Doctoral Education Nursing Scholarship in North America
For both the North American countries (Canada and the USA), the expanding body of knowledge reflects the values of the countries and more specifically, the nursing discipline’s strong focus on the health of individuals, their families, as well as communities. There is a commitment to promoting health as well as
facilitating individual response to illness and disease conditions. The emphasis is on the whole individual, family or community rather than on the illness or disease (Stewart, 1997; Hébert, 2003). In both countries, the attention of the researchers in the scientific community has been on generating clinical nursing research programs and programs focused on shaping the environment for nursing practice.
In Canada, a number of clinical research programs have focused on palliative care for individuals and families experiencing end-of-life concerns, understanding and managing chronic illness, health promotion, and issues in women’s health (ACEN et al, 2002). The same types of issues are identified in the first Handbook of Clinical Nursing Research published in the USA (Hinshaw et al, 1999).
The doctoral programs in both countries reflect seminars and concentrations focused on these areas of clinical nursing research. In addition, doctoral education in the two countries includes many core courses on theory development, research methodologies, measurement strategies and statistical processes. From a methodological perspective, the holistic philosophical commitment has demanded a pluralistic approach. Qualitative and quantitative methods are both valued for the richness they provide to the research data.
In North America, the development of knowledge through research has increased rapidly due to expanding resources. With the establishment of the National Institute of Nursing Research (NINR) at the National Institutes of Health (NIH) in 1986 (Merritt, 1986) nursing research in the USA advanced dramatically.
Starting with slightly over US$11 million for research and research training in 1986 to over US$130 million in 2003, strong support has been provided for the generation of knowledge for nursing practice and research training monies for institutional grants and individual fellowships for doctoral and postdoctoral education .
Three major Canadian organizations, the Academy of Canadian Executive Nurses (ACEN), the Association of Canadian Academic Healthcare Organizations (ACAHO), and the Canadian Association of University Schools of Nursing (CAUSN) identified the four primary federal and private funding agencies for nursing research : Canadian Institutes of Health Research (CIHR), Canadian Health Services Research Foundation (CHSRF), the Canadian Foundation for Innovation (CFI) and the Social Science Health Research Council (SSHRC) (ACEN et al, 2002).
While there is no designated funding agency for nursing research, Canadian nursing scholars are quite active and successful in competing for research and research training funds. In some areas, such as research training, specific monies are allocated for ‘capacity building in nursing research’. In 2001 and 2002, CASN reported that nursing research funding from all sources totaled CAN$31,843,905 and CAN$17,872,567, respectively. In the new CIHR, established in 2000, Canadian scholars are active members of seven of the 13 institute advisory boards and are competing for research funding in several of the new institutes.
As in the USA, the expansion of resources has advanced the clinical research and health services nursing research programs. But in both countries, there is room for much more growth, first in the area of resources, and second, in the research and research training programs. The current expansion of knowledge for nursing has increased the opportunities for doctoral education.
Factors Influencing Knowledge Development/ Doctoral Programs
Contextual Factors
The development of knowledge to guide nursing practice in Canada and the USA has been influenced by multiple social, economic, political, demographic and healthcare contextual factors. In turn, these factors have shaped doctoral education in the nursing discipline in both countries.
Social Factors
From a social perspective, a major concern in the USA and Canada is the disparity in healthcare including access to and the quality of health care, as well as outcomes for patients and their families. A recent Institute of Medicine (IOM) report (2003a), Unequal treatment: confronting racial and ethnic disparities in health care, reviewed several studies confirming the existence of disparity in relation to race, ethnicity and socioeconomic position, eg those who are uninsured for healthcare in the USA.
These factors affect the healthcare people receive and subsequently their health (Waidmann and Rajan, 2000; Villarruel, 2001). Research shows that the incidence of certain diseases as well as the morbidity and mortality outcomes for several conditions such as cardiovascular disease, premature infants and cancer treatment differ among individuals of minority populations and between men and women (Sternberg, 2001).
