The Evolution of Nursing Research

Abstract

THE RESEARCH CULTURE in nursing has evolved in the last 150 years, beginning
with Nightingale’s work in the mid-1850s and culminating in the creation of the
National Institute of Nursing Research (NINR) at the National Institues of Health
(NIH). This article highlights nursing’s efforts to facilitate the growth of the
research culture by developing theory, establishing the importance of a
research-based practice, advancing education, and providing avenues for
dissemination of research. Similarities with the chiropractic profession are
discussed, along with a commentary by Cheryl Hawk, D.C, Ph.D.

Keywords: Nursing education, Nursing research, Nursing theory, Research

culture, Research dissemination

EVOLUTION OF NURSING RESEARCH

The development of a research culture in nursing in many ways parallels that of

chiropractic, and by reviewing key aspects of the evolution of the science of
nursing, there are lessons to be learned, and mistakes to be avoided. Nursing
research has changed dramatically in the past 150 years, beginning with
Florence Nightingale in the 19th century. Clearly, nursing research has not
always had the influence and significance it holds today. In fact, for a number of
years after Nightingale’s work, little is found in the literature concerning nursing
research. This is perhaps due to the past perception of nursing as an
apprenticeship in a task-oriented caring profession (1). Although research was
conducted with respect to nursing education and administration in the first half
of the 20th century, it was not until the 1950s that nursing research began the
advancement that has been seen in the past three decades. This is due to many
factors: an increase in the number of nurses with advanced academic
preparation, the establishment of vehicles for dissemination of nursing
research, federal funding and support for nursing research, and the upgrading of
research skills in faculty and students. This article provides a brief review of the
development of research in nursing, and along with it, the theory that has
guided that process.
NURSING THEORY DEVELOPMENT

As with other practice professions, nursing requires a knowledge foundation

that is based on theory and derived from systematic research. The first nursing
theorist, Florence Nightingale, created detailed reports of both medical and
nursing matters as chief nurse for the British in the Crimean War in the mid-
1850s. Nightingale noted that “… apprehension, uncertainty, waiting,
expectation, fear of surprise, do a patient more harm than any exertion” (p. 6)
(2). As a result, Nightingale’s conceptualization of nursing included the need to
have an understanding of the laws of nature, the prevention of disease, and the
use of personal power. She viewed persons as both physical and spiritual
beings, emphasizing the importance of the environment and the need to care
for the patient, not the disease. With her emphasis on the environment,
changes in nutrition, hydration, and sanitation resulted, and mortality rates
dropped drastically during the Crimean War (3). In subsequent years,
Nightingale developed “laws of nursing” that formed the basis for nursing
science and guided nursing education in the United States from 1850 to the
1950s (4).

In the 1960s, nursing theory was used to guide teaching rather than research or
practice. This was a natural outgrowth of nursing’s earlier focus on education
and professional identity. Additionally, the National League for Nursing (the
professional accrediting body) stipulated a conceptual framework for
curriculum. Paradigmatic concepts integral to nursing were identified as person,
environment, health, and nursing (5–7), and scientific energies were spent
developing curriculum that corresponded to existing theories (7). At this point in
time, nurse educators began to urge students to “care for the whole person”
and textbooks underscored the importance of “holism” in nursing, with subtitles
such as “The Biopsychosocial Approach.” Nurse authors acknowledged multiple
causality in human illness, but all too often research, curricula, and textbooks
reflected linear cause-and-effect models rather than multivariate approaches.

The 1950s and 1960s saw the development of theories explaining the art and
science of nursing. Hildegard Peplau published Interpersonal Relations in
Nursing (8) in 1952, based on her work as a psychiatric nurse. Other theories.
included Levine’s Conservation Principles of Nursing (9) in, 1967; Roger’s
Introduction to the Theoretical Basis of Nursing (10) in 1970, and The Science of
Unitary Man (11) in 1980, followed by The Science of Unitary Human Beings, a
Paradigm for Nursing (12) in 1983. Imogene King published A Theory for
Nursing: Systems, Concepts, Process (13) in 1981, and Sister Calista Roy
published her adaptation model (14) in 1980. These “grand” theories were
complex and key concepts were hard to measure empirically. Thus it was
difficult to test these early nursing theories through research. With the
emphasis on clinical nursing research, the recent trend has been to develop and
test midrange theories that describe patient problems and nursing practice.

