Comment on this article
The
New Nurses
Not
so long ago, nurses were viewed as a kind of auxiliary to the medical
profession. Today,they are primary care providers, clinical specialists,
and, increasingly, investigators. As it celebrates its 75th anniversary,
Yale's School of Nursing is helping to redefine the profession.
November
1998
by Mark Alden Branch '86
Yale
nursing professor Ann Williams '81MSN has been around people with
AIDS and HIV about as long as anyone in medicine.
Since the days when health care workers were still trying to figure
out what caused the disease, Williams has nursed people through
its most devastating symptoms and complications. Lately, of course,
there has been some good news: Many patients are reporting dramatic
success with a combination, or "cocktail," of drugs that fight HIV.
But the drugs only work if people take them, which is harder than
it sounds.
"The schedules are
complicated, and you don't have the window of forgiveness you have
with other medications," says Williams. "If you miss even one dose,
you can really screw yourself up. You allow the virus to develop
resistance, and then there's a risk that more resistant strains
get transmitted." A patient who fails to keep up with the regimen,
in other words, may not only get sick, but could also become a public-health
hazard.
In her clinical practice
in New Haven, Williams has noticed something that seems to help
patients stay on track with their medication. "Sometimes when they're
in the office I say to them, 'How about if I just come over to the
house?'" she says. "Every time I make a home visit, it helps."
A few years ago, a nurse
might have thought this observation was, at best, worthy of passing
on casually to colleagues. But Williams wants to put her experience
to the test. Accordingly, she is about to embark on a controlled
study, funded by the National Institutes of Health, to determine
the efficacy of home nursing visits on compliance with an anti-HIV
drug regimen. Like a growing number of nurses, she is incorporating
clinical research into her career. At this stage in the managed-care
revolution, most people are probably aware that nurses can be more
than just "helpers" in starched uniforms. Increasingly, health maintenance
organizations and other providers are placing patients in the care
of nurse practitioners and nurse midwives—nurses with advanced
degrees and training in primary and specialty care. But clinical
research into patient care has also emerged as an integral part
of nursing—and a crucial strategy for a health care system that
is trying to cut costs without sacrificing patient well-being. Yale's
75-year-old School of Nursing, which was a pioneer in the integration
of research into a nurse's education in the 1950s, is becoming known
as a center of student and faculty research, especially since the
introduction of a research-based doctoral program in nursing science
four years ago.
"In general,
nursing research is concerned with the caring aspects of health
care rather than the curative,"
says Margaret Grey '76MSN, associate dean for research affairs at
the School of Nursing, whose own research involves diabetes management.
"The great majority of our work deals with helping people cope with
the hand they were dealt. My job isn't to fix diabetes. It's to
help people manage it in the best possible way, and from a holistic
point of view. That's the essence of nursing research."
Grey says that while
research has been part of nursing for decades, the amount of research
in the field has grown tremendously in recent years. "The first
nurse-researcher was, of course, Florence Nightingale," says Grey.
"She effected change in health care because she collected data in
a systematic way. Then there was a long period in which nursing
research was mostly about efficiency and time-motion studies. In
the 1950s and 1960s, there began to be studies in the outcomes of
nursing practice, but it's really been in the last 10 to 15 years
that we've had a clear focus on clinical nursing research."
A signal event in that
history was the establishment of the National Center for Nursing
Research, an arm of the National Institutes of Health, in 1986.
(The center became a full-fledged institute in 1993.) Now, nurses
have access to the same funding mechanism that drives other biomedical
research, funding that is becoming an important part of a school's
financial health. "In the past five years, there has been more attention
to research among faculty," says Williams, whose last two studies
have been funded by NIH components, including the National Institute
for Nursing Research. "This is partly driven by economics. You have
to land grants to survive."
While the level of research
at the school may be a new development, the School of Nursing has
always been concerned with strengthening the academic base of the
nursing profession. In fact, it was a dissatisfaction with the hospital-based
apprenticeship system of nursing education that led the Rockefeller
Foundation, beginning in 1923, to fund the first experimental years
of the School. As associate professor Helen Varney Burst '63MSN
says in her recent history of the School: "Education was to take
precedence over service to a hospital, with training based on an
educational plan rather than on service needs."
