate, and when possible pool funds, to expand baccalaureate programs to enroll more students by offering scholarships and loan forgiveness, hiring more faculty, expanding clinical instruction through new clinical partnerships, and using technology to augment instruction. These efforts should take into consideration strategies to increase the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution.

The U.S. Secretary of Education, other federal agencies including the Health Resources and Services Administration, and state and private funders should expand loans and grants for second-degree nursing students.

Schools of nursing, in collaboration with other health professional schools, should design and implement early and continuous interprofessional collaboration through joint classroom and clinical training opportunities.

Academic nurse leaders should partner with health care organizations, leaders from primary and secondary school systems, and other community organizations to recruit and advance diverse nursing students.

Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.

The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should monitor the progress of each accredited nursing school to ensure that at least 10 percent of all baccalaureate graduates matriculate into a master’s or doctoral program within 5 years of graduation.

Private and public funders, including the Health Resources and Services Administration and the Department of Labor, should expand funding for programs offering accelerated graduate degrees for nurses to increase the production of master’s and doctoral nurse graduates and to increase the diversity of nurse faculty and researchers.

Academic administrators and university trustees should create salary and benefit packages that are market competitive to recruit and retain highly qualified academic and clinical nurse faculty.

Recommendation 6: Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.

Faculty should partner with health care organizations to develop and prioritize competencies so curricula can be updated regularly to ensure that graduates at all levels are prepared to meet the current and future health needs of the population.

The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should require that all nursing students demonstrate a comprehensive set of clinical performance competencies that encompass the knowledge and skills needed to provide care across settings and the lifespan.

Academic administrators should require all faculty to participate in continuing professional development and to perform with cutting-edge competence in practice, teaching, and research.

All health care organizations and schools of nursing should foster a culture of lifelong learning and provide resources for interprofessional continuing competency programs.

Health care organizations and other organizations that offer continuing competency programs should regularly evaluate their programs for adaptability, flexibility, accessibility, and impact on clinical outcomes and update the programs accordingly.

Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should

prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses.

Nurses should take responsibility for their personal and professional growth by continuing their education and seeking opportunities to develop and exercise their leadership skills.

Nursing associations should provide leadership development, mentoring programs, and opportunities to lead for all their members.

Nursing education programs should integrate leadership theory and business practices across the curriculum, including clinical practice.

Public, private, and governmental health care decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions.

Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

The Workforce Commission and the Health Resources and Services Administration should coordinate with state licensing boards, including those for nursing, medicine, dentistry, and pharmacy, to develop and promulgate a standardized minimum data set across states and professions that can be used to assess health care workforce needs by demographics, numbers, skill mix, and geographic distribution.

The Workforce Commission and the Health Resources and Services Administration should set standards for the collection of the minimum data set by state licensing boards; oversee, coordinate, and house the data; and make the data publicly accessible.

The Workforce Commission and the Health Resources and Services Administration should retain, but bolster, the Health Resources and Services Administration’s registered nurse sample survey by increasing the sample size, fielding the survey every other year, expanding the data collected on advanced practice registered nurses, and releasing survey results more quickly.

The Workforce Commission and the Health Resources and Services Administration should establish a monitoring system that uses the most

current analytic approaches and data from the minimum data set to systematically measure and project nursing workforce requirements by role, skill mix, region, and demographics.

The Workforce Commission and the Health Resources and Services Administration should coordinate workforce research efforts with the Department of Labor, state and regional educators, employers, and state nursing workforce centers to identify regional health care workforce needs, and establish regional targets and plans for appropriately increasing the supply of health professionals.

The Government Accountability Office should ensure that the Workforce Commission membership includes adequate nursing expertise.

Berwick, D. M. 2003. Disseminating innovations in health care. JAMA 289(15):1969-1975.

Naylor, M. D., P. H. Feldman, S. Keating, M. J. Koren, E. T. Kurtzman, M. C. Maccoy, and R. Krakauer. 2009. Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice 15(6):1164-1170.

The Future of Nursing explores how nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system.

At more than 3 million in number, nurses make up the single largest segment of the health care work force. They also spend the greatest amount of time in delivering patient care as a profession. Nurses therefore have valuable insights and unique abilities to contribute as partners with other health care professionals in improving the quality and safety of care as envisioned in the Affordable Care Act (ACA) enacted this year.

Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States. To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates. Furthermore, regulatory and institutional obstacles—including limits on nurses' scope of practice—should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care.

In this book, the Institute of Medicine makes recommendations for an action-oriented blueprint for the future of nursing.

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MARK H. EBELL, M.D., M.S., JAY SIWEK, M.D., BARRY D. WEISS, M.D., STEVEN H. WOOLF, M.D., M.P.H., JEFFREY SUSMAN, M.D., BERNARD EWIGMAN, M.D., M.P.H., AND MARJORIE BOWMAN, M.D., M.P.A.

Am Fam Physician. 2004;69(3):548-556

See editorial on page 483.

A large number of taxonomies are used to rate the quality of an individual study and the strength of a recommendation based on a body of evidence. We have developed a new grading scale that will be used by several family medicine and primary care journals (required or optional), with the goal of allowing readers to learn one taxonomy that will apply to many sources of evidence. Our scale is called the Strength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidence and allows authors to rate individual studies or bodies of evidence. The taxonomy is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use of this taxonomy will improve the ability of authors and readers to communicate about the translation of research into practice.

Review articles (or overviews) are highly valued by physicians as a way to keep up-to-date with the medical literature. Sometimes, though, these articles are based more on the authors' personal experience, anecdotes, or incomplete surveys of the literature than on a comprehensive collection of the best available evidence. As a result, there is an ongoing effort in the medical publishing field to improve the quality of review articles through the use of more explicit grading of the strength of evidence on which recommendations are based. 1 – 4

Several journals, including American Family Physician and The Journal of Family Practice , have adopted evidence-grading scales that are used in some of the articles published in those journals. Other organizations and publications also have developed evidence-grading scales. The diversity of these scales can be confusing for readers. More than 100 grading scales are in use by various medical publications. 5 A level B recommendation in one journal may not mean the same thing as a level B recommendation in another. Even within journals, different evidence-grading scales sometimes are used in separate articles within the same issue. Journal readers do not have the time, energy, or interest to interpret multiple grading scales, and more complex scales are difficult to integrate into daily practice.

Therefore, the editors of the U.S. family medicine and primary care journals (i.e., American Family Physician, Family Medicine, The Journal of Family Practice, Journal of the American Board of Family Practice , and BMJ-USA ) and the Family Practice Inquiries Network (FPIN) came together to develop a unified taxonomy for the strength of recommendations based on a body of evidence. The new taxonomy should: (1) be uniform in most family medicine journals and electronic databases; (2) allow authors to evaluate the strength of recommendation of a body of evidence; (3) allow authors to rate the level of evidence for an individual study; (4) be comprehensive and allow authors to evaluate studies of screening, diagnosis, therapy, prevention, and prognosis; (5) be easy to use and not too time-consuming for authors, reviewers, and editors who may be content experts but not experts in critical appraisal or clinical epidemiology; and (6) be straightforward enough that primary care physicians can readily integrate the recommendations into daily practice.

Definitions

A number of relevant terms must be defined for clarification.

Disease-Oriented Outcomes

These outcomes include intermediate, histopathologic, physiologic, or surrogate results (e.g., blood sugar, blood pressure, flow rate, coronary plaque thickness) that may or may not reflect improvement in patient outcomes.

Patient-Oriented Outcomes

These are outcomes that matter to patients and help them live longer or better lives, including reduced morbidity, reduced mortality, symptom improvement, improved quality of life, or lower cost.

Level of Evidence

The validity of an individual study is based on an assessment of its study design. According to some methodologies, 6 levels of evidence can refer not only to individual studies but also to the quality of evidence from multiple studies about a specific question or the quality of evidence supporting a clinical intervention. For purposes of maintaining simplicity and consistency in this proposal, we use the term “level of evidence” to refer to individual studies.