NURSING RESEARCH DEVELOPMENT

In 1859, Nightingale used the battlefield hospitals of the Crimean War as her
research laboratory, using an epidemiological process to describe the morbidity
and mortality of sick and injured soldiers. Her pioneering epidemiological
research and statistical methodology (documenting the relationship between
the environment and health status of soldiers) was the hallmark of scientific
investigation in nursing (4,15).

An historical review from 1900 to 1949 reveals that nursing research in the
United States (see Table 1) was in its infancy, focusing on nursing education,
nurses, nursing students, and ways to organize nurses’ work. As noted earlier, at
this time, nursing theory was discussed solely as a means of developing and
organizing educational curriculum. Early educators were unable to develop
educational programs that both represented a nursing perspective and helped
students focus on nursing concepts and problems rather than medical concepts
and problems. In the first half of this century, groups were formed to answer
such questions as: what is nursing, what do nurses do, and how unique is
nursing from other health science disciplines? Professional debates raged as to
whether nursing was merely a “poor stepsister” of medicine or whether it was
part of the biological, natural, or physical sciences (4). Research during this
period was essentially nonexistent in terms of nursing practice.
It was not until the 1980s that nursing devoted a sizeable portion of its research
effort to patients and patient behavior, an emphasis that emerged logically as
nurses began to recognize the interplay between behavior and rehabilitation or
recovery from illness. Historically, nurses searched for single causative agents
when promoting health or preventing illness, even as they acknowledged the
contributions of multiple other factors. Predominant modes of inquiry relied on
early in the development of a culture of nursing research were empirical (logical
positivist). Nurse researchers modeled themselves after colleagues in the basic
and biomedical sciences, perhaps in an effort to seek scientific validation. Only
during the 1980s and 1990s did nurses increasingly use qualitative research
methods, such as phenomenology and ethnography, to explain complex human
phenomena. Therefore, nurse researchers are just beginning to respond to the
need to view human problems in less reductionistic terms when the research
questions call for a holistic combination of quantitative and qualitative research
methodologies (16). Over the past two decades, many nurses have pursued
further education, consultation, or research to enhance their understanding and
ability to respond constructively to patient behavior. For example, by the mid-
1980s, there was a sizable increase in nursing studies of individuals and families
experiencing developmental, environmental, or illness-generated crisis
situations involving both acute and long-term stress responses (17–20).

During the 1990s, nursing practice underwent a clinical revolution in response

to societal, medical, scientific, and technologic advances. Changes in nursing
practice began to result from nursing research (e.g., research-based practice
guidelines) as the efforts of individuals both in and outside of nursing (e.g.,
National Academy of Science, National Institute for Nursing Research, and major
foundations) coalesced to stimulate and support clinical nursing research.
Concurrently, there was a new surge of interest among nurses themselves in
redefining the problems of their practice and delineating the gaps in knowledge
underpinning their practice base. As noted earlier, the current decade has been
marked by interest in multiple modes of inquiry (qualitative and quantitative)
for a practice discipline which must address complex human phenomena. In the
past, the type of research questions most often addressed through nursing
research were of a descriptive or exploratory nature. However, nurse
researchers are now going beyond “what is” and “how” questions and are
addressing more explanatory or predictive-level questions using
methodologically rigorous experimental and quasi-experimental designs as they
redefine clinical problems and systematically address gaps in their knowledge
base. After becoming established in the research arena, nursing researchers
have expanded to incorporate and collaborate on interdisciplinary studies,
health care systems and health services research, and taxonomies such as
Nursing Intervention Classification (NIC) (21) and Nursing Outcomes
Classification (NOC) (22). The taxonomies represent efforts to define what
nurses do and outcomes sensitive to nursing interventions.

The culture of nursing research has now advanced to the point where
consideration can be given not just to the conduct of research, but also to its
application in practice. The conduct of research is not the end, but rather a
means through which practice is improved by utilizing research findings.
Research utilization is the process of conveying and applying research-based
knowledge to impact or change existing practices in the health care system (23).
The primary components of research utilization involve summarizing knowledge
generated through research; imparting the research knowledge to nurses, other
health professionals, policymakers, and consumers of health care; and
accomplishing desired outcomes for patients, their families, and health care
providers and agencies. Models for research utilization were developed in the
1970s, beginning with the Western Interstate Commission for Higher Education
in Nursing (WCHEN) Regional Program for Nursing Development (24). Other
models include the Conduct and Utilization of Research in Nursing (CURN)
project (25), the Stetler/Marram model (26), the retrieval and application of
research in nursing (RARIN) model (27) and the Iowa model of research in
practice (28). The primary goal of research utilization programs is to make
research findings an integral part of nursing practice, assuring research-based
care delivery models. Research utilization is an excellent model for application
of research findings to practice by advanced practice nurses.

