Abstract

The question posed to me for this column was: "From a leader's perspective, what will change in nursing research over the next five years?" The question carries with it a number of assumptions - that I in some way fulfill the requirement for leadership, that I know with some precision where nursing research is in 2003 and that I can foretell the (albeit short-term) future. Feeling on shaky ground on at least two of these assumptions, I turned to others - in and outside the nursing profession, well known and not - for direction. My colleagues foretold glory days, gnashed teeth, told me what should be, wrung hands and presaged a barren, post-apocalyptic landscape. A few ignored me. With little recourse, I resolved to create a new question, one I could answer. My complaints about the original question were numerous: it was the wrong question; it was not nearly a long enough period of time in which to see observable change; it wasn't an important enough question; and why wasn't I given the better question: What should change in five years? I did not arrive at a newer and better question, and so found myself alone again … the cursor blinking unremittingly.

Sometime during the last procrastinating trip out to prune the roses, I decided there was nothing to do but answer the question based on my travels, recently attended research events, the spate of reports written lately on nurses and conversations with countless nurses in the past 25 years. I do not know with objective precision the state of nursing research in Canada today, nor can I predict the future, even in the short term. But here are my best efforts as a successful career scientist in this country, working in a field that 10 years ago was proclaimed by some as nonviable. I will make my predictions after a quick glance at four recent events.

First, there are the proclamations of Canadian Institutes of Health Research (CIHR) president Alan Bernstein during the latest round of public consultations for CIHR's Blueprint 2007 (Bernstein 2003). Bernstein argued that the following would characterize health research in Canada as early as 2007:

  • more multidisciplinary teams
  • an increase in critical mass of researchers
  • increased speed of research conduct
  • more international collaborations
  • a richer and more diverse funding landscape
  • increased importance of partnerships and shared vision
  • high faculty turnovers
  • issues of faculty attraction, retention and mobility
  • a much greater emphasis on research and activity in knowledge translation (or KT, now being cast as a vehicle to demonstrate a return on funding investments by the federal government).

Little in this list is new to Canadian nurse researchers. On-the-ground wisdom has us already interpreting the writing on the wall and moving to incorporate these elements into our programs, capitalizing where possible on the relatively lucrative funding opportunities of late.

Second, the policy synthesis on healthy workplaces by Baumann et al. (2001) saw a focused call for attention to the environments in which nurses practice. Since the landmark study by Knaus et al. (1986), we have seen dramatic increases in both the volume and quality of research that points to the critical link between environment and outcomes (Aiken et al. 2002; Needleman et al. 2002).

Third, the Canadian Nursing Advisory Committee (2002), concerned with the impending human resource crisis in nursing, has recommended that researchers continue to study the nursing workforce, focusing on:

  • licensed practical nurses and registered psychiatric nurses
    workload measurement
  • the ratio of nurses to clients and effects on quality of care
  • the effects of shift length on nurses and clients
  • the dynamics of overtime, absenteeism and turnover
  • the impact of relationships between nursing human resources and client outcomes, including economic impacts
  • skill mix
  • management information systems
  • development and refinement of indicators of quality of work life and nurse-sensitive quality outcomes for clients
  • refinement of human resources planning methods that consider the needs of populations, take into account the manner in which nursing resources are managed and deployed, and are linked to population, provider and health outcomes.

Finally, the recently released report on RN retirement in Canada (Canadian Institute for Health Information 2003) predicts that the percentage reduction in the Canadian nursing workforce will range from 13% to 28% of actual 2001 workforce numbers. These percentages translate into 30,000 to 64,000 nurses. Ours is an aging, dwindling workforce under siege in a healthcare system that has never had fewer nursing leaders.

With the above in mind, and recalling some of the more apocalyptic messages that appeal so cunningly to one's dark side, here are my attempts to answer the question: Where will nursing research be in five years?

We will be heavily engaged in research that can generally be classified as organizational. We will be investigating health human resources, practice environments, care delivery systems, health informatics and decision-support systems, and their impact on provider, client and system outcomes. Such activity is and will continue to be important, but not without untoward consequences if the agenda continues to be primarily a reactive one.

The bulk of our scarce research resources will be devoted to training faculty to fill academic posts across a wide range of institutions, most of them not research-minded, let alone research- intensive. Our doctoral seats will continue to be predominantly filled by an aging cohort, many of whom will have significantly less than 20 years to unfold a research program when they graduate. These two factors will stretch an already beleaguered group of senior and mid-career researchers to the breaking point. Worse, they will threaten our ability to survive, and surely our ability to develop high-risk, innovative programs - traditionally the purview of the young and energetic.

The relentless push to increased accountability (return on investment) will ensure that the majority of our research is applied and reactive. Theory will suffer. Our highest-profile doctoral programs will increase their emphasis on ensuring that students leave with full and flexible methodological toolkits. These efforts will, if all goes well, curry us favour with funders and result in high-quality, relevant research that influences decision and policy makers. However, the neglect of basic research and theory development and testing will not be benign in a still-emerging discipline.

