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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.”  |