Strength of Recommendation

The strength (or grade) of a recommendation for clinical practice is based on a body of evidence (typically more than one study). This approach takes into account the level of evidence of individual studies; the type of outcomes measured by these studies (patient-oriented or disease-oriented); the number, consistency, and coherence of the evidence as a whole; and the relationship between benefits, harms, and costs.

Practice Guideline (Evidence-Based)

These guidelines are recommendations for practice that involve a comprehensive search of the literature, an evaluation of the quality of individual studies, and recommendations that are graded to reflect the quality of the supporting evidence. All search, critical appraisal, and grading methods should be described explicitly and be replicable by similarly skilled authors.

Practice Guideline (Consensus)

Consensus guidelines are recommendations for practice based on expert opinions that typically do not include a systematic search, an assessment of the quality of individual studies, or a system to label the strength of recommendations explicitly.

Research Evidence

This evidence is presented in publications of original research, involving collection of original data or the systematic review of other original research publications. It does not include editorials, opinion pieces, or review articles (other than systematic reviews or meta-analyses).

Review Article

A nonsystematic overview of a topic is a review article. In most cases, it is not based on an exhaustive, structured review of the literature and does not evaluate the quality of included studies systematically.

Systematic Reviews and Meta-Analyses

A systematic review is a critical assessment of existing evidence that addresses a focused clinical question, includes a comprehensive literature search, appraises the quality of studies, and reports results in a systematic manner. If the studies report comparable quantitative data and have a low degree of variation in their findings, a meta-analysis can be performed to derive a summary estimate of effect.

Existing Strength-of-Evidence Scales

In March 2002, the Agency for Healthcare Research and Quality (AHRQ) published a report that summarized the state-of-the-art in methods of rating the strength of evidence. 5 The report identified a large number of systems for rating the quality of individual studies: 20 for systematic reviews, 49 for randomized controlled trials, 19 for observational studies, and 18 for diagnostic test studies. It also identified 40 scales that graded the strength of a body of evidence consisting of one or more studies.

The authors of the AHRQ report proposed that any system for grading the strength of evidence should consider three key elements: quality, quantity, and consistency. Quality is the extent to which the identified studies minimize the opportunity for bias and is synonymous with the concept of validity. Quantity is the number of studies and subjects included in those studies. Consistency is the extent to which findings are similar between different studies on the same topic. Only seven of the 40 systems identified and addressed all three of these key elements. 6 – 11

Strength of Recommendation Taxonomy (SORT)

The authors of this article represent the major family medicine journals in the United States and a large family medicine academic consortium. Our process began with a series of e-mail exchanges, was developed during a meeting of the editors, and continued through another series of e-mail exchanges.

We decided that our taxonomy for rating the strength of a recommendation should address the three key elements identified in the AHRQ report: quality, quantity, and consistency of evidence. We also were committed to creating a grading scale that could be applied by authors with varying degrees of expertise in evidence-based medicine and clinical epidemiology, and interpreted by physicians with little or no formal training in these areas. We believed that the taxonomy should address the issue of patient-oriented evidence versus disease-oriented evidence explicitly and be consistent with the information mastery framework proposed by Slawson and Shaughnessy. 2

After considering these criteria and reviewing the existing taxonomies for grading the strength of a recommendation, we decided that a new taxonomy was needed to reflect the needs of our specialty. Existing grading scales were focused on a particular kind of study (e.g., prevention or treatment), were too complex, or did not take into account the type of outcome.

Our proposed taxonomy is called the Strength of Recommendation Taxonomy (SORT). It is shown in Figure 1 . The taxonomy includes ratings of A, B, or C for the strength of recommendation for a body of evidence. The table in the center of Figure 1 explains whether a body of evidence represents good-quality or limited-quality evidence, and whether evidence is consistent or inconsistent. The quality of individual studies is rated 1, 2, or 3; numbers are used to distinguish ratings of individual studies from the letters A, B, and C used to evaluate the strength of a recommendation based on a body of evidence. Figure 2 provides information about how to determine the strength of recommendation for management recommendations, and Figure 3 explains how to determine the level of evidence for an individual study. These two algorithms should be helpful to authors preparing papers for submission to family medicine journals. The algorithms are to be considered general guidelines, and special circumstances may dictate assignment of a different strength of recommendation (e.g., a single, large, well-designed study in a diverse population may warrant an A-level recommendation).

Recommendations based only on improvements in surrogate or disease-oriented outcomes are always categorized as level C, because improvements in disease-oriented outcomes are not always associated with improvements in patient-oriented outcomes, as exemplified by several well-known findings from the medical literature. For example, doxazosin lowers blood pressure in black patients—a seemingly beneficial outcome—but it also increases mortality rates. 12 Similarly, encainide and flecainide reduce the incidence of arrhythmias after acute myocardial infarction, but they also increase mortality rates. 13 Finasteride improves urinary flow rates, but it does not significantly improve urinary tract symptoms in patients with benign prostatic hypertrophy, 14 while arthroscopic surgery for osteoarthritis of the knee improves the appearance of cartilage but does not reduce pain or improve joint function. 15 Additional examples of clinical situations where disease-oriented evidence conflicts with patient-oriented evidence are shown in Table 1 . 12 – 24 Examples of how to apply the taxonomy are given in Table 2 .

We believe there are several advantages to our proposed taxonomy. It is straightforward and comprehensive, is easily applied by authors and physicians, and explicitly addresses the issue of patient-oriented versus disease-oriented evidence. The latter attribute distinguishes SORT from most other evidence-grading scales. These strengths also create some limitations. Some clinicians may be concerned that the taxonomy is not as detailed in its assessment of study designs as others, such as that of the Centre for Evidence-Based Medicine (CEBM). 25 However, the primary difference between the two taxonomies is that the CEBM version distinguishes between good and poor observational studies while the SORT version does not. We concluded that the advantages of a system that provides the physician with a clear recommendation that is strong (A), moderate (B), or weak (C) in its support of a particular intervention outweighs the theoretic benefit of distinguishing between lower quality and higher quality observational studies, particularly because there is no objective evidence that the latter distinction carries important differences in clinical recommendations.

Any publication applying SORT (or any other evidence-based taxonomy) should describe carefully the search process that preceded the assignment of a SORT rating. For example, authors could perform a comprehensive search of MEDLINE and the gray literature, a comprehensive search of MEDLINE alone, or a more focused search of MEDLINE plus secondary evidence-based sources of information.

Walkovers: Creating Linkages with SORT

Some organizations, such as the CEBM, 25 the Cochrane Collaboration, 7 and the U.S. Preventive Services Task Force, 6 have developed their own grading scales for the strength of recommendation based on a body of evidence and are unlikely to abandon them. Other organizations, such as the FPIN, 26 publish their work in a variety of settings and must be able to move between taxonomies. We have developed a set of optional walkovers that suggest how authors, editors, and readers might move from one taxonomy to another. Walkovers for the CEBM and BMJ Clinical Evidence taxonomies are shown in Table 3 .

Many authors and experts in evidence-based medicine use the “Level of Evidence” taxonomy from the CEBM to rate the quality of individual studies. 25 A walkover from the five-level CEBM scale to the simpler three-level SORT scale for individual studies is shown in Table 4 .

Final Comment

The SORT is a comprehensive taxonomy for evaluating the strength of a recommendation based on a body of evidence and the quality of an individual study. If applied consistently by authors and editors in the family medicine literature, it has the potential to make it easier for physicians to apply the results of research in their practice through the information mastery approach and to incorporate evidence-based medicine into their patient care.

Like any such grading scale, it is a work in progress. As we learn more about biases in study design, and as the authors and readers who use the taxonomy become more sophisticated about principles of information mastery, evidence-based medicine, and critical appraisal, it is likely to evolve. We remain open to suggestions from the primary care community for refining and improving SORT.

Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420-5.

