Nursing Research: Historical Background and Teaching Information Strategies BY JEANNE M. SARKIS, Senior Clinical Medical Librarian VERONICA L. CONNERS, Associate Dean University ofMissouri-Kansas City Health Sciences Library 2411 Holmes Kansas City, Missouri 64108

ABSTRACT one generation of nurses to the next by word of mouth. This did little to foster interest in or under- The expansion of research-based literature is one of the foremost goals of the nursing profession. Linked to this standing of the information process, and perhaps goal are the utilization and further development of nurs- nurses inadvertently limited their access to litera- ing libraries. This paper discusses some historical factors ture sources. that have influenced nursing literature. It presents a Nursing care based on nonstructured learning model for teaching graduate nursing students the rela- continued for centuries-sometimes with admira- tionship between research and library information skills. ble results, as in the nursing orders of Catholic sisters. In other instances the results were deplor- able, as exemplified by the Charles Dickens char- ONE OF THE most important goals of the nurs- acter Sairey Gamp in The Life and Adventures of ing profession is the production of a research-based Martin Chuzzlewit, an 1844 novel that drew atten- body of literature. Nurses, especially those in aca- tion to the state of nursing care in England. At that demic settings, are now writing the works that will time, nurses were often uneducated members of the form the nursing library collections of the future. lower social classes who could find no other As an emerging profession, nursing provides a employment. Nursing care, especially for the poor unique opportunity to demonstrate the relationship in public hospitals, was disorganized, unsanitary, of research to literature, and of libraries and infor- and lacking in scientific foundation. mation networks to further research. Investigation At this bleak point in nursing history, Florence of the historical patterns of the research/literature Nightingale, an affluent young woman educated in relationships adds another dimension. These obser- Latin, mathematics, philosophy, religion, and mod- vations can in turn be applied to teaching the ern languages, decided to use her resources to fundamentals of the research network to nursing reform nursing. Among her numerous achieve- students. ments in public health, military medicine and hos- pital administration were two of special interest. HISTORICAL BACKGROUND The first was recognition of the necessity for col- The history of nursing reveals attitudes that have lecting scientific data. Her careful documentation long discouraged the expansion of nursing litera- and logical planning during the Crimean War have ture, as well as several landmark occasions that been credited with reducing the death rate of encouraged its change and growth. Although nurs- wounded soldiers from 427 per 1,000 to 22 per ing as an occupation has a history virtually as old as 1,000 in a six-month period. Because of her abili- humanity, nursing literature was almost nonexis- ties with statistics, one writer has called her the tent before this century. Nursing encompasses the "Lady with the Slide Rule" [1]. She was elected to responsibilities of nurturing-attention to hygiene, fellowship in the Royal Statistical Society in 1858, food, comfort, and safety. Knowledge of these skills and she continued her research in public health and tends to be based on common sense, folklore, and disease prevention for many years after her return trial and error, rather than on written documents. to England. For the most part, the essential activities that made Her second major achievement was the founding nursing a distinctive endeavor were passed from of modern nursing education. In 1860, she estab-

Bull. Med. Libr. Assoc. 74(2) April 1986 121 SARKIS AND CONNERS lished the Nightingale Training School for Nurses. varied greatly in quality. In some institutions, This involved securing financial support from student nurses were a cheap source of labor. They influential people, designing the curriculum, writ- were required to work long hours under systems of ing a philosophy of nursing, and determining rigid discipline, and they received little formal admission criteria. Of more than a thousand appli- instruction. Other hospitals, however, provided var- cants, only thirty students were accepted into the ied learning experiences, well-planned classes, and first class. Although St. Thomas' Hospital was some theoretical foundation. A number of nurse chosen for the clinical learning experience, the educators did write textbooks for nursing students, school was an independent educational institution. but the establishment of nursing libraries was Nightingale believed that "a hospital alone was not sporadic and limited. to be the center for the education and practice of The