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17]
Original Article
ABSTRACT
Aim: To explore the development of nursing research and provide some examples of research relevant to clinical practice.
Background: Nursing research developed in the last century as did nursing theories and models. However, nursing research
does not have the same high profile as, for example, medical research and has tended to lag behind medical, and other forms
of research, in terms of funding and in the apparent impact it has on clinical practice.
Design: Discussion paper.
Methods: Using a popular nursing model based on activities of daily living, nursing research that is relevant to these activities
of daily living is explored and exemplified using a few key examples. Some of these examples are historical and some are
current.
Conclusion: Nursing research has developed greatly over the past century and continues to develop in the 21st century.
Nursing research is relevant to the needs of patients and has had an impact on clinical practice.
that nurses have no need of a university education[7] methods other than clinical trials and quantitative
– which is where such research generally takes place surveys.[9]
– and only need to know how to care for people and
that all the required skills are innate… and usually Research nurses or nurse researchers?
feminine. These views are merely the combination of At this point, the identity of those who carry out research
ignorance and prejudice and while ignorance can be in nursing should be explored. Many are familiar in the
dispelled, prejudice is usually immutable; this article clinical areas with research nurses. These are highly
is not aimed at the prejudiced and does not judge the skilled and increasingly, highly trained nurses who
ignorant. Nursing has, traditionally, been quite poor at conduct research but usually as part of and under the
articulating its knowledge base and in explaining the direction of a medical or surgical research team. Their
value of nursing research. purpose is data collection and in this role, they are
the day-to-day managers of clinical trials, organizing
Nursing research – unlike medical research – is rarely the recruitment of patients, allocation to treatment
reported in the media. This is changing, however, and
and control arms and completing and recording the
some publishing houses are having success with a few
complex documentation that is required by clinical
selected journals in bringing nursing research into the
trials regulating bodies.[10] Nevertheless, these are not
public domain. Nevertheless, nursing research rarely
nursing researchers nor are they normally engaged in
has the immediate impact of medical research; people
nursing research. Nursing researchers are normally
want to hear about “miracle cures” (albeit that today’s
academics working in university nursing schools and
“miracle cure” often transpires to be tomorrow’s health
who are graduates and often trained in research to
warning or current advice on disease prevention often
PhD level. In the early days of nursing research, they
transpires to be impossible to replicate). Nursing is
commonly had first degrees in other disciplines and
rarely concerned, directly with curing disease, rather
it is concerned with the care needed by people who also had conducted their PhDs in other areas due to
have disease or distress and who are recovering from the shortage of university nursing schools and nursing
the adverse consequences of medical and surgical degree programs. Increasingly, however, they have
intervention. As such, nursing has no monopoly on first degrees and higher degrees obtained in university
care; it shares this domain with other professions such nursing schools.
as medicine, social work, and the various therapies.[8]
However, nursing is almost uniquely about caring and FUNDING
its research, concomitantly, is almost uniquely about
caring and the remainder of this article will explore Obtaining funding for nursing research has always been
selected areas of research related to this fundamental difficult and models for funding vary across the world.
aspect of nursing. From a UK perspective, it has been particularly difficult
as there is no specific stream of research funding
Before proceeding, and for the person who may pick identified for research into nursing, and the situation
up a current issue of a nursing journal, a great deal deteriorates. The statutory bodies which govern nursing
of what passes for nursing research – or research education and practice, variably called the National
conducted by nurses – may seem far removed from Boards or equivalent for the four countries of the UK
the everyday experience of patients and what people, which existed alongside the UK Central Council for
including medical colleagues, consider to be nursing. Nursing, Midwifery, and Health Visiting and later
Nursing research uses many mainstream research merged into the Nursing and Midwifery Council, did
methods such as the clinical trial and the social survey. provide funding for research into nursing education and
However, nursing research also espouses some of aspects of professional practice, but they no longer do
the more “exotic” methods of social research and the this. The UK government department, which runs the
humanities including qualitative research and discourse UK National Health Service also provided funding for
analysis. It is apparent that nursing research has no research into nursing but usually into preparation for
specific methods of its own; it can, therefore, hardly practice but they no longer provide this. All government
be described as a discipline – a point which some may funding for research which nurses could apply for is
dispute. However, nursing adopts and applies these managed through either the various research councils
wider methods to try to understand and convey what – the Medical Research Council (http://www.mrc.ac.uk/
nursing is about to itself and to others as it continues index.htm) being the closest to nursing interests – or
to explore and explain its professional identity. In this via the National Institute for Health Research (http://
process, nursing research has made contributions to www.nihr.ac.uk/Pages/default.aspx). Nurses have some
other fields and indeed, has had an influence on medical success in obtaining funding from these bodies but
research and medical research bodies and leading usually as part, and sometimes in the lead, of multi-
medical journals now fund and publish research using disciplinary collaborative teams. Medical research
charities in the UK have funded nurses to do research within the framework of the nursing process. The nursing
but none fund nursing research as such and there are process was based on industrial quality assurance
few charities – with very limited funding – which fund mechanisms and proceeds in a cycle of: assessment;
nursing research. planning; implementation; and evaluation, leading back
to assessment and a further cycle of the process.
