Perspectives
JONA Volume 44, Number 12, pp 622-624 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Advancing Leadership Education and Research
Nursing Administration Research An Evolving Science Lyn Stankiewicz Murphy, PhD, MBA, RN Elaine S. Scott, PhD, RN, NE-BC Nora E. Warshawsky, PhD, RN, CNE The nature and focus of nursing administrative research have evolved over time. Recently, the research agenda has primarily reflected the national health policy agenda. Although nursing research has traditionally been dominated by clinical interests, nursing administrative research has historically addressed the interface of reimbursement, quality, and care delivery systems. This article traces the evolution of nursing administrative research to answer questions relevant to scope, practice, and policy and suggests future directions. Since Florence Nightingale, there has been a need for well-educated leaders who use evidence-based strategies. As an integralist, Nightingale was concerned about not only the Author Affiliations: Director and Associate Professor (Dr Murphy), School Of Nursing, University of Maryland, Baltimore; Director and Associate Professor (Dr Scott), East Carolina University, Greenville, North Carolina; Assistant Professor (Dr Warshawsky), School of Nursing, University of Kentucky, Lexington. The authors declare no conflicts of interest. Correspondence: Dr Murphy, School Of Nursing, University of Maryland, 655 W Lombard St, Baltimore, MD 21201 (lmurphy@ son.umaryland.edu). DOI: 10.1097/NNA.0000000000000137
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most basic human needs, but also data collection, procedures, protocols, and improvement of patient and organizational outcomes.1 As Nightingale recognized, nurses are challenged to not only care for their patients, but also to manage the organization and delivery of optimal nursing care. Despite these early indications that research in nursing leadership and administration was important, nursing administration research (NAR) remains a marginalized element of nursing inquiry in the United States. Countries, such as Canada and the United Kingdom, with centralized healthcare payment and care delivery systems are better positioned to study the relationships between administrative functions, patient safety, and quality care. The Council on Graduate Education for Administration in Nursing is committed to the advancement of administrative research; thus, the purpose of this article was to provide a historical review of NAR priorities and the continuing narrative of administrative concerns.
Early Beginnings The study of care delivery and outcomes has always been important
to solving the issues facing healthcare. In the early 1970s, clinical nursing research took precedence over NAR. While the applicability of NAR to nursing care delivery was not recognized early on,2 the need for NAR surged during the 1980s. Promulgated through funding from the Division of Nursing (Health Resources and Services Administration), Henry et al3 published the definition of NAR along with the top 20 NAR priorities. The National Nursing Administration Research Priorities (NNARP) study was the 1st of its kind, providing guidance and direction for nursing administration researchers to follow. Building on these findings, Henry et al examined NAR in progress among hospitals and schools of nursing.4 The study concluded that for hospitals, nursing intensity/patient classification; job satisfaction, recruitment, and retention; and nursing productivity were of top priority. For schools of nursing, the top research topics were nurse administrator characteristics; job satisfaction, recruitment, and retention; and home health and long-term care. Nurse job satisfaction and cost containment were the only research priorities common to
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Perspectives Advancing Leadership Education and Research
both hospitals and schools of nursing.4 Similarly, Ingersoll et al5 examined NAR more broadly as health services research. A total of 113 studies were reviewed with the topics of cost and quality of healthcare, care delivery approach, nursing satisfaction and retention, healthcare environment or climate, characteristics of the nurse, classification development, productivity, and healthcare consumers being commonly studied. Ventura and Waligora-Serafin6 used a similar strategy of the NNARP to determine the research agenda among Veterans Administration hospitals and concluded that the quality of nursing practice must be rooted in empirical foundations. Despite these efforts, McDaniel7 described NAR as ‘‘atomic and concerned itself with the caregiver rather than the management and outcome of that care.’’7(p192) She concluded that a scientific revolution was needed and that NAR needed to not simply study nurses, but rather how nurses influenced care outcomes and what constituted relevant nursing care. Similarly, Hermansdorfer et al8 concluded that ‘‘little consensus exists about priority problemsI research focusing on the relationship among quality, cost, outcomes, and design of nursing systemsI remained largely undone.’’8(p547) NAR needed to articulate applicable research questions that related directly to nursing administration and its impact on care environments and patient outcomes. Moving Forward By 1992, the American Organization of Nurse Executives announced its NAR scholar program with the hope to generating a strong scientific base for administrative practice and informing health policy.9
