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Evaluation of the Research Agenda for Rehabilitation Nursing
From 1993 to 1995, under the direction of the board of directors of the Association of Rehabilitation Nurses (ARN), the Rehabilitation Nursing Foundation (RNF) created a research agenda for the field, which was published in 1996. The goal of the agenda was to identify a broad range of issues in rehabilitation practice that could be examined to advance the scientific knowledge base. Ten years later, the board of directors of ARN directed RNF to evaluate and update the agenda. A committee of three ARN members was formed to undertake this task. This article reports the committee’s evaluation of the 1996 Rehabilitation Nursing Research Agenda. A separate article reports on the process of revising the agenda.
The profession of nursing has a rich history of research. Beginning with Florence Nightingale’s work in epidemiology (Nightingale, 1859/1946) and continuing throughout the last century, nurse researchers have explored the breadth and depth of the profession. Many organizations have established research priorities, including the National Institute of Nursing Research (NINR; 2005) and Sigma Theta Tau International (2005). Since the 1970s, several nursing specialty organizations, such as the American Association of Critical-Care Nurses and the Oncology Nursing Society among others, have set research priorities for their specialties (American Association of Critical-Care Nurses, 2004; Berry, 2003).
In 1993, the Rehabilitation Nursing Foundation (RNF), under the direction of the Association of Rehabilitation Nurses (ARN), initiated a process to develop a research agenda for rehabilitation nursing (Gordon, Sawin, & Basta, 1996). The goal of the agenda was to “identify the gaps in rehabilitation nursing knowledge and to facilitate and encourage research that can improve that knowledge” (RNF, 1996). Ten years later, the board of directors of ARN directed RNF to evaluate the effectiveness of the Rehabilitation Nursing Research Agenda (RNRA) and revise it if needed. This article reports the committee’s evaluation of the 1996 RNRA.
Gordon, Swain, and Basta (1996) engaged in a comprehensive process to develop research priorities for rehabilitation nursing. Through a combination of quantitative and qualitative research, they developed an agenda that outlined the critical issues to be studied to advance rehabilitation nursing practice. A broad range of issues, described by 26 clinical and 20 contextual statements were synthesized into five categories (RNF, 1996). The final document, incluing 27 statements, was widely disseminated both within ARN and throughout the nursing and rehabilitation professions. The RNRA was used to guide the RNF Research Grant Program.
The evaluation committee members were chosen for the diversity of their expertise and their geographic locations. Recognizing that the influence of the RNRA may be broad and difficult to identify, the committee limited the evaluation to (a) research articles published in the official journals of ARN, Rehabilitation Nursing journal (RNJ) and Rehabilitation Nursing Research journal (RNR), and (b) the RNF Research Grant Program process and the resulting publications.
One committee member searched the Cumulative Index for Nursing and Allied Health Literature (CINAHL) database for articles published in RNJ and RNR from January 1995 through December 2004. (RNR ceased publication at the end of 1996.) This search revealed 590 entries, of which 202 articles were identified in CINAHL as research. These 202 articles were analyzed for content related to the RNRA. No attempt was made to identify rehabilitation research in journals other than those published by ARN because the committee reasoned that the influence of ARN’s agenda would be most obvious in its own journals. Using qualitative research techniques, all titles were coded using the statements of the existing RNRA as code labels.
Concurrently, another committee member reviewed the titles of the 41 research grants awarded since the inception of the RNF Research Grant Program in 1988 through 2004. Grant titles were coded using the areas on the 1996 RNRA: 37 were coded as corresponding to areas of the RNRA; four were coded as being focused outside the research agenda. There were 39 grant recipients, of whom two received a second grant in another year. The majority of recipients (59%) were not members of the ARN. The grant recipients names were searched using the CINAHL and Medical Literature Analysis and Retrieval System Online (MEDLINE) databases to capture publications resulting from their research. In an attempt to capture all publications generated from the grant program, 23 grant recipients (59%) were contacted, and of these, 16 (70%) responded to confirm their publications. For the other grant receipents, contact information was unavailable or not current.
