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An evaluation of neuroscience nursing research published during the decade of the brain.

Abstract: The purpose of this study was to extend a previous evaluation of neuroscience nursing research to an assessment of the research published during the 1990s--the Decade of the Brain. The evaluation was conducted to assess the focus of neuroscience nursing research and to identify research strategies and scientific methods. The Journal of Neuroscience Nursing, Nursing Research, Research in Nursing & Health, and Western Journal of Nursing Research were canvassed. An assessment form developed by the authors was used to evaluate selected articles published between January 1989 and December 2000. The number of neuroscience research studies published in nursing journals increased substantially during the 1990s. The studies focused more on individuals with neurological disorders and less on neurological trauma. The findings demonstrated major changes in subspecialty area, care orientation, and nature of study variables from that observed in the previous evaluation in which acute care and physiological variables were most representative of the pre-1989 studies. As noted in the previous evaluation, the trend toward theory-then-research studies continued and the scientific methods grew more complex.

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In 1960, neuroscience nursing research was in its infancy. The next three decades saw tremendous growth in the field, so that by 1990 neuroscience nursing research was well established. In 1990, in an article in the Journal of Neuroscience Nursing, DiIorio presented the results of an evaluation of the neuroscience nursing research published between 1960 and 1988. This assessment provided a means of determining progress in the field, identifying strengths and weaknesses of the published research, identifying contributions to the literature and areas that could benefit from more research, and delineating future directions for research. There were five major findings: (a) neuroscience nursing research published between 1960 and 1988 increased substantially, (b) the orientation of the studies shifted, from chronic care to rehabilitation and acute care, (c) the nature of the study variables was primarily physiological, (d) the primary strategy was research-then-theory, and (e) the types of methods and analysis increased in complexity.

Based on the results of the evaluation, DiIorio (1990) concluded studies are needed to address prevention of neurological injuries and insults, chronic neurological disorders, and neurological conditions affecting the elderly. She also noted that nurse researchers should consider sociological and psychological variables in their research, expand the development and testing of instruments, and use more sophisticated study designs and analyses.

The purpose of this study was to extend the previous evaluation to neuroscience nursing research published during the 1990s--the Decade of the Brain. The research questions first posed by DiIorio were modified and used to guide the current evaluation. These questions were as follows:

* Was there an increase from 1989 to 2000 in the number of neuroscience studies published in selected nursing journals? If so, how does the increase compare to that from 1960 to 1988?

* Did the focus of neuroscience nursing research shift in subspecialty area, care orientation, and the nature of study variables from 1989 to 2000? Is the focus different from that between 1960 and 1988?

* Is there a primary strategy for the development of neuroscience nursing knowledge? If so, did it change from 1989 to 2000? How does it compare to the strategy from 1960 to 1988?

* What scientific methods are employed in neuroscience nursing research? Did these change from 1989 to 2000? Are the methods different from those between 1960 and 1988?

Methods

Four nursing journals were canvassed for articles of reports about neuroscience nursing research: Journal of Neuroscience Nursing, Nursing Research, Research in Nursing and Health, and Western Journal of Nursing Research. The same journals reviewed in the original evaluation were selected for the present evaluation to maintain consistency with the previous evaluation. For the review process, each issue published between January 1989 and December 2000 was examined.

The first two authors independently reviewed the titles of all articles in the sampling frame and selected those that appeared to be reports of neuroscience nursing research. All articles we agreed upon were obtained. Articles for which a decision could not be made from the title alone were also obtained, as were those requiring a more detailed review before a final decision could be made. Each article was evaluated to determine whether the research included participants with nervous system disorders or their caretakers, and whether the relationship between the sample of participants and the research problem was clear. Those meeting these criteria were included in the final sample.

In the previous evaluation, DiIorio (1990) included only articles in which the first author was a registered nurse. In the current evaluation, the professional background of the authors was not provided in some issues. Consequently, all articles regardless of the professional background of the first author were selected.

For this evaluation, neuroscience nursing research was defined as research that addressed problems of importance to neuroscience nurses and published in one of the four selected journals during the review period. In the previous evaluation, DiIorio (1990) also included case studies. In the current review, 10 case studies were identified. Because most review criteria did not apply to case studies, however, they were excluded from the analyses reported here. As a result, the sample for the present evaluation consisted of 194 articles.

Articles selected for review were divided among the authors. We conducted a systematic review of each article and used a data collection instrument to record information on characteristics of the study authors and the research. To assess interrater reliability in coding characteristics of the research, each of us reviewed 15 articles and compared coding with that of the person who reviewed the same 15 articles. Differences in coding were discussed until a common understanding of the coding system was reached. All of us discussed issues in coding to agree how information should be coded. Agreement was more than 90% for the first set of articles; each remaining article was reviewed and evaluated by one of us. As a final check, the first author reviewed the coding for all articles. Discrepancies were discussed and resolved.