Nursing research will be increasingly influential. However, serious seeds of non-sustainability will be sown if we attend only to what funders and policy makers need (almost always a reactive agenda) and sacrifice substantial basic research entirely to the sometimes more seductive applied agenda. Five more high-speed years on a predominantly reactive path will leave us irrevocably changed - perhaps without the ability to undertake a meaningful course correction.

Nurse researchers will do and publish increasingly sophisticated methodological work in both the quantitative and qualitative domains, but quantitative approaches will realize the greatest advances among nurse researchers. Qualitative research, now mainstream in the health research community generally, will continue to pose difficulties with respect to securing adequate large-scale funding. Because of its labour intensity and analytic complexity, investigators will have difficulty sustaining large-scale programs having a qualitative methodological focus.

Nursing research will be increasingly characterized by multidisciplinary and interdisciplinary teams (transdisciplinarity will remain a goal to which we will aspire) and more "decision-maker" partnerships. Requirements to train researchers will outstrip the capacity of the limited number of senior researchers in Canada. Farsighted (and ultimately successful) universities will, however, find ways to support and retain their senior and mid-career researchers. These two factors will contribute to a research workforce in nursing that in five years will, if institutions do not respond, increasingly remove itself from mainstream nursing education. Researchers will begin to drift to "research shops" and find alternative ways to pursue their work. Even the most single-minded, committed, driven, energetic, ambitious researcher will not endure endless frustration.

Research grants will incorporate more and better strategies for knowledge translation, but as they do the demand for innovative KT strategies will increase. KT as a declared area of inquiry will abound, unless funding dwindles. As a field itself, KT will have begun a transformation that calls for its integration with workplace (e.g., practice environment) and outcomes research. This scenario contrasts with that of KT researchers who move quickly to the "return on investment" arena, rather than study the mechanisms and processes of knowledge travel and translation. Scholars of both leanings now working in relative isolation will have begun to form generative collaborations.

These are my thoughts, reasoned opinions, and perhaps a little of my dark side talking. The next five years do hold much promise. On many counts the nursing research community has never been more vigorous, or our horizon brighter. But even the most optimistic among us knows the devilish disappointment of promise. It is unrealistic to expect all research leadership to come from the already heavily taxed group of senior researchers in this country. Nonetheless, if five years from now our current group of senior researchers has not mobilized its considerable resources and led, taking some control of this careening agenda, we may indeed be disappointed. Equally if not more important, if mid- and junior-career researchers have not also stepped up to the leadership plate - knowing full well they are there prematurely - then what should happen in nursing research will be a dim possibility.

It is not for deans and associate deans, vice-presidents and sage advisers to show us the way so much as it is for us as researchers to refuse to abdicate our responsibility. We need those individuals to lead, yes - but their agendas are broad, composed of competing interests, negotiation and compromise. They do not and cannot focus with singularity on research. Many of us can come much closer to such a focus. And if we do not lead, who will?

About the Author

Carole A. Estabrooks, RN, PhD
Associate Professor, Faculty of Nursing
University of Alberta, Edmonton

Acknowledgment

This work was supported by a Canadian Institutes of Health (CIHR) career award.

References

Aiken, L.H., S.P. Clarke, D.M. Sloane, J. Sochalski and J.H. Silber. 2002. "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction." Journal of the American Medical Association 288(16): 1987-93.

Baumann, A., L. O'Brien-Pallas, M. Armstrong-Stassen, J. Blythe, R. Bourbonnais, S. Cameron, D. Irvine Doran, M. Kerr, L. McGillis Hall, M. Vezina, M. Butt and L. Ryan. 2001. Commitment and Care: The Benefits of a Healthy Workplace for Nurses, Their Patients and the System. Ottawa: Canadian Health Services Research Foundation. Retrieved September 18, 2003. < http://www.chsrf.ca/docs/ finalrpts/pscomcare_e.pdf >.

Bernstein, A. 2003. Investing in Canada's Future: CIHR's Blueprint for Health Research and Innovation. Draft, July 7. Ottawa: Canadian Institutes of Health Research. Retrieved September 18, 2003. < http://www.mobile.cihr.ca/main/SPV11.pdf >.

Canadian Institute for Health Information. 2003. "Bringing the Future into Focus: Projecting RN Retirement in Canada." Ottawa: Author. Retrieved September 18, 2003. < http://secure.cihi.ca/cihiweb/ dispPage.jsp?cw_page=AR_1023_E >.

Canadian Nursing Advisory Committee. 2002. Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses. Ottawa: Health Canada. Retrieved September 18, 2003. < http://www.hc-sc .gc.ca/english/for_you/nursing/cnac_report/index.html >.

Knaus, W.A., E.A. Draper, D.P. Wagner and J.E. Zimmerman. 1986. "An Evaluation of Outcome from Intensive Care in Major Medical Centres." Annals of Internal Medicine 104: 410-18.

Needleman, J., P. Buerhaus, S. Mattke, M. Stewart and K. Zelevinsky. 2002. "Nurse-Staffing Levels and the Quality of Care in Hospitals." New England Journal of Medicine 346(22): 1715-22.