complicated issues surrounding the notion of nursing" [2]. nursing as "women's work" undoubtedly played a With the establishment of the Nightingale role in the conflicting attitudes toward the training Training School and the Nightingale philosophy of or educating of nurses. With the industrial revolu- nursing education, one might expect to see the tion and the various feminist movements, both in beginning of an autonomous profession based on Europe and the United States, society was forced to research and scholarship. However, this did not consider the idea of women working to support happen-at least not in a unified and clearly themselves. Feminist leaders asserted that women defined manner. There are several possible reasons need not rely on fate, marriage, or charity alone. why the growth of nursing literature was slow and Finding dignified work became an option for the fragmented. One reason was the social class struc- unmarried or widowed woman. The rapidly prolif- ture of Victorian England. Reforming nursing care erating hospital schools of nursing provided career meant "reforming" the working-class women who opportunities for many women who could not had been giving nursing care. Nightingale's rules of afford higher education. The economic advantages personal conduct addressed the issues of sobriety, offered to women in the vocational training honesty, and truthfulness; strengthening moral approach to nursing may have damaged profes- character was as important as teaching technical sional opportunities and obscured the goals of skills [3]. Also, her system of nursing administra- academic nursing education. tion actually divided nurses into two classes. A There is little doubt that the need for nursing small number of "gentle women" were recruited research and academic education was recognized and educated for leadership positions as matrons well before 1900. However, change came very and ward sisters. During the training period they slowly. Before 1910, Mary Adelaide Nutting and were called "lady probationers" and they were Isabel Stewart, both nursing professors at Colum- given better living conditions, more lectures, and bia University, made specific efforts to move nurs- more time for personal study and professional ing education into the college or university setting. reading than was given to the working class proba- Over the years, baccalaureate programs increased tioners [4]. It is possible that this two-tier system- in number, but it was not until 1965 that the one small group of better educated nurses and one American Nurses' Association articulated that large group of technically trained nurses-discour- preference in a position paper: "Education for those aged broad-based nursing research. It may also who work in nursing should take place in institu- account for the indifference to nursing literature tions of learning within the general system of that persisted in spite of efforts to improve educa- education" [6]. tion. Concerning the meagerness of nursing research, Another factor that seems to have retarded an editorial in the December 1949 issue of the nursing scholarship was the hospital reform move- American Journal of Nursing said: "One of the ment. Public pressure for better hospital care most serious handicaps to effective research in increased the demand for more trained nurses. nursing ... has been our failure to make definite Christopher Maggs, a British nurse historian, plans for scientific investigation. The nursing pro- observes, "By the end of the nineteenth century, the fession has made no concerted effort to promote, fad for training nurses had percolated [into] nearly support, direct, or evaluate research in nursing and every voluntary hospital as well as many Poor Law there has been no central clearing house for infirmaries; now almost every hospital, even if it exchange of information" [7]. Three years later, in had only five or so beds, offered to train women as 1952, the journal Nursing Research began publica- nurses" [5]. The education offered by hospitals tion. An editorial in the first issue cited its two

122 Bull. Med. Libr. Assoc. 74(2) April 1986 NURSING RESEARCH purposes: "To inform members of the nursing influence of psychology, sociology, anthropology, profession and allied professions of the results of and education. Nurses investigated their own atti- scientific studies in nursing, and to stimulate tudes, their relationships with other health profes- research in nursing" [8]. Both statements indicated sions, their functions in work and political settings, that an information imperative had finally surfaced and numerous other introspective topics. in nursing. Nursing studies of patient care also tended to emphasize psychosocial issues. In order to establish NURSING LITERATURE AND RESEARCH nursing as a distinct profession, independent from The early literature of nursing, beginning with medicine, much effort was made to