Data Analysis

To answer the research questions, data were first analyzed using descriptive statistics for the entire period (1989-2000). To analyze trends, the years were first grouped into three periods: 1989-1992, 1993-1996, and 1997-2000; then comparisons were made using cross-tabulations.

Results

Research Question 1. Was there an increase from 1989 to 2000 in the number of neuroscience studies published in selected nursing journals? If so, how does the increase compare to that from 1960 to 1988?

A total of 194 neuroscience studies was published in the selected nursing journals between 1989 and 2000. Of these, 68 studies were published between 1989 and 1992, 71 between 1993 and 1996, and 55 between 1997 and 2000 (Table 1). Despite the decline in the number of studies published in the last four years of the review period, the total number during the 12-year period was considerably greater than that between 1960 and 1988. Between 1960 and 1988, 71 studies were published, most (n = 59) of them between 1980 and 1988. The data from the present study show that the upward trajectory in the number of neuroscience nursing studies reported for the decade of the 1980s continued into the 1990s.

In her evaluation, DiIorio (1990) found the Journal of Neuroscience Nursing (JNN) was the primary outlet for the publication of neuroscience nursing studies, accounting for 68% of all studies published between 1960 and 1988. In the present analysis, 61.3% of all studies were published in JNN. Nursing Research (NR) accounted for 16% of all publications, Research in Nursing & Health (RINAH) slightly fewer (13.9%); and Western Journal of Nursing Research (WJNR) accounted for 8.8%. In comparison to the earlier evaluation, the percentage of articles published in NR declined, but the percentage published in RINAH nearly doubled and in WJNR, tripled. These findings demonstrate that while JNN continues to be the journal of choice for presenting neuroscience research conducted primarily by nurses, other publication outlets are considered.

In addition to the number of neuroscience studies, we examined the characteristics of the authors, including their educational preparation, certification, primary occupation, and place of employment/association. The number of authors per article ranged from 1 to 11. A single author wrote 34% of all articles, and two authors wrote 27.3% percent of articles; 12.8% of articles were written by five or more authors. The percentage of first authors with doctorates was 58.8% for the entire period (Table 2); 28% held master's degrees; and 3.1% held baccalaureates. The educational background of 8.8% of the authors could not be determined. Fifteen authors were first authors on more than one research article. One author was listed first on nine articles, one on eight, one on three, and twelve on two articles.

Excluding those first authors (n = 20) for whom no information on nursing background was provided, of the remainder, all but one first author was a nurse, and 28.4% reported certification in a nursing specialty area. The most common certification was CNRN, or certified neuroscience nurse (10.8%). Fifteen first authors reported fellowship in the American Academy of Nursing, accounting for 24 (12.4%) of articles reviewed. Of first authors who published in NR, 41.9% were fellows; in WJNR, 17.6%; in JNN, 5.9%; and in RINAH, 3.7%. Most (62.4%) first authors held academic positions. About 24% reported a primary clinical role, and 4.6% were in student roles. Seventy percent of authors were with a university or school with 61.9% with a school of nursing. Twenty-six percent were in a hospital or clinical setting. The percentage of authors who were faculty members increased slightly during the review period, as reflected by the greater percentage of authors in university/college divisions and fewer in hospital and clinical settings.

Compared to the results of DiIorio's evaluation (1990), there has been an increase in the percentage of first authors with doctorates. In the 1980s, 30% of first authors were prepared at the doctoral level, and 51% held master's degrees. By the end of the 1990s, the percentage of first authors with doctoral degrees almost doubled to 58.8%. As in previous years, the proportion of first authors with doctoral degrees was higher for articles in NR, RINAH, and WJN than in JNN. The percentage of first authors with doctoral degrees is similar to the 52% noted by Smith and Lusk (2002) in their review of occupational health nursing research.

As might be expected, the most common certification for authors was in neuroscience nursing; consequently, dissemination of information is being conducted by those most committed to careers in neuroscience nursing. Likewise, a considerable number of nurses involved in neuroscience nursing are members of the Academy of Nursing. Because requirements of the academic role include dissemination of research, it was expected that most authors would hold academic positions in universities and schools of nursing. One-quarter of the authors, however, reported clinical roles, demonstrating that research interests are not limited to academic settings. Also, students were first authors on almost 5% of articles--most likely an indication of mentoring by their professors and clinical instructors. Because data on certification, position, and association were not collected on the 1960-1988 evaluation, comparisons of trends for these characteristics were not possible.