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a medical information master: feeling good about not knowing everything. J Fam Pract. 1994;38:505-13.

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39:489-99.

Siwek J, Gourlay ML, Slawson DC, Shaughnessy AF. How to write an evidence-based clinical review article. Am Fam Physician. 2002;65:251-8.

Systems to rate the strength of scientific evidence. Summary, evidence report/technology assessment: number 47. AHRQ publication no. 02-E015, March 2002. Agency for Healthcare Research and Quality, Rockville, Md. Accessed November 13, 2003, at: http://www.ahrq.gov/clinic/epc-sums/strengthsum.htm.

Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3 suppl):21-35.

Clarke M, Oxman AD. Cochrane reviewers' handbook 4.2.0. The Cochrane Collaboration, 2003. Accessed November 13, 2003, at: http://www.cochrane.org/resources/handbook/handbook.pdf.

Gyorkos TW, Tannenbaum TN, Abrahamowicz M, Oxman AD, Scott EA, Millson ME, et al. An approach to the development of practice guidelines for community health interventions. Can J Public Health. 1994;85(suppl 1):S8-13.

Briss PA, Zaza S, Pappaioanou M, Fielding J, Wright-De Aguero L, Truman BI, et al. Developing an evidence-based guide to community preventive services—methods. Am J Prev Med. 2000;18(1 suppl):35-43.

Greer N, Mosser G, Logan G, Halaas GW. A practical approach to evidence grading. Jt Comm J Qual Improv. 2000;26:700-12.

Guyatt GH, Haynes RB, Jaeschke RZ, Cook DJ, Green L, Naylor CD, et al. Users' guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users' guides to patient care. JAMA. 2000;284:1290-6.

Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT) [published correction in JAMA 2002;288:2976]. JAMA. 2000;283:1967-75.

Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. N Engl J Med. 1991;324:781-8.

Lepor H, Williford WO, Barry MJ, Brawer MK, Dixon CM, Gormley G, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med. 1996;335:533-9.

Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-8.

Dwyer T, Ponsonby AL. Sudden infant death syndrome: after the “back to sleep” campaign. BMJ. 1996;313:180-1.

Yusuf S, Dagenais G, Pogue J, Bosch J, Sleight P. Vitamin E supplementation and cardiovascular events in high-risk patients. N Engl J Med. 2000;342:154-60.

Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D. Pharmacological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2003(1):CD001960.

Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-33.

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-53.

Meunier PJ, Sebert JL, Reginster JY, Briancon D, Appelboom T, Netter P, et al. Fluoride salts are no better at preventing new vertebral fractures than calcium-vitamin D in post-menopausal osteoporosis: the FAVOStudy. Osteoporos Int. 1998;8:4-12.

MacMahon S, Collins R, Peto R, Koster RW, Yusuf S. Effects of prophylactic lidocaine in suspected acute myocardial infarction. An overview of results from the randomized, controlled trials. JAMA. 1988;260:1910-6.

Grumbach K. How effective is drug treatment of hypercholesterolemia? A guided tour of the major clinical trials for the primary care physician. J Am Board Fam Pract. 1991;4:437-45.

Heidenreich PA, Lee TT, Massie BM. Effect of beta-blockade on mortality in patients with heart failure: a meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1997;30:27-34.

Centre for Evidence-Based Medicine. Levels of evidence and grades of recommendation. Accessed November 13, 2003, at: http://www.cebm.net/levels_of_evidence.asp.

Family Practice Inquiries Network (FPIN). Accessed November 13, 2003, at: http://www.fpin.org .

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Access Device Guidelines: Recommendations for Nursing Practice and Education (Fourth Edition)

It is critical that oncology nurses understand the latest research, guidelines, and evidence-based practices in access devices. With the latest edition of Access Device Guidelines: Recommendations for Nursing Practice and Education , nurses can explore a foundation for practice and support in their day-to-day care of patients with cancer.  

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• Venous Access Devices
• Care Setting
• Inpatient Care
• Nursing Roles and Professional Practice
• Quality & Safety
• Practice Guidelines and Standards

Learn more about group purchasing and volume discount pricing.

The fourth edition of this text explores recommendations for a range of access devices, their common complications, and other relevant indications. Oncology nurses will learn about updates in dressing changes, flushing and locking, contraindications for peripheral IV administration, implanted port flushing frequency, and more. Additionally, the latest edition includes aseptic non-touch technique terminology and framework throughout the book and new appendices on dressings and vascular access teams. 

With access device technology becoming more complex, this book is an essential resource for practicing nurses in a wide range of settings to ensure safe and effective care of patients with vascular access devices. 

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Institute of Medicine (US) Division of Health Care Services. Nursing and Nursing Education: Public Policies and Private Actions. Washington (DC): National Academies Press (US); 1983.

Nursing and Nursing Education: Public Policies and Private Actions.

• Hardcopy Version at National Academies Press

Summary and Recommendations

Our study estimates that there are more than 1.3 million registered nurses employed in the United States today. They are the largest single professional component of a health care system that represents almost 10 percent of the gross national product. Their responsibilities are diverse. Two-thirds work in the nation's hospitals, providing or supervising the care of patients. Others care for patients in their homes, in nursing homes, community health centers and public health clinics, physicians' offices, and health maintenance organizations. Still others work in schools, industry, and public administration. They are involved not only in care of those acutely ill, but also in preventive services and in care of the chronically ill and disabled.

The leadership component of this nurse population also has highly differentiated functions. Top nurse administrators manage large and complex nursing services in hospitals where they often are responsible for multi-million dollar budgets. In all the varied institutional and community settings of patient care, they manage services provided by approximately 915,000 staff level registered nurses, more than 500,000 licensed practical nurses, and an estimated 850,000 aides. Faculty in schools of nursing educate future nurses and conduct research to improve the care of patients through the practice of nursing. An increasingly important part of the advanced nursing cadre are specialists, such as nurse practitioners, nurse midwives, and a variety of clinical nurse specialists in hospitals.

During the late 1970s, when this study was mandated by Congress, concern about nursing shortages was strong and was expressed publicly in terms of the need for more generalist ''bedside" nurses. The study was, in effect, asked to respond to the following kinds of questions: Will there be enough registered nurses (RNs) of the types needed to ensure an adequate future supply of the various types of nurses? Should the federal government continue its specific support of generalist nursing education in order to assure the adequacy of their supply? What are the means to bring better nursing services to underserved populations in rural and inner city areas, as well as to elderly and minority populations who generally lack adequate access to nursing care? Finally, what is the true extent of RN dropout, and what are the means for retaining such nurses in their profession? The last question arose from a widespread opinion that investment of public funds to train RNs was wasteful because they would soon leave for higher paying, less stressful occupations.

Because concern for all these aspects of current and possible future nurse shortages appeared to be a motivating force for the study, the committee examined the various aspects of nursing and nursing education in that general framework. In our analysis, we found reasons to distinguish sharply between shortages or maldistribution of nurses prepared as generalists to provide direct care to patients, and shortages of nurses in leadership and specialty nursing. The problems and the possible solutions are quite different for these two groups.

• The Committee's Recommendations

Our recommendations are framed not only in the general context of the provisions of the Nurse Training Act (NTA) of 1965 and its subsequent amendments, but also in the context of other federal, state, and local government and private sector actions that influence both the demand for and the supply of RNs and LPNs. Many factors enter into the alleviation of current numerical and distributional scarcities of nurses and in the prevention of future scarcities. In most instances, the responsibilities of the various public and private sectors interact. In consequence, the committee's recommendations generally involve shared funding to stimulate the kind of collaborative approaches most likely to ensure desired results.

This section presents the committee's specific responses to the three congressional questions of its study charge. Each recommendation addresses a topic that is, in effect, a subset of the overall study question under consideration. The recommendation under each of these topics is accompanied by an abstract of the conclusions that led to its formulation. The congressional questions and the topics and recommendations are set forth in the sequence in which they appear in the statutory charge and in the chapters of the full report.