An important trend is the use of research findings to serve as the basis for
treatment decision making called evidence-based practice (29). Using this
process, a question involving treatment is developed, and determination of the
adequacy of current research is made. If the research base is adequate, it is
synthesized, protocols are developed and applied, and evaluation is completed.
Through these efforts, the nursing profession, in partnership with other
professions, bridges the gap between research and practice to improve patient
care.
EDUCATIONAL ADVANCEMENT

Early nursing education took place in hospital training programs (nursing

diploma), modeled on Florence Nightingale’s work in the United Kingdom (30).
In 1915, nursing’s educational accrediting body, the National League for Nursing
(NLN) called for university-level education. Baccalaureate programs in nursing
emerged in 1923 at Yale University and Western Reserve University, but the
majority of nursing education took place in hospital-based diploma programs. In
1971, the first community college programs for nursing education opened,
providing graduates with an associate degree in nursing. Today, entry into
nursing practice takes place primarily in associate degree programs, with
baccalaureate programs second. Gradually, diploma programs have decreased
in number, and few exist today. Associate degree programs may introduce
nursing students to research, but baccalaureate programs included nursing
research in the upper division curriculum. From 1900 to the 1960s, most nursing
leaders obtained their graduate-level preparation in schools of education (30).
For many years, the Master’s degree was considered the terminal degree in
nursing.

The number of nurses whose career was devoted to research was miniscule in
the 1960s. Indeed, even by the 1970s only about 400 nurses in the United States
held a doctoral degree (31). In 1955, the Nursing Research Grants and
Fellowship Program of the Division of Nursing, United States Public Health
Service (USPHS) was established. This program awarded grants for nursing
research projects, nursing research fellowships, and nurse-scientist graduate
training (32). Early funding was for nurses to obtain their doctorates in fields
outside of nursing, because there were no nursing doctoral programs available.
As a result, nurse-physiologists, nurse-anthropologists, and so forth emerged in
the field. They were educated to conduct research, but often stayed in the field
of their doctorate and did not apply their research efforts to nursing care
problems.The emphasis during this period continued to be on establishing
nursing’s rightful place in the academic setting of the university. As nursing
became integrated into university life during the 1970s, nursing faculty became
aware of their responsibility to develop new knowledge, and in many
university-based schools of nursing, faculty members began to prepare both
themselves and their students to become investigators (33).
Currently, three types of doctoral degrees in nursing are available. A Nursing
Doctorate (ND), first established at Case Western Reserve University in 1979,
was designed to be equivalent to the Doctor of Medicine degree, providing
students preparation for the practice of generalized nursing and future
leadership, but not for advanced practice. Professional doctorates, Doctor of
Nursing Science (DNS, DNSc, DSN), emphasized advanced clinical,
administrative, or policy-related practice and leadership. The Doctor of Nursing
Science degree focuses on applied rather than basic research, and on applying
and testing new knowledge in practice. Although the Doctor of Philosophy (PhD)
was first available to nurses at Teachers College at Columbia University in the
1920s, interest in doctoral education was rekindled in the 1970s. The number of
doctoral programs in nursing has increased from zero in the 1950s to over 65
institutions, three-fourths of which are academic doctorates (PhD) that prepare
graduates for a lifetime of scholarship and research (34). More recently, nurses
in academic settings have been encouraged to obtain postdoctoral research
training with support available through both individual (F32) and institutional
(T32) traineeships through the National Institutes of Health (NIH).

RESEARCH FUNDING AND SUPPORT

Several factors stimulated the growth of nursing research in the 1980s and
1990s. Perhaps the most important factor was the creation in 1986 of the
National Center for Nursing Research (NCNR) in the United States Public Health
Service (USPHS). The development of this Center resulted from intense political
action by the American Nurses’ Association (ANA) (23). The primary aim of the
NCNR was “the conduct, support, and dissemination of information regarding
basic and clinical nursing research, training and other programs in patient care
research” (p. 2) (35). Prior to the establishment of the NCNR, most of the federal
funds supporting research were designated for medical studies that
concentrated on the diagnosis and cure of disease. Thus, creation of the NCNR
was a major achievement for nurse researchers. In 1993, the NCNR became the
National Institute of Nursing Research (NINR), strengthening nursing’s position
by giving the Center institute status within the NIH. This advance served to put
nursing into the mainstream of research activities and on more equal status
with scientists and other health professions. With the establishment of the
Center and then the Institute, federal funding for nursing research has grown. In
1986, the NCNR had a budget of $16.2 million. In 1996, the budget for the NINR
was about $55 million (1), more than a threefold increase over a decade. The
NINR elected to foster five research priorities for 1995 through 1999:
community-based nursing models, effectiveness of nursing interventions in
HIV/AIDS, cognitive impairment, living with chronic illness, and biobehavioral
factors related to immunocompetence (22).