In addition to collecting data on the characteristics of authors, we assessed the degree of collaboration and funding support (Table 3). Collaboration within nursing was deemed present if more than one author was a nurse or an acknowledgment indicated collaboration with a nurse. Interdisciplinary collaboration was present if both a nurse and a nonnurse coauthored the article or an acknowledgment indicated such a relationship. The percentage of articles indicating collaboration among nurses was 70.6% for JNN, 66.7% for RINAH, and 54.8% for NR. The percentage of articles indicating interdisciplinary collaboration was 31.9% for JNN, 29.0% for NR, and 25.9% for RINAH. WJNR showed relatively lower rates of both nursing (35.3%) and interdisciplinary collaboration (17.6%).

An acknowledgment of funding was indicated for 60.3% of the studies (Table 3). The percentage of studies receiving financial support increased from 54.4% during the first 4 years to 72.7% in the final 4-year review period. Governmental organizations and departments provided funding for 39.3% of the studies. Twenty-two percent of studies received university binding, 22.2% nursing organization (e.g., AANN and others) funding, 23.1% foundation or society funding, 10.3% hospital or industry funding, and 6% some other funding source. Almost 20% (18.8%) of authors received funding from more than one source. The percentage of studies with an acknowledged funding source ranged from 85.2% for RINAH to 47.9% for JNN. Although funding sources were not assessed during the previous review, the current level of funding for neuroscience nursing research seems to be consistent with that for nursing research in general. In a review of research articles published in nursing journals, Anderson et al., (2003) found 40.8% of studies reported were at least partially supported by funding.

As neuroscience nursing research matures, the types of research questions are becoming more complex. It is difficult to answer complex research questions using small samples and short questionnaires. The use of more advanced research methods associated with complex research questions necessitates an array of researchers with different areas of expertise and large-scale studies that require considerable amounts of funding. Based on the results of this evaluation, it appears that both collaboration and funding are becoming more common for neuroscience nursing research.

Research Question 2. Did the focus of neuroscience nursing research shift in subspecialty area, care orientation, and the nature of study variables from 1989 to 2000? Is the focus different from that between 1960 and 1988?

Neurological nursing studies outnumbered neurosurgical and trauma studies throughout the review period. In the first 4 years of the review period, 70.6% of the studies addressed neurological issues, and in the final 4 years, 89.1% (Table 4). The most common neurological conditions studied were Alzheimer's disease/cognitive dysfunction, Parkinson's disease, epilepsy, and multiple sclerosis. The percentage of studies addressing neurosurgical problems increased as well, from 2.9% at the beginning of the review period to 7.3% at the end. Common neurosurgical conditions studied included lumbar and spinal surgery and issues related to intracranial pressure. In contrast, the percentage of studies on neurotrauma, primarily brain and spinal cord injuries, declined markedly from 22.1% to 3.6%, and only a small percentage of studies (4.1%) included a combination of neurological and neurosurgical patients.

The classification of subspecialty area of neuroscience nursing studies in this review period differ from that reported in 1988. During the previous reporting period, there was a steady decline in the percentage of studies that focused on neurological issues and a slight decline in the percentage of studies that addressed neurosurgical issues. In addition, the percentage of studies classified as neurotrauma remained constant at about 25%. The sharp decline in the percentage of neurotrauma studies from the decade of the 1980s to the 1990s is interesting. Currently, it appears the interest of neuroscience nursing researchers is shifting to more chronic neurological conditions. One reason for this shift might be that nurses are publishing the results of neurotrauma studies in journals not included in this review. Also, the number and accessibility of people with neurological conditions for research might be greater than that of people with brain, spinal cord, and other neurological injuries.

As in the previous review, studies also were classified by care orientation. Those focusing on primary prevention were grouped together, as were those focusing on acute care and rehabilitation. During the review period, the majority of studies examined chronic and rehabilitation problems, accounting for 63.9% of all studies (Table 4). Acute care studies accounted for 28.9%, and primary prevention studies, for 3.6% of the studies. The percentage of studies classified as chronic care increased, and those classified as acute care decreased. These trends differed from those between 1960 and 1988, when the emphasis shifted from chronic care to acute care so that at the end of 1988, 61% of all studies addressed acute care problems. Based on more current data, it appears the shift back to an emphasis on chronic care and rehabilitation happened around 1990; and is directly linked to the subspecialty area of the studies. Most people with neurological conditions are cared for outside of hospitals and have long-term conditions. In contrast to the increase in chronic care and rehabilitation studies, a decline was noted in studies on primary prevention; 10% of studies in the 1980s focused on primary prevention, compared to 3.6% of the studies during the 1990s.