Congressional Question One: IS THERE A NEED TO CONTINUE A SPECIFIC PROGRAM OF FEDERAL FINANCIAL SUPPORT FOR NURSING EDUCATION?

Meeting Current and Future Needs for Nurses 1

Recommendation 1.

No specific federal support is needed to increase the overall supply of registered nurses, because estimates indicate that the aggregate supply and demand for generalist nurses will be in reasonable balance during this decade. However, federal, state, and private actions are recommended throughout this report to alleviate particular kinds of shortages and maldistributions of nurse supply.

During the 1970s, increasing sophistication of medical technology and growing complexity of health services continuously increased the demand for more and better prepared nurses. Supply fell behind explosive demand, and local labor markets for nurses during most of that decade manifested obvious scarcities in numbers and types of nurses whom hospitals and other health facilities wanted to employ. Nonetheless, in the short time between two official surveys in 1977 and 1980, the supply of active registered nurses (RNs) jumped by 30 percent, a figure well in excess of prior predictions. Four out of five of these additional RNs were employed by hospitals, where two-thirds of all RNs and almost two-thirds of all licensed practical nurses (LPNs) work. The number of practical nurses also has grown, but at a slower rate.

On the basis of all evidence it has been able to study, the committee concluded that, as of the fall of 1982, in the aggregate there was not a significant national shortage of generalist RNs or of LPNs. We have, however, identified shortages that occur unevenly throughout the nation in different geographic areas, in different health care settings--especially those that serve the economically disadvantaged--within institutions, and in specialty nursing. The resolution of such particular shortages depends both on the operation of market forces and on concerted actions by the federal, state, and private sectors following the lines of this study's recommendations.

• State and Local Planning for Generalist Nursing Education by Program Type

Recommendation 2

The states have primary responsibility for analysis and planning of resource allocation for generalist nursing education. Their capabilities in this effort vary greatly. Assistance should be made available from the federal government, both in funds and in technical aid.

Most decisions affecting the allocation of resources for the education of generalist nurses take place at state and institutional levels. Shortages are often viewed by members of the nursing profession, employers, and others in terms of the need for RNs specifically prepared in one or more of the three different types of basic nursing education programs--diploma, associate degree, and baccalaureate in nursing--and of the additional need for LPNs. The committee concluded that there was no evidential basis for making national recommendations on the desired proportions of RNs to be prepared in each basic educational pathway, or on the distribution of RN and LPN nursing service personnel within and among diverse nurse employment settings. In the past, these settings have sustained market demand for the output of each type of basic nursing education program.

The committee analyzed a large number of state reports dealing with efforts to disaggregate future state RN supply according to educational preparation. It is apparent that issues of educational differentiation are squarely on the agenda of nursing education policy. It also is apparent that state studies estimating future supply and need mainly on the basis of professional judgments of numbers and kinds of nursing personnel needed (by type of educational preparation) produced widely different estimates in levels and mix of staffing (and of amounts of time required by nursing service personnel per patient day) for similar practice settings from one state to another.

Many states appear not to be well organized to deal with nursing issues and nursing education policy on a continuing basis. The committee noted the apparent inefficiency of ad hoc, short-term efforts as states struggled to ascertain their current and future needs for RNs and LPNs and to identify related nursing education priorities. In many cases, the follow-through on these attempts has not been coordinated or appears not to have led to consensus building on goals for basic nursing education. Finally, projections of needed future supply of nurses appear to be hampered by the absence of balanced methodological alternatives for estimating anticipated future market demands. A relatively small outlay of federal technical assistance dollars is necessary to assist states in developing a more consistent methodology for their estimates of future demand and to promote ongoing state planning for nurse supply.

• Federal Education Financing to Help Sustain the Basic Nurse Supply

Recommendation 3

The federal government should maintain its general programs of financial aid to postsecondary students so that qualified prospective nursing students will continue to have the opportunity to enter generalist nursing education programs in numbers sufficient to maintain the necessary aggregate supply.

The assessments of future supply on which our first recommendation is based were made in the face of concern that current levels of federal financing of education might not be maintained. Limited available evidence suggests that nursing students are substantially dependent on general higher education student aid programs.

Considerations that go into making projections at both federal and state levels do not reveal the complex decision making processes and the great variety of influences that ultimately determine, locally, the size and composition of the future pool of RNs. The committee has attempted to answer the congressional questions on comparative educational costs and on sources of financing to the extent that data could be found or developed. Estimates of student and institutional costs for various programs, however, permit only cautious comparisons among programs. Conclusions as to the societal utility or professional value of one type of program or another should not be made on cost considerations alone.

Students' education costs have risen rapidly over the past few years and increases are projected to continue. Nursing students, who are predominantly women, finance their tuition and living costs from a combination of sources: the very limited funding remaining under the Nurse Training Act scholarship and loan programs; general federal programs of financial aid for all postsecondary students; state and collegiate grant programs; earnings; and personal and family savings. Higher education--and nursing education in particular--is entering a period in which resources will be more constrained than in the past. Nursing students tend to come from families with moderate incomes or to count heavily on their own resources to finance their education. They bear the cost without the assurance of earnings comparable to those of students in other fields who make similar educational investments.

General federal financial aid programs for postsecondary students, designed to improve equality of access to education, have been a major source of financing for students in basic nursing education programs. Reductions in these programs could curtail the number of students entering basic nursing education or seriously limit students' choices among educational programs. Such reductions were not presupposed in any of the assumptions that led to our estimates of future supply; their impact would be unpredictable.

• Continued State and Private Support of Nursing Education

Recommendation 4

Institutional and student financial support should be maintained by state and local governments, higher education institutions, hospitals, and third-party payers to assure that generalist nursing education programs have capacity and enrollments sufficient to graduate the numbers and kinds of nurses commensurate with state and local goals for the nurse supply.

State tax dollars appropriated for higher education represent the largest source of governmental and institutional support for nursing education. Local governments and private donors are important financing sources for community colleges and private educational institutions, respectively. Hospitals support nursing education by offering diploma programs in nursing and/or staff development programs, providing educational fringe benefits, and subsidizing nurse employees who are advancing their level of education in college-based programs in return for service commitments. These costs are financed principally through third-party reimbursements.

Fiscal pressures on state and local governments, as well as cost containment efforts in hospitals, threaten to reduce funds available from these sources for nursing education. This would, in turn, increase the cost burden on students and diminish their educational opportunities. These considerations link this recommendation and the preceding ones, because it is essential to maintain a monitoring capacity at both national and state levels to track current supply and demand and to refine at the level of each state the continuing adjustments necessary in resource allocation to assure continuing adequate accretions to the pool of generalist nurses.

• Attracting New Recruits to Nursing

Recommendation 5

To assure a sufficient continuing supply of new applicants, nurse educators and national nursing organizations should adopt recruitment strategies that attract not only recent high school graduates but also nontraditional prospective students, such as those seeking late entry into a profession or seeking to change careers, and minorities.

Actions taken by the administrators and faculty of nursing education programs can strongly influence both the numbers and types of applicants to their programs. Because changes in the nation's demography have led to a shrinking pool of high school graduates, and because of the attractions of other careers for women, nurse educators must recruit students from new sources in order to maintain the output of their programs. So-called nontraditional candidates are likely to respond to special arrangements made to facilitate their entry into nursing. These candidates include mature women first entering the labor market, men, minorities, and people seeking career changes. In the latter category, people who have completed other courses of education or have embarked on other careers may wish to change to nursing. Additionally, there may be people who find their careers disrupted by technological changes, industrial dislocations, or altered priorities in public expenditures.

• Improving Opportunities for Educational Advancement

Recommendation 6

Licensed nurses at all levels who wish to upgrade their education so as to enhance career opportunities should not encounter unwarranted barriers to admission. State education agencies, nursing education programs, and employers of nurses should assume a shared responsibility for developing policies and programs to minimize loss of time and money by students moving from one nursing education program level to another.

