Introduction

The main goal of nursing research should ultimately be to improve patient care and every nurse wants to do that. Since the health care system today is driven by cost, research about outcomes related to cost is especially important.

Those institutions who pay for health care such as Ministries of Health or insurance providers strive to decrease the cost of patient care. Costs related to patient care basically have three components.

1. the cost of the treatment itself
2. the cost of paying the salaries and benefits to those who are providing the care
3. the cost of overhead of providing those services within an institutional framework.

The first two areas are directly related to nursing. Nursing research can evaluate what nursing actions work best, or in other words which nursing treatments provide the greatest benefit for the least cost. An excellent example of this type of research is that of Brooten, et. al. (1986) which was done in the United States. Dr. Brooten and her colleagues demonstrated a significant cost savings with comparable health outcomes when low birth-weight babies were discharged early from the Neonatal Intensive Care Unit with supervision at home by master's prepared nurses as compared to the traditional hospital treatment.

The second source of costs involves the salaries and benefits of health care workers. Nurses make up the largest percentage of health care workers. Therefore, nursing research can involve a justification of why nurses are needed, and what type of nurses are most cost effective for what types of tasks or roles. Other related questions which are very important to nurses in the present health care delivery environment are: Is the organizational structure of the health care institution the most cost effective? What is the best way to staff a unit - with all RNs, or part RNs and part non-RNs? These types of research could greatly benefit the cause of nursing in Israel.

These questions are especially important in Israel in light of the recent attempts by the Israeli Ministry of Health to decrease costs. The recent passage of several health care-related bills such as universal health insurance and the patient rights law also greatly affect the delivery of health care in Israel. International trends to cut costs such as the replacement of nurses by non-professional personnel are also worrisome and need to be investigated.

All of these developments come together with an increasing proportion of patient care involving technology, increasing patient acuity in hospitals and the trend to discharge patients sooner back into the community. The effect of these trends on the delivery of health care (for example, what works best in what situation) should be evaluated not only to decrease costs but to provide quality care.

It should also be mentioned that nursing is one profession in Israel that in general, is not highly regarded by some other professionals, especially by our colleagues, the physicians. In order to gain more respect and level the playing field, we must learn to how to play by their rules and then play by them. One of the driving forces behind modern medicine today is research and so we must be engaged in research to provide a scientific basis to our discipline, and also to gain the respect of our colleagues. In this way nursing will develop in parallel to medicine.

History of Nursing Research in Israel

In an excellent review of the history of nursing research in Israel, Golander and Krulik (1996) describe the movement of nursing research from the 1960's to the 1990's. In the 1960's nursing research primarily was involved in the investigation of nursing education and administration. It should also be noted that most of this research was not conducted by nurses but by people in other fields about nurses and nursing.

In the 1970's there was an even distribution of nursing research studies related to clinical aspects, education, social aspects and administration. The vast majority (82%) of these studies were conducted to meet student requirements for graduate studies.

The third decade, that of the 1980s, saw an explosion of nursing research (an increase of 170% over the previous decade) with a large increase in clinical studies and a concomitant decrease in studies related to nursing education. The spectrum of research subjects was broadened as well as the types of research methods used. The same percentage of studies were conducted by graduate students; however, the domain of said studies was also greatly widened.

The review only evaluated research studies until 1993. However, during the 1990s the focus of research remained clinical in nature dealing with such topics as care and symptoms of pain, psychogeriatrics, quality of life and quality of care.

An Assessment of Nursing Research in Israel

Bergman (1988) identified major areas omitted in nursing research: research on who does research, why nurses do research, what is being produced in research, how nursing research is being done, research about nursing associations, research about non-responsive patients and master plans for research. She believed that in order to set priorities in nursing research it is necessary to assess past achievements and omissions, consider current issues and ongoing research, and creatively project for the future (Bergman, 1992). One way to assess past achievements and omissions is to view the phases of the development of nursing research in Israel. The phases that occurred in the United States can be a useful guide for this assessment.

The development and maturation of nursing research in the United States underwent four phases: the simulated, the individualistic, the unified, and the balanced (Marchette, 1987). The stimulated phase was characterized by the generation of enthusiasm about the importance of nursing research. Individual nurses conducted nursing research of personal interest with some technical assistance from statisticians or directors of nursing research during the individualistic phase. Individual studies did not significantly contribute to nursing science. In the unified phase, nurse researchers contributed to the development of nursing science with numerous research studies related to the same phenomena such as pain and stress. A characteristic of this phase was the development of an infrastructure (organized support networks) for nursing research.

The last phase, the balanced phase is exemplified by collaborative scholarly programs of research that are adequately supported through a well developed infrastructure. Nursing research in Israel can be viewed similarly, and these authors contend that nursing research is approaching the unified phase. The continued development of an excellent infrastructure is critical for Israeli nursing research to progress to the balanced phase in Israel.