Finally, in the 1989-2000 review study variables were classified as physiological, psychosocial, teaching-learning, and combined. Although some fluctuation was noted in the percentage of studies that included physiological and psychosocial variables, overall, the majority of studies included psychosocial variables or a combination of psychosocial and physiological variables. The trend toward the inclusion of psychosocial variables is different from that between 1960 and 1988, in which most variables were physiological. To some extent, the shift in variables might be attributed to the background of the authors. Nurse researchers working in clinical settings are more likely to raise research questions related to acute care. For example, JNN, which had a greater percentage of authors in clinical settings, published 65% of the studies evaluating physiological variables. Nurse researchers in academic settings might find it more difficult to conduct studies requiring data collection within clinical settings. Based on this evaluation, interest in the study of physiological variables has continued, but is surpassed by the large increase in the research of psychosocial variables.

Research Question 3. Is there a primary strategy for the development of neuroscience nursing knowledge? If so, did it change from 1989 to 2000? How does it compare to the strategy from 1960 to 1988?

To answer this research question, articles were categorized according to the conceptualization of the research problem. Areas assessed were presence of a theoretical or conceptual framework, adequacy of the incorporation of the framework into the study, testing of hypotheses, statement of aims, and replication or extension of previous studies.

By using criteria developed by Reynolds (1971), studies were classified as theory-then-research or research-then-theory. Forty-six percent of the studies were based on a theoretical or conceptual framework or identified theoretical links among study variables, and these were classified as theory-then-research (Reynolds, 1971). The remaining studies in which the research problem was not placed within the context of a theoretical framework were classified as research-then-theory. The percentage of studies in which theory guided the research increased from 44.1% during 1989-1992 to 49.1% in 1997-2000. The percentage of studies classified as theory-then-research was higher among the three research journals, ranging from 52.9% in WJNR to 74.2% in NR. In contrast 34.5% of JNN articles were classified theory-then-research.

Criteria for the full integration of a theoretical framework into a study include the identification of the framework, selection of variables from the theory, statement of relationships from theory, testing hypotheses, and a statement of the link between the findings and the theory. Based on these criteria, the 89 articles first classified as theory-then-research were then categorized as adequate, minimal, or insufficient based on criteria established by Silva (1986). Fifty-six percent of these studies were categorized as adequate, 13.5% as insufficient, and 30.3% as minimal. Although 97.8% of these studies included stated aims, only 32.6% included an explicit statement of hypotheses.

Between 1960 and 1988, 26.7% of studies were classified as theory-then-research. The increase in the percentage of studies classified as theory-then-research during the 1990s demonstrates a trend toward the use of theoretical frameworks, and this is consistent with nursing research in general. Anderson et al. (2003) found that 44.5% of the articles published in 1999 used a theory, conceptual framework, or philosophical underpinning as a guide for research.

There are two possible explanations for the increase. First, theory testing is a technique usually taught at the doctoral level. The increase in theory-then-research studies might reflect the increase in the percentage of first authors holding doctoral degrees. Second, the number and variety of theories available to guide the development of research studies has increased. Although theory-then-research studies are often noted as a characteristic of a mature science, research-then-theory studies also contribute to the development of nursing knowledge. It is important to use a combination of approaches because new questions can often arise from clinical observations and must be addressed without the guidance of theory. As theories are developed, however, it is important that they be tested prior to being accepted as the basis for clinical care.

During the study period, few studies (2.6%) were identified as replication of previous studies; however, 24.7% of the studies were identified as extensions of previous work. The development of neuroscience nursing requires not only the exploration of new areas of study, but also the validation of research already conducted. It is encouraging to note that 15 authors have published more than one study related to a program of research. Gulick and DiIorio each have published eight studies related to multiple sclerosis and epilepsy sell-management. In addition, several areas of interest have benefited from the work of more than one author. For example, 36 studies examined cognitive issues including those related to Alzheimer's disease; 11, Parkinson's disease; and 11, stroke. Studies that expand previous work are necessary to make substantial contributions to developing a body of neuroscience nursing research.

Research Question 4. What scientific methods are employed in neuroscience nursing research? Did these change from 1989 to 2000? Are the methods different from those between 1960 and 1988?

To answer this research question, data were collected on the research design, timeframe for the study, data collection methods, instruments, sampling, and data analyses techniques.

Research Design

Each study was classified as descriptive, descriptive-comparative, descriptive-correlational, pre-experimental, quasi-experimental, experimental, or instrument development. Most studies were classified as some form of descriptive study. Eighteen percent were classified as descriptive in which the primary analysis consisted of frequencies and percentages. Together, descriptive-comparative and descriptive-correlational studies accounted for another 41.7% of the studies.

Seventeen percent of the studies were classified as pre-experimental, quasi-experimental, or experimental. The percentage of quasi-experimental studies declined over the study period, whereas the percentage classified as pre-experimental and experimental increased. The focus of 9.3% of the studies was on instrument development and testing.