JONA Vol. 44, No. 12 December 2014
The research foci included nurse management practice; nursing ethics; and nursing characteristics related to job satisfaction, employee retention, patient satisfaction, quality of care, and cost.9 However, by the mid-1990s, NAR become less visible as compared with clinical research,10 and despite best efforts, the concerns of NAR ‘‘have been largely ignored.’’11(p9) Subsequently, using the Healthy People 2000 report as a framework, Lynn and Cobb12 convened a group of nursing leaders to identify relevant NAR priorities. As a result, the Nursing Administration Research Project emerged in 1996 to ‘‘focus NAR efforts and funding on areas of highest priority to the discipline.’’13(p5) The advent of the 21st century brought to the nursing forefront historic changes driven by a number of complex forces. Concerns about patient care quality and safety became a priority with the publication of the Institute of Medicine’s (IOM’s) seminal reports, To Err Is Human14 and Crossing the Quality Chasm,15 both of which called for fundamental changes in the American healthcare system. The IOM’s release of Keeping Patients Safe: Transforming the Work Environment of Nurses16 built on these prior reports by examining the relationship between the nursing work environment and patient safety. The report identified that nurses are the primary providers of patient care and are thus significant contributors to patient outcomes. In 2005, Jones and Mark17 concluded that NAR was similar in nature to health services research and generally focused 3 specific areas: cost of care, quality of care, and nursing delivery systems. These researchers convened an interdisciplinary group, and a collective
effort was made to develop a research agenda for NAR that included access to and utilization of care, health and health behaviors, quality of care and patient safety, cost of care and cost-effective care, and organization and delivery of care. The requisite educational needs to advance the agenda were identified, and the agenda was cross-walked with clinical practice, healthcare systems, and public policy. Moving Beyond Understanding the influence of nursing on the delivery of health services through research is critical to achieving the health goals of the nation. This article presented an overview of the nature and evolution of NAR priorities over time. NAR has consistently focused on nurse satisfaction and the work environment, the cost of care delivery, and the quality and safety of care delivery. While NAR may have been classified as ‘‘episodic and without focus,’’12(p12) NAR has responded to the broader national context of healthcare. Healthcare is on the brink of another major paradigm shift given the implementation of the Patient Protection and Affordable Care Act (PP-ACA). The NAR priorities need to reflect and address the transformation of our healthcare system. Understanding successful nursing innovations that reduce cost, improve outcomes, and optimize the use of nursing is essential to realize the promise of the PP-ACA. REFERENCES 1. Henry B, Woods S, Nagelkerk J. Nightingale’s perspective of nursing administration. Nurs Health Care. 1982; 11(4):201-206. 2. Hanson RL. Research: a necessity in nursing. J Nurs Adm. 1973;3(3):14-15, 61.
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Perspectives Advancing Leadership Education and Research 3. Henry B, Moody LE, Pendergast JF, O’Donnell J, Hutchinson SA, Scully G. Delineation of nursing administration research priorities. Nurs Res. 1987;36(5): 309-314. 4. Henry B, O’Donnell JF, Pendergast JF, Moody LE, Hutchinson SA. Nursing administration research in hospitals and schools of nursing. J Nurs Adm. 1988;18(2):28-31. 5. Ingersoll GL, Hoffart N, Schultz AW. Health services research in nursing: current status and future directions. Nurs Econ. 1990;8(4):229-238. 6. Ventura R, Waligora-Serafin B. Setting priorities for nursing research. J Nurs Adm. 1981;11(6):30-34. 7. McDaniel C. Nursing administration research as a paradigm reflection. Nurs Health Care. 1990;11(4):191-193.
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8. Hermansdorfer P, Henry B, Moody L, Smyth K. Analysis of nursing administration research, 1976-1986. West J Nurs Res. 1990;12(4):546-557. 9. Fralic MR. AONE’s first nursing administration research scholars. J Nurs Adm. 1992;22(7/8):14-15. 10. Lynn MR, Layman EL, Englebardt SP. Nursing administration research priorities: a national Delphi study. J Nurs Adm. 1998;28(5):7-11. 11. Lynn MR, Layman EL. The nature of nursing administration research: knowledge building or fire stomping? J Nurs Adm. 1996;26(5):9-14. 12. Lynn MR, Cobb BK. Changes in nursing administration research priorities: a sign of the times. J Nurs Adm. 1994; 24(4S):12-18.
13. Lynn MR, Layman EL, Richard S. The final chapter in the nursing administration research priorities saga: the state of the state. J Nurs Adm. 1999;29(5): 5-9, 20. 14. Institute of Medicine. To Err Is Human. Washington, DC: National Academy Press; 1999. 15. Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press; 2001. 16. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2003. 17. Jones CB, Mark BA. The intersection of nursing and health services research: an agenda to guide future research. Nurs Outlook. 2005;53(6):324-332.