Prerequisites for Research

Prerequisites for the development and growth of nursing research are the same worldwide. They can be categorized into individual, professional, institutional and federal commitments (Hinshaw, 1992). Individual commitments are sufficient numbers of master's and Ph.D. nurses, commitment to the conduct of research, and the time to do research. Master's and Ph.D. nurses are needed not only to do nursing research, but to act as mentors and teachers so that a cadre of nurse researchers are developed in Israel. Nurses who pursue the master's or Ph.D. have a variety of motives for getting advanced education. Ehrenfeld, Ziv and Bergman (1993) found that the most frequent reason for nurses pursuing advanced education was job advancement. Hopefully, a large number of nurses with advanced education will be socialized in their advanced programs so that they have a personal commitment and a professional obligation to do nursing research.

Personal commitment is important in advancing research. The vast majority of nurses do not have research as their first or second priority; rather it often is the last priority due to other activities that need immediate attention taking precedence. This is true for nursing faculty, nursing administrators, and nurses in practice. The planning, development, performance, and evaluation of nursing research, as well as the dissemination of nursing research via publication and presentation takes time; individuals need to set aside time for research.

Professional commitments that facilitate nursing research include professional foundations/values, professional organizations, and professional journals, meetings, databases and conferences. Hinshaw (1992) identifies three key professional foundations to maintain long-term, maximally developed nursing research: a) establishing the value of research and the critical nature of its relationship to nursing practice; b) building the research resources and structures needed to facilitate full-scale research programs; and c) developing a commitment to generate a body of knowledge required to guide nursing practice (p. 486). The nursing scientific community that fosters these foundations is comprised of educators, practitioners, and administrators who need to work together. One place where this is possible is in a professional nursing association. Nurses can network with others in their area, present their research to colleagues, and receive money for pilot research projects. In the United States, professional associations have established databases of researchers and research libraries, journals, conferences and meetings. Nurses in Israel have made significant progress. The last biannual nursing conference contained the highest percentage of research studies conducted by nurses in Israel's nursing history. More and more Hebrew nursing journals are being published, including specialty journals. These journals often publish the results of research reports conducted in Israel.

An institutional commitment to nursing research is as important as a personal and professional commitment. The institution needs to create an environment for research. This can take many forms from rather minor support such as encouragement, consultation, a peer review process, and library resources to more major commitments including release time, money for research and travel, and a research center with a director, statisticians and computers. Some of the bigger institutions in Israel have recently hired in-house nurse researchers who act as coordinators and advisors. Many hospitals in Israel have their own medical libraries; however the vast majority have very few nursing literature journals. There is a national lending service where university medical libraries will provide specific references upon request for a relatively large fee. Outside of the universities, no formal resources exist for computer, translation and statistical help or consultation. All nurses in Israel receive eight days off from their normal work schedule for continuing education programs. This condition is part of the national nurses labor contract.

The last major commitment needed to do quality nursing research is a national commitment. The country needs to invest money for research. The money spent on educating nurses in master's and Ph.D. programs will assure that there are sufficient qualified nurses to do the research. Money can also be applied to doing the research, educating nurses to pursue cutting- edge research and to funding of a National Institute of Nursing Research. Two of the major contributions of the National Institute of Nursing Research in the United States are a national nursing research agenda and a pot of money for only nursing research. In contrast, Israel has no coordinated national center for nursing research nor does it have a national nursing research policy. There are no monies officially designated for nursing research. However, nurses with doctorates can compete against physicians and basic scientists for research funding.

Prerequisites for Israel

Based upon the four commitments that are necessary prerequisites for nursing research, what should be done in Israel? There are currently 696 master's prepared and 40 Ph.D. prepared nurses in Israel (Ministry of Health, 1998). Whereas the numbers have increased significantly over the past ten years, there is a continuing great need for nurses with advanced degrees. The increasing percentages of nurses with academic degrees leads to an increased recognition by nurses and their colleagues that nurses are professionals who should be doing research.

Government investment in nursing education would likely facilitate more nurses pursuit of advanced degrees, which would ultimately result in more nursing research. Israel provided no specific funds for nursing education in 1998 other than the highly successful program integrating promising nursing students and the army. An army nursing program for highly qualified students trains men and women for the army while at the same time educates nurses in the university. In contrast, The Nurse Education Act in the United States, which subsidizes nursing education, provided US $65.6 million for 1998 (Capitol Update, Feb. 13, 1998) and is requesting US $78 million for 2001 (Capitol Update, April 14, 2000). The need for national funding of nursing education is based on the shortage of adequately prepared nurses coupled with the increased complexity of care, changing demographics and aging nursing work force. Money within the Nurse Education Act is specifically designated for advanced education as should be the case in Israel.