avoid the the Nightingale period, is marked by handbooks or medical model in nursing research. This did not textbooks. In some regards, Nightingale's book, mean that nursing journals or textbooks ceased to Notes on Nursing: What It Is and What It Is Not, publish anything related to the medical care of fits this category [9]. Much was included on practi- patients. With the surge of health technology in the cal aspects of the nursing care of patients, as well as 1960s, nurses were faced with the need to under- philosophical and administrative aspects. The ear- stand many new therapies, pharmaceuticals, and liest schools of nursing borrowed heavily from the pieces of complicated equipment (electronic moni- medical literature for instructional materials, and toring systems, respirators, and drug infusion sys- the role played by physicians in early nursing tems, to name a few). Nurses wrote papers to education should not be ignored. One of the first inform their colleagues about the nursing care American nursing textbooks, the New Haven Man- responsibilities associated with these subjects. ual ofNursing, published in 1879, was written by a Papers of this nature continue to appear in the committee of physicians and nurses [10]. journals most widely read by hospital nurses. Nurse The documentation of patient care, or the nurs- researchers, however, have tended to avoid patho- ing case study, was another early form of nursing physiologic clinical subjects as areas for investiga- literature. The maintenance of written records tion, and instead have studied psychological, social, about the patient's condition, progress, and nursing or administrative facets of health technology. As care was a component of Nightingale's nursing the nursing profession becomes more secure in its practice. She has been recognized as an innovator understanding of itself, it seems likely that nurses in the field of hospital medical records [11]. will feel free to investigate a broader range of Although these descriptive reports started as stu- health care questions. Also, as nursing approaches dent nurses' educational exercises, they also pro- its goal of academic education for entry into prac- vided a format for early journal articles. The tice, nurses will appreciate the importance of hav- publication of nursing case studies during the ing their own literature and information network. 1920s and 1930s led to the nursing care plan concept, and thus to a clearer definition of nursing TEACHING APPROACHES as a discipline [12]. In fact, the definition of In view of the somewhat halting progress of nursing was and still is a major focus of nursing academic nursing and nursing literature, how can research projects. nurses prepare to contribute to the literature? It During the 1940s and 1950s attitudes toward may be possible to teach library practices and also higher education began to change in many occupa- to convey the pleasures of discovering the informa- tions. College preparation, at least at the baccalau- tion network. At the University of Missouri- reate level, became the accepted standard for Kansas City School of Nursing, students are intro- teachers, pharmacists, and other groups who had duced to library skills in several traditional ways- previously been educated in apprenticeship or voca- tours, lectures, exercises, and individual assistance tional-type settings. At this time nursing education with thesis preparation. However, when they have a itself became a subject of research. Studies were theoretical basis, these activities are more mean- initiated to determine which level of nursing educa- ingful and more enjoyable. tion was most effective, what effect education had The relationship between nursing research and on nursing as a career, and what nurses themselves information can be visualized in several ways. One thought about nursing education requirements. As information concept uses a spiral figure to demon- college and university programs increased in num- strate that one piece of research has its foundation ber, academic nursing began to use the tools of in another piece. The circles of the spiral increase social science research. Consequently, many nurs- in diameter as the literature in the area grows. This ing studies from the 1950s to the present reflect the has proven to be an effective means of teaching Bull. Med. Libr. Assoc. 