It is essential that annual accretions to the nurse supply from new graduates be maintained, but it also is increasingly important to improve the opportunities of nurses already in the work force to attain higher levels of education. Although pursuit of higher education by large numbers of RNs already licensed will not necessarily augment overall numbers in practice, over time it can significantly change the characteristics of the supply, enhance individual opportunities for career advancement, and provide candidates for employment in categories that employers may find in short supply. Advancement of diploma and associate degree graduates to the baccalaureate level not only produces a result consistent with a goal espoused by many leaders in the profession but also enlarges the pool from which graduate nursing education can draw. Educational progression from less than a baccalaureate degree to higher degrees has been characteristic of the careers of many nurses who now hold advanced degrees.

In 1980, one in every ten RNs was enrolled in some form of educational program intended to advance his or her credentials. Although many educational programs have responded to the need of nurses for educational advancement by facilitating credit transfers or providing for advanced placement credits, many others still do not actively pursue this objective. Upward mobility for both LPNs and RNs has been hindered in many places by past failures of educational systems and individual institutions to plan their programs to make successive stages of nursing education "articulated," so that academic credits obtained can contribute maximally toward admission and progression in the next stage. Many state studies have identified educational advancement as a high priority, and in some states significant progress has been made toward this goal. Educational institutions will inevitably incur some added costs for steps taken to ease students' transitions from one educational program to another. On the other hand, where experienced nurses successfully challenge clinical requirements, educational institutions may also benefit from proportionately fewer enrollments in the more expensive clinical components of their nursing education programs.

Motivation is growing ever stronger for RNs and LPNs to pursue further education. Professional pressures on the individual come in part from the growing complexity and variety of nursing responsibilities and in part from anticipation that future career and promotional opportunities may rest on qualifications that differentiate nurses by academic credentials. Although not an approach preferred by some educators in terms of time and cost, attainment of future supply goals may well depend on a continual upgrading of the quality of a pool of nurses that is primarily nourished by streams of new entrants whose initial career objective may have been merely to secure nursing employment at minimum personal cost.

• Improving Collaboration Between Nursing Education and Nursing Services

Recommendation 7

Closer collaboration between nurse educators and nurses who provide patient services is essential to give students an appropriate balance of academic and clinical practice perspectives and skills during their educational preparation. The federal government should offer grants to nursing education programs that, in association with the nursing services of hospitals and other health care providers, undertake to develop and implement collaborative educational, clinical, and/or research programs.

Many employers tend to believe that newly graduated nurses from academic programs are inadequately prepared to assume the responsibilities of clinical nursing. Many nurse educators, on the other hand, believe that employers do not offer their graduates--especially those with baccalaureate preparation--the opportunity to practice at the level of professional skills for which they have been prepared. There is increasing concern and attention among nursing leaders to reduce this discord. Some few prototypes exist of organizational structures that provide unified nursing accountability, and to bring together the perspectives of educators and employers of nurses for the mutual benefit of patients, students, and nursing staffs. Other kinds of increased collaboration between nurse educators and nursing service staffs are found across the country.

The development of practical arrangements for improving communication and collaborative efforts between nurse educators and nursing service administrators requires the solution of a great many logistical, organizational, and financial problems among a large variety of institutions that do not have close affiliations. It is difficult and time consuming to provide incentives to test untried relationships and new patterns of accountability. Further experimentation and demonstrations are needed to guide institutions of all types in moving toward appropriate goals. Modest grants should be available to demonstrate innovative ways of implementing collaborative arrangements, including those that emphasize clinical and research appointments for faculty. Although the financial burden of developing new collaborative arrangements should fall primarily on those to whom benefits will accrue, some federal support would indicate a strong national interest in the problem and would provide impetus for wider experimentation. A reconciliation of differences between the goals and expectations of leaders in nursing practice and in education must occur to improve both the education of students and the care of patients.

• Increasing the Supply of Nurses with Graduate Education to Fill Advanced Positions in Nursing

Recommendation 8

The federal government should expand its support of fellowships, loans, and programs at the graduate level to assist in increasing the rate of growth in the number of nurses with master's and doctoral degrees in nursing and relevant disciplines. 2 More such nurses are needed to fill positions in administration and management of clinical services and of health care institutions, in academic nursing (teaching, research, and practice), and in clinical specialty practice.

In examining the future need for nurses, the committee identified a wide range of problems that can be alleviated only by increasing substantially the supply of nurses with advanced education. The nation's cadre of professional nurses is short of persons who have been educationally prepared for advanced positions in the administration of nursing services and nursing education programs, in education (including research), and in clinical specialty areas.

The complexity of today's health care settings demands managers who are skilled not only in nursing but in the techniques of human resource management, decision making, and budgetary management. Also, the competencies of nurses delivering care at the bedside depend to a great extent on the capabilities of their teachers, who must, within a relatively short period, guide and facilitate the students' acquisition of the theoretical knowledge and clinical experiences necessary to produce competent professionals. The claim of nursing education leaders that many members of current nursing school faculties are inadequately prepared to accomplish this purpose is borne out by the comments of employers of nurses as well as by comparisons of the academic preparation of nursing faculty to that of faculty in other disciplines. A closely related problem is the short supply of faculty engaged in research--a function performed in most disciplines by those who are academically based. Finally, although well qualified generalist nurses can deliver care effectively, the growing complexity of care in many health settings presents problems that increasingly require the specialized knowledge and experience of nurses with advanced nursing degrees, both to provide direct care and to provide consultation and training to less highly prepared staff nurses caring for patients with complex illnesses.

In times of severe economic constraints, states may be more willing to finance basic nursing education programs that are perceived as directly fulfilling local demand for nurses rather than to support master's and doctoral programs, whose graduates may leave a given state labor market because they have more opportunities. The committee believes that RNs with high quality graduate education are a scarce national resource and that their education merits continued federal support.

Although the demand for highly qualified nursing administrators, faculty members, researchers, and clinical specialists prepared at the graduate level has been increasing and is expected to continue to increase, the evidence of a scarcity of nurse educators is most apparent. Only a small portion of nurse faculty is prepared at the doctoral level. To increase the nation's supply of nurses with advanced degrees, public and private universities with graduate programs in nursing must expand and strengthen their nursing faculties. In the face of the shortage of academically qualified faculty with expertise in nursing-related disciplines, such as management, the behavioral and basic sciences, and research methodology, deans of schools of nursing have opportunities to attract faculty from relevant schools and departments in their universities or neighboring institutions both to fill immediate needs and to help build future teaching and research capabilities. Joint programs and other forms of collaborative arrangements between university academic units, such as with business schools, health administration programs, and social science departments (e.g., psychology, anthropology, and sociology), may be found desirable. Programmatic support from the federal government can help to improve graduate level nursing education in these and in other ways.

Lowering financial barriers through loans and grants to encourage full-time enrollment of RN graduate students will increase the supply more rapidly, because master's and doctoral students who must work to support their education take longer to complete it. Federal financial assistance to students in master's programs should be packaged with funds for programmatic support. The committee would expect, in line with the objective of strengthening the nursing profession as well as nursing education, that such programmatic and accompanying student support for master's programs would be available through competitive grants. In practice, nursing programs would be in an excellent competitive position to secure such grants, but arrangements in other programs should be possible.

Federal doctoral level support should result primarily in the strengthening of existing programs in nursing and not in the proliferation of new and possibly weak doctoral offerings. However, until schools of nursing have sufficient numbers of qualified faculty to meet the full range of scholarly interests and professional needs of doctoral students, financial aid in the form of fellowships to RN doctoral students should be designed so that such students are not precluded from pursuing doctoral studies in nursing-related disciplines. To encourage graduate students to return to nursing when they have earned their degrees, loans based on need should carry such service obligations. On the other hand, most committee members believe that fellowships awarded on the basis of scholarly excellence and promise of a fundamental contribution to the knowledge base should not carry the same kind of obligation.