In
its early years, the School awarded a Bachelor of Nursing degree
to women who had previously completed two years of college.
In 1937, the entrance requirement was changed to a bachelor's degree,
and the degree, accordingly, became the Master of Nursing. This
program continued to provide a basic nursing education to college-educated
women (and, after 1955, men) until 1956, when President A. Whitney
Griswold ordered it replaced with a two-year Master of Science in
Nursing, an advanced degree program that was to be open only to
people who already had professional degrees in nursing. Griswold
hoped the School, like other parts of the University he was working
to reform, would emphasize academic inquiry over vocational training.
While the demise of
the MN program disappointed the School's faculty, students, and
alumni, they embraced their new mission, teaching research methodology
to faculty and students and embarking on original clinical research
into effective patient care. "In 1959, research by nursing faculty
in clinical practice was virtually unknown," writes Burst. But a
research project was—and still is—required of all MSN candidates.
Ann Williams credits
the research component of the MSN program with opening her mind
to the idea of combining research and practice. "I got a very positive
introduction to nursing research at Yale," she says. "Donna Diers
[Dean of the School from 1972 to 1984] was the kind of person who
tells you there are no boundaries. All this meant that a few years
later, when we were sitting around the clinic trying to figure out
what this new disease [AIDS] was, I wasn't intimidated by the idea
of doing research."
In 1965, the School
added a program to train nurse practitioners, and in 1974 it initiated
a three-year MSN program for college graduates without prior training
in nursing. Meanwhile, the idea for a doctoral program in nursing
had been under discussion since the early 1960s. By 1989, a doctoral
program was incorporated into a strategic plan for the School.
But
financially, times weren't good for the School or the University,
and instead of expansion, the School actually faced the threat of
extinction. Like many programs, departments, and schools
at Yale, the School of Nursing was given a hard look by President
Benno Schmidt and Provost Frank Turner, who were struggling to balance
Yale's budget. Schmidt in 1990 charged a committee with reviewing
the School of Nursing and making recommendations as to its future.
Closing the School, he said, was an option.
The committee gave
a halfhearted recommendation that the School remain open, although
a minority wanted to close it. Dean Judith Krauss responded with
what Burst calls a "strategy of nonconfrontational education" of
University officers and Corporation members about the School and
its importance. In the end, the strategy worked: Although the School
endured budget cuts along with the rest of the University, it was
allowed not only to stay in business, but to proceed with the new
doctoral program.
The new program, which
leads to a Doctor of Nursing Science (DNSc), calls for the most
extensive research the School has ever required of students. Margaret
Grey oversaw the introduction of the program in the fall of 1994
and led it until this year, when Ruth McCorkle was recruited from
the University of Pennsylvania. In May, the School awarded its first
DNSc degrees to three members of the first class to enter in 1994.
There are now 24 students in the program (including one man).
Grey
says that while there are dozens of doctoral programs in nursing
across the country, Yale's is unique because of the breadth of its
goals. "Our focus
is on clinical nursing research and its translation into health
policy," she explains. "Unlike most schools, our mission is to improve
health care, not just to improve nursing."
Students in the program
are paired with faculty researchers with whom they share an area
of interest. "We take seriously the notion that clinical research
is learned in a mentor relationship," says Grey. "We want students
who are interested in what our faculty members are doing."
Grey's own mentoring
of a doctoral candidate serves as an example. A nurse practitioner,
Grey has worked for 27 years with children who have Type 1 diabetes
(often called juvenile diabetes). While people with this condition
can live more or less normal lives, they must pay strict attention
to diet, exercise, and metabolism, watching their carbohydrate intake,
administering insulin shots, and testing their blood sugar four
or more times a day. Studies show that by keeping their blood sugar
within a prescribed range, diabetics can avoid complications such
as circulatory problems and blindness.
Compliance is more or
less achievable when capable parents are responsible for monitoring
their children's diabetes. But as children enter their teens, they
take on more of that responsibility—at the same time they are
facing a whole new set of emotional and social challenges. Under
such circumstances, managing diabetes can be difficult.