Compared to the previous evaluation, fewer studies were classified as descriptive, and more were classified as instrument development studies. Overall, the percentage of experimental studies (all categories) remained the same. In comparison to the 1980s, however, there was a slight decline during the 1990s in the percentage of studies classified as experimental, along with a slight increase in the percentage of studies classified as pre-experimental. The decline in the percentage of experimental studies was unexpected, as nurse research leaders have given considerable emphasis to need for controlled clinical trials. Although our classification system was different, it appears the percentage of studies classified as a form of descriptive or experimental is somewhat comparable to those classified by others. For example, Goldrick, Baigis, Larsen, and Lemert (2000) found that 35% of studies on HW/AIDS nursing research were classified as descriptive, 53% as correlational, and 24% as experimental, quasi-experimental, or intervention.

Timeframe

Studies first classified as descriptive, descriptive-comparative or descriptive-correlational were also classified by timeframe as retrospective, cross-sectional, or longitudinal. Most of these studies (67%) were classified as cross-sectional studies, 17.4% as longitudinal, 15.7% as retrospective. The percentage of cross-sectional studies increased in 1993-1996 but declined in 1997-2000, while the percentage of longitudinal studies demonstrated a steady increase and the percentage of retrospective studies a steady decline during the study period. The evaluation of neuroscience nursing research studies conducted between 1960 and 1988 revealed that although most descriptive studies were cross-sectional, there was a trend toward longitudinal studies; this trend continued throughout the 1990s.

Data Collection Methods

Methods used to collect data included equipment to collect information on physiological processes, scales and questionnaires to collect self-report data, and recording forms to collect data from charts and records. Physiologic data were collected in 17% of the studies, and self-report data in 76.8% of studies (Table 5). The most common type of self-report instrument was a scale (39.2%), and the most common method used to collect self-report data was a self-administered paper and pen (37.6%) form. In the previous evaluation (DiIorio, 1990), physiological data were collected in 34% of studies and self-report data in fewer than 50% of studies. The current evaluation shows a shift toward the use of scales, questionnaires, and interviews as means to collect data, and away from physiologic data collection.

Instruments

Fifty-three percent of the studies included information on the reliability--and 34% on the validity--of the first instrument used to collect data. Across all studies, 445 instruments were described for data collection. Reliability information was provided for 70.1% and validity for 38.2% of the instruments. Internal consistency reliability was the most frequently mentioned for 49.7% of the instruments. Test-retest and intra or interrater reliability was mentioned for 15.7% and 15.5% of studies, respectively. The types of validity assessed included content (12.4%), criterion (16.2%), and construct (14.2%) validity. The percentage of studies in which reliability was included increased from 1989-1992 to 1997-2000, while reports for validity declined over the 12-year review period. Articles published in NR and RINAH were more likely to include reliability and validity information than those in WJNR and JNN. The results of this evaluation demonstrate an increase in the inclusion of evidence for reliability but a decrease in the inclusion of evidence for validity. This finding was surprising, as nurse researchers have raised awareness of the importance of including evidence of reliability and validity in the report of studies (Strickland, 1997).

The results of the assessment of reliability are comparable to those of Anderson et al. (2003), who noted 61.9% of studies published in 1999 in nursing journals reported reliability. However, they found that 58.6% of studies reported validity, a percentage that is somewhat higher than what we found. One explanation might be a higher percentage of studies with physiological variables in our review. In general validity information is not presented on equipment such as that used to measure intracranial pressure (ICP). A statement of instrument calibration, however, would indicate reliability assessments. Likewise, an instrument used to record observations might provide estimates of intra- or interrater reliability, but not validity.

Sampling

As shown in Table 5, the most likely setting for data collection was outside the hospital. About 30% of studies were conducted in hospitals, including intensive care units. Outside of hospitals, the typical place for data collection was in homes. Over time there was a decline in data collection conducted within medical facilities and an increase in data collection in homes and long-term-care settings. To some extent, the change reflects the decrease in hospital stays and declining admission rates in the 1990s. In addition, the setting for a study generally reflects the type of sample and the type of research questions. The most common place for data collection has changed since the previous assessment. Between 1960 and 1988, the preferred setting was a hospital, with more than 70% of studies reporting data collection in hospital settings. The home setting was used in only 5.6% of the studies.

Sample Characteristics

For this group of studies, the researchers typically used convenience samples. Almost 90% of studies included convenience samples, and 5.7% reported the inclusion of random samples. There was a slight increase in the percentage of convenience samples during 1993-1996, but a decline during 1997-2000. In contrast, the percentage of studies with random samples declined during the second study period, and then increased between 1997 and 2000.