Congressional Question Two: WHAT ARE THE REASONS NURSES DO NOT SERVE IN MEDICALLY UNDERSERVED AREAS AND WHAT ACTIONS COULD BE TAKEN TO ENCOURAGE NURSES TO PRACTICE IN SUCH AREAS?

An important exception to the generalization that there is a sufficient existing supply of generalist nurses for direct patient care was noted in the discussion following Recommendation 1 . That exception arises from the fact that the labor market cannot function properly when there are financial, geographic, and other barriers to the provision of medical care and other health services for disadvantaged segments of the population.

Lack of access to preventive and primary care services by residents of rural and inner-city areas remains one of our nation's most pressing health problems. The committee has found, not surprisingly, that there are serious shortages of nurses who are willing or able to work in such areas, and to care for patients in public hospitals and nursing homes. The shortages largely coincide with the lack of adequate medical facilities and services for many low-income people and the elderly. Many of the root causes lie in the nation's health care financing arrangements. Possible solutions to this overriding national health care problem are beyond the scope of the committee's assignment, but we have, nonetheless, identified actions closely related to the committee's charge that would help to encourage nurses to practice in underserved areas and to work with the elderly and other underserved populations.

• Alleviating the Maldistribution of Nurses by Educational Outreach

Recommendation 9

To alleviate nursing shortages in medically underserved areas, their residents need better access to all types of nursing education, including outreach and off-campus programs. The federal government should continue to cosponsor model demonstrations of programs with states, foundations, and educational institutions, and should support the dissemination of results.

There can be no major expectation that the nurse labor market will improve significantly in inner-city and rural areas unless concerted actions are taken to develop an indigenous supply. The greatest potential for relieving such shortages lies in attracting into nursing--and advancing within the profession--people who live in shortage areas.

Many potential candidates, however, cannot relocate or commute to places where they may find available nursing education suitable to their career goals and circumstances. New forms of communication technology offer opportunities for present programs to engage in nursing education, including advanced nurse training and continuing education. They have not been sufficiently exploited. Various forms of outreach programs can be designed to suit the requirements and convenience of students who, for reasons of family, residence, or the need to continue employment while studying, cannot readily attend existing campus programs. Where prototypes of such programs are now in existence, evaluation and dissemination of results should be supported by the federal government. Where, because of special difficulties, promising efforts require encouragement through modest financial support, the government should participate financially in a small number of model demonstrations.

• Encouraging Consortia of Nurse Educators and Nurse Employers in Shortage Areas to Increase Minority Student Opportunities

Recommendation 10

To meet the nursing needs of specific population groups in medically underserved areas and to encourage better minority representation at all levels of nursing education, the federal government should institute a competitive program for state and private institutions that offers institutional and student support under the following principles:

• Programs must be developed in close collaboration with, and include commitments from, providers of health services in shortage areas.
• Scholarships and loans contingent on commitments to work in shortage areas should be targeted, though not limited, to members of minority and ethnic groups to the extent that they are likely to meet the needs of underserved populations, including non-English-speaking groups.

Minority groups in the population, including new immigrants, are particularly disadvantaged both in their access to health services and in their access to educational opportunities in nursing. The committee recommends scholarships and loans for these purposes contingent on service commitments to shortage areas, although some members questioned the effectiveness or the equity of such provisions. Strategies to develop minority manpower to provide more adequate nursing services in medically underserved areas have been stated as goals, though inadequately supported by past legislation. These goals require re-emphasis and new approaches through a redirection of authorization and funding available under the Nurse Training Act.

Thus, in addition to general educational outreach efforts, nurse educators and health care employers should jointly develop programs to ensure that students are recruited from these special groups, that they will be given employment preference, and that they will gain clinical experience in shortage area facilities, e.g., rural and inner-city hospitals, nursing homes, and public health clinics. We believe that educational programs and health care facilities by working together in consortia can be successful in designing programs to recruit well-motivated students who will be attracted by improved prospects of future employment. The facilities themselves may benefit by work-study arrangements that will assure a future continuing supply of newly graduated nurses who live in the vicinity and are already familiar with their operations. Patients will benefit under the care of nursing service personnel who are more likely to be familiar with their health needs and life styles.

• Adequate Revenues for Inner-City Hospitals

Recommendation 11

Differential allowances in payment should take into account the special burdens on inner-city hospitals that demonstrate legitimate difficulties in financing services because of disproportionate numbers of uninsured or Medicaid and Medicare patients. Federal, state, and local governments and third-party payers should pay their fair shares of amounts necessary to prevent insolvency and to support acceptable levels of service, including nursing care.

Many inner-city public hospitals (that is, county-, city-, or state-owned), and some inner-city voluntary hospitals bear a primary burden of serving the unsponsored poor. They generally also serve disproportionately large numbers of Medicare and Medicaid patients for whose care they may not recover full payment of necessary expenditures. Many of these hospitals are teaching institutions affiliated with academic health centers and serve as regional referral centers for very sick patients requiring extraordinary inpatient medical and nursing attention. On an outpatient basis, they also provide a heavy volume of episodic primary care and emergency room services to otherwise medically underserved persons.

Failure of federal and state governments to cover certain services, or to allow payment sufficient to recover necessary outlays for services that are covered, threatens the existence of this essential part of the nation's health services structure. It stands in the way both of good patient care and of improving poor physical plant and general working conditions that contribute to the traditional difficulties these institutions encounter in recruiting and retaining nurses.

The service missions of some inner-city hospitals may result in justifiably higher costs and lower revenues than those in institutions classified as comparable in size or scope of service. Differential payments should take these factors into account. Although differential payments cannot assure an adequate nursing supply, they may be necessary to maintain institutional solvency. When new methods of payment are developed, it will be important to allow for the expense of service and management improvements to redress past deficiencies. By making service improvements possible, such payments may promote attainment of more competitive salary structures and better staffing of nursing services.

• Nursing Education for Care of the Elderly

Recommendation 12

The rapidly growing elderly population requires many kinds of nursing services for preventive, acute, and long-term care. To augment the supply of new nurses interested in caring for the elderly, nursing education programs should provide more formal instruction and clinical experiences in geriatric nursing. Federal support of such efforts is needed, as well as funding from states and private sources.

The most rapidly growing segment of the population--the elderly--is a group particularly in need of the many services that nurses can provide. Those among the elderly who are age 75 and older are the most prone to multiple disabilities and chronic diseases. They use hospital, nursing home, and home care services at rates double or triple those of the population as a whole. Elderly patients are found in almost all health care settings. Their needs for care range from preventive, acute care, and rehabilitative services that help them maintain maximum independent functioning to care that eases the course of terminal illness and its impact on both patient and family. Nursing students need realistic preparation to dispel common misconceptions about the problems of the elderly, including attitudinal orientation that will enable them to provide the most effective care in all institutional settings and in patients' homes. Neither basic nor advanced nursing education programs yet focus sufficiently on academic preparation and clinical experiences in geriatrics.

• Upgrading Existing Staff in Nursing Homes

Recommendation 13

Nursing service staffs in nursing homes certified as ''skilled nursing facilities" and in other institutions and programs providing care to the elderly often lack necessary knowledge and skills to meet the clinical challenges presented by these patients. Such facilities, in collaboration with nursing education programs and other private and public organizations, should develop and support programs to upgrade the knowledge and skills of the aides, LPNs, and RNs who work with elderly patients. States should assist vocational and higher education programs to respond to these needs. Federal support of such programs should be maintained.

Today in nursing homes there are large numbers of licensed nurses as well as aides and orderlies whose education and training did not provide them with the special knowledge needed to care for elderly patients who require skilled nursing. A cost effective way to improve the quality of care for the close to a million patients in these settings would be to provide staff already engaged in their care with additional in-service training or continuing education in geriatric nursing. However, in many localities adequate financing, program, and faculty resources are lacking and must be developed.

