Florence Nightingale

Nightingale has been described as a reformer, reactionary, and researcher who influenced nursing specifically and health care in general. Nightingale’s book, Notes on Nursing (1859), described her initial research activities, which focused on the importance of a healthy environment in promoting the patient’s physical and mental well-being. She identified the need to gather data on the environment, such as ventilation, cleanliness, temperature, purity of water, and diet, to determine their influence on the patient’s health (Herbert, 1981).

Nightingale is also noted for her data collection and statistical analyses during the Crimean War. She gathered data on soldier morbidity and mortality rates and the factors influencing them and presented her results in tables and pie charts, a sophisticated type of data presentation for the period (Cohen, 1984; Palmer, 1977). Nightingale was the first woman elected to the Royal Statistical Society (Oakley, 2010), and her research was highlighted in the periodical Scientific American in 1984 (Cohen, 1984).

Nightingale’s research enabled her to instigate attitudinal, organizational, and social changes. She changed the attitudes of the military and society toward the care of the sick. The military began to view the sick as having the right to adequate food, suitable quarters, and appropriate medical treatment, a change that greatly reduced the mortality rate (Cook, 1913). Nightingale improved the organization of army administration, hospital management, and hospital construction. Because of Nightingale’s research evidence and influence, society began to accept responsibility for testing public water, improving sanitation, preventing starvation, and decreasing morbidity and mortality rates (Palmer, 1977).

Early 1900s

From 1900 to 1950, research activities in nursing were limited, but a few studies advanced nursing education. These studies included the Nutting Report, 1912; Goldmark Report, 1923; and Burgess Report, 1926 (Abdellah, 1972; Johnson, 1977). On the basis of recommendations of the Goldmark Report, more schools of nursing were established in university settings. The baccalaureate degree in nursing provided a basis for graduate nursing education, with the first master of nursing degree offered by Yale University in 1929. Teachers College at Columbia University offered the first doctoral program for nurses in 1923 and granted a degree in education (Ed.D.) to prepare teachers for the profession. The Association of Collegiate Schools of Nursing, organized in 1932, promoted the conduct of research to improve education and practice. This organization also sponsored the publication of the first research journal in nursing, Nursing Research, in 1952 (Fitzpatrick, 1978).

A research trend that started in the 1940s and continued in the 1950s focused on the organization and delivery of nursing services. Studies were conducted on the numbers and kinds of nursing personnel, staffing patterns, patient classification systems, patient and nurse satisfaction, and unit arrangement. Types of care such as comprehensive care, home care, and progressive patient care were evaluated. These evaluations of care laid the foundation for the development of self-study manuals, which are similar to the quality assurance manuals of today (Gortner & Nahm, 1977).

Nursing Research in the 1950s and 1960s

In 1950, the American Nurses Association (ANA) initiated a 5-year study on nursing functions and activities. The findings were reported in Twenty Thousand Nurses Tell Their Story, and this study enabled the ANA to develop statements on functions, standards, and qualifications for professional nurses. Also during this time, clinical research began expanding as specialty groups, such as community health, psychiatric, medical-surgical, pediatric, and obstetrical nurses, developed standards of care. The research conducted by ANA and the specialty groups provided the basis for the nursing practice standards that currently guide professional nursing practice (Gortner & Nahm, 1977).

Educational studies were conducted in the 1950s and 1960s to determine the most effective educational preparation for the registered nurse. A nurse educator, Mildred Montag, developed and evaluated the 2-year nursing preparation (associate degree) in junior colleges. Student characteristics, such as admission and retention patterns and the elements that promoted success in nursing education and practice, were studied for both associate and baccalaureate degree–prepared nurses (Downs & Fleming, 1979).

In 1953, an Institute for Research and Service in Nursing Education was established at Teachers College, Columbia University, which provided research-learning experiences for doctoral students (Werley, 1977). The American Nurse’s Foundation, chartered in 1955, was responsible for receiving and administering research funds, conducting research programs, consulting with nursing students, and engaging in research. In 1956, a Committee on Research and Studies was established to guide ANA research (See, 1977).