The number of participants in the studies ranged from 4 to 3,116. The median sample size was 52.5, which is higher than the median sample size of 36 reported by DiIorio for the 1980s. There were 24,167 reported participants across all the studies. Of the 161 studies reporting sample characteristics, there were 12,934 females and 6,936 males. The median number of females (29) was slightly higher than the number of males (23). The average age of all participants was 50.7 years, with a range of mean age from 4 to 87 years (age range was newborn to 104). Sixty-three studies included a report of race or ethnicity of the samples. Of these studies, 60 included white participants, 33 included African Americans; 6 studies included Hispanics; and 4 included Asians. In the previous evaluation, 20% of the reviewed studies reported ethnicity, and of these, half included African Americans. The current review shows that more authors are reporting ethnicity, but it is disappointing that a considerable number do not. A current priority in health research is the investigation of factors associated with health disparity (Phillips & Weekes, 2002; Flaskerud et al., 2002). To interpret study results, researchers and policy makers must know the composition of samples. In addition, large-scale studies that include representative samples of participants should be encouraged.

Methods of Data Analysis

Eighty-six percent of studies included quantitative analysis, and 20.1% included qualitative analysis, with some studies including both types of analysis. The percentage of studies using qualitative methods increased over the review period; the percentage of studies including quantitative analyses decreased slightly. Frequencies and percentages were used to evaluate data in 69.6% of studies. About 75% of the studies used correlations, t test, or ANOVA. Fewer studies (12.9% and 13.4%) used chi square or regression analysis. In comparison to studies conducted between 1960 and 1988, the studies the 1990s demonstrated a shift toward more sophisticated qualitative types of analyses including ethnography and phenomenology. In addition, the use of advanced statistical techniques including structural equation modeling, MANOVA, and multiple regression modeling was noted. These findings demonstrate the continued development of neuroscience nursing research.

Discussion

Compared to 1960-1988, there was a considerable increase in the number of neuroscience research studies published in nursing journals during the 1990s, although the number declined during the last third of the decade. Second, orientation focused more on studies of individuals with neurological disorders and less on studies related to neurological trauma. At the end of the decade, a greater percentage of studies focused on chronic and rehabilitation conditions and fewer on physiological variables. The findings demonstrate changes in subspecialty area, care orientation, and nature of study variables versus those observed in the previous evaluation, in which acute care and physiological variables were most representative of the studies. Third, the trend toward theory-then-research studies noted in 1960-1988 continues. Although the research-then-theory approach to building a body of nursing knowledge was the primary strategy then, the current evaluation showed the two methods were used about equally by neuroscience nurse researchers. Fourth, the scientific methods grew more complex during the decade, continuing a trend recognized in the previous review.

As stated in the introduction, in 1990, DiIorio noted that studies were needed to address prevention of neurological injuries and insults, chronic neurological disorders, and neurological conditions affecting elderly patients. She urged nurse researchers to consider sociological and psychological variables in their research, expand the development and testing of instruments, and use more sophisticated study designs and analyses. Based on this analysis, these recommendations have been met in all areas, except for studies on primary prevention, for which the percentage of studies continues to be low. This may be because nurses are not in positions to address these issues or their research is published in journals devoted to primary prevention, such as Public Health Nursing. A future review of neuroscience nursing research might be expanded to include such journals.

The current analysis reveals considerable progress has been made in descriptive research on living with chronic neurological conditions, including multiple sclerosis, Parkinson's disease, and epilepsy. Continued work in these areas might include developing and testing interventions to improve various aspects of quality of life. Research is lacking on the needs of individuals with so-called orphan diseases such as Gaucher disease and amyotrophic lateral sclerosis. In addition, although research data suggest the diagnosis, care, and treatment of individuals with cardiovascular problems varies by race, leading to poor health outcomes for minorities and the poor (Wyatt et al., 2003), very little is known about health disparities for neurological conditions. Neuroscience nurses can conduct studies to enhance understanding of health disparities related to neurological disorders. A first step is to be more attentive to the inclusion of information about sample characteristics in research articles.

The present review indicates nurses are now more focused on chronic conditions and conditions of elderly patients, including Alzheimer's disease. This change might be related to changing U.S. demographics, which now reflect a higher percentage of older Individuals and people who are living longer with chronic illnesses. Interestingly, the percentage of studies devoted to acute care has diminished. Shorter hospital stays might make it difficult for nurses to collect information in the hospital setting, or the accessibility of patients outside of hospitals might make it easier for nurse researchers to collect data in nonacute settings (particularly for nurses who lack clinical contacts). This finding suggests a need for collaboration between academic and hospital-based nurses to address acute care research questions.

There is still a tendency to conduct cross-sectional studies. Although model testing using sophisticated analytical techniques, which has increased in the past decade, can answer some important questions about relationships among variables, future research should focus more on interventional studies using experimental and quasi-experimental designs. This is especially true for areas such as epilepsy serf-management and multiple sclerosis, in which considerable descriptive research has been conducted.