Professional commitments to nursing research begin with the socialization of nursing students to value nursing research as critical to nursing practice. The Histadrut HaAchayot, or the National Nurses Association, has a nursing research committee that has sponsored continuing education programs and research conferences. They also sponsor the only general nursing journal in Hebrew, HaAchot Biyisroel which is sent to every Israeli Nurse. Specialty organizations, such as the Israeli Oncology Nurses Association, also sponsor conferences as well as provide money for research projects. These efforts are to be commended and broadened. Professional associations need to develop electronic databases of nurses doing research and research findings in Israel, establish excellent libraries, continue to develop additional specialty nursing journals, support nurses to attend international, national, and local conferences, and develop mechanisms to acquire money so that nursing organizations can fund substantial nursing research projects.

Creating an environment for nursing research to flourish is a process. Institutions can begin by including research activities in role descriptions, rewarding nurses involved in research, establishing a research peer review process comprised of nurses, providing consultation on an as needed basis, and making library resources available. As a group of nurses show their readiness and commitment to conduct nursing research, additional institutional expenditures will be necessary to pay for release time for investigators, fund costs of research projects, and to establish and maintain a research center including a director, statisticians and computers.

At present, Israel is experiencing a nursing shortage. If the government and the health care delivery system want to end this shortage, they should attempt to attract as many qualified candidates as possible. One method is through subsidizing nursing education over and above the usual government subsidies for university education. However, Israel needs to fund nursing research as well as nursing education. The National Institute of Nursing Research in the United States received US $63.5 million in 1998 (Capitol Update, Feb. 13, 1998) and US $90 million in 2000 (Capitol Update, April 14, 2000). The institute is responsible for nursing research as well as research training related to nursing practice and patient care. It is important to note that the United States government support for research training of nurses began in 1955 with only US$125,000. Therefore, any pot of money earmarked for only nursing research would be an excellent beginning point to move toward the eventual creation of a National Institute of Nursing Research in Israel. The institute would have sufficient money to fund scientifically sound nursing research in Israel.

Priorities for Israeli Nursing Research

A nursing research institute would be responsible for developing a national research agenda so that priorities for nursing research in Israel would be identified and agreed upon. It is interesting to know that Bergman called for a master plan for nursing research in Israel in 1977 and reported that efforts to set up the plan met with little success (Bergman, 1977). Twenty years later, there still is no master plan. In contrast, the National Institute of Nursing Research in the United States develops 5-year priorities and grants are funded based upon these priorities.

The establishment of research priorities in Israel is important because significant research problems are culturally and geographically determined. For example, the Israeli health care delivery system underwent major health reform several years ago. Two years ago the first national law related to patient rights was enacted. The impact of these reforms on nurses and patient care should be addressed. Studies which investigated patient rights or universal health care in other countries might address similar issues but can not be directly relevant because the milieu in which these changes took place are very different. Research priorities for the United States will not be appropriate for Israel. Priorities should be developed by the nursing community and based on criteria similar to those used in the United States: a) a health concern to the Israeli public; b) a practice area in which nursing can make an impact; c) an area that is expensive in terms of a health care burden to the public and where there are sufficient nurse researchers to conduct research; d) an area that is promising for innovative ideas. In addition, we believe that priority should be given to nursing research in Israel that addresses the relationships between quality of care, costs, and outcomes. One example which applies to Israel and not the US would be the impact of the constant threat of war and terrorism on the health of Israelis. The large influx of Russian and Ethiopian Jews into Israel necessitates nursing research specifically targeting these groups. Priorities would also assist researchers with the understanding of what research will most likely be funded. The end result would be movement of nursing research to the balanced phase where scholarly nursing research with adequate support and collaboration with other disciplines is the norm.

Nursing research has come a long way in Israel since the first reported research study in 1959. Nurses need to come together as a group to assure that the infrastructure for nursing research is developed fully. Every nurse in Israel has a stake in the support of nursing research. After all, the ultimate goal of nursing research is to guide quality nursing practice.

Authors

Greer Glazer PhD, RN, CNP, FAAN

Greer Glazer, PhD, RN, CNP, FAAN graduated with a BSN from the University of Michigan and an MSN and PhD from Frances Payne Bolton School of Nursing, Case Western Reserve University. She is professor and director of Parent Child Nursing at Kent State University.

Freda DeKeyser PhD, RN

Freda DeKeyser graduated with a BSN from New York University and an MSN and PhD from the University of Maryland at Baltimore. She also conducted her Post-Doctoral Fellowship at Johns Hopkins University. Freda is a lecturer and coordinator of Nursing Research at Hadassah-Hebrew University, School of Nursing in Jerusalem, Israel.