Nursing figures for the patient

January 19, 1996

Florence Nightingale was the first to research patient care. Margaret Alexander and Jenny Hunt look at her followers. "For we who nurse, our nursing is a thing which, unless in it we are making progress every year, every month,every week, take my word for it we are going back."

These words were penned over a century ago by possibly the very first nurse researcher, Florence Nightingale. Her meticulous statistics and detailed observations of nursing care and its affect on her patients, the soldiers of the Crimean War, represent the beginning of a systematic, scientific building up of knowledge about nursing.

It was almost a century before any similar systematic nursing research was undertaken, and even longer before the relevance of research to nursing practice was recognised.

The 1972 Briggs report was the watershed. Throughout, the need for a sound research base for nursing and midwifery practice was clear in such statements as "nursing should become a research-based profession". Most practising nurses simply did not know what this meant as the nursing curriculum at that point made no reference to research and virtually no nursing research existed. It also said "research-mindedness should be fostered during pre-registration education", but no nurse educators had the appropriate preparation to do this.

"Research should begin in the ward itself or at field level in the community" was another statement. Previously, especially in the 1950s and 1960s, what research did exist was about nurses, their attrition rates, their appropriate roles, predictors of success or failure as recruitment strategies and other matters of interest to researchers from other disciplines who conducted these studies. It was not about nursing practice.

The comment, "Too little research is at present carried out by nurses and midwives themselves", was not surprising because only a tiny proportion of nurses had the academic preparation to fit them to conduct research.

To say this report was electrifying is an understatement. A variety of actions followed that rapidly moved nursing research forward, although as a profession we still have some way to go before we have a critical mass of nurses not only academically prepared with research degrees, but educated to be able to read research reports with an analytical and critical eye, a prerequisite to the competent application of findings. There is no doubt that it was the growth of nursing as an academic discipline from small beginnings in Scotland in the late 1950s that gave the real impetus to nursing research.

Contrary to popular myth, the development of nursing in higher education did not divorce nursing education from practice. It enhanced many links, and it led gradually to the provision of post-registration programmes for nurses, including opportunities for supervision to undertake research degrees. Inevitably, this supervision was initially given by academics from other disciplines, as nursing gradually "grew its own researchers". Also of key importance in the growth and development of nursing research were Government-funded initiatives such as the provision of nurse research training fellowships and of university-based nurse research units, one in Scotland and two in England.

So, why nursing research, and what is it about? Its raison d'etre is the advancement of knowledge about the effectiveness of nursing care and the improvement of the quality of that care. Nurses constitute the largest group of healthcare professionals in the United Kingdom, costing the economy in the region of Pounds 5 billion every year. What they do, or do not do, has a big impact on patient outcomes.

In today's political and economic climate, evidence-based nursing is as much a necessity as is evidence-based medicine. Some examples of nursing research which have shown how nursing care can influence patient outcomes in a positive manner relate to: care of patients' wounds, including pressure area care; pain management; care of the dying patient; pre-operative fasting of patients; promotion of continence and prevention of incontinence; patient education and the giving of information to patients and carers.

Interestingly, there are some differences in the favoured approaches to research in medicine and in nursing. Traditionally, research by our colleagues in medicine has concentrated on what is termed the positivistic approach, epitomised by the randomised controlled trials of, for example, the efficacy of particular forms of treatment, be that new surgical techniques or new medication. In order to achieve results which are statistically significant, such studies normally require very large samples and so the emphasis has been on quantitative research.

Nursing research, on the other hand, although it uses the randomised controlled trial and quantitative approach for studies of the prevention and treatment of pressure sores, or of wound infection for example, has pioneered and greatly developed the application of qualitative research design in the in-depth study of patient care.

From time to time, a hot debate rages as to the merits and demerits of the different approaches. As multidisciplinary research teams grow in number, the debate promises to be interesting. But for nursing research it is only of use in the promotion of improved quality of care if sufficient nurses know about it, understand it and have the motivation, power and influence to implement it where relevant. This is not as simple as it sounds. It often requires a team effort to implement research-based practice. For example, changes in pain management require co-operation with and concerted action by not only nurses, but doctors, pharmacists and indeed managers and funders of the service.

Likewise, while it remains important for nurses to conduct research into nursing and into nurse education, it is also important for nurses to join with others in conducting multidisciplinary research into health and patient care and to do that within the context of the ongoing NHS reforms and the national priorities of the research and development strategies in the four UK countries.

Nursing research is as much a part of these strategies as is medical research and research conducted by other health-care professionals.

The recent funding by the Scottish Office of the Nursing Research Initiative for Scotland is an interesting example. The NRIS has taken over from the nursing research unit at Edinburgh University, and is charged with providing a new national focus for direct patient-care research. The details of its remit mean that the initiative, although nurse-led, will, whenever possible, undertake research which is interdisciplinary in nature. However, since nurses are the largest single group of National Health Service workers, nursing will be a central theme. The NRIS is based in Glasgow Caledonian University, in close association with the department of nursing and community health and the Victoria Infirmary Hospital Trust in Glasgow. The research portfolio of the department is strong, and focuses on three main areas - community nursing, nursing care of the elderly in hospital and educational evaluation.

In conclusion, the challenges for nursing research are many. We need to "grow" our own critical mass of experienced researchers, who can not only go on to develop their own interests in post-doctoral work, but can also supervise research students. We need to embrace multidisciplinary research while not losing the nursing emphasis; to replicate studies to gain greater understanding of particular areas of nursing and health care; to seek out and systematically investigate and report good practice and effective outcomes. But we must still have the courage to explain where care is not effective, and to be innovative and persevering in forging links between researchers and those in nursing practice, education and management, because, in seeking to improve patient care, we are all in it together.

Margaret Alexander is director of the World Health Organisation collaborating centre for nursing, education, research, practice and management at Glasgow Caledonian University. Jenny Hunt is director of the Nursing Research Initiative for Scotland.

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