Neuroscience nurse researchers also have a tendency to use serf-report measures. This is understandable, given the increase in the number of studies focusing on psychosocial variables in which measurement is predominantly through serf-report. Nurse researchers, however, should give more consideration to using objective measures for the study of some variables. For example, activity monitors and medication event monitoring systems are available to measure activity levels and medication adherence. These and similar types of measures could be incorporated into studies assessing serf-management and care needs of older adults.

Although nurse researchers have always been vigilant about using reliable and valid instruments in their work, attention to instruments was not as evident as it could have been in studies published within the past decade. Editors of nursing journals and their reviewers can help by requiring statements of reliability and validity prior to accepting the manuscripts for publication.

In this evaluation, we limited our assessment to the contribution of the first author. To track the development of areas of scientific interest, future evaluations could include an assessment of individual author's contributions to the development of nursing science. Nurse researchers who serve as mentors may be listed as coauthors on research studies derived from their own work but conducted by students or junior faculty. This type of evaluation could demonstrate the role of individual nurse researchers and shed light on the role of mentoring in advancing nursing science. Beyond noting the number of studies written about a given topic, we did not gather detailed information about specific areas of research, regardless of author. Future researchers could examine the development of key areas. The American Association of Neuroscience Nurses and other neuroscience nursing groups could use this information to develop research objectives that can guide neuroscience nursing research during the coming years.

Summary

The explosion of neuroscience nursing within the past 20 years indicates a significant and enduring interest of nurses for the systematic study of nursing science. Considerable strides have been made in research addressing psychosocial variables of specific neurological conditions. Of note are advances in nursing research in the areas of epilepsy, multiple sclerosis, Parkinson's disease, and Alzheimer's disease. The role of theory in guiding research studies has strengthened during the past decade, which is evident in the use of more sophisticated descriptive analytical techniques. In looking toward the future, the field of neuroscience nursing research could benefit from more studies using experimental designs. Continued vigilance is required to ensure the inclusion of complete descriptions of sample characteristics and the psychometric properties of instruments in research reports.
Table 1. Neuroscience Nursing Research Studies Published in Four
Journals Between 1989 and 2000

 1989-1992 1993-1996

Journal Number Percentage Number Percentage

Nursing Research 11 16.2 9 12.7
Research in Nursing and Health 12 17.6 8 11.3
Western Journal of Nursing
 Research 8 11.8 5 7.0
Journal of Neuroscience Nursing 37 54.4 49 69.0
Total 68 100 71 100

 1997-2000 Total

Journal Number Percentage Number Percentage

Nursing Research 11 20.0 31 16.0
Research in Nursing and Health 7 12.7 27 13.9
Western Journal of Nursing
 Research 4 7.3 17 8.8
Journal of Neuroscience Nursing 33 60.0 119 61.3
Total 55 100 194 100

Table 2. Selected Characteristics of First Authors

 1989-1992 1993-1996

Characteristic Number Percentage Number Percentage

Education
 Doctorate 41 60.3 44 62.0
 Master's 23 33.8 21 29.6
 Baccalaureate 1 1.5 3 4.2
 Other 1 1.4
 Unable to Determine 3 4.4 2 2.8
Registered Nurse
 Yes 61 89.7 69 97.2
 No
 Unable to Determine 7 10.3 2 2.8
Certification in Nursing
 Yes 22 32.4 21 29.6
 No/Unable to Determine 46 67.6 50 70.4
Fellow of AAN
 Yes 7 10.3 11 15.5
 No 61 89.7 60 84.5
Position
 Academic 41 60.3 44 62.0
 Clinical 19 27.9 18 25.4
 Research 1 1.5 3 4.2
 Student 3 4.4 1 1.4
 Other 2 2.9 1 1.4
 Unable to Determine 2 2.9 4 5.6
Place of Employment
 Academic Setting 43 63.2 48 67.6
 Clinical Setting 23 33.8 19 26.8
 Other 3 4.2
 Unable to Determine 2 2.9 1 1.4

 1997-2000 Total

Characteristic Number Percentage Number Percentage

Education
 Doctorate 29 52.7 114 58.8
 Master's 11 20.0 55 28.4
 Baccalaureate 2 3.6 6 3.1
 Other 1 1.8 2 1.0
 Unable to Determine 12 21.8 17 8.8
Registered Nurse
 Yes 43 78.2 173 89.2
 No 1 1.8 1 0.5
 Unable to Determine 11 20.0 20 10.3
Certification in Nursing
 Yes 12 21.8 55 28.4
 No/Unable to Determine 43 78.2 139 71.6
Fellow of AAN
 Yes 6 10.9 24 12.4
 No 49 89.1 170 87.6
Position
 Academic 36 65.4 121 62.4
 Clinical 9 16.4 46 23.7
 Research 3 5.5 7 3.6
 Student 5 9.1 9 4.6
 Other 3 1.5
 Unable to Determine 2 3.6 8 4.1
Place of Employment
 Academic Setting 45 81.8 136 70.1
 Clinical Setting 9 16.4 51 26.3
 Other 3 1.5
 Unable to Determine 1 1.8 4 2.1