• Adequate Payment for Long-Term Care

Recommendation 14

The federal government (and the states, where applicable) should restructure Medicare and Medicaid payments so as to encourage and support the delivery of long-term care nursing services provided to patients at home and in institutions. For skilled nursing facilities, such payment policies should encourage the continuing education of present staffs and the recruitment of more licensed nurses (RNs and LPNs), and should permit movement toward a goal of 24-hour RN coverage.

Private insurance rarely offers benefits to cover the costs of health services that patients require for long-term illnesses and disabilities, either in their homes or in nursing homes. Medicare benefits, too, are almost entirely limited to acute care services. While Medicaid provides extensive benefits for the destitute elderly in nursing homes, in most states restrictive payment practices appear to discourage the employment of licensed nurses (RNs and LPNs).

Among the nursing homes certified for payment under the Medicaid and Medicare programs, slightly less than two-thirds of the patients are in homes certified either as a skilled nursing facility (SNF) only, or as some combination of SNF and intermediate care facility (ICF). Patients in such institutions usually are severely disabled and frequently are disoriented. Their conditions often require expert nursing services. By far the largest proportion of nursing service personnel in SNFs and combined SNF/ICFs are aides. Licensed nurses (RNs and LPNs) are responsible for their supervision, as well as for the direct care of patients, for recordkeeping, and for decisions about emergency situations that usually must be made with no physician in immediate attendance. Federal certification requirements call for only minimal RN staffing, i.e., in SNFs a full-time RN on the day shift every day of the week. Facilities have few incentives to exceed minimal staffing standards because such standards are likely to influence strongly the basis on which payment levels are calculated in the Medicaid program. Given the magnitude of nursing responsibilities for SNF patients, the committee believes that regulations and payment systems should be modified to advance toward a goal of 24-hour RN coverage.

• Legal and Reimbursement Barriers to Expanded Nursing Practice

Recommendation 15

There is a need for the services of nurse practitioners, especially in medically underserved areas and in programs caring for the elderly. Federal support should be continued for their educational preparation. State laws that inhibit nurse practitioners and nurse midwives in the use of their special competencies should be modified. Medicare, Medicaid, and other public and private payment systems should pay for the services of these practitioners in organized settings of care, such as long-term care facilities, free-standing health centers and clinics, and health maintenance organizations, and in joint physician-nurse practices. (Where state payment practices are broader, this recommendation is not intended to be restrictive.)

Nurse practitioners (NPs) are nurses whose education extends beyond the basic requirements for licensure as an RN and prepares them for expanded nursing functions in diagnostic and treatment needs of patients, as well as in primary prevention and health maintenance measures. At the beginning of 1983, there were about 20,000 NPs, of whom about 2,600 were nurse midwives. Many of them serve in rural and inner-city communities, especially with underserved populations, such as migrant workers, low-income mothers and children, and the elderly.

The provisions of some state practice acts have slowed or prohibited this expanded nursing practice, and varying degrees of limitation on payment for their services by Medicaid, Medicare, and third-party payers often prevent payment even for legally authorized services. Approximately half the states now provide some type of reimbursement under their Medicaid programs for physician extender services provided both by NPs and physician assistants. Since 1977, the Rural Health Clinic Services Act waives payment restrictions in the Medicare and Medicaid programs under defined safeguards if such physician extenders practice in certified rural health clinics located in designated underserved areas.

When they are employed in organized settings, NPs and nurse midwives have been shown to contribute to productivity gains and cost reductions. Even with the anticipated ample increases in physician supply, it is likely that NPs will be needed to serve hard-to-reach populations, to facilitate new organizational arrangements for providing health care in cost effective ways, especially in practice settings that operate within fixed budgets, and to augment the quality of care provided in nursing homes. Continued funding is needed for NP training, weighted toward supporting the preparation of RNs most likely to practice in underserved areas, in nursing homes, and in caring for the elderly in other settings. Thus, special attention should be directed to training as nurse practitioners RNs who already live in underserved areas or who work in long-term care settings.

Congressional Question Three: WHAT IS THE RATE AT WHICH AND THE REASONS FOR WHICH NURSES LEAVE THE NURSING PROFESSION? WHAT ACTIONS COULD BE TAKEN TO ENCOURAGE NURSES TO REMAIN OR RE-ENTER THE NURSING PROFESSION, INCLUDING ACTIONS INVOLVING PRACTICE SETTINGS CONDUCIVE TO THE RETENTION OF NURSES?

• Improving the Use of Nursing Resources

Recommendation 16

The proportion of nurses who choose to work in their profession is high, but examination of conventional management, organization, and salary structures indicates that employers could improve both supply and job tenure by the following:

• providing opportunities for career advancement in clinical nursing as well as in administration
• ensuring that merit and experience in direct patient care are rewarded by salary increases
• assessing the need to raise nurse salaries if vacancies remain unfilled
• encouraging greater involvement of nurses in decisions about patient care, management, and governance of the institution
• identifying the major deterrents to nurse labor force participation in their own localities and responding by adapting conditions of work, child care, and compensation packages to encourage part-time nurses to increase their labor force participation and to attract inactive nurses back to work.

The committee found that the problems of retention in the profession and high turnover in hospitals are less severe today than commonly believed. More than three out of every four RNs holding current licenses are actively engaged in nursing. Only about 5 percent have left nursing for other types of employment. A major reason labor force participation rates are high--having risen 6 percentage points in the last 3 years--may be that the profession affords the option of part-time and evening or night work for nurses with family responsibilities. However, the committee believes that many institutions have opportunities to further increase the effective participation of nurses in the part-time and inactive supply. Investments in measures to accomplish this goal are especially pertinent in areas of local shortage.

Turnover rates apparently are lower today than in the past. Although precise data are not systematically and comprehensively available, the average turnover in RN positions does not appear to be very much higher now than it is for women in any other stressful occupation. Much of the recent improvement has come about because employers engaged in strenuous recruitment campaigns and in the use of temporary nursing agencies have come to realize that strategies for retention are essential. Frequently they are more cost effective than alternatives that reinforce competition between hospitals for nurses inclined to change jobs in their search for better career opportunities, better working conditions, or better compensation.

Congress asked this study to suggest actions involving practice settings that would be conducive to the retention of nurses. Our conclusions focus on the responsibility of health care management to engage in analysis of the effect of its decisions--its actions and its lack of action--that cause nurses to enter and leave employment.

Of particular concern is the necessity for employers to retain experienced nurses. In light of the growing complexity of hospital care, their contributions should not be undervalued. Despite recent gains in the earnings of nurses, continuing activity is required to improve career opportunities and work environment. RNs earn significant promotions in hospitals today largely by moving into supervisory and management positions. Attention must also be given to promotions and salaries progressively adjusted to reward merit and experience in direct patient care.

• Cost Accounting for Nursing Services

Recommendation 17

Lack of precise information about current costs and utilization of nursing service personnel makes it difficult for nursing service administrators and hospital managers to make the most appropriate and cost effective decisions about assignment of nurses. Hospitals, working with federal and state governments and other third-party payers, should conduct studies and experiments to determine the feasibility and means of creating separate revenue and cost centers for direct nursing care units within the institution for case-mix costing and revenue setting, and for other fiscal management alternatives.

As cost containment pressures force hospital management to become more skilled at using resources productively, it becomes important that managers have the tools to identify nursing revenue and to allocate nursing costs accurately and that systems be developed especially to enable nurse management to accept responsibility for using nursing service staffs most effectively. To achieve these goals, management needs to develop much more accurate methods for disaggregating revenue and costs associated with nursing.

In the absence of greater operational experience and evaluation of effects, the committee can only conditionally endorse the concept of separate cost/revenue centers for nursing activities, but strongly recommends federal sponsorship and assessment by the hospital industry (with third-party payer encouragement) of experiments with methods potentially applicable to different types of providers under varying payment arrangements. This will require studies to determine the information requirements, costing procedures, effects on the delivery of nursing services, and cost impact of such developments.