The UK situation contrasts with that in the USA where
there is a dedicated branch of the National Institutes for Turning to the Roper, Logan and Tierney model, the
Health which funds nursing research (http://www.ninr. 12 ADLs are:
nih.gov/). In Australia and Taiwan, nurses fare very well • Maintaining a safe environment
in competition with other areas of research for generic • Communication
government funding streams. This background is given • Breathing
to contextualize developments in nursing research,
• Eating and drinking
especially those in the UK where funding has not been
• Elimination
extensive.
• Washing and dressing
• Controlling temperature
NURSING THEORY
• Mobilization
The place of theory in nursing is disputed territory; • Working and playing
nursing is a highly practical subject with little need • Expressing sexuality
for theory on a daily basis. In some cases there have • Sleeping
been extreme developments in theory, especially in • Death and dying
the USA where the concept of nursing as a discipline
is more strongly defended. Nevertheless, if nursing is It is interesting to note how distinct these are from the
going to be taught and contextualized and researched, medical domain or “the medical model” as it is often
then some theory is essential.[11] Research questions and disparagingly referred to by some nursing academics.
hypotheses emanate from theory and research findings However, neither Henderson nor Roper, Logan, and
can only add to a body of knowledge if that knowledge Tierney were concerned about setting up an alternative
has some theoretical dimension to it. I will explore, model to medicine or to separate us from our medical
briefly, one nursing theory; this has not explicitly colleagues. The intention was to encapsulate what was
guided the body of nursing research but the particular unique about nursing and to help nurses understand
theory – of Virginia Henderson – and its application by what they did and to help them do it better.
Roper, Logan and Tierney, has had a profound influence
on nursing education and practice, which persists, There is no particular hierarchy within these ADLs.
and as it is one way of encapsulating what nursing is Breathing is the only one of the ADLs related to a vital
and nurses do, it is a convenient way to present some physiological function without which life is threatened.
selected examples of nursing research. However, the notion of breathing in the model is more
related to assisting the patient to breathe comfortably
VIRGINIA HENDERSON (1897-1996) and without distress. This may well have physiological
consequences but in nursing care is more related to
Virginia Henderson was a North America nursing the physical and psychological comfort of the patient.
academic who developed a theory of nursing around As such, these ADLs are often located within another
14 activities of living (ALs) which were at the core of layer of theory, that of Maslow’s hierarchy of needs
nursing care. The relationship between these ALs and which, essentially, says that the higher order ALs
nursing was expressed in her maxim that the aim of such as cognitive processes leading, ultimately, to
nursing was “assisting individuals to gain independence self-actualization cannot be achieved without those
in relation to the performance of activities contributing “lower” order activities which are mainly about comfort
to health or its recover.”[12] Henderson’s theory has and survival being met.[14] Put simply, it is hard to
found its widest application through the work of UK appreciate a good novel or film if you are in excruciating
nursing academics Roper, Logan, and Tierney who pain. Therefore, the ADLs are really essential aspects
based their model on 12 activities of daily living (ADLs) of care that are in the domain of nursing; some may
and incorporated Henderson’s idea of assisting the refer to these as “basic” aspects of care; however,
patient by establishing a model in which deficits in there is nothing “basic” in the ingenuity, patience and
patients’ abilities could be assessed and then a plan of knowledge required, for example, to assess pain in a
nursing care initiated to help the patient recover, gain person with dementia and then to help them to eat
independence or die a peaceful death.[13] The nursing and maintain their skin integrity, often against their
care plan was not static, rather, it was dynamic and this immediate wishes and usually in an ethical and legal
– in common with other nursing models – was operated “minefield.”
hasten death rather than preserve life.[21] Artificial in their roles related to these aspects of personal life;
feeding also requires restraint, an issue that was simple things such as making sure that spouses, partners
discussed earlier, and there are many legal and ethical and children can visit, for example, is important.
issues to be considered.