Table 3. Studies for which Collaboration or Funding Was Noted

 1989-1992 1993-1996

Variable Number Percentage Number Percentage

Nursing Collaboration 45 66.2 48 67.6
Interdisciplinary Collaboration 18 26.5 25 35.2
Funding 37 54.4 40 56.3

 1997-2000 Total

Variable Number Percentage Number Percentage

Nursing Collaboration 32 58.2 125 64.4
Interdisciplinary Collaboration 14 25.5 57 29.4
Funding 40 72.7 117 60.3

Table 4. Studies Classified by Problem Areas

 1989-1992 1993-1996

General Problem Area Number Percentage Number Percentage

Clinical Practice
 Neurological 48 70.6 49 69.0
 Neurosurgical 2 2.9 4 5.6
 Neurotrauma 15 22.1 10 14.1
 Combined 8 11.3
 Other 3 4.4
Care Orientation
 Primary Prevention 3 4.4 2 2.8
 Acute 21 30.9 22 31.0
 Chronic/Rehabilitation 40 58.8 47 66.2
 Other 4 5.9
Nature of Study Variables
 Physiological 8 11.8 16 22.5
 Psychosocial 28 41.2 25 35.2
 Teaching/Learning 4 5.9 2 2.8
 Combined 28 41.2 28 39.4
Total 68 71

 1997-2000 Total

General Problem Area Number Percentage Number Percentage

Clinical Practice
 Neurological 49 89.1 146 75.3
 Neurosurgical 4 7.3 10 5.2
 Neurotrauma 2 3.6 27 13.9
 Combined 8 4.1
 Other 3 1.5
Care Orientation
 Primary Prevention 2 3.6 7 3.6
 Acute 13 23.6 56 28.9
 Chronic/Rehabilitation 37 67.3 124 63.9
 Other 3 5.5 7 3.6
Nature of Study Variables
 Physiological 5 9.1 29 14.9
 Psychosocial 22 40.0 75 38.7
 Teaching/Learning 2 3.6 8 4.1
 Combined 26 47.3 82 42.3
Total 55 194

Table 5. Studies Classified by Data Collection Methods

 1989-1992 1993-1996

Data Collection Methods * Number Percentage Number Percentage

 Records 15 22.1 16 22.5
 Observations 12 17.6 17 23.9
 Physiological Measures 14 20.6 9 12.7
 Report 47 69.1 55 77.5

Setting for Study

 Hospital 26 38.2 23 32.4
 Home 13 19.1 15 21.1
 Rehabilitation 2 2.9 2 2.8
 Long Term 6 8.8 3 4.2
 Community 9 13.2 11 15.5
 Outpatient 6 8.8 10 14.1
 Combined 2 2.9 5 7.0

 1997-2000 Total

Data Collection Methods * Number Percentage Number Percentage

 Records 9 16.4 40 20.6
 Observations 11 20.0 40 20.6
 Physiological Measures 10 18.2 33 17.0
 Report 47 85.5 149 76.8

Setting for Study

 Hospital 10 18.2 59 30.4
 Home 17 30.9 45 23.2
 Rehabilitation 1 1.8 5 2.6
 Long Term 7 12.7 16 8.2
 Community 6 10.9 26 13.4
 Outpatient 5 9.1 21 10.8
 Combined 5 9.1 12 6.2

* Some studies used more than one method.


Acknowledgment

This research was supported in part by grant numbers R01-NR04770 and R01-NR04857 from the National Institute of Nursing Research

References

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Editor's Note: This article was the winning entry in the JNN 2003 Case Study Writing Contest.

Questions or comments about this article may be directed to: Jennifer R. Boyd, MHSc RN CNN(C) MSCN, by phone at 416/813-7738 or by e-mail at jennifer.boyd@sickkids.ca. She is a clinical nurse specialist in the Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada.

Mara Hebbard, RN CNN(C), is a clinical leader on the Neurology, Endocrinology and Metabolic Genetics Unit at the Hospital for Sick Children, Toronto, ON, Canada.

Note: Although this case study is based on a real experience, Zahra S. is a fictitious name used to maintain confidentiality.
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Author:DiIorio, Colleen; Yeager, Katherine A.; Donahue, Barbara H.; Wasserman, Jill; Postier, Andrea; Brode
Publication:Journal of Neuroscience Nursing
Date:Apr 1, 2004
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