A Department of Nursing Research was established in the Walter Reed Army Institute of Research in 1957. This was the first nursing unit in a research institution that emphasized clinical nursing research (Werley, 1977). Also in 1957, the Southern Regional Educational Board (SREB), the Western Interstate Commission on Higher Education (WICHE), Midwest Nursing Research Society (MNRS), and the New England Board of Higher Education (NEBHE) were developed. These organizations are actively involved in promoting research and disseminating the findings today. ANA sponsored the first of a series of research conferences in 1965, and the conference sponsors required that the studies presented be relevant to nursing and conducted by a nurse researcher (See, 1977). During the 1960s, a growing number of clinical studies focused on quality care and the development of criteria to measure patient outcomes. Intensive care units were being developed, promoting the investigation of nursing interventions, staffing patterns, and cost-effectiveness of care (Gortner & Nahm, 1977).

Nursing Research in the 1970s

In the 1970s, the nursing process became the focus of many studies, with the investigations of assessment techniques, nursing diagnoses classification, goal-setting methods, and specific nursing interventions. The first Nursing Diagnosis Conference, held in 1973, evolved into the North American Nursing Diagnosis Association (NANDA). In 2002, NANDA became international and is now known as NANDA-I. NANDA-I supports research activities focused on identifying appropriate diagnoses for nursing and generating an effective diagnostic process. NANDA’s journal, Nursing Diagnosis, was published in 1990 and was later renamed International Journal of Nursing Terminology and Classifications. Details on NANDA-I can be found on their website at http://www.nanda.org/.

The educational studies of the 1970s evaluated teaching methods and student learning experiences. The National League for Nursing (NLN), founded in 1893, has had a major role in the conduct of research to shape nursing education. Currently, NLN provides programs, grants, and resources to advance nursing education research in “pursuit of quality nursing education for all types of nursing education programs” (NLN, 2011; http://www.nln.org/aboutnln/index.htm/). A number of studies were conducted to differentiate the practices of nurses with baccalaureate and associate degrees. These studies, which primarily measured abilities to perform technical skills, were ineffective in clearly differentiating between the two levels of education.

Primary nursing care, which involves the delivery of patient care predominantly by registered nurses (RNs), was the trend for the 1970s. Studies were conducted to examine the implementation and outcomes of primary nursing care delivery models. The number of nurse practitioners (NPs) and clinical nurse specialists (CNSs) with master’s degrees increased rapidly during the 1970s. Limited research has been conducted on the CNS role; however, the NP and nurse midwifery roles have been researched extensively to determine their positive impact on productivity, quality, and cost of health care. In addition, those clinicians with master’s degrees acquired the background to conduct research and to use research evidence in practice.

In the 1970s, nursing scholars began developing models, conceptual frameworks, and theories to guide nursing practice. The works of these nursing theorists also directed future nursing research. In 1978, a new journal, Advances in Nursing Science, began publishing the works of nursing theorists and the research related to their theories. The number of doctoral programs in nursing and the number of nurses prepared at the doctoral level greatly expanded in the 1970s (Jacox, 1980). Some of the nurses with doctoral degrees increased the conduct and complexity of nursing research; however, many doctorally prepared nurses did not become actively involved in research. In 1970, the ANA Commission on Nursing Research was established; in turn, this commission established the Council of Nurse Researchers in 1972 to advance research activities, provide an exchange of ideas, and recognize excellence in research. The commission also prepared position papers on subjects’ rights in research and on federal guidelines concerning research and human subjects, and it sponsored research programs nationally and internationally (See, 1977).

Federal funds for nursing research increased significantly, with a total of slightly more than $39 million awarded for research in nursing from 1955 to 1976. Even though federal funding for nursing studies rose, the funding was not comparable to the $493 million in federal research funds received by those doing medical research in 1974 alone (de Tornyay, 1977).

Sigma Theta Tau, the International Honor Society for Nursing, sponsored national and international research conferences, and the chapters of this organization sponsored many local conferences to promote the dissemination of research findings. Image was a journal initially published in 1967 by Sigma Theta Tau now titled Journal of Nursing Scholarship, the journal publishes many nursing studies and articles about research methodology. A major goal of Sigma Theta Tau is to advance scholarship in nursing by promoting the conduct, communication, and use of research evidence in nursing. The addition of two new research journals in the 1970s, Research in Nursing & Health in 1978 and Western Journal of Nursing Research in 1979, also increased the communication of nursing research findings. However, the findings of many studies conducted and published in the 1970s were not being used in practice, so Stetler and Marram (1976) developed a model to promote the communication and use of research findings in practice.