Nevertheless, nursing research must go beyond this
Therefore, the study of feeding difficulty in dementia into more sensitive areas of sexuality if we are to help
is warranted and when I entered this field as a staff solve some of society’s problems by helping individuals
nurse many years ago, there was no evidence base to understand their bodies and their relationships. In
to guide practice and there was no valid method of this sense, nursing moves beyond simple clinical care
assessing feeding difficulty and therefore, of measuring into a wider social role and nurses find themselves
deterioration or improvement. Toward that end the working alongside other professionals working in
Edinburgh Feeding Evaluation in Dementia (EdFED) these areas. A much more profound understanding
instrument was developed and remains the only of social subjects is required and nurses must be less
afraid to ask really difficult questions and to develop
validated instrument in the world for measuring feeding
the concomitant research methods. For example, in the
difficulty in dementia.[22] In addition to providing a
UK, there is a significant issue of teenage pregnancy
measure of difficulty, the EdFED also provided an
due to the changing moral landscape and a decline
insight into how feeding difficulty develops along
in traditional marriage. Many teenagers cope well
a specific and cumulative pattern which is highly
with this; however, many do not and these teenagers
reproducible across settings and cultures.[23] The EdFED often come from socially deprived backgrounds
has been used as a measurement outcome on clinical and educational “black-spots.” Teenage pregnancy
trials of interventions to alleviate feeding difficulty interrupts education – especially for young women
and as a correlate of other measures such as body – and reduces employability, thus creating a vicious
mass index.[24] The EdFED correlates well with other cycle of deprivation and social problems. The work of
measures and is a sensitive instrument for measuring Hayter and Christina[28] provides important insight into
improvement in feeding ability in clinical trials.[25] why young men and women seek advice, or not, and
especially their involvement in sexual relationships,
Controlling temperature often with attitudes that seem irresponsible to the rest
Nursing research is not confined to “finding things out” of society. Without such an understanding, appropriate
but is often concerned with questioning established non-judgmental[29] and effective services cannot be
nursing – and even medical – practice. One example designed and delivered to this “hard to reach” sector
is the work of Purssell[26] where he questions the value of the population.
of routine administration of antipyretic medication to
children with elevated body temperature. The actual Sleeping
incidence of convulsions is very low and while clearly Achieving a good night’s sleep is often difficult in
distressing for parents, not usually fatal. Purssell[27] hospital; patients are anxious and in pain and the
follows this up with an evolutionary analysis of host environment often militates against sleeping. We
and infective agent relationship, making the point that have known this for a long time but are usually
the response of the host to infection – which is often unaware of exactly how noisy hospitals are and
what we treat – has evolutionary and by implication, what the precise sources of noise are. Studies by
biological advantage. This is a prime example of the Christensen[30] and Akansel and Kaymakçi [31] have
application of knowledge from other disciplines by applied technological approaches to the problem which,
nurses trained in scholarship outside of nursing and given the implementation of their findings, could help
who can; therefore, speak with authority in these fields hospitals to locate sources of noise and reduce them.
as well as nursing.
Death and dying
Expressing sexuality Death and dying have long been in the domain of the
This has often been a misunderstood aspect of the nurse and this is one area where nurses have often taken
nursing process but it does not, necessarily, refer to sex the lead professionally and in research. The leading light
in the physical sense; although this is undoubtedly a in palliative care, as delivered by the hospice model,
legitimate ADL, it is about helping people to recognize was Dame Cecily Saunders and it should be noted that
their sexual roles in society in the face of impediments she developed her approach to care of the terminally ill
to this imposed by illness. For example, it is important patient as a nurse and later qualified as a doctor (http://
for nurses to understand patients’ sexuality and also, for www.bmj.com/content/suppl/2005/07/18/331.7509.
example, marital status and whether or not they have DC1; accessed 1 June 2012). The involvement of
children. Nurses can do a great deal to facilitate patients nurses – often leading multidisciplinary teams – in
palliative care is now well established and the concept 11. McKenna H. Nursing Theories and Models. London: Routledge;
of palliative care has now extended well beyond the 1997.
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14. Maslow AH. A theory of human motivation. Psych Rev
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15. Nightingale F. Notes on Nursing. New York: Appleton & Co.;
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16. Watson R. Restraint. In: Heath HJ, Watson R, editors. Older
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People: Assessment for Health and Social Care. London: Age
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