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JONA Volume 44, Number 12, pp 622-624 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Advancing Leadership Education and Research
Nursing Administration Research An Evolving Science Lyn Stankiewicz Murphy, PhD, MBA, RN Elaine S. Scott, PhD, RN, NE-BC Nora E. Warshawsky, PhD, RN, CNE The nature and focus of nursing administrative research have evolved over time. Recently, the research agenda has primarily reflected the national health policy agenda. Although nursing research has traditionally been dominated by clinical interests, nursing administrative research has historically addressed the interface of reimbursement, quality, and care delivery systems. This article traces the evolution of nursing administrative research to answer questions relevant to scope, practice, and policy and suggests future directions. Since Florence Nightingale, there has been a need for well-educated leaders who use evidence-based strategies. As an integralist, Nightingale was concerned about not only the Author Affiliations: Director and Associate Professor (Dr Murphy), School Of Nursing, University of Maryland, Baltimore; Director and Associate Professor (Dr Scott), East Carolina University, Greenville, North Carolina; Assistant Professor (Dr Warshawsky), School of Nursing, University of Kentucky, Lexington. The authors declare no conflicts of interest. Correspondence: Dr Murphy, School Of Nursing, University of Maryland, 655 W Lombard St, Baltimore, MD 21201 (lmurphy@ son.umaryland.edu). DOI: 10.1097/NNA.0000000000000137
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most basic human needs, but also data collection, procedures, protocols, and improvement of patient and organizational outcomes.1 As Nightingale recognized, nurses are challenged to not only care for their patients, but also to manage the organization and delivery of optimal nursing care. Despite these early indications that research in nursing leadership and administration was important, nursing administration research (NAR) remains a marginalized element of nursing inquiry in the United States. Countries, such as Canada and the United Kingdom, with centralized healthcare payment and care delivery systems are better positioned to study the relationships between administrative functions, patient safety, and quality care. The Council on Graduate Education for Administration in Nursing is committed to the advancement of administrative research; thus, the purpose of this article was to provide a historical review of NAR priorities and the continuing narrative of administrative concerns.
Early Beginnings The study of care delivery and outcomes has always been important
to solving the issues facing healthcare. In the early 1970s, clinical nursing research took precedence over NAR. While the applicability of NAR to nursing care delivery was not recognized early on,2 the need for NAR surged during the 1980s. Promulgated through funding from the Division of Nursing (Health Resources and Services Administration), Henry et al3 published the definition of NAR along with the top 20 NAR priorities. The National Nursing Administration Research Priorities (NNARP) study was the 1st of its kind, providing guidance and direction for nursing administration researchers to follow. Building on these findings, Henry et al examined NAR in progress among hospitals and schools of nursing.4 The study concluded that for hospitals, nursing intensity/patient classification; job satisfaction, recruitment, and retention; and nursing productivity were of top priority. For schools of nursing, the top research topics were nurse administrator characteristics; job satisfaction, recruitment, and retention; and home health and long-term care. Nurse job satisfaction and cost containment were the only research priorities common to
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Perspectives Advancing Leadership Education and Research
both hospitals and schools of nursing.4 Similarly, Ingersoll et al5 examined NAR more broadly as health services research. A total of 113 studies were reviewed with the topics of cost and quality of healthcare, care delivery approach, nursing satisfaction and retention, healthcare environment or climate, characteristics of the nurse, classification development, productivity, and healthcare consumers being commonly studied. Ventura and Waligora-Serafin6 used a similar strategy of the NNARP to determine the research agenda among Veterans Administration hospitals and concluded that the quality of nursing practice must be rooted in empirical foundations. Despite these efforts, McDaniel7 described NAR as ‘‘atomic and concerned itself with the caregiver rather than the management and outcome of that care.’’7(p192) She concluded that a scientific revolution was needed and that NAR needed to not simply study nurses, but rather how nurses influenced care outcomes and what constituted relevant nursing care. Similarly, Hermansdorfer et al8 concluded that ‘‘little consensus exists about priority problemsI research focusing on the relationship among quality, cost, outcomes, and design of nursing systemsI remained largely undone.’’8(p547) NAR needed to articulate applicable research questions that related directly to nursing administration and its impact on care environments and patient outcomes. Moving Forward By 1992, the American Organization of Nurse Executives announced its NAR scholar program with the hope to generating a strong scientific base for administrative practice and informing health policy.9