74(2) April 1986 123 SARKIS AND CONNERS research replication. Students can see that the author of one study has cited other studies that are similar in nature. With this concept, the use of tertiary sources such as indexes to journal litera- ture is easier to grasp. Providing a concrete reason for attention to details of citations, subject head- ings, and author statements relieves some of the tedium often associated with library skills classes. Some level of competence with tertiary sources is essential for the review of the literature that pre- cedes the thesis proposal. Nursing students can foresee the possibility of their own theses being cited by future authors, thus widening the circles of the spiral. The second concept can be illustrated by a web-like network in which one research project influences several other projects that are different from the original piece (Figure 1). This diagram shows students the principles behind indexes such as Science Citation Index and Social Science Cita- tion Index, so they can visualize the varied reasons for citing an older paper. The newer papers may have used a previous statistical finding, philosophy, or theory, and the newer papers may have sup- ported or refuted the evidence in the previous paper. The web-like network concept teaches the diverging, creative aspects of research; it demon- FIG. 2.-Emerging professions use existing informa- strates the ways in which a new idea can be tion resources in the production of their own literature. As triggered by an older article. Students who under- the new literature grows and expands, it forms a similar stand that serendipity can play a role in research complex of collections and networks that perpetuate are free to explore new ideas and to use their library research. skills creatively. The third concept shows the whole information Gardner, W.J. system centered upon individual units of research 1954 literature (Figure 2). This diagram is formed by two pyramids, one inverted over the other. When a discipline like nursing begins to generate its own Bliss, M.R. body of literature, it inevitably uses the literature of 7 64 other disciplines. For example, a nursing study may use a test instrument from psychology, a theory Garrow, C. 1970 from education, or clinical information from phar- Jones, R.F. macology, medicine, or physiology. The older com- 1971 ponents of the study come from the established | o~Jones, R.F. l 1,75 information systems in the inverted pyramid. As Michocki, R.J. the literature of nursing grows, it in turn will form j976 its own information system to be used by future Michocki, R.J. Elhag, K.M. 1977 1977 researchers both in nursing and in other fields. This is the upright pyramid. With this concept in mind, Geldreic, E.E. Reasoner the student can understand the value of interlibrary 1978 1978 loan processes within regional library network sys- FIG. 1.-In 1954 a physician, W. J. Gardner, and a tems and be more comfortable using a variety of nurse, R. M. Anderson, published a paper on decubitus ulcers. This study has been cited by other authors, and the libraries within the community to retrieve interdis- later papers have also been cited to form a network of ciplinary works. The concept can also introduce relationships. students to the important area of computerized 124 Bull. Med. Libr. Assoc. 74(2) April 1986 NURSING RESEARCH bibliographic databases and other computerized 2. Dolan JA, Fitzpatrick ML, Herrmann EK. Nursing communication systems. This diagram is the in society: a historical perspective. 15th ed. Phila- broadest in concept. It demonstrates the interweav- delphia: W. B. Saunders, 1983:354. 3. Baer ED. Nursing's divided house-an historical ing of one discipline's literature with another. It view. Nurs Res 1985 Jan-Feb;34(1):32-8. also shows the expansive aspects of information 4. Ibid. from one unit or document to the sophisticated 5. Maggs CJ. The registration disputes: the background electronic systems that link scholars worldwide. to the appendix. Bull Hist Nurs Group R Coll Nurs 1984 Spring;4:3-9. CONCLUSION 6. American Nurses' Association's first position on Continuing nursing research and nursing litera- education for nursing. Am J Nurs 1965 Dec; ture is dependent upon the acquisition of skills in 65(12):106-11. 7. Research in nursing (editorial). Am J Nurs 1949 retrieval and utilization of information. As infor- Dec;49(12):743-4. mation systems expand and incorporate current 8. Bunge HL. A cooperative venture. Nurs Res 1952 and developing technologies, these skills will June;1(1):5. become ever more critical. It must become the task 9. Nightingale F. Notes on nursing: what it is and what of educational institutions to integrate the acquisi- it is not. Facsimile of 1st ed. (1946). London: tion of these skills into the learning experiences of Harrison, 1859. students. This requires close collaboration between 10. Anderson NE. The historical development of Ameri- librarians and nursing faculty. The rewards of this can nursing education. JNE 1981 Jan;20(1):18- collaboration can be significant both for the disci- 36. 11. Cohen IB. Florence Nightingale. Sci Am 1984 pline and for the individuals involved. Mar;250(3):128-37. REFERENCES 12. Bramwell L. Nursing science: retrospect and pros- pect. Can Nurse 1985 Mar;81(3):45-8. 1. Winslow CA. Florence Nightingale and public health. Public Health Nurs 1946 July;38(7):330- 2. Received May 1985; accepted October 1985.

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