Professor Archie Cochrane originated the concepts of evidence-based practice with a book he published in 1972 titled Effectiveness and Efficiency: Random Reflections on Health Services. Cochrane advocated the provision of health care based on research to improve the quality of care and patient outcomes. To facilitate the use of research evidence in practice, the Cochrane Center was established in 1992, and the Cochrane Collaboration in 1993. The Cochrane Collaboration and Library house numerous resources to promote EBP, such as systematic reviews of research and evidence-based guidelines for practice (discussed later in this chapter) (see the Cochrane Collaboration at www.cochrane.org/).

Nursing Research in the 1980s and 1990s

The conduct of clinical nursing research was the focus in the 1980s and 1990s. A variety of clinical journals (Achieves of Psychiatric Nursing; Cancer Nursing; Cardiovascular Nursing; Dimensions of Critical Care Nursing; Heart & Lung; Journal of Neurosurgical Nursing; Journal of Obstetric, Gynecologic, and Neonatal Nursing; Journal of Pediatric Nursing; Oncology Nursing Forum; and Rehabilitation Nursing) published a growing number of studies. One new research journal was started in 1987, Scholarly Inquiry for Nursing Practice, and two in 1988, Applied Nursing Research and Nursing Science Quarterly.

Even though the body of empirical knowledge generated through clinical research grew rapidly in the 1970s and 1980s, little of this knowledge was used in practice. Two major projects were launched to promote the use of research-based nursing interventions in practice: the Western Interstate Commission for Higher Education (WICHE) Regional Nursing Research Development Project and the Conduct and Utilization of Research in Nursing (CURN) Project. In these projects, nurse researchers, with the assistance of federal funding, designed and implemented strategies for using research findings in practice. The WICHE Project participants selected research-based interventions for use in practice and then functioned as change agents to implement the selected intervention in a clinical agency. Because of the limited amount of research that had been conducted, the project staff and participants had difficulty identifying adequate clinical studies with findings ready for use in practice (Krueger, Nelson, & Wolanin, 1978).

The CURN Project was a 5-year venture (1975-1980) directed by Horsley, Crane, Crabtree, and Wood (1983) to increase the utilization of research findings by (1) disseminating findings, (2) facilitating organizational modifications necessary for implementation, and (3) encouraging collaborative research that was directly transferable to clinical practice. Research utilization was seen as a process to be implemented by an organization rather than by an individual nurse. The Project team identified the activities of research utilization to involve identification and synthesis of multiple studies in a common conceptual area (research base) as well as transformation of the knowledge derived from a research base into a solution or clinical protocol. The clinical protocol was then transformed into specific nursing actions (innovations) that were administered to patients. The implementation of the innovation was to be followed by clinical evaluation of the new practice to ascertain whether it produced the predicted result (Horsley et al., 1983). The clinical protocols developed during the project were published to encourage nurses in other healthcare agencies to use these research-based intervention protocols in their practice (CURN Project, 1981-1982).

To ensure that the studies were incorporated into nursing practice, the findings needed to be synthesized for different topics. In 1983, the first volume of the Annual Review of Nursing Research was published (Werley & Fitzpatrick, 1983). This annual publication contains experts’ reviews of research in selected areas of nursing practice, nursing care delivery, nursing education, and the profession of nursing. The Annual Review of Nursing Research continues to be published each year to (1) expand the synthesis and dissemination of research findings, (2) promote the use of research findings in practice, and (3) identify directions for future research.