• A Center for Nursing Research

Recommendation 18

The federal government should establish an organizational entity to place nursing research in the mainstream of scientific investigation. An adequately funded focal point is needed at the national level to foster research that informs nursing and other health care practice and increases the potential for discovery and application of various means to improve patient outcomes.

A substantial share of the health care dollar is expended on nursing care, and yet there is a remarkable dearth of research in nursing practice. The federal government's principal nursing research initiative--$5 million annually--is not at a level of visibility and scientific prestige to encourage scientifically oriented RNs to pursue careers devoted to research of direct applicability to the problems that nurses confront in patient care. The lack of adequate funding for research and the resultant scarcity of talented nurse researchers have inhibited such investigation.

The committee believes that a center of nursing research is needed at a high level in the federal government to be a focal point for promoting the growth of quality nursing research. Such an organizational base, adequately funded, would provide necessary leadership to expand the pool of experienced nurse researchers who can become more competitive for general health care research dollars. It would also promote closer interaction with other bases of health care research.

• Studies of the Competencies of RNs Prepared in Different Types of Education Programs

Recommendation 19

Federal and private funds should support research that will provide scientifically valid measurements of the knowledge and performance competencies of nurses with various levels and types of educational preparation and experience.

Many different pathways in nursing education lead to initial licensure as an RN. Nurse educators, nursing service administrators, and other nurse employers often have different perceptions about the outcomes from these different educational inputs and, more fundamentally, on the outcomes that should be expected, both in the short and long term.

As with most other kinds of postsecondary education, there is little empirical evidence on the performance differences of the graduates of these different types of nursing education programs according to established measurable criteria of knowledge, skills, and range of competencies. This creates problems for nurse educators planning curricula to encourage educational advancement, for nursing service administrators trying to utilize RNs and LPNs most efficiently, and for the various organized groups within nursing who are seeking to establish new levels of licensure or to retain the current ones. The current lack of consensus on objectives and performance measures and evidence seriously handicaps the efforts of higher education bodies and state university systems attempting to allocate resources for nursing education in ways that will best match demand or needs for nurses with different kinds of competencies.

• Evaluation of Promising Management Approaches

Recommendation 20

As national and regional forums identify promising approaches to problems in the organization and delivery of nursing services, there will be a need for wider experimentation, demonstration, and evaluation. The federal government, in conjunction with private sector organizations, should participate in the critical assessment of new ideas and the broad dissemination of research results.

Although individual health care institutions often develop better approaches to problems in the organization and delivery of nursing services, there is a dearth of systematic information on their generalizability. The committee recommends that the hospital industry and the professions of nursing and medicine develop a concerted effort to continue the work begun by the National Commission on Nursing to identify and assess existing experience with proposed innovative solutions. We also conclude that there is a federal role in stimulating innovation by disseminating information, by according national recognition to model solutions, and by supporting more rigorous evaluation than is likely to be employed by the industry itself. By focusing federal attention on these areas of research, the effect will be to draw the interest of other sources of support in the private sector.

• Information for Future Monitoring of the Nation's Nurse Demand and Supply

Recommendation 21

To ensure that federal and state policymakers have the information they need for future nurse manpower decisions, the federal government should continue to support the collection and analysis of compatible, unduplicated, and timely data on national nursing supply, education, and practice, with special attention to filling identified deficits in currently available information.

In order to maintain the necessary capability for monitoring the future balance between the nation's demand and perceived needs for licensed nurses (RNs and LPNs) and the supply, analysts depend on continuing streams of reliable national information from many sources. Some is collected periodically, some occasionally. Some is badly outdated, as in the instance of survey information concerning LPNs.

Data collection and analysis require the continued support of the federal and state governments and/or professional associations. The collection of new data to yield information not now available may require some rearrangement of priorities within available funding. In the course of this study, we have identified serious gaps in such areas as the costs and sources of financing of nursing education, nursing education curricula, the supply and distribution of LPNs, and the staffing of nursing homes.

The federal government, in cooperation with the nursing profession, nursing organizations, health care institutions, and state governments, should continue to provide leadership in nurse manpower data collection in order to maintain and improve definitional conformity, to provide a sense of priorities, and to minimize duplicative efforts.

• Costs and Financing to Implement the Recommendations

The committee has kept in mind the ever increasing economic pressures on public budgets and the concomitant emerging constraints on health care providers and educational institutions. We have culled from many desirable proposals those of less than urgent priority. We believe that each recommendation presented would require financial support for implementation. In combination, they represent a concerted public-private strategy for the effective use of the nation's health care resources. They build on solid foundations of policy reassessment and, thus, are designed to obtain maximum return from investments in nursing education and nursing services.

Three sources of federal support for the recommendations are discussed below: continued funding under the NTA, as amended; continued funding of student support for general higher education; and payment for services under Medicare and Medicaid. Specific costs of recommendations to the federal government are assessed only for the first source, the one that deals exclusively with nursing. The committee has not attempted to estimate expenditures needed to support recommendations concerning aid to secondary education or improvement in Medicare and Medicaid.

Support for recommended activities within the scope of the NTA objectives can be accommodated with modest additional sums, assuming continued authorization of the NTA and redirection of some of its existing provisions.

We estimate that our various recommendations for the strengthening and redirection of NTA programs could be implemented if funding for the NTA is restored to a level of about $80 million--the approximate average of annual appropriations between 1980 and 1982. This includes restoration of federal support for graduate education and other advanced nurse training to the average 1980-1982 level of $40 million. It also includes the added costs of improving access of the disadvantaged to nursing care and nursing education, of special project grants or contracts to support demonstrations and encourage new programs of educational and clinical collaboration, of outreach to minorities, of off-campus programs, of improvements in curricula to increase students' abilities to serve the elderly, of continuing education programs to upgrade skills of nursing home personnel, and of certain employer experiments in the better management of nursing resources.

The costs of implementing the committee's recommendations for stronger federal support of research and data collection involve modest increments in expenditures. For example, an increase on the order of $5 million per year for research could have a substantial impact in stimulating growth of capacity for research on nursing-related matters. A similar amount would greatly strengthen federal-state planning efforts for manpower studies and resource allocation. Many such activities primarily would entail redirection of effort.

Levels of expenditure for non-NTA programs are beyond the capacity of this study to quantify, except in terms of existing general levels of effort. We examined some problems, for example, those of inner-city hospitals and of nursing care for the elderly, that we felt unable to ignore but whose solutions would require substantial resources not fairly attributable to nursing even though nursing improvements indirectly may be at stake.

The committee also has presented strategies that private sector groups and institutions should pursue, such as improving the management of nursing personnel, attracting to a career in nursing students from nontraditional sources, and improving collaboration between nursing education and nursing service. To encourage such efforts, we recommend modest federal demonstration, evaluation, and dissemination expenditures under the NTA authority in the range of $1-2 million per year. Of course, there will be costs to others engaged in implementing these recommendations, but we expect that anticipation of either commensurate long-run savings or associated benefits to patients and to educational and employing institutions will be considered worth the cost.

In summary, the budgetary impact of the committee's recommendations entails (1) modest increases in essential expenditures under the NTA directed at resolving certain particular nurse shortages, (2) holding the line against possible erosion of outlays for higher education generally at both federal and state levels, and (3) modifying payment systems of public and third-party payers to permit providers of service to the poor and elderly to become financially secure and, thus, to increase the quality of their nursing services.

When the term "nurse" is used without qualification, it refers to a person licensed as a nurse, whether holding the license as a registered nurse or a practical nurse.

Two members of the committee wished to delete the words "and relevant disciplines." Their statement of exception is in Chapter V .

• Cite this Page Institute of Medicine (US) Division of Health Care Services. Nursing and Nursing Education: Public Policies and Private Actions. Washington (DC): National Academies Press (US); 1983. Summary and Recommendations.
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