It is becoming increasingly evident that part of the difficulty is the disparity in people’s access to healthcare and differences in the diagnosis and treatment processes (Jackson et al, 2002). A series of reports by the IOM on the large population of uninsured people in the USA suggests that such individuals seek healthcare late in an illness trajectory, experience more complications and incur higher economic costs to themselves and society (IOM, 2002).
Losing or not having health insurance impacts on families and total communities, not just individuals. The most recent report, A Shared Destiny, outlines how the ‘quality, quantity, and scope’ of health services within a community are influenced by a sizeable uninsured population (IOM, 2003b).
Even with the Canadian health system of care for all citizens, the particular needs of vulnerable populations are still of concern. Inequalities still exist in the healthcare system (Browne et al, 2001). Inequities also occur in healthcare research with issues of women’s health not always being well attended. Many nurse researchers are delighted with the new Institute of Gender and Health which is part of the CIHR established in 2000 (Stewart et al, 2001) as a forum for addressing concerns about the differences in health issues between men and women.
Health disparities (USA) or inequalities (Canada) have surfaced as a strong priority for nursing research given the profession’s commitment to vulnerable populations (Butler et al, 2002). Specifically, the approach focuses on identifying the areas in which disparities occur and preventing these situations.
Nurse researchers in both countries have developed centers for studying health disparities, particularly in minority populations and are developing the knowledge needed to counter such problems. The doctoral and master’s programs are incorporating health disparities and inequalities in the curricula and providing doctoral students opportunities to study such issues with the faculty funded for health disparities research (Villarruel, 2001).
Economic Factors
The cost of healthcare in the USA is escalating rapidly. Major steps have been taken to contain and curtail such costs. The acute care hospitals have been the prime focus of new healthcare cost models since they provide the majority of the care and have been so expensive. A number of managed care models have been developed with a common purpose: to control costs and improve quality and access to healthcare. By 1995, over 60% of the total US population belonged to some type of managed care (IOM, 1997b).
One of the best strategies for controlling costs was to shift as much of the healthcare as possible to community agencies. This shift to community care was accompanied by a strong philosophical approach focused on self-care or self-management by individuals and families of their healthcare issues. With nursing’s long history of working in the community, their services were in high demand through home care, community public health and hospice agencies.
Major research programs of nursing scientists in the USA and Canada have focused on chronic illnesses, primarily care in the community and health promotion, risk reduction and self-management studies. Prevention and self-management of chronic illness are perceived as cost containment strategies for healthcare. Concentrations in both of these areas have been developed in many of the nursing doctoral programs in both countries.
A number of centers of excellence that have been established in schools of nursing in the USA focused on, for example, health promotion across the life span or health promotion among the elderly population. Stewart (1997) outlined the Canadian commitment to health promotion describing the 14 centers launched in this area in the past ten years. These centers provide doctoral students with the experience of being immersed in these areas of research if that is their interest.
Another major economic factor that has influenced the development of knowledge for nursing practice in the USA was the doubling of the NIH budget and concurrently, doubling of the NINR budget. The NINR is the major funding body for nursing research in the USA. The commitment to health research on the part of the public and the Congress of the USA, and their determination to double the NIH budget in order to stimulate more research has greatly increased knowledge development for nursing.
The funding for nursing research grants went from 56 million in 1998 to over 130 million in 2003 (Grady, 2003). This higher level of funding for nurse researchers has also provided enhanced opportunities for doctoral students to work with their study teams and to do research. In addition, the research training funds to support doctoral students and postdoctoral fellows also doubled from 4.6 million in 1998 to 9.3 million in 2002, increasing the numbers of individuals in full-time study.
In Canada, the federal agency for funding health research—CIHR—was established in 2000. This replaces the old Medical Research Council. Nurse researchers and leaders expect to have increased access to shaping the nation’s policies and acquiring funding from the CIHR.
Nurse researchers have been active members of the Governing Council, sit on seven of the 13 institute advisory boards, and a number of the research review committees. According to Alcock (2002) nurse researchers’ success rate in acquiring funding from CIHR is increasing, but greater growth can be achieved.