For both parts in the evaluation process, new codes were developed for titles of publications or grants that did not fit within one of the priority areas in the research agenda. Finally, all three committee members independently read the coded data. The members then discussed the placement of the coded data in the 1996 RNRA areas until consensus was reached.
Tables 1 and 2 present the breakdown of articles and grants by research area, within and outside, the RNRA respectively. In the following sections, the evaluation of each area of the 1996 RNRA and the additional areas are discussed.
The research priorities in this category focus on clinical interventions by rehabilitation nurses. This category includes seven high-priority issues or statements addressing interventions for physical aspects of disability and chronic illness, such as bowel and bladder function, skin integrity, sexuality, falls, and self-care issues for individuals with cognitive and behavior issues.
Of the 202 RNJ or RNR research articles reviewed, 33 (16%) were related to this area (see Table 3). Each statement was addressed by at least one article (range 1–10). The most commonly addressed statements were bladder function, followed by skin integrity, self-care for individuals with cognitive problems, falls, sexuality, and chronic pain. Only one research article addressed bowel function.
Of the 41 research grants, six (15%) were awarded in this area. Most focused on bladder function and management. None were related to the statements of bowel function, pressure ulcers, sexuality, or falls. Only one publication (in RNJ) was related to urinary management. No grant-related publications were found in CINAHL or MEDLINE.
Health Promotion and Prevention Strategies
The focus of this area is the health of individuals with disability and chronic illness. This category included five statements, focused on enhancing self-care, barriers to self-care, gender and developmental differences in the experience of disability, problems in health promotion, and ethical issues in providing care to patients who do not value rehabilitation.
Research articles published in RNJ or RNR addressed three of the five statements for this area (Table 4). Of the 37 articles addressing this area, most (18%) related to intervention to promote health and self-care. Other areas of high frequency included gender and developmental issues in the experience of rehabilitation and exploration of specific patient problems related to maintaining health. No research that focused on barriers to health promotion or on ethical issues related to rehabilitation care for patients who do not value independence and wellness was published in ARN journals.
Twelve grants (29%) were awarded in the area. Most grants focused on problems in health promotion and self-care (n = 7); these grants led to nine publications in various refereed nursing journals, such as The Nurse Practitioner, Journal of Nursing Scholarship, and Cancer Nursing, including one article in RNJ. Four of the remaining grants focused on interventions that enhance or maintain health promotion and self-care; they resulted in three publications.
Rehabilitation Practices in the Changing Healthcare System
This category of the RNRA addresses the ongoing transformation of rehabilitation services, systems, and practice. The committee identified eight articles (4%), which described research addressing three of the four statements in this area (Table 5). Four studies compared the outcomes of comprehensive community-based and facility-based rehabilitation programs. Three articles reported research exploring the effect of changing healthcare priorities on the practice of rehabilitation nursing. One article reported on research that explored the relationships among patient acuity, functional status, and caregiver staffing. No research exploring the effect of clinical pathways and community case management on rehabilitation outcomes was published in RNJ or RNR during the study period. No research grants were awarded in this area.
Community Context of Care
Research priorities in this category were concerned with issues that affect all rehabilitation nurses, particularly those whose practice involves helping patients make the transition from an institution to the community or those who work in settings other than healthcare institutions. There are eight statements of research priorities in this category. Seventy-three research articles (36%) addressing the statements in this area were found in RNJ or RNR (Table 6). Only one statement, focused on the impact that a violence-induced disability has on the rehabilitation trajectory, had no published research related to it. Each of the other statements were addressed in several publications.
The most frequently addressed priority in this category was the meaning of disability and quality of life to individuals with a disability (n = 19). The effects of caregiving on family members who provide care in the home to individuals with chronic illness or disability was also a frequently addressed problem. Other articles covered the transfer of newly learned skills to the community environment by the patient and the family, the impact that parent-child interventions can have on the acquisition of autonomy skills by a child with a disability, and the effects of culture on rehabilitation process and outcomes.