The NINR’s strategic plan for the next millenium includes funding nursing
research on chronic illnesses (e.g., improving adherence to chemotherapy, pain
relief), quality and cost effectiveness of care, health promotion and disease
prevention, management of symptoms (e.g., gender differences in response to
therapeutics, managing the pain cycle), health disparities (e.g., cultural
sensitivity), adaptation to new technologies (e.g., transplants), and palliative
care at the end of life. Special allocations and Requests for Applications (RFA)
have facilitated research in these target areas, although investigator-initiated
research topics are funded if they are significant to nursing or patient care. The
projected budget for NINR for the year 2000 is over $70 million, which is
approximately distributed as follows: 73% for extramural research project
grants; 8% for pre- and postdoctoral training; 3.5% for career development;
3.5% for Core Centers in specialized areas of research inquiry; 3% for the
intramural program. Planning research for the next 5 years and into the next
century is a welcome challenge for the NINR and the scientific community (36).

RESEARCH DISSEMINATION

Significant milestones in the development of nursing science began in the mid-

1950s (see Table 1). From 1950 to 1959, there was growing emphasis on the
need to identify a body of knowledge for the developing profession of nursing in
order to justify its presence in post-World War II universities (37). Not only was
the first journal of Nursing Research established in 1952; several textbooks
related to nursing research were also published. Another critical step in the
evolution of the culture of nursing science was the establishment of the
American Nurses Foundation by the American Nurses Association specifically to
promote nursing research. During the 1950s, regional research conferences
were instituted for the first time, and federal support of nursing research began
(4,33,37). All these elements were essential to the development of a science of
nursing.

Several new nursing research journals, including Applied Nursing Research

(ANR), were instituted in the late 1980s. ANR publishes research reports of
special significance to nurse clinicians (1). Increasingly, clinical specialty (i.e.,
Heart and Lung, Journal of Gerontological Nursing) journals are publishing data-
based articles as well.

Another important event in the development and dissemination of nursing

theory and research was the creation of the Annual Review of Nursing Research
in 1983. This publication includes critical analyses of research pertinent to
nursing and health, including nursing practice, nursing care delivery, nursing
education, and the nursing profession. Chapters systematically assess
knowledge development in nursing, encourage the use of research findings in
practice, and provide direction for future research (22). More recently, scholars
have joined to create the Encyclopedia of Nursing Research (38), a publication
that provides a comprehensive overview of research studies, the history of
nursing research, and the evolution of theory development in nursing.

CONCLUSION

The next century challenges nursing research with critical imperatives for
improving health care. Changes in our nation’s population and their needs and
expectations will impact the direction of nursing research. Consumers are
becoming more involved in managing their own health care, and practitioners
are continually adjusting to new technologies as well as innovative health care
systems. The broad spectrum of nursing research encompasses both clinical and
basic investigations with the patient as the central focus. Nursing must
concentrate on making certain that our valuable scientific findings are
incorporated into practice and focus on developing the next generation of nurse
researchers (36).

The research culture in chiropractic is similar to where nursing research was in

its early years. To move chiropractic research forward will require many of the
same changes that occurred in nursing, such as educational advancement,
collaboration in academic settings, federal acknowledgement and support, and
development of more avenues for research dissemination to practitioners. Just
as nursing had to overcome significant barriers such as attitudes and low
educational and professional status, so, too, will the chiropractic profession
have to strive to develop a research tradition in order to integrate research as
part of its practice culture.

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 Reflection 

Research is the lifeblood of improvement and the essence of change. Research

provides a means for answering all manner of questions that may come about
through observation or theoretical inquiry. It is the fuel that drives the machine
called progress.
Although nursing research has not always had the prominence and importance it
enjoys today, its long and interesting history portends a distinguished future. Table
1 summarizes some of the key events in the historical evolution of nursing
research.

Nursing research continues to develop at a rapid pace and will undoubtedly

flourish in the 21st century. Broadly speaking, the priority for nursing research in
the future will be the promotion of excellence in nursing science. Toward this end,
nurse researchers and practicing nurses will be sharpening their research skills, and
using those skills to address emerging issues of importance to the profession and
its clientele.