Political Factors
The major political influence on knowledge development in the health sciences in the USA is the terrorist event of September 11, 2001 that destroyed the World Trade Center in New York City and killed many individuals. The USA reacted to the event as a ‘wake-up’ call for any number of terrorist events that could occur. Obviously, in the health field, biological, chemical, radiological and other such events are being considered.
This response has led to multiple centers for bioterrorism and preparedness for bioterrorism being established in universities across the country. However, terrorism and bioterrorism are not confined to one country given the long, common border between Canada and the USA. This has provided new fields of study and new opportunities for doctoral students to be involved in funded research.
Demographic Factors
In Canada and the USA, the fastest growing population is the cohort of individuals over 85 years (Algase , 2001). The number of individuals 65 years of age and over is rapidly increasing. These demographics raise several important issues for nursing and the knowledge for nursing practice. One issue is the high number of individuals and families experiencing chronic illnesses in the over-65 population, as discussed earlier.
In addition, the issues involved with families and care-giving responsibilities are critical—issues that nurses are intimately involved in while caring for families. Another concern is the ‘approaching death’ issue (IOM, 1997a), of increasing concern to individuals and families who are involved with end-of-life decisions. These are all issues that nurse investigators are studying.
A number of doctoral programs offer concentrations in end- of-life , palliative care, family care-giving and chronic illness adaptation, as knowledge is rapidly evolving with the faculty building strong research programs in these fields. Doctoral students are offered research experiences in such investigative programs in both countries (Callahan, 1985; ACEN et al, 2002).
Health Trends
Several health trends have influenced knowledge development for nursing practice. The genetic revolution is rapidly changing the practice of medicine and nursing as well as other health professions. Treatment therapies, symptom management, and family counseling are only a few of the areas that are dramatically affected by the exploding knowledge in genetics.
The knowledge of genetics will revolutionize nursing practice and research globally. The research programs of nursing researchers have only just begun to illustrate the major changes that will be demanded in nursing practice. A limited number of doctoral programs are beginning to offer concentrations and research experiences in nursing with a genetic component.
In the USA, another healthcare trend has been the restructuring of acute care hospitals due to managed care and the need to control costs. Strategies for controlling costs resulted in the creation of hospital environments that were not conducive to adequate staffing and quality nursing practice. Research shows that poor patient outcomes and higher mortality accompanied inadequate staffing (Buerhaus , 2000; Aiken et al, 2003).
In the nursing systems areas, knowledge is being developed regarding adequate staffing levels for nursing and the development of environments to facilitate better patient outcomes, as well as the recruitment and retention of nurses in healthcare facilities (McClure and Hinshaw, 2002). Thus, doctoral nursing students interested in creating stronger environments for professional practice and quality patient outcomes, can select programs with faculty conducting research in nursing and organizational systems (IOM, 2003c).
In Canada, research has also focused on human resources and health systems. The health systems differ greatly between the two countries but there are similar resource issues with the shortage of nurses and how to shape efficient work environments to recruit and retain nurses who can provide quality nursing care (O’Brien-Pallas et al, 2002).
In summary, a number of contextual factors influencing knowledge development in the nursing discipline and doctoral programs have been considered. Examples of the major aspects of each factor, particularly as it impacts on doctoral education and knowledge evolution in nursing have been provided.
Priorities for Knowledge Development: Future directions for Doctoral Program
Knowledge development in the USA and Canada has advanced from broad concepts with limited research substantiation to the refinement of concepts and testing of the relationships among them. Many research programs for nurse researchers provide evidence for the development of the concepts and relationships (Hinshaw et al, 1999; Hébert, 2003). Knowledge development in the discipline has consistently focused on knowledge for a purpose; ie to guide nursing practice.
The evolving knowledge base is built from a nursing perspective to provide evidence for the practice of the profession. The knowledge will be used by and built on by many researchers in numerous disciplines but for the purpose of nursing, it focuses on critical healthcare issues that nurses can influence through their practice, and thus ‘make a difference’ in the quality of life and health of the nations’ people. Concurrent with the advancement of the knowledge base for nursing, there have been changes in the doctoral programs.