JONA Vol. 44, No. 12 December 2014
The research foci included nurse management practice; nursing ethics; and nursing characteristics related to job satisfaction, employee retention, patient satisfaction, quality of care, and cost.9 However, by the mid-1990s, NAR become less visible as compared with clinical research,10 and despite best efforts, the concerns of NAR ‘‘have been largely ignored.’’11(p9) Subsequently, using the Healthy People 2000 report as a framework, Lynn and Cobb12 convened a group of nursing leaders to identify relevant NAR priorities. As a result, the Nursing Administration Research Project emerged in 1996 to ‘‘focus NAR efforts and funding on areas of highest priority to the discipline.’’13(p5) The advent of the 21st century brought to the nursing forefront historic changes driven by a number of complex forces. Concerns about patient care quality and safety became a priority with the publication of the Institute of Medicine’s (IOM’s) seminal reports, To Err Is Human14 and Crossing the Quality Chasm,15 both of which called for fundamental changes in the American healthcare system. The IOM’s release of Keeping Patients Safe: Transforming the Work Environment of Nurses16 built on these prior reports by examining the relationship between the nursing work environment and patient safety. The report identified that nurses are the primary providers of patient care and are thus significant contributors to patient outcomes. In 2005, Jones and Mark17 concluded that NAR was similar in nature to health services research and generally focused 3 specific areas: cost of care, quality of care, and nursing delivery systems. These researchers convened an interdisciplinary group, and a collective
effort was made to develop a research agenda for NAR that included access to and utilization of care, health and health behaviors, quality of care and patient safety, cost of care and cost-effective care, and organization and delivery of care. The requisite educational needs to advance the agenda were identified, and the agenda was cross-walked with clinical practice, healthcare systems, and public policy. Moving Beyond Understanding the influence of nursing on the delivery of health services through research is critical to achieving the health goals of the nation. This article presented an overview of the nature and evolution of NAR priorities over time. NAR has consistently focused on nurse satisfaction and the work environment, the cost of care delivery, and the quality and safety of care delivery. While NAR may have been classified as ‘‘episodic and without focus,’’12(p12) NAR has responded to the broader national context of healthcare. Healthcare is on the brink of another major paradigm shift given the implementation of the Patient Protection and Affordable Care Act (PP-ACA). The NAR priorities need to reflect and address the transformation of our healthcare system. Understanding successful nursing innovations that reduce cost, improve outcomes, and optimize the use of nursing is essential to realize the promise of the PP-ACA. REFERENCES 1. Henry B, Woods S, Nagelkerk J. Nightingale’s perspective of nursing administration. Nurs Health Care. 1982; 11(4):201-206. 2. Hanson RL. Research: a necessity in nursing. J Nurs Adm. 1973;3(3):14-15, 61.
623
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Perspectives Advancing Leadership Education and Research 3. Henry B, Moody LE, Pendergast JF, O’Donnell J, Hutchinson SA, Scully G. Delineation of nursing administration research priorities. Nurs Res. 1987;36(5): 309-314. 4. Henry B, O’Donnell JF, Pendergast JF, Moody LE, Hutchinson SA. Nursing administration research in hospitals and schools of nursing. J Nurs Adm. 1988;18(2):28-31. 5. Ingersoll GL, Hoffart N, Schultz AW. Health services research in nursing: current status and future directions. Nurs Econ. 1990;8(4):229-238. 6. Ventura R, Waligora-Serafin B. Setting priorities for nursing research. J Nurs Adm. 1981;11(6):30-34. 7. McDaniel C. Nursing administration research as a paradigm reflection. Nurs Health Care. 1990;11(4):191-193.
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8. Hermansdorfer P, Henry B, Moody L, Smyth K. Analysis of nursing administration research, 1976-1986. West J Nurs Res. 1990;12(4):546-557. 9. Fralic MR. AONE’s first nursing administration research scholars. J Nurs Adm. 1992;22(7/8):14-15. 10. Lynn MR, Layman EL, Englebardt SP. Nursing administration research priorities: a national Delphi study. J Nurs Adm. 1998;28(5):7-11. 11. Lynn MR, Layman EL. The nature of nursing administration research: knowledge building or fire stomping? J Nurs Adm. 1996;26(5):9-14. 12. Lynn MR, Cobb BK. Changes in nursing administration research priorities: a sign of the times. J Nurs Adm. 1994; 24(4S):12-18.
13. Lynn MR, Layman EL, Richard S. The final chapter in the nursing administration research priorities saga: the state of the state. J Nurs Adm. 1999;29(5): 5-9, 20. 14. Institute of Medicine. To Err Is Human. Washington, DC: National Academy Press; 1999. 15. Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press; 2001. 16. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2003. 17. Jones CB, Mark BA. The intersection of nursing and health services research: an agenda to guide future research. Nurs Outlook. 2005;53(6):324-332.
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