There were 16 research grants (39%) awarded for six of the eight priority issues, making this the largest area of funded research. Of these grants, 12 were equally divided among the effect of care giving on the family, the meaning of disability and quality of life to individuals with disability, and interventions to improve the quality of life of individuals with disability. These researchers produced a total of 30 articles (e.g., appearing in Topics in Stroke Rehabilitation, Qualitative Health Research), as well as RNJ and RNR. The articles covered five of the six priority issues related to these grants; only the issue of family characteristics that contribute to the success of functional outcomes in rehabilitation was not represented (see Table 6).
Outcomes and Costs
This area addresses the impact that structural variables in rehabilitation nursing have on patient and organizational outcomes. Eighteen research articles (9%) addressed the three priority statements in this category (Table 7). Eleven studies explored the effects of nursing practice models, advanced practice nursing, and nurses’ competency levels on patient outcomes in various service settings. Four articles reported studies focused on the relationship of patients’ functional outcomes to the type, intensity, and duration of rehabilitation nursing services, as well as to the staff mix necessary to provide care. The remaining three articles reported on research focused on the contributions and the cost of rehabilitation nurses as components of the rehabilitation process.
Three grants (7%) were awarded in this area. Two grants examined the contributions and the cost of rehabilitation nurses as components of the rehabilitation process, and one grant queried the effects of nursing practice models, advanced practice nursing, and nurses’ competency levels on patient outcomes in various service settings. No grants were awarded related to the issue of the relationship of patients’ functional outcomes to the type, intensity, and duration of rehabilitation nursing services, as well as to the staff mix necessary to provide care. No publications associated with these grants were found in the two databases searched.
Topics Outside the Research Agenda
The major topics addressed that were outside the scope of the research agenda (Table 2) were the profession of rehabilitation nursing (n = 8), interdisciplinary rehabilitation interventions (n = 7), attitudes toward people with disabilities (n = 4), patient education (n = 3), and self-management of chronic illness (n = 3). Other topics with fewer publications included living with chronic illness or disability, peer support, and the experience of being a rehabilitation provider. One publication was identified addressing each of the following areas: the experience of rehabilitation, issues of accessibility, determinants of discharge from rehabilitation, rehabilitation research, and rehabilitation program planning.
Four grants (10%) were classified as being focused outside the RNRA. Three were assocated with the topic of the profession of rehabilitation nursing and one with the patient or consumer experience of rehabilitation. There were eight publications in various healthcare and nursing journals, such as Disability and Society and Scholarly Inquiry for Nursing Practice: An International Journal, including four articles in RNJ (see Table 2).
Limitations of the Evaluation Processes
There are several limitations to this review process. First, human error might have occurred in searching for publications in RNJ and RNR, as well as in searching for grant recipients’ publications in CINAHL and MEDLINE. Some publications may have been omitted. Second, although it is hypothesized that rehabilitation nursing research would most likely be captured in the CINAHL and MEDLINE databases, this may not have been true, and publications may have been missed. Third, some citations listed in the searched databases had titles very similar to the grants awarded. However, when the grant recipients were contacted, it was learned that the publication was associated not with the RNF Research Grant program but with similar studies funded by other organizations. The same may have been true for recipients who could not be contacted or who did not reply; there is a risk that some publication data may not in fact reflect RNF grants. Finally, some areas and high-priority statements on the 1996 RNRA were redundant. Because of this overlap in content, some publications and research grant titles were difficult to code to one area or statement. The committee members reached consensus, but only after much deliberation.
Many areas of the RNRA developed 10 years ago continue to have relevance in the current healthcare world. In some areas, a substantial body of research has been published. Only four high-priority statements (2%) listed in the research agenda had no published research in RNJ and RNR. These issues were “barriers to these health promotion and self-care behaviors,” “ethical issues related to rehabilitation care for patients who do not value independence and wellness,” “the effect of clinical pathways and community case management on patient outcomes,” and “the impact that a violence-induced disability has on the rehabilitation trajectory.”