In the early stage of knowledge development (mid-1970s), the majority of the courses offered in the doctoral curricula were process-oriented in nature, dealing with theory construction, research methodologies and statistical analysis. While these types of courses continue to be offered, doctoral programs now provide multiple areas of content concentration reflecting the refinement of science: eg palliative care, women’s health, family care and the frail elderly, health promotion behavioral change strategies, and bio-behavioral interventions for symptom management.
Numerous priorities have shaped the directions of nursing research. Usually, the priorities reflect the critical health and illness issues of the country. In 2000, four major priorities were reported for six or more countries/regions (Africa, European Nursing Research Work Group, Great Britain, the Nordic countries, Thailand, and the USA): health promotion, care of the elderly, health care systems and symptom management (Hinshaw, 2000). The USA was one of the five countries citing the need for these four areas of study. These priorities are already evident in the content offered by a number of US and Canadian doctoral programs.
In the USA, the NINR facilitated the development of an early set of national nursing priorities with nursing researchers in the scientific community (Bloch, 1990). With the increased funding of nursing research since the establishment of NINR in 1986, any new priorities and topics have been advanced in the past 17 years.
The priorities and themes have facilitated the focusing of scientific endeavors in nursing and the development of multiple research programs in concentrated areas of study. This has resulted in areas of substantiated research such as the strategies for preventing premature infancy and family care-giving for elderly people. Other investigator-initiated areas of study provide the richness from which new areas of research evolve.
What are the future knowledge priorities in the USA that can be expected to influence doctoral programs? The NINR (2003) provides one source of leadership in defining future priorities with the nursing research themes (Hébert, 2003). These themes were identified through dialogue with panels of nurse researchers from the discipline’s scientific community. For the next several years, five nursing research topics have been provided;
- Changing lifestyle behaviors for better health
- Managing the effects of chronic illness to improve quality of life
- Identifying effective strategies to reduce health disparities
- Harnessing advanced technologies to serve human needs
- Enhancing the end-of-life experience for patients and their families (Grady, 2003, 2000)
These research themes are reinforced in terms of importance since they reflect the social, economic, and demographic factors, and new healthcare trends discussed earlier. These priorities differ considerably from those identified for less developed countries: health of women, infant and childhood diseases and mortality concerns; assessment and management of infectious diseases; and nutrition and public health.
Canadian nurse researchers also have a strong orientation towards clinical nursing research. Jeans (1992), Dawson (1998) and CAUSN (1999) cite several areas of clinical research: assessment of the client’s condition in terms of the health and illness continuum, health promotion, rehabilitative care and its effectiveness as well as long-term care . Several Canadian nurse researchers are leading scholars in the areas of human resources, work environment of nurses and the impact on patient outcomes (O’Brien-Pallas et al, 2002; Tourangeau et al, 2002).
Three major problems for nursing research in Canada are developmental in nature: insufficient numbers of well-qualified nurse researchers to conduct research, insufficient time for them to exercise their expertise, and insufficient funds and support services for researchers (CAUSN, 1999). Given these concerns, the 2002 White Paper by ACEN, AACAHO, and CASN outlines four priorities for nursing research:
- identify gaps and strategies to minimize barriers to the conduct of nursing research
- increase designated university and hospital funding for nursing research
- achieve provincial and national support to fund nursing research
- increase designated federal government funding to support nursing research.
While these four priorities focus on funding nursing research, the CASN Research Mandate (CASN/ACESI, 2003) also strongly addresses research training in several of its objectives:
- educate nurse scholars/researchers
- develop federal and international exchanges for nursing research training
- obtain increased funding for graduate education in nursing science
- provide incentives for development of ‘fast-track’ research-intensive graduate nursing program.
In summary, the nursing research priorities for Canada and the USA show consistently evolving depth and refinement in the science for nursing practice. In both countries there is continuous pressure to develop the resources required for both research and research training.
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