Many nurses obtained master’s and doctoral degrees during the 1980s and 1990s, and postdoctoral education was encouraged for nurse researchers. The ANA (1989) stated that nurses at all levels of education have a role in research, which extends from reading research to conducting complex, funded programs of research (see Chapter 1). Another priority of the 1980s and 1990s was to obtain greater funding for nursing research. Most of the federal funds in the 1980s were designated for studies involving the diagnosis and cure of diseases. Therefore, nursing received a small percentage of the federal research and development (R&D) funds (approximately 2% to 3%) compared with medicine (approximately 90%), even though nursing personnel greatly outnumbered medical personnel (Larson, 1984). However, in 1985, the ANA achieved a major political victory for nursing research with the creation of the National Center for Nursing Research (NCNR) within the National Institutes of Health (NIH). This center was created after years of work and two presidential vetoes (Bauknecht, 1986). The purpose of the National Center was to support the conduct of basic and clinical nursing research and the dissemination of findings. With its creation, nursing research had visibility at the federal level for the first time. In 1993, during the tenure of its first director, Dr. Ada Sue Hinshaw, the NCNR became the National Institute of Nursing Research (NINR). This change in title enhanced the recognition of nursing as a research discipline and expanded the funding for nursing research.

Outcomes research emerged as an important methodology for documenting the effectiveness of healthcare services in the 1980s and 1990s. This type of research evolved from the quality assessment and quality assurance functions that originated with the professional standards review organizations (PSROs) in 1972. During the 1980s, William Roper, the director of the Health Care Finance Administration (HCFA), promoted outcomes research for determining the quality and cost-effectiveness of patient care (Johnson, 1993).

In 1989, the Agency for Health Care Policy and Research (AHCPR) was established to facilitate the conduct of outcomes research (Rettig, 1991). This Agency also had an active role in communicating research findings to healthcare practitioners and was responsible for publishing the first evidence-based national clinical practice guidelines in 1989. Several of these guidelines, including the latest research findings with directives for practice, were published in the 1990s. The Healthcare Research and Quality Act of 1999 reauthorized the AHCPR, changing its name to the Agency for Healthcare Research and Quality (AHRQ, 2012). This significant change positioned the AHRQ as a scientific partner with the public and private sectors to improve the quality and safety of patient care by promoting the use of the best research evidence available in practice.

Building on the process of research utilization, physicians, nurses, and other healthcare professions focused on the development of EBP during the 1990s. A research group led by Dr. David Sackett at McMaster University in Canada developed explicit research methodologies to determine the “best evidence” for practice. The term evidence based was first used by David Eddy in 1990, with the focus on providing EBP for medicine (Craig & Smyth, 2012; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).

In 1990, the ANA leaders established the American Nursing Credentialing Center (ANCC) and approved a recognition program for hospitals called the Magnet Hospital Designation Program for Excellence in Nursing Services (ANCC, 2012). This program has evolved over the last 20 years but has remained true to its commitment to promote research conducted by nurses in clinical settings and to support implementation of care based on the best current research evidence.

Nursing Research in the 21st Century

The vision for nursing research in the 21st century includes conducting quality studies through the use of a variety of methodologies, synthesizing the study findings into the best research evidence, using this research evidence to guide practice, and examining the outcomes of EBP (Brown, 2009; Craig & Smyth, 2012; Doran, 2011; Melnyk & Fineout-Overholt, 2011). The focus on EBP has become stronger over the last decade. In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised the accreditation policies for hospitals to support the implementation of evidence-based health care. To facilitate the movement of nursing toward EBP in clinical agencies, Stetler (2001) developed her Research Utilization to Facilitate EBP Model (see Chapter 19 for a description of this model). The focus on EBP in nursing was supported with the initiation of the Worldviews on Evidence-Based Nursing journal in 2004.

The focus of healthcare research and funding has expanded from the treatment of illness to include health promotion and illness prevention. Healthy People 2000 and Healthy People 2010, documents published by the U.S. Department of Health and Human Services (U.S. DHHS 1992, 2000), have increased the visibility of health promotion goals and research. Health People 2020 (U.S. DHHS, 2012) information is now available at the department’s website, http://www.healthypeople.gov/2020/. Some of the new topics covered by Healthy People 2020 include: adolescent health; blood disorders and blood safety; dementias; early and middle childhood; genomics; global health; healthcare-associated infections; lesbian, gay, bisexual, and transgender health; older adults; preparedness; sleep health; and social determinants of health. In the next decade, nurse researchers will have a major role in the development of interventions to promote health and prevent illness in individuals, families, and communities.

The AHRQ has been designated the lead agency supporting research designed to improve the quality of health care, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. The AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes, quality, cost, use, and access. This research information promotes effective healthcare decision making by patients, clinicians, health system executives, and policy makers. The three future goals of the AHRQ are focused on the following:

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