For the RNF Research Grant Program, only one area—rehabilitation practices in the changing healthcare system—did not have funded research projects. The other areas also had high-priority statements without grants. In the area related to nursing interventions, there were no grants awarded for interventions related to bowel protocols, pressure ulcers, falls, or sexuality. In the area of health promotion and prevention strategies, no grants were awarded to examine barriers to health promotion and self-care behaviors or ethical issues related to rehabilitative care for patients who do not value independence and wellness. In the fourth category, there were two issues without funding: transfer of newly learned skills to the community environment by the patient and the family and the effects of culture on rehabilitative process and outcomes. In the category of outcomes, no grants were awarded for the issues of the relationship of patients’ functional outcomes to the type, intensity, and duration of rehabilitation nursing services, as well as to the staff mix necessary to provide care.
The issues lacking publications or funded grants were either stated in very narrow terms (e.g., ethical issues relating to care of patients who do not value independence) or addressed systems that were common at the time the agenda was developd (e.g., care maps), but may no longer be the current standard of practice. It should be noted that these unrepresented issues may have been addressed in research funded by other organizations, such as the NINR, the American Association of Critical-Care Nurses, the Oncology Nursing Society, or the Association of Spinal Cord Injury Nurses. Overall, there were publications identified in all five areas but not for all priorities within those areas.
In summary, most of the clinical issues in the the research agenda have corresponding published research in RNJ or RNR. This funding demonstrates that the research agenda was relevant to the profession of rehabilitation nursing during this time period. On a broader scale, publications on these topics appeared in various well-known national and international healthcare and nursing journals. Thus, rehabilitation nursing researchers are sharing their findings with a wide audience. Additional publications may emerge from the research grant program, because some grants awarded during 2002–2004 are still in the data collection and analyses phases.
The 202 research publications appearing from 1995 through 2004 in RNJ and RNR disseminated the findings of a variety of research endeavors and, most importantly, supported the RNRA. Forty-one projects sponsored by the RNF Research Grants Program, awarded to 39 researchers, resulted in publications specific to the RNRA to advance the science of rehabilitation nursing. These publications and grants also identified new areas of research interest not listed on the 1996 RNRA. In the next phase of this project, RNF updated the 1996 RNRA to make sure it is as relevant in the coming decade, as it was in the decade when it was originally developed. This part of the project is reported in a seperate article.
The development of this manuscript was partially supported by Center for Self and Family Management for Vulnerable Populations, Yale School of Nursing (T32NR008346).
About the Authors
Cynthia S. Jacelon, PhD RN CRRN-A, is an assistant professor at the School of Nursing, University of Massachusetts Amherst. Address correspondence to her at Yale School of Nursing, University of Massachusetts Amherst, 233 Arnold House, 715 N. Pleasant Street, Amherst, MA 01003 or jace firstname.lastname@example.org.
Linda L. Pierce, PhD RN CNS CRRN FAHA, is a professor at the College of Nursing, Medical University of Ohio at Toledo.
Richard Buhrer, MN RN CRRN-A ARNP, is a clinical nurse specialist/adult nurse practitioner at Seattle VA Medical Center.
American Association of Critical-Care Nurses. (2004). AACN’s research priority areas. Retrieved September 3, 2005, from www.aacn.org.
Berry, D. (2003). Oncology Nursing Society research agenda 2003-2005. Retrieved September 3, 2005, from www.ons.org.
Gordon, D., Sawin, K., & Basta, S. (1996). Developing research priorities for rehabilitation nursing. Rehabilitation Nursing Research, 5, 60–66.
Nightingale, F. (1859/1946). Notes on Nursing: What it is and what it is not. Philadelphia: J. P. Lippincott.
Rehabilitation Nursing Foundation. (1996). A Research Agenda for Rehabilitation Nursing. Retrieved January, 2005, from www.rehabnurse.org.
Sigma Theta Tau International. (2005). Global health and nursing research priorities resource paper. Retrieved September 3, 2005, from www.nursingsociety.org.