Observing this, Grey
led a team of researchers on a study to see if adolescents could
improve their control through "coping skills training" that includes
role-playing and examining various situations involving peers and
parents.
"The
usual way to try to improve teenagers' compliance is to beat them
over the heads with information," says
Grey. "But they already know the answers. It's when they get with
other kids that things get complicated. We tried to give them the
skills to negotiate social situations in win-win ways. And it improved
their metabolic condition and their quality of life."
The group that received
training in coping skills showed a 42 percent improvement in metabolic
control over a group that had standard treatment. Grey's study won
an award from the American Nursing Association's Council for Nursing
Research.
One of Grey's research
assistants on the study was a doctoral candidate named Susan Sullivan-Bolyai,
whose dissertation project grew out of that study. "In between data
collection with Margaret, I talked with the parents," Sullivan-Bolyai
remembers. "Even though their kids were teenagers, they remembered
very clearly their initial learning experiences when their children
were diagnosed. I began to wonder about the experiences of day-to-day
management with children under four." Sullivan-Bolyai has devised
a study that examines how parents learn to deal successfully with
their children's diabetes.
Sullivan-Bolyai's study
falls under the heading of "qualitative" research, a kind of inquiry
that often involves questioning patients about their conditions,
their understanding of them, and their strategies for coping with
them—questions with answers that are not always easily quantifiable
but are nonetheless useful to people making health care policy.
"There are standards for evaluating the rigor of this type of scientific
method," says Catherine Lynch Gilliss, who became Dean of the School
last summer, "but these methods and the standards are less well
known in the biomedical community."
"I move back and forth
between qualitative and quantitative research," says Ann Williams.
"You really can't do one without the other. When I did my first
study on IV drug users and HIV, we realized we couldn't even write
a survey questionnaire because we didn't know what they did. So
we started with an open-ended study to find out about their lives."
Whether quantitative
or qualitative, research about patient care has become ever more
critical as government and industry try to bring health care costs
under control. "Managed care has looked to find the least expensive
care providers," says Gilliss. "Throughout the whole system you've
seen a squeezing down. People are trying to find the lowest-level
person who could do the job well."
Or, if
not a person, a machine.
Nursing professor Marge Funk '84MSN, '92PhD, whose specialty is
cardiovascular critical care nursing, has built her research career
on questions surrounding the use of advanced technology with heart
patients. Her last study was a direct response to a budget cut that
alarmed many in her profession: the elimination of registered nurses
who watched for life-threatening heart-rhythm abnormalities in hospitalized
heart patients from a central bank of monitors. Her nine-month study
showed that potentially dangerous arrhythmias were less likely to
be detected without a monitor watcher present, but since the study
did not show that deaths were more likely to occur, it had little
impact on hospital policy.
Funk's current project
addresses the trend toward shorter hospital stays for patients who've
had heart surgery. To try to learn what happens to these patients
after they leave the hospital, Funk has persuaded a number of them
to wear small pager-like monitors with leads attached to their chests
for two weeks following their discharge. If and when they feel unusual
symptoms that may indicate heart rhythm problems, they can press
a button on the monitor to record the incident. They can then send
the data over the telephone to Funk or a member of her team, who
can tell them instantly if there is cause for concern.
In addition to testing
the efficacy of the technology, Funk says that the patients in the
study have appreciated the telephone contact with her team. "If
they have any minor concerns," she says, "we can talk to them and
reassure them."
Such approaches to
treatment, like Williams's home visits for people with AIDS, may
become an increasing part of health care in the coming years. "There
aren't as many nurses as there used to be," says Funk. "Now we have
to get creative: home monitoring, home visits, telephone calls—just having a knowledgeable voice on the other end of the phone
can be valuable."
While research has become
more and more common among Yale's nursing faculty, don't expect
them to disappear from the classroom or the hospital anytime soon.
For the most part, the kind of research being done at the School
grows out of the tradition of faculty involvement in clinical practice.
The faculty have always worked in hospitals, clinics, and other
patient-care settings to inform their teaching; now it informs their
research as well. "The wonderful thing about nursing research is
that it brings intellectual challenge and academic rigor to the
practice of care," says Ann Williams. "